The effect of metrics-based feedback on acquisition of sonographic skills relevant to performance of ultrasound-guided axillary brachial plexus block.

The objective of this study was to examine the effect of metrics-based vs. non-metrics-based feedback on novices learning predefined competencies for acquisition and interpretation of sonographic images relevant to performance of ultrasound-guided axillary brachial plexus block. Twelve anaesthetic trainees were randomly assigned to either metrics-based-feedback or non-metrics-based feedback groups. After a common learning phase, all participants attempted to perform a predefined task that involved scanning the left axilla of a single volunteer. Following completion of the task, all participants in each group received feedback from a different expert in regional blocks (consultant anaesthetist) and were allowed to practise the predefined task for up to 1 h. Those in the metrics-based feedback group received feedback based on previously validated metrics, and they practised each metric item until it was performed satisfactorily, as assessed by the supervising consultant. Subsequently, each participant attempted to perform ultrasonography of the left axilla on the same volunteer. Two trained consultant anaesthetists independently scored the video recording pre- and post-feedback scans using the validated metrics list. Both groups showed improvement from pre-feedback to post-feedback scores. Compared with participants in the non-metrics-based feedback group, those in the metrics-based feedback group completed more steps: median (IQR [range]) 18.8 (1.5 [17-20]) vs. 14.3 (4.5 [11-18.5]), p = 0.009, and made fewer errors 0.5 (1 [0-1.5]) vs. 1.5 (2 [1-6]), p = 0.041 postfeedback. In this study, novices' sonographic skills showed greater improvement when feedback was combined with validated metrics.

Construct validity of a novel assessment tool for ultrasound-guided axillary brachial plexus block.

The purpose of this study was to examine the construct validity and reliability of a novel metrics-based assessment tool, previously developed for ultrasound-guided axillary brachial plexus block. Five expert and eight novice anaesthetists performed a total of 18 ultrasound-guided axillary brachial plexus blocks on the same number of patients. A trained investigator video-taped procedures according to a pre-defined protocol. Two trained consultant anaesthetists independently scored the videos using the assessment tool. Compared with novices, experts completed more steps (mean 41.0 vs. 33.1, p = 0.001), had fewer procedural errors (2.8 vs. 7.9, p < 0.0001), had fewer critical errors (0.8 vs. 1.3, p = 0.030), and fewer total errors (3.5 vs. 9.1, p < 0.0001). The mean inter-rater reliability for scoring of experts' performance was 0.91, for novices' performance was 0.84, and for all performance combined (n = 18) was 0.88. This assessment tool is valid, and discriminates reliably between expert and novice performance for placement of ultrasound-guided axillary brachial plexus blocks.

Effect of epidural analgesia on change in Mallampati class during labour.

Mallampati class has been shown to increase during labour. Epidural analgesia might influence this change. The aim of our study was to compare the change in Mallampati class during labour in parturients who did and did not receive epidural analgesia and study the association of these changes with pre-defined clinical characteristics. We performed a prospective observational study of 190 parturients. Using standard methodology, photographs of the upper airway were taken with a digital camera during early labour and within 90 min of delivery. Two to three consultant anaesthetists, blinded to the origin of the photographs, evaluated the images obtained and assigned a Mallampati class to each. Overall, Mallampati class increased in 61 (32.1%), decreased in 18 (9.5%) and did not change in 111 (58.4%) parturients (p<0.001). The proportions of parturients in the epidural and non-epidural groups who demonstrated an increase, decrease and no change in Mallampati class were similar. Of the relationships between change in Mallampati class and the other factors studied, only the total dose of epidural levobupivacaine during labour demonstrated a weak positive correlation 0.17 (p=0.039) with Mallampati class. This study confirms that labour is associated with an increase in the Mallampati class in approximately one third of parturients. Our findings indicate that having an epidural does not influence the likelihood of a change in Mallampati class during labour.

Validation of a clinical assessment tool for spinal anaesthesia.

BACKGROUND: There is a need for a procedure-specific means of assessment of clinical performance in anaesthesia. The aim of this study was to devise a tool for assessing the performance of spinal anaesthesia, which has both content and construct validity. METHODS: The clinical assessment tool was generated using a focus group discussion of practicing anaesthetists. The tool comprised three components: a checklist of 11 pre-defined errors, two time intervals and a six-item global rating scale (GRS). Thirty-one anaesthetists at three different levels of experience underwent testing using the clinical assessment tool: novice (n=10), intermediate (n=10) and expert (n=11). RESULTS: The error checklist and GRS scores but not the time intervals were significantly different between the three groups (P<0.005). CONCLUSION: The error checklist and GRS form the basis for a procedure-specific assessment tool for spinal anaesthesia.

