Anaesthesia
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Randomized Controlled Trial Clinical Trial
Epidural anaesthesia as a method of pre-emptive analgesia for abdominal hysterectomy.
The effect of pre- versus postincisional epidural blockade without the use of systemic opioids was investigated in a randomised, double-blind study of two groups of 25 patients undergoing abdominal hysterectomy performed under general anaesthesia. The first group received, via a lumbar epidural catheter, 0.9% saline (16 ml) 15 min prior to surgical incision and 0.5% bupivacaine (15 ml) and fentanyl 50 micrograms (1 ml) 15 min prior to skin closure. ⋯ Visual analogue pain scores and patient-controlled morphine consumption were measured at specified times for 48 h. We were unable to detect any significant difference in either of the outcome measures of the two groups and thus were unable to demonstrate that epidural blockade using local anaesthetic and opioid has a pre-emptive effect.
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Caudal epidural injection is a simple procedure that carries a low risk of complications. The whoosh test (injection of air into the caudal epidural space with simultaneous auscultation over the thoracolumbar spine) has been recommended as an aid to correct needle placement. A 1-year prospective study, using fluoroscopic imaging to identify needle position, was conducted to compare the sensitivity and specificity of the whoosh test with that of clinical impression alone in assessing correct needle placement in the caudal space. ⋯ Clinical impression alone had a sensitivity of 94% and a specificity of 20%. The whoosh test had a sensitivity of 80% and a specificity of 60%. The whoosh test is superior to clinical judgment in detecting incorrect caudal needle placement.
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Clinical Trial
Use of the Combitube for airway maintenance during percutaneous dilatational tracheostomy.
The Combitube airway allows short-term ventilation during cardiopulmonary resuscitation and can be useful in the management of the difficult airway. In a prospective observational study we assessed its use during percutaneous dilatational tracheostomy (PDT). Twenty-one intensive care patients scheduled for elective PDT had their tracheal tube replaced by a Combitube airway retaining the same ventilator settings. ⋯ A high mean (SD) transmural pressure of 14.7 (5) kPa was exerted by the distal cuff. The Combitube provided a satisfactory alternative airway to the tracheal tube during performance of PDT in 85% of our patients. Potential problems associated with its use in intensive care patients are outlined.
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Randomized Controlled Trial Comparative Study Clinical Trial Retracted Publication
Recovery of post-tetanic count and train-of-four responses at the great toe and thumb.
We have studied the recovery of post-tetanic count and train-of-four responses at the great toe and thumb accelerographically after the administration of vecuronium 0.2 mg.kg-1. Sixty adult patients scheduled for anaesthesia with nitrous oxide and isoflurane were studied. The times to the return of the first post-tetanic twitch were comparable at the great toe and thumb (mean (SD) times: 30.0 (6.5) min and 35.0 (8.5) min, respectively). ⋯ Also, time to the return of the first twitch of the train-of-four did not differ significantly at the great toe and the thumb (47.5 (9.6) min vs. 49.7 (10.5) min). Similarly, time to the return of the second, third and fourth twitches of the train-of-four did not significantly differ at the great toe and the thumb. However, the value of the first twitch of the train-of-four, expressed as a proportion of control twitch, was significantly higher than that at the thumb between 50 min and 110 min after the vecuronium injection, and the train-of-four ratio at the great toe was significantly higher than that at the thumb between 60 min and 100 min after the vecuronium injection.
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We report a case of Streptococcus salivarius meningitis following combined spinal-epidural analgesia for labour. Although rare, bacterial meningitis following combined spinal-epidural anaesthesia is being increasingly described. We review the previously reported cases and discuss the possible aetiological causes and the aseptic precautions likely to reduce the incidence of infectious complications.