Anaesthesia
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Randomized Controlled Trial Clinical Trial
Effect of milrinone on vecuronium-induced neuromuscular block.
We examined the effect of milrinone, a phosphodiesterase III inhibitor, on neuromuscular block induced by vecuronium. Thirty adult patients were randomly assigned to one of two equal groups: the milrinone group and the control group. Subjects in the milrinone group received an intravenous loading dose of milrinone 5 microg x kg-1x min-1 for 10 min, followed by an infusion at a rate of 0.5 microg x kg-1x min-1. ⋯ The onset of neuromuscular block in the milrinone group was significantly slower than in the control group. The times to the returns of the four twitches of the train-of-four, times to recovery of the ratio of the first twitch to the control twitch to 25% and 50%, and the times to the recovery of the train-of-four ratio to 25% and 50% were significantly shorter in the milrinone group than in the control group. We conclude that milrinone delays the onset of neuromuscular blockade but hastens its recovery in anaesthetised patients receiving vecuronium.
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Recent recognition that artificial ventilation may cause damage to the acutely injured lung has caused renewed interest in ventilation techniques that minimise this potential harm. Many ventilation techniques have proved beneficial in small trials of very specific patient groups, but most have subsequently failed to translate into improved patient outcome in larger trials. ⋯ High frequency ventilation, inverse ratio ventilation, prone positioning and inhaled nitric oxide are all techniques that may be considered when, in spite of optimal artificial ventilation, the patient's gas exchange remains dangerously poor. Under these circumstances, the choice of technique is dependent on their availability, local expertise and individual patient needs.
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Randomized Controlled Trial Clinical Trial
The rigid nasendoscope as a tool for difficult tracheal intubation: a manikin study.
We examined the use of the 30 degrees rigid nasendoscope in aiding difficult tracheal intubations. A Cormack and Lehane grade 4 difficult intubation (no view of glottis or epiglottis) was set up on a manikin. After 10 s of tuition, 40 anaesthetists attempted to pass a standard gum elastic bougie between the cords, with and without the nasendoscope, in randomised order. ⋯ Using the standard bougie 13/40 (33%) passed the bougie between the cords without the nasendoscope, compared with 31/40 (78%) when using the nasendoscope (p < 0.001). The 'optimal curve' bougie resulted in 29/40 (73%) and 39/40 (98%) success rates without and with the nasendoscope, respectively (p = 0.004). The nasendoscope is a simple and easy to use tool in grade 4 intubation, and results are improved further by the use of an 'optimal curve' bougie.
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Clinical Trial
Factors affecting the spread of bupivacaine in the adult thoracic paravertebral space.
Factors affecting the spread of bupivacaine in the paravertebral space were investigated in patients undergoing paravertebral nerve blocks for the treatment of chronically painful conditions. Injections of bupivacaine 0.5%, 10-15 ml mixed with depomedrone up to 80 mg were repeated at 2-wk intervals up to a maximum of four times. A blinded observer mapped out the subsequent distribution of sensory loss to cold on both sides of the torso at 5-min intervals after each injection. ⋯ A single bolus of bupivacaine produces a safe but unpredictable block. Yet to be defined physical properties and anatomical factors are probably key determinants of the spread of bupivacaine in the paravertebral space. This single bolus technique may be better supplanted by a reversion to the older multiple level injection technique.
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We describe a nurse-led pre-assessment system at an elective surgical centre. A targeted referral system was used by trained nurses to direct referrals to a supervising consultant anaesthetist or to the surgical team. Of 2726 patients pre-assessed in the first 2 years, 105 patients (3.9%) were cancelled or postponed for medical optimisation after pre-assessment. ⋯ A review suggested that four of these transfers could have been reasonably predictable from the patients' medical history. We conclude that a pre-assessment clinic has an important role to play in minimizing cancellations on the day of surgery and also in reducing the number of patients transferred to other hospitals. This last conclusion has an important implication for the planning of systems in hospitals that perform only elective surgery.