Behaviour of spectral entropy, spectral edge frequency 90%, and alpha and beta power parameters during low-dose propofol infusion.

BACKGROUND: In this study we analyse the behaviour, potential clinical application and optimal cortical sampling location of the spectral parameters: (i) relative alpha and beta power; (ii) spectral edge frequency 90%; and (iii) spectral entropy as monitors of moderate propofol-induced sedation. METHODS: Multi-channel EEG recorded from 12 ASA 1 (American Society of Anesthesiologists physical status 1) patients during low-dose, target effect-site controlled propofol infusion was used for this analysis. The initial target effect-site concentration was 0.5 microg ml(-1) and increased at 4 min intervals in increments of 0.5 to 2 microg ml(-1). EEG parameters were calculated for 2 s epochs in the frequency ranges 0.5-32 and 0.5-47 Hz. All parameters were calculated in the channels: P4-O2, P3-O1, F4-C4, F3-C3, F3-F4, and Fp1-Fp2. Sedation was assessed clinically using the OAA/S (observer's assessment of alertness/sedation) scale. RESULTS: Relative beta power and spectral entropy increased with increasing propofol effect-site concentration in both the 0.5-47 Hz [F(18, 90) = 3.455, P<0.05 and F(18, 90) = 3.33, P<0.05, respectively] and 0.5-32 Hz frequency range. This effect was significant in each individual channel (P<0.05). No effect was seen of increasing effect-site concentration on relative power in the alpha band. Averaged across all channels, spectral entropy did not outperform relative beta power in either the 0.5-32 Hz [Pk=0.79 vs 0.814 (P>0.05)] or 0.5-47 Hz range [Pk=0.81 vs 0.82 (P>0.05)]. The best performing indicator in any single channel was spectral entropy in the frequency range 0.5-47 Hz in the frontal channel F3-F4 (Pk=0.85). CONCLUSIONS: Relative beta power and spectral entropy when considered over the propofol effect-site range studied here increase in value, and correlate well with clinical assessment of sedation.

Can state or response entropy be used as a measure of sleep depth?

SUMMARY: In this prospective observational study we examined the potential of the spectral entropy measures 'state' and 'response' entropy (Entropy monitor), as measures of sleep depth in 12 healthy adult subjects. Both median state and response entropy values varied significantly with sleep stage (p = 0.017 and p = 0.014 respectively; ANOVA). Median state or response entropy did not decrease significantly during the transition from awake to stage I sleep (p > 0.017). State entropy values decreased significantly between sleep stages I and II (p < 0.001). Both state and response entropy values were significantly less (40 and 45 arbitrary units respectively) in stage III (slow wave sleep) vs stage II sleep (p = 0.008). We conclude that state and response entropy values, when expressed as a function of time, may be a useful means of quantifying aspects of sleep.

Determinants of learning to perform spinal anaesthesia: a pilot study.

BACKGROUND AND OBJECTIVE: This study examined attitudes and views held by stakeholders regarding their experience of training in spinal anaesthesia. The aim was to identify key factors related to learning and teaching processes which were perceived to influence the acquisition of competence in spinal anaesthesia. METHODS: The study was carried out at a busy acute tertiary referral teaching hospital over a period of 1 yr. It applied a qualitative research approach in three phases, namely (i) completion of preliminary questionnaires, (ii) completion of focused questionnaires and (iii) focus group discussions. RESULTS: Five factors were perceived to be critical 'determinants of learning': (i) the existence of a formal, structured training programme; (ii) time constraints/theatre efficiency; (iii) trainer-trainee interaction; (iv) patient safety/trainee/trainer stressors; and (v) visualization of the anatomy and procedure. CONCLUSION: The study highlighted the need for a formal and structured training programme in spinal anaesthesia, through which many of the undesirable and discouraging factors (such as stress, adverse trainer-trainee interaction and time constraints) identified in the study could be minimized. Further studies are needed to validate the results in other hospital settings, as well as to define the relative importance of each of the proposed determinants and their interrelationships.

The effect of midazolam on cerebral endothelial (P-selectin and ICAM-1) adhesion molecule expression during hypoxia-reperfusion injury in vitro.

