An atypical case of successful resuscitation of an accidental profound hypothermia patient, occurring in a temperate climate.

Cases of accidental profound hypothermia occur most frequently in cold, northern climates. We describe an atypical case, occurring in a temperate climate, where a hypothermic cardiac-arrested patient was successfully resuscitated using extracorporeal circulation (ECC).

Prevention of spinal anaesthesia-induced hypotension in the elderly: i.m. methoxamine or combined hetastarch and crystalloid.

We have compared two methods of reducing hypotension during spinal anaesthesia in elderly patients, 6% hetastarch and crystalloid or methoxamine 10 mg i.m., in terms of haemodynamic stability and requirements for additional vasopressors. Sixty-two patients (aged 60-97 yr) undergoing surgical fixation of fractured neck of femur were allocated randomly to receive 6% hetastarch (Hespan) 500 ml followed by Hartmann's solution 500 ml (group HS, n = 32) or a bolus injection of methoxamine 10 mg i.m. (group MX, n = 30), 10 min before induction of spinal anaesthesia with 0.5% hyperbaric bupivacaine 2.25-3.0 ml. Arterial pressure was measured non-invasively by an oscillotonometer at 2-min intervals from 0 to 40 min and at 5-min intervals thereafter. Methoxamine 2 mg i.v. was given if systolic arterial pressure (SAP) decreased to < 100 mm Hg. Hypotension was defined as a 25% decrease from baseline SAP or mean arterial pressure (MAP). Patient data, sensory level and blood loss were similar in the two groups. SAP and MAP increased initially from baseline until induction of spinal anaesthesia and then decreased for 30 min in both groups, but remained higher in group MX (P < 0.05). Heart rate (HR) decreased from baseline in group MX (P < 0.05) and was less than in group HS at all times from 2 to 60 min (P < 0.01). The incidence of SAP hypotension (47% vs 75%; P = 0.03, odds ratio (OR) = 3.43) and MAP hypotension (47% vs 67%; P = 0.09, OR = 2.51) was less in group MX than in group HS. Requirements for rescue methoxamine i.v. (27% vs 53%, P = 0.04, OR = 3.11) was less in group MX than in group HS but the dose of rescue methoxamine given (mean 6.3 (95% confidence intervals 3.0-9.6) vs 8.9 (5.6-12.2) mg) and time to onset of hypotension (20.7 (14.5-26.7) vs 17.3 (11.4-23.1) min) were similar in groups MX and HS, respectively. We conclude that methoxamine 10 mg i.m., given 10 min before induction of spinal anaesthesia in normovolaemic elderly patients, reduced subsequent SAP and MAP hypotension, HR and requirements for rescue vasopressor therapy compared with a combination of 6% hetastarch 500 ml and crystalloid 500 ml. The previously reported benefit of such volume administration may not extend to the elderly.

Laparoscopic cholecystectomy in adult cystic fibrosis.

Two female patients with Cystic Fibrosis, attending the Adult Regional Cystic Fibrosis centre at the Cork University Hospital, were investigated for upper abdominal pain and found to have gallstones at ultrasonography. Laparoscopic cholecystectomy was performed successfully and, without complication, in both patients.

Isoflurane for refractory status epilepticus: a clinical series.

General anesthesia has been recommended to control convulsive status epilepticus that is refractory to conventional anticonvulsant therapy. Halothane has been the recommended agent, but without experimental justification. Isoflurane, which has no reported organ toxicity and produces electrographic suppression at clinically useful concentrations in normal humans, should be a better volatile anesthetic for this purpose. The efficacy and safety of isoflurane administered to control convulsive status epilepticus were assessed on 11 occasions in nine patients in seven North American hospitals. Isoflurane, administered for 1-55 h, stopped seizures in all patients and was able to be titrated to produce burst-suppression patterns on electroencephalograms. Blood pressure support with iv fluids and/or pressor infusions was required in all of the patients. Seizures resumed upon discontinuation of isoflurane on eight of 11 occasions. Six of the nine patients died. The three survivors sustained cognitive deficits. In one patient urine fluoride concentrations were elevated, although not to nephrotoxic levels. These cases suggest that isoflurane 1) is an effective, rapidly titratable anticonvulsant; 2) does not reverse underlying causes of the refractory seizures; and 3) usually necessitates hemodynamic support with fluids and/or pressors. Isoflurane may be administered for seizures, but only when iv agents in anesthetic doses are ineffective or produce unacceptable side effects.

