Basic airway management by junior doctors: assessment and training on human apnoeic subjects in the anaesthetic room.

We assessed the airway management skills of 20 junior doctors on patients in the anaesthetic room, using a self-inflating bag with digital flowmeter to measure exhaled tidal volume. Following induction of anaesthesia the junior doctor attempted to ventilate the patient's lungs with five breaths. If two of these breaths were > 250 ml the assessment was completed. If not, a period of instruction was given followed by a further five-breath assessment. Eight doctors did not need further training; of these, six were senior house officers and seven had been on an Advanced Life Support course. Twelve doctors required instruction and re-assessment. Four were senior house officers and two had been on an Advanced Life Support course. They showed some improvement following the instruction period but never reached the standard of the other eight. Validated courses improve resuscitation skills but hands-on training in the anaesthetic room can also be of benefit in maintaining these skills.

Sedation for neuroradiology revisited: comparison of three techniques for cerebral angiography.

BACKGROUND AND OBJECTIVE: Previous work in our department, prior to the advent of digital subtraction angiography, showed that anaesthetist-administered sedation for cerebral angiography using propofol infusion-bolus fentanyl resulted in significantly more patients with early recall than a bolus fentanyl and midazolam technique. Our present study reassessed, 10 yr after our original study, the effectiveness of sedation for neuroradiological digital subtraction cerebral angiography, using three techniques currently in use in the department. METHODS: A total of 88 adult patients were sedated for neuroradiological angiograms by one of three anaesthetist-administered regimens: propofol-alfentanil infusion; boluses of fentanyl with a propofol infusion and boluses of fentanyl and midazolam. The latter two regimens had been used in our previous sedation study. Patients were assessed for time to orientation at the completion of the procedure, and followed up the next day to determine their last memory before sedation, first memory after the angiogram and any recall of the procedure itself. RESULTS: All three techniques were found to give satisfactory sedation and showed minimal difference in the time to orientation at the end of the procedure (3.7, 4.3 and 5.1 min), any awareness of the procedure itself (20% of patients overall) and numbers of patients having early recall; that is, recall of still being in the radiology department before return to the ward (22/29, 16/29 and 20/30). CONCLUSIONS: Our results show that since the introduction of digital subtraction angiography we may have a different end-point of sedation compared to our original study, as well as a shorter angiogram time. Satisfactory anaesthetist-administered sedation can be provided for cerebral angiography by either infusion or incremental techniques. We feel that the success and safety of a sedation technique depends considerably on the skill and experience of the administrator such that these sedation techniques are only suitable for safe use by an anaesthetist.

Disappearance of intraperitoneal gas following gynaecological laparoscopy.

We investigated 25 day case gynaecological laparoscopy patients to determine the duration of the pneumoperitoneum, the rate at which residual gas disappeared and the relative contribution of this gas to pain in the early postoperative period. The volume of gas was calculated from measurements of the subdiaphragmatic gas bubble obtained from an erect chest X-ray. Each patient was X-rayed twice, either immediately prior to discharge and at 24 h post laparoscopy, or at 24 h and 48 h post surgery. Patients were contacted by telephone at 24 and 48 h to confirm fitness to return for the X-ray and at the same time verbal pain and activity scores were recorded. We found that residual gas was almost entirely gone by 48 h following surgery and that it appeared to reduce in an exponential manner. The contribution of this gas to postoperative pain was significant in the first 24 h, but by 48 h it was considerably reduced. We conclude that in day case gynaecological laparoscopy patients, postoperative pneumoperitoneum is short-lived, and that by 48 h its volume and contribution to postoperative pain should be minimal.

Desflurane or sevoflurane for gynaecological day-case anaesthesia with spontaneous respiration?

Sixty gynaecological day-case patients were anaesthetised with either desflurane or sevoflurane in oxygen/nitrous oxide, following intravenous induction. Mean end-tidal desflurane was 4.5% at 5 and 10 min post induction, whereas mean end-tidal sevoflurane was 1.7%. There were five untoward airway events (coughing, hiccoughs) in the desflurane group and three in the sevoflurane group, including one laryngospasm. Time to eye opening and orientation following anaesthesia were significantly faster in the desflurane group (2.8 min/4.8 min) than in the sevoflurane group (7.0 min/9.8 min; p < 0.0001). Time to being ready for discharge home was also significantly earlier in the desflurane group (3 h compared with 3.5 h). Telephone interview on the first postoperative day showed that in the desflurane group 29 of 31 were fully returned to normal activity compared with only 15 out of 29 in the sevoflurane group (p < 0.01).

Serum myoglobin and creatine kinase following surgery.

