Akbar Vohra

Pain on injection of propofol Methods of alleviation

A controlled randomised double‐blind design was used to study the effect of lignocaine on the pain produced by intravenous injection of propofol. Patients received a 2‐ml pretreatment solution with temporary venous occlusion, followed by an induction solution. One hundred and three patients were assigned to one of five groups: saline pretreatment, followed by induction with propofol plus saline 2 ml; lignocaine 20 mg pretreatment, followed by induction with propofol plus saline 2 ml; lignocaine 40 mg pretreatment, followed by induction with propofol plus saline 2 ml; saline pretreatment, followed by induction with propofol plus lignocaine 20 mg; or saline pretreatment, followed by induction with propofol plus lignocaine 40 mg. Pain was reduced significantly in all groups in which lignocaine was used and a dose of 40 mg was more effective than 20 mg. There were no significant differences in the incidence of pain among the groups which received lignocaine as pretreatment and the groups which received lignocaine mixed with propofol. Sixty‐eight percent of patients who experienced pain or discomfort recalled it in the postoperative period.

The effect of four different surgical prone positions on cardiovascular parameters in healthy volunteers

Twenty healthy volunteers were placed in four different surgical prone positions: on pillows, on an evacuatable mattress, on pelvic props and in the knee—chest position. The normal supine position was used as a control for the measurement of cardiovascular parameters. Mean arterial pressure was measured by automated oscillotonometry. Transthoracic electrical bioimpedance was used to measure cardiac output and heart rate. Cardiac index and total vascular resistance index were derived from these data. No significant changes in heart rate or mean arterial pressure occurred when the volunteers were moved from the supine position to any of the four prone positions or when returned to the supine position again. Cardiac index decreased significantly on going from the supine to the knee—chest position (20%) and onto the props (17%) but not onto the evacuatable mattress (11%) or the pillows (3%).

The reinforced laryngeal mask airway (RLMA) protects the airway in patients undergoing nasal surgery — an observational study of 200 patients

PurposeThe laryngeal mask airway (LMA) is used in nasal surgery but there is some concern of tracheal or laryngeal contamination with blood and secretions. We have evaluated the ability of the LMA to prevent airway contamination until full emergence from anesthesia.MethodsTwo hundred adults, ASA I–III patients, undergoing nasal surgery under general anesthesia were included in