Isoflurane for the management of status epilepticus.

When conventional therapy fails in status epilepticus, general anesthesia is recommended. We present our experience with isoflurane, an inhalational anesthetic, in the management of a patient with refractory status epilepticus. The seizures were controlled with relatively small concentrations of isoflurane. Hypotension, the only adverse effect of isoflurane, was managed with fluid and dopamine infusions.

Cerebral oedema and the fat embolism syndrome.

A 19-year-old woman who sustained multiple trauma, but no head injury, developed the fat embolism syndrome. Her severe, fulminant and reversible neurological deterioration was associated with cerebral oedema. We suggest that cerebral oedema may contribute to the neurological deterioration in the fat embolism syndrome.

Phaeochromocytoma removal and postoperative hypoglycaemia.

A case of postoperative hypoglycaemia following removal of a phaeochromocytoma is presented. The hypoglycaemia is due to a reactive rise in insulin and is augmented by alpha adrenoceptor blocking agents. Beta adrenoceptor blockers impair recovery from this hypoglycaemia. Frequent monitoring of blood glucose and the administration of an appropriate solution of dextrose both during and after this operation is recommended.

The measurement of tidal volumes in spontaneously breathing children during general anaesthesia using a Haloscale infant Wright respirometer.

The accuracy of tidal volume measurements made with a Wright Haloscale infant respirometer in children breathing spontaneously during general anaesthesia was assessed by a bench test. The tidal volumes and peak flow rates of 20 spontaneously breathing, anaesthetised children were measured with a pneumotachograph before and during surgery, and similar volumes, at the same flow rates, were delivered by a calibrated syringe simultaneously to the respirometer and a pneumotachograph. The results reveal that the mean (+/- s.d.) peak gas flow rates of children aged 6 years and less, 7.5 (+/- 1.6) and 9.3 (+/- 0.1) l/min before surgery and during surgery respectively, are significantly less than the peak flow rates, 11.3 (+/- 1.0) and 11.9 (+/- 1.5) before and during surgery, respectively, of children aged more than 6 years; and that the respirometer underestimates tidal volume by 10% when the peak flow rate is 11 l/min, and the percentage error in tidal volume estimation by the respirometer increases as the peak gas flow declines below 10 l/min.

Effects of nitrous oxide on the respiratory pattern of spontaneously breathing children during anaesthesia.

The effects of the withdrawal of nitrous oxide from the inspired gas mixture were studied in 10 spontaneously breathing children during nitrous oxide-halothane anaesthesia, before and during surgery, using a computerized system for the measurement, recording and analysis of data. Before surgery the decline in the alveolar nitrous oxide concentration was associated with an increase in minute ventilation (32.7%, P less than 0.05), and a decrease in alveolar carbon dioxide concentration (8.4%, P less than 0.05). These effects were produced solely by an increase in tidal volume (42.7%, P less than 0.001), as no significant change in respiratory rate was observed. The hypoventilation produced by an alveolar mixture of 60% nitrous oxide and 0.9% halothane, a reduction of VE by 50%, exceeded the hypoventilation caused by 0.9% halothane alone, which reduced VE by 36.6%; and the hypoventilation produced by nitrous oxide and halothane was rapidly reversed by the withdrawal of nitrous oxide from the inspired gas mixture. During surgery all indices of ventilation were stimulated, and there was greater variability of response, but the pattern and degree of change in response to nitrous elimination, VE increased by 33.3%, VT by 33.8%, closely resembled the changes before surgery. Five children had received papaveretum as premedication, and five thiopentone per rectum; the depression of carbon dioxide responsiveness was more severe in the group who received papaveretum, and their responses to nitrous oxide elimination were less than, and occurred later than the responses in the group given thiopentone.