Anaesthesia
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Twenty five patients were treated with an epidural blood patch for persistent headache, following a known or suspected dural puncture. Fifteen to 20 ml blood was injected into the epidural space through a catheter inserted one space away from the dural puncture. The catheter technique was useful in confirming the clinical diagnosis of previously unrecognised dural tap in six patients with severe headache. It was possible to perform the blood patch single-handed.
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Knowledge of common anaesthetic drugs, techniques and complications amongst junior surgical staff at a typical district general hospital is assessed. The implications for patient care are discussed and suggestions made for improved education.
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The Reverend Doctor Robert Laws (1851-1934) followed in the footsteps of David Livingstone to Central Africa. At the beginning of a long and distinguished career as a medical missionary in Christian service to the country that has since become the Republic of Malawi, he was a prime mover in the setting up of a mission station at Cape Maclear, on the shores of Lake Malawi (formerly known as Lake Nyasa and closely associated with the discoveries of Doctor Livingstone). There, on 2 March 1876, Laws used chloroform to produce surgical anaesthesia when he operated on a young African male who had a cystic tumour above his left eye.
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Assessment of pain on injection of the emulsified formulation of di-isopropylphenol (propofol, 'Diprivan') was undertaken in 120 unpremedicated patients and comparison made with thiopentone. A high incidence of pain (37.5%) was found using dorsal hand veins, but use of forearm veins showed only a 2.5% incidence of pain. The use of intravenous lignocaine immediately before propofol injection only partially reduced the incidence of pain using dorsal hand veins (17.5%). A degree of cardiorespiratory depression accompanied induction but the incidence of other side effects was low.
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Review
Neuromuscular transmission and its blockade. Pharmacology, monitoring and physiology updated.
The role of two recently introduced muscle relaxants--atracurium and vecuronium--in contemporary anaesthetic practice is assessed. Recent advances in the physiology of neuromuscular transmission, particularly the roles of calcium and calmodulin, are reviewed, and new ideas concerning the reversal and monitoring of neuromuscular blockade are discussed.