Serum myoglobin (by radioimmunoassay) and creatine kinase were measured for up to 7 days in 30 patients following surgical procedures, including total hip replacement and bilateral subcostal abdominal incisions. Serum myoglobin reached a maximum of 1390 micrograms litre-1 (median 345 micrograms litre-1 for major surgery patients) on the first postoperative day but levels were still elevated by day 7 in some patients. Creatine kinase reached a maximum of 1339 i.u. litre-1 at day 2 (median 422 i.u. litre-1 for major surgery patients), generally peaking 1 day after myoglobin in individual patients. These values may have significance when investigating a suspicion of coincident perioperative events such as myocardial infarction or malignant hyperthermia.

Cortical evoked potentials in the ruptured anterior cruciate ligament.

The sensory role of the intact and ruptured anterior cruciate ligament was studied by the use of cortical evoked potentials during arthroscopy. This showed a response from the intact ligament in four patients that was reproducible. This response was consistent with those obtained from stimulation of the ipsilateral posterior tibial nerve. No response was elicited from either the femoral or tibial stump of ruptured ligaments using the same technique in six patients who had ruptured their anterior cruciate ligament (two femoral and four mid-substance ruptures). We believe that this demonstrates that there is no functional nervous tissue within the anterior cruciate ligament after rupture.

Unusual consequences of heroin overdose: rhabdomyolysis, acute renal failure, paraplegia and hypercalcaemia.

A 29-yr-old man, known to be a heroin addict, was found at home totally unrousable, bent on his hips in the lotus position. On admission, he required frequent ventricular defibrillation, external pacing and infusion of calcium. A diagnosis of rhabdomyolysis caused by heroin and cocaine overdose was made. He developed paraplegia below T12, acute renal failure, acute compartment syndrome in one leg and a coagulation defect. Despite a fasciotomy, a through-knee amputation of the leg was required. Haemodialysis was required for 26 days, and this period was complicated by increased serum calcium concentrations, which was treated with disodium pamindrate. Calcium deposits were palpable in the muscles and could be seen in vessels on limb x-rays. After 34 days, he was eventually discharged to a general surgical ward and subsequently into the community.

Suxamethonium, masseter spasm and later malignant hyperthermia.

A 25-year-old man admitted with severe upper torso trauma displayed masseter muscle spasm after suxamethonium given during resuscitation. Anaesthesia was initially maintained with intravenous agents during transfer and X-ray angiography. However, during surgery to correct a brachial artery injury, malignant hyperthermia was triggered when isoflurane was given, 2.5 h after the suxamethonium. He responded to treatment, including dantrolene administration. Peak serum and urine myoglobin were 12,947 micrograms.l-1 and 54,571 micrograms.l-1, respectively, while maximum serum creatinine kinase was 17,300 IU. The patient made an uneventful recovery and later proved positive for malignant hyperthermia susceptibility on muscle contracture tests.

Serum and urinary myoglobin following an aborted malignant hyperthermia reaction.

A 13-year-old boy presenting for correction of bat ears was anaesthetised with thiopentone and suxamethonium, the administration of which was followed by jaw spasm, poor peripheral perfusion (without cyanosis) and marked tachycardia. The procedure was abandoned, dantrolene and Ringer lactate IL were given intravenously and the patient regained consciousness 1 h later. Levels of serum myoglobin, urinary myoglobin and creatine kinase were followed until they returned to normal. Despite a peak serum myoglobin of 58.000 micrograms.l-1 and peak urinary level of 446,000 micrograms.l-1, no renal impairment occurred. Subsequent testing for susceptibility to malignant hyperthermia proved positive for the patient and four other members of the family.

Does post-laparoscopy pain relate to residual carbon dioxide?

We studied 20 day case gynaecological laparoscopy patients, who had an erect chest X ray taken before discharge. Patients were telephoned the next day for a semi-structured interview. Particular note was made of shoulder tip pain and pain relieved by changing posture. The X ray was analysed for measurements of the length of arc and height of the gas bubble under each hemi-diaphragm, from which an estimation of bubble volume was also made. We found statistically significant correlations between both the length of arc (p = 0.005) and volume of gas bubble (p = 0.008) on the right side, with the pain score. Residual gas can be a prominent cause of post-laparoscopy pain.

Akathisia following low-dose droperidol for antiemesis in day-case patients.

Akathisia has been described following the use of droperidol for antiemetic prophylaxis. In a double-blind, placebo-controlled study, we investigated both the incidence of akathisia and its relationship to the dose of droperidol (0.5 or 1 mg). One hundred and twenty healthy women undergoing day-case gynaecological surgery were anaesthetised with propofol, fentanyl, isoflurane and droperidol according to group. Patients were assessed by structured telephone interview at 24 h. There was an increasing incidence of both restlessness (p = 0.01) and unpleasant restlessness (p = 0.02) between the groups on Chi-squared testing. Compared to the control group, those women given droperidol 1 mg suffered more restlessness (p = 0.001) and unpleasant restlessness (p < 0.01). No statistical difference could be demonstrated between the two droperidol groups. We conclude that droperidol may commonly cause akathisia and may not, therefore, be an appropriate prophylactic antiemetic for day-case anaesthesia.