BACKGROUND AND OBJECTIVE: Hypoxia-reperfusion injury is an important determinant of secondary brain injury. In the acute phase of cerebral reperfusion, pro-inflammatory events enhance expression of cerebral endothelial (intercellular adhesion molecule-1 and P-selectin) adhesion molecules, which play an important role in brain hypoxia-reperfusion injury. Midazolam is the most commonly used sedative in patients with brain injury. The objective of this investigation was to examine the effect of midazolam on the expression of cerebral endothelial intercellular adhesion molecule-1 and P-selectin during hypoxia-reperfusion injury in vitro. METHODS: The up-regulation of mouse cerebral endothelial cells intercellular adhesion molecule-1 and P-selectin was assessed following hypoxia-reoxygenation (hypoxia-reperfusion). Cells were pre-treated with three different concentrations of midazolam (0, 5 and 50 microg mL(-1)) prior to hypoxia. Flow cytometry was used to estimate adhesion molecule expression mean channel fluorescence. Data are presented as mean +/- SD. RESULTS: Mouse cerebral endothelial cell intercellular adhesion molecule-1 and P-selectin expression was greater after exposure to hypoxia-reoxygenation compared to normoxia (mean channel fluorescence) 241 +/- 12 vs. 140 +/- 7 and 120 +/- 14 vs. 46 +/- 7, respectively, P < 0.05. Intercellular adhesion molecule-1 and P-selectin expression was decreased by midazolam (5 microg mL(-1)) pre-incubation compared to control, mean channel fluorescence 184 +/- 10 vs. 241 +/- 12 and 51 +/- 7 vs. 120 +/- 14, respectively, P < 0.05. Midazolam at 50 microg mL(-1) had the same effect as 5 microg mL(-1). CONCLUSION: Pre-treatment with midazolam diminishes increased expression of cerebral endothelial intercellular adhesion molecule-1 and P-selectin expression following hypoxia-reoxygenation.

Circulating granulocyte macrophage colony-stimulating factor in plasma of patients with the systemic inflammatory response syndrome delays neutrophil apoptosis through inhibition of spontaneous reactive oxygen species generation.

In the normal resolution of an acute inflammatory response apoptosis of neutrophils is essential to maintain immune homeostasis and limit inappropriate host tissue damage by decreasing neutrophil tissue load, function, and release of phlogistic reactive oxygen species and proteases. The systemic inflammatory response syndrome (SIRS), a massive pro-inflammatory immune state, is associated with delayed neutrophil apoptosis, however, the systemic circulating factors and intracellular signal transduction pathways important in regulating neutrophil apoptosis in SIRS are poorly described. Neutrophils isolated from patients with SIRS on admission to the intensive care unit showed significantly (p<.01) delayed spontaneous neutrophil apoptosis compared with healthy neutrophils as quantified using annexin V-FITC and terminal deoxyuridine triphosphate (dUTD) nick end labeling (TUNEL) flow cytometry methods. Plasma from SIRS patients markedly (41.5+/-7.2%, p<.01) inhibited apoptosis of healthy neutrophils compared with controls (69.7+/-4.8%) indicating the presence of soluble circulating factors that can modify the expression of neutrophil apoptosis. Various pro-inflammatory (IL-6, granulocyte macrophage colony-simulating factor, interleukin (IL)-1beta, tumor necrosis factor-alpha) mediators, known to modulate neutrophil apoptosis in vitro, were elevated in the plasma of our cohort of SIRS patients compared with controls. However, the anti-apoptotic effect of SIRS plasma was specifically attenuated (75.5%, p<.01) by neutralizing SIRS plasma of granulocyte macrophage-colony-stimulating factor, but not IL-6, IL-1beta, tumor necrosis factor-alpha. Although the anti-inflammatory cytokine IL-10 was elevated in SIRS plasma (median level 7.2 pg/mL), further boosting SIRS plasma with recombinant human IL-10 (10 ng/mL, levels found in septic shock patients) significantly countered (63.8%, p<.01) the inhibitory effect of SIRS plasma on neutrophil apoptosis. Suppression of neutrophil apoptosis was concomitant with delayed spontaneous elevation of reactive oxygen species, quantified as peroxide production, and reversed by addition of neutralizing antibodies to GM-CSF, and recombinant human IL-10 to SIRS plasma. These results identify circulating GM-CSF as a significant inhibitor of neutrophil apoptosis in patients with SIRS, and that this effect can be countered by boosting SIRS plasma with IL-10. GM-CSF and IL-10 appear to modulate neutrophil apoptosis by altering reactive oxygen species generation in neutrophils.

