Magnesium as first line therapy in the management of tetanus: a prospective study of 40 patients.

A prospective observational study was conducted to examine the efficacy and safety of magnesium sulphate for control of spasms and autonomic dysfunction in 40 patients with tetanus. Magnesium was infused intravenously, aiming to control spasms despite suppression of patellar reflex or respiratory insufficiency. Spasms were controlled in 38 of the 40 patients within a serum Mg(2+) range of 2-4 mmol.l(-1) with only two patients needing additional neuromuscular blocking drugs. Seventeen of 24 patients (< 60 years) and six of 16 patients (> or = 60 years) did not require ventilatory support. Thirty-six patients were conscious and co-operative throughout their management. Sympathetic over-activity was controlled without supplementary sedation. Overall mortality was 12%; all five deaths were in patients > or = 60 years and no deaths were due to autonomic dysfunction. We recommend magnesium as possible first line therapy in the routine management of tetanus.

Magnesium sulphate for control of spasms in severe tetanus. Can we avoid sedation and artificial ventilation?

A prospective pilot study was undertaken to investigate the ability of magnesium sulphate to control the spasms of severe tetanus without the need for sedation and artificial ventilation. All eight patients admitted with severe tetanus to our intensive care unit within the last year were given magnesium sulphate intravenously as a 5-g loading dose followed by an infusion of 2-3 gh-1. The infusion rate was increased to control spasms while retaining the patella tendon reflex, which proved a valid guide to avoid overdose. Spasms were effectively controlled and serum magnesium concentrations were maintained within the therapeutic range. Spontaneous ventilation was adequate, ventilatory support being required only for the management of lung pathology. There was no evidence of cardiovascular instability due to sympathetic over activity. No supplementary sedation was required for the control of spasms or autonomic dysfunction during magnesium therapy. We conclude that magnesium sulphate can be used as the sole agent for the control of spasms in tetanus without the need for sedation and artificial ventilation.

Subcutaneous morphine for postoperative analgesia.

OBJECTIVE: a. To confirm the efficacy of subcutaneous morphine infusion for postoperative analgesia and compare this effect with three-hourly subcutaneous bolus injections of morphine. b. To evaluate the suitability of a simple micro-infusion set to deliver subcutaneous infusion, as conventional infusion pumps are expensive and not readily available. SETTING: Double blind, prospective controlled clinical trial. PATIENTS: 21 patients belonging to the American Society of Anaesthesiologists' (ASA) classes I or II, who underwent major elective abdominal surgery were studied in an intensive care unit. INTERVENTION: All patients were given loading doses of morphine intravenously (iv) followed by subcutaneous (sc) infusion in two groups and three-hourly sc bolus injections in the third group. The doses were titrated on an individual basis. The infusion was delivered by a power driven pump in one group and by a microinfusion set in the other. Those with significant pain during this regime were given morphine supplements intravenously. MEASUREMENT: Pain scoring was done hourly using a modified verbal rating scale. The percentage of patients who required intravenous supplements in each group was compared to draw statistical conclusions. RESULTS: 1. Subcutaneous infusion provided adequate analgesia in 86% of the patients studied. 2. There was no significant difference between the groups in terms of additional iv supplement requirement. 3. The microinfusion set required frequent readjustments to maintain constant flow. CONCLUSIONS: Intermittent subcutaneous bolus injections of morphine given through an indwelling butterfly needle is a simple, safe, and effective method for postoperative analgesia after major abdominal surgery. Simple infusion sets are not suitable to deliver subcutaneous infusions, and the need for infusion pumps makes the infusion technique unsuitable for routine use in wards.

Cutaneous leishmaniasis in Sri Lanka. An imported disease linked to the Middle East and African employment boom.

Cutaneous leishmaniasis acquired by two Sri Lankan nationals while they were employed in Iraq and Northern Nigeria respectively constitutes examples of an imported disease related to the 'Middle East and African employment boom'. In both cases the diagnoses were confirmed by demonstrating the parasites in smears from the lesions and in tissue sections, and by culturing the parasites in vitro. Since leishmaniasis, neither visceral nor cutaneous is prevalent in Sri Lanka the risks of 'introduced' diseases is discussed here in the context of these two cases.

Control of spinal blockade. A volume expansion technique with hyperbaric cinchocaine.

Subarachnoid anaesthesia was performed using 2 ml of hyperbaric cinchocaine diluted with cerebrospinal fluid in 83 patients. When different volumes of the diluted cinchocaine (6 ml or 8 ml) were injected in the same manner into two comparable groups of patients in the height range of 150-180 cm, there was a statistically significant (p less than 0.001) difference in the mean levels of the analgesia obtained. Individual values had a narrow range of spread for a given volume of injectate. There was no significant correlation between maximum analgesic levels and age and height in this group. When the smaller volume of 6 ml was given to 21 patients under 150 cm in height, there was a statistically significant correlation (r = -0.74) between height and levels obtained. It is possible to obtain the required analgesic levels by varying the volume of dilution without altering the drug dosage, but height is an important consideration in patients of less than 150 cm.