British journal of anaesthesia
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We have studied the immediate and long term (up to 28 days) effects of short and long bevelled needle impalement of the rat sciatic nerve. Three techniques were used to assess neural trauma and its consequences: stained longitudinal nerve sections were assessed by light microscopy and scored for injury; the extravasation of Evan's Blue dye, after antidromic electrical nerve stimulation, was used as a test of unmyelinated fibre function; the flexion withdrawal times from a noxious stimulus were measured. ⋯ Nerve injury induced by short bevelled needles was associated with persisting signs of injury 28 days after the injury. These results suggest that the current practice of using short bevelled needles to prevent nerve injury complicating regional anaesthesia be reassessed.
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A patient is described in whom breakthrough of pain occurred from uterine rupture during effective extradural analgesia, demonstrating the hypothesis of the "extradural sieve". Subsequent abolition of this pain by addition of fentanyl to bupivacaine 0.25% raises the question whether or not this combination should be avoided in women with a scarred uterus undergoing "trial of labour".
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We have studied the disposition of alfentanil in six patients (who had suffered 10-30% surface area burns 5-21 days previously) undergoing surgical debridement and grafting and compared the data with those from a control group of six patients matched for age, sex and weight undergoing body surface surgery of similar duration. Plasma samples were collected up to 480 min after an i.v. bolus of alfentanil 50 micrograms kg-1. Drug concentrations were measured by radioimmunoassay and alfentanil binding to plasma proteins by equilibrium dialysis. ⋯ There was a good correlation between AAG concentration and protein binding (r = 0.8). The volume of distribution and total clearance of alfentanil were reduced significantly in the burns group. The clearance of the unbound fraction and the elimination half-life of alfentanil were not decreased significantly.
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We report the successful use of combined spinal and extradural anaesthesia for elective Caesarean section in a primigravid patient with Ehlers-Danlos type IV (EDS IV). EDS IV is a rare disorder with a high pregnancy-related mortality. ⋯ It is not possible to be didactic about anaesthetic technique for such patients. The relative risks of general and regional anaesthesia must be discussed fully, and the risks weighed against the wishes of the woman and her partner.