Metered-dose inhaler salbutamol-induced tracheal epithelial lesions in intubated rabbits. Effects of the site of administration and time.

STUDY OBJECTIVES: To determine (1) whether metered-dose inhaler (MDI) salbutamol administered at the elbow connector of the anesthetic circuit produced tracheal epithelial lesions in intubated rabbits, and (2) the time course for resolution of tracheal lesions produced by MDI salbutamol through an intratracheal catheter. DESIGN: Prospective, randomized, controlled trial. SETTING: University-affiliated animal research laboratory. PARTICIPANTS: Thirty-nine adult New Zealand white rabbits. INTERVENTIONS: (1) Twenty-one intubated rabbits received 0,5, or 20 puffs of MDI salbutamol delivered at the elbow connector of the anesthetic circuit. (2) Eighteen intubated rabbits received five puffs of MDI salbutamol through an intratracheal catheter and were killed 1 h, 24 h, or 1 week later. MEASUREMENTS: Samples of trachea, bronchi, and lungs were examined by light microscopy, and the degree of epithelial injury was assessed semiquantitatively. RESULTS: MDI salbutamol (5 or 20 puffs) administered at the elbow did not induce tracheal epithelial injury. When administered through an intratracheal catheter, MDI salbutamol (five puffs) produced moderate or severe tracheal epithelial injury in those killed 1 h after the study. Evidence of epithelial regeneration was observed 24 h after the injury and recovery was virtually complete by 1 week. CONCLUSION: Epithelial lesions do not occur when the MDI salbutamol (5 or 20 puffs) is administered at the elbow connector of the ventilation circuit. Tracheal epithelial lesions produced by MDI salbutamol (five puffs) administered through an intratracheal catheter resolve within 1 week of the injury.

Inhibition of neutrophil apoptosis after elective surgery.

BACKGROUND: Neutrophils play a crucial role in host defense against infections, but their inappropriate infiltration and activation within tissues can cause host tissue damage through release of reactive oxygen metabolites, metalloproteinases, and proinflammatory cytokines. The termination of a neutrophil-mediated inflammatory response is effected through programmed cell death or apoptosis. Delayed neutrophil apoptosis is associated with proinflammatory diseases, such as the systemic inflammatory response syndrome. Surgery induces a profound inflammatory response; therefore, neutrophil apoptosis of patients undergoing elective surgery was investigated. METHODS: Nonseptic patients undergoing elective orthopedic surgery while under epidural anesthesia had neutrophils and platelet-poor isolated from whole venous blood harvested at 4 time points: pre-epidural, 45 minutes postepidural but before surgical intervention, 1 hour postsurgical incision, and 24 hours postsurgery. Neutrophil apoptosis was quantified at 1, 12, and 24 hours in culture by immunofluorescence flow cytometry of annexin V and propidium iodide staining and confirmed by TUNEL (terminal deoxynucleotidyl transferase nick end labeling) assay for DNA strand breaks. Serum cytokines were quantified by specific enzyme-linked immunosorbent assay. RESULTS: Spontaneous neutrophil apoptosis after elective surgery was significantly (P < .001) inhibited with an effect evident within an hour of surgical incision and persisting at 24 hours postsurgery. The addition of patients' 24 hour postoperative plasma to healthy neutrophils markedly (P < .01) reduced neutrophil apoptosis, whereas plasma taken an hour after surgical incision was ineffective. Interleukin (IL)-6 was notably increased (1395 +/- 196 pg/mL, P < .01) 24 hours postsurgery and at this postoperative concentration inhibited (P < .01) apoptosis of normal neutrophils. Levels of other inflammatory mediators (IL-1 beta, tumor necrosis factor alpha, granulocyte-macrophage colony-stimulating factor, soluble Fas, soluble Fas ligand) were unaltered. The anti-inflammatory cytokine IL-10 was only slightly increased 24 hours postsurgery (8.32 +/- 2.99 pg/mL); however, the addition of recombinant human IL-10 (10 ng/mL) counteracted (P < .05) inhibition of neutrophil apoptosis induced by IL-6 and post-surgery plasma. CONCLUSIONS: These results identify marked inhibition of neutrophil apoptosis after elective surgery and suggest that the inhibition of neutrophil apoptosis in the postoperative period is, at least in part, a result of soluble circulating factors. The marked imbalance favoring proinflammatory over anti-inflammatory cytokine release in the immediate postoperative period mediates the overwhelmingly antiapoptotic net capacity of postsurgery plasma.

