Anaesthesia
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A specially designed 20 ml syringe for eliciting the loss of resistance test is described together with a suitably adapted Tuohy needle. This syringe and needle are primarily intended for use by those gaining experience in extradural analgesia (and such experience is readily transferred to any syringe) but it is considered that the consummate ease of operation will be appreciated by others.
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The management of a patient is described who has a blood patch for spinal headache, but who had a recurrence of symptoms 1 day later which was successfully treated by a second patch. A second case is described in which there was a second dural puncture immediately prior to the blood patch and, immediately following the blood patch, the patient complained of severe debilitating 'paralysing' pain in both legs. This pain was of short duration and the blood patch was successful. Some further observations on the use of a blood patch are recorded.
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Upper and lower limb blood flow was measured in 4 fullterm pregnant women in the left lateral and supine positions before and after epidural block. Radial artery mean blood pressure was recorded in 6 full term pregnant women under the same conditions. Before epidural block there was a much greater reduction in lower limb blood flow (39-1%) than in upper limb blood flow (13-5%) when women moved from the lateral to the supine position; this was probably the result of aortic compression. ⋯ In the supine position, a greater flow to the legs, associated with a decreased mean arterial pressure, would be expected to lead to a diminution in placental perfusion, which is the probable mechanism for foetal decompensation. Therefore the supine position should be avoided with an epidural block. In other patients it would be wise not to rely upon maternal compensatory mechanisms.
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Intravenous regional analgesia using bupivacaine (Marcain) was employed as the anaesthetic technique in a series of 50 cases undergoing a variety of surgical procedures on the upper limb. A short pilot study was undertaken to determine the optimal dosage and concentration of bupivacaine. This was found to be 1-5 mg/kg in 0-2% concentration and proved suitable for all patients regardless of age or physical condition. ⋯ The degree of muscle relaxation was, however, always adequate for the successful reduction of fractures. Only one patient exhibited an adverse reaction to the dose of bupivacaine used and this was limited to a brief period of slight drowsiness. The results of this series suggest that bupivacaine may provide advantages over previously used local analgesic agents for intravenous regional analgesia and that it may be the agent of choice for this useful technique.
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The attitude of Joseph Lister (1827-1912) to chloroform is considered with particular reference to contemporary methods of administration and the effect of the agent on cardiac and respiratory function.