British journal of anaesthesia
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Myasthenia gravis is an uncommon autoimmune disease resulting in destruction of the postsynaptic nicotinic receptors at the neuromuscular junction. We describe a 43-yr-old, 95 kg patient who presented for elective laparoscopic cholecystectomy. ⋯ Subsequent investigation led to a diagnosis of myasthenia gravis. We discuss the investigation, diagnosis, and subsequent management of such a patient and emphasize that tactile estimation of the train-of-four ratio is not a reliable indicator of adequate recovery of neuromuscular function.
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The veterinary neurosteroid anaesthetic Saffan has the same formulation as Althesin now withdrawn from human use and is a mixture of two neurosteroids, alphadolone, and alphaxalone. The molecular structures of these two pregnanes and their properties as i.v. anaesthetics were reported to be similar. Preliminary experiments showed that alphadolone caused powerful antinociceptive effects without sedation when given i.p. ⋯ These effects were reversed at the level of the spinal cord by intrathecally-administered bicuculline (10 pmol). We conclude that a metabolite of alphadolone acetate produced in the liver leads to antinociceptive effects after i.p. and intragastric administration of the parent compound. This antinociception involves spinal cord GABA(A) receptors, even though the drug was administered via a non-spinal route.
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Patients suspected of anaphylaxis during anaesthesia have been referred to the senior author's clinic since 1974 for investigation. Since release of rocuronium on to the worldwide market, concern has been expressed about its propensity to cause anaphylaxis. ⋯ The incidence of rocuronium allergy in New South Wales, Australia has risen in parallel with sales, while there has been an associated fall in reactions to other neuromuscular blocking drugs. Data from intradermal testing suggested that rocuronium is intermediate in its propensity to cause allergy in known relaxant reactors compared with low-risk agents (e.g. pancuronium, vecuronium) and higher-risk agents (e.g. alcuronium, succinylcholine).
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Randomized Controlled Trial Clinical Trial
Clonidine decreases propofol requirements during anaesthesia: effect on bispectral index.
Assessment of the effect of clonidine on depth of anaesthesia is difficult because clonidine combines analgesic, sedative and direct haemodynamic effects. We thus evaluated the influence of clonidine on the bispectral index (BIS) and its potential dose-sparing effect on propofol. After induction of anaesthesia with target-controlled infusion of propofol and obtaining an unchanged bispectral index (pre-BIS), clonidine 4 microg kg(-1) or placebo was administered randomly to 50 patients in a double-blind manner. ⋯ Administration of clonidine resulted in a decrease in the BIS from 45 (SD 4) to 40 (6) (P<0.001), which allowed a reduction of propofol target concentration from 3.3 (0.6) to 2.7 (0.7) microg ml(-1) (P<0.001) and measured propofol concentration from 2.9 (0.6) to 2.5 (0.7) kg ml(-1) (P=0.009) in order to maintain the pre-BIS value. During subsequent surgery, propofol requirements were reduced by 20% (P=0.002) in the clonidine group and a similar amount of remifentanil was used in each group. The increase in anaesthetic depth given by clonidine can therefore be measured with bispectral EEG analysis and allows reduction of the propofol dose to achieve a specific depth of anaesthesia.
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Randomized Controlled Trial Clinical Trial
Autologous blood transfusion in total knee replacement surgery.
We compared allogeneic blood usage for two groups of patients undergoing total knee replacement surgery (TKR). Patients were randomized to receive either their post-operative wound drainage as an autotransfusion (n=115) after processing or to have this wound drainage discarded (n=116). Allogeneic blood was transfused in patients of either group whose haemoglobin fell below 9 g dl(-1). ⋯ There was a higher incidence of infection requiring intervention in the allogeneic group (P<0.036). Total patient costs were Pound Sterling 113 greater in the autotransfusion group. We conclude that in this type of surgery post-operative cell salvage is a safe and effective method for reducing allogeneic blood use.