Dose-response relationship of atracurium besylate in the halothane-anaesthetised pig.

The dose response relationship for the intermediate-acting non-depolarising muscle relaxant, atracurium besylate in the pig was determined using evoked electromyography. An incremental dose technique was used in seven Large White/Landrace crossbred pigs anaesthetised with nitrous oxide and halothane. ED50 and ED95 were 510 +/- 87 micrograms kg-1 and 1150 +/- 270 micrograms kg-1, respectively. Although these values may represent an overestimate, they provide a reasonable guideline for the use of atracurium by veterinary anaesthetists.

Addition of epinephrine to epidural ropivacaine during labour--effects on onset and duration of action, efficacy, and systemic absorption of ropivacaine.

Addition of epinephrine to epidural anaesthetic solutions may enhance efficacy and duration of analgesia. We postulated that addition of epinephrine 5 microg.mL(-1) to epidural ropivacaine would improve efficacy, decrease systemic absorption and reduce neonatal effects. Twenty-one multiparous women were studied. An initial dose of ropivacaine 30 mg followed by an infusion of ropivacaine 10 mg.h(-1) was given via a lumbar epidural catheter. According to random allocation, epinephrine 5 microg.mL(-1) was added to ropivacaine. Ropivacaine concentrations were measured in maternal venous plasma after one hour of infusion and in both umbilical venous and maternal plasma at delivery. Neonatal neurologic and adaptive capacity score (NACS) tests were performed at 2 and 24 h postpartum. All women delivered vaginally. The groups had similar ropivacaine dose requirements, epidural-delivery intervals and satisfaction scores. Bromage scores for motor block were greater in the epinephrine group (2; range: 1-3) than controls (1; range: 0-2). Mean plasma ropivacaine concentrations (+/-SD) were less in the epinephrine group (0.17 +/- 0.05 mg.L(-1), n = 10) than controls (0.31 +/- 0.14 mg.L(-1), n = 11; P < 0.05) after one h of infusion but not at delivery. UV ropivacaine concentrations and NACS scores were similar in the two groups. The addition of epinephrine to ropivacaine decreases maternal plasma concentrations after one h of epidural infusion but also increases motor block.

Haemodynamic changes caused by oxytocin during caesarean section under spinal anaesthesia.

The haemodynamic effects of oxytocin receive scant attention in pharmacology texts, but may be clinically significant in vulnerable patients. Despite prescriber information recommending a dose of 5 international units by slow i.v. injection, it is the authors' experience that it is very common practice in the UK to give 10 units as a rapid injection. We therefore conducted a randomised, double-blind study of the haemodynamic changes induced by rapid bolus of 5 or 10 units of oxytocin in 34 healthy term parturients at caesarean section under spinal anaesthesia. There was a small but statistically significant (P < 0.05) reduction in mean arterial pressure from baseline 30 s after a 10-unit bolus. However, large, statistically significant increases in heart rate and cardiac output occurred 1 min after 5 units and 2 min after 10 units. These changes peaked 1 min after oxytocin administration and were greater in the 10-unit group (P < 0.05). The importance of these findings is that some women with hypovolaemia or cardiac disease may be unable to mount these compensatory responses and are therefore at risk of haemodynamic collapse after oxytocin boluses. This has been illustrated by a maternal death reported to the Confidential Enquiries into Maternal Deaths in the United Kingdom. The need to adhere to a dose regimen of 5 units by slow injection needs re-emphasis, but no evidence exists to claim that even this will be haemodynamically inert. We therefore recommend that oxytocin boluses be avoided in women with hypovolaemia or cardiac disease.

Airway obstruction following application of cricoid pressure.

The widely practiced rapid-sequence induction with application of cricoid pressure is designed to facilitate endotracheal intubation in patients considered to be at high risk of aspiration. We describe a case in which this maneuver was performed on a patient with an undiagnosed traumatic injury to the larynx. The resulting airway obstruction required emergency surgical intervention. The clinical presentation, diagnosis, and management of such injuries are discussed.

Using the laryngeal indices caliper to predict difficulty of laryngoscopy with a Macintosh #3 laryngoscope.

STUDY OBJECTIVE: (1) To evaluate a device of the authors' design, the laryngeal indices caliper, which quantitates the position of the anterior edges of the larynx relative to the upper teeth and the external auditory canals; (2) to determine how relative laryngeal position affects ease of direct laryngoscopy with a Macintosh #3 laryngoscope. DESIGN: Randomized, double-blind study. SETTING: Inpatient surgery center at a university medical center. PATIENTS: 101 renal lithotripter patients. INTERVENTIONS: Patients were measured with the laryngeal indices caliper prior to induction of general endotracheal anesthesia. They were then given a sleep dose of thiopental sodium (4 mg/kg) and paralyzed with a bolus dose of succinylcholine (1 mg/kg). MEASUREMENTS AND MAIN RESULTS: Of the measurements taken or calculated, only laryngeal tilt (LT) showed a significant correlation with grade of difficulty of laryngoscopy. When the anterior surface of the thyroid cartilage was tilted more than 20 degrees anteriorly to a line perpendicular to the laryngeal indices line, the vocal cords could not be seen in 83% of the patients. CONCLUSIONS: (1) Laryngeal tilt is a good predictor of difficulty of laryngoscopy with a Macintosh #3 laryngoscope; (2) the laryngeal indices caliper is a simple pocket device to measure LT indirectly.

Using the bubble inclinometer to measure laryngeal tilt and predict difficulty of laryngoscopy.

STUDY OBJECTIVE: To evaluate a simple device, the bubble inclinometer, to measure degrees of laryngeal tilt (LT) for predicting difficulty of direct laryngoscopy using a Macintosh #3 laryngoscope. DESIGN: Randomized, double-blind study. SETTING: Inpatient surgery center at a university medical center. PATIENTS: 50 renal lithotripter patients. INTERVENTIONS: Patients were measured with the bubble inclinometer and the laryngeal indices caliper. A sleep dose of thiopental sodium (4 mg/kg) and a muscle-relaxing dose of succinylcholine (1 mg/kg) were then given to each patient. MEASUREMENTS AND MAIN RESULTS: LT was measured by both methods (directly and indirectly). Difficulty of laryngoscopy was graded as follows: Grade 1 = all of vocal cords seen; Grade 2 = part of vocal cords seen; Grade 3 = no part of vocal cords seen. CONCLUSIONS: The bubble inclinometer accurately and reproducibly measures relative LT, and the anterior tilt of the larynx directly correlates with the ability to see the laryngeal opening during direct laryngoscopy with a Macintosh #3 laryngoscope.

Assessment of patient position for fiberoptic intubation using videolaryngoscopy.

STUDY OBJECTIVE: To compare laryngoscopic appearance obtained during flexible fiberoptic laryngoscopy with the patient's atlanto-occipital joint in the neutral and extended positions. DESIGN: Controlled clinical trial with each patient (in the neutral position) acting as his or her own control. SETTING: University teaching hospital. PATIENTS: 20 adult ASA physical status I and II patients, without anatomical airway abnormalities, undergoing elective surgical procedures. INTERVENTIONS: Fiberoptic laryngoscopy was performed on each patient with his or her atlanto-occipital joint in the neutral and extended positions. MEASUREMENTS AND MAIN RESULTS: Photographs of the laryngoscopic appearances were graded on a scale of 1 to 4 by a blinded observer according to the proportion of the laryngeal inlet visible. Atlanto-occipital extension improved laryngoscopic appearance in 14 cases and produced no change in the remaining 6. CONCLUSION: Atlanto-occipital extension is a useful maneuver during attempted fiberoptic intubation.

Benzodiazepines inhibit the rate of neutrophil apoptosis.

BACKGROUND: Benzodiazepines, which are commonly administered perioperatively, can depress immune function. Neutrophil apoptosis plays a central role in the regulation of inflammation. This is particularly important during and after surgery. AIM: To examine the effects of benzodiazepines (midazolam and diazepam) on neutrophil apoptosis. METHODS: Venous blood samples were withdrawn from patients scheduled to undergo elective surgery, (a) immediately prior to, and 10 minutes after administration of midazolam 0.2 mg/kg intravenously (n=11) and (b) immediately prior to, and 60 minutes after administration of diazepam 10 mg p.o. (n=10). Neutrophil apoptosis was measured by Annexin V-FITC after 1 and 12 hours in culture. RESULTS: The percentage of apoptotic cells was significantly less after midazolam at 12% (11.9) hours in culture compared to pre-midazolam 29.7% (13.3) (p<0.05). After diazepam, the rates of neutrophil apoptosis were also significantly less after 12 hours in culture (p<0.05). CONCLUSION: Administration of benzodiazepines in clinically relevant doses inhibits neutrophil apoptosis. In the perioperative period, this may influence the inflammatory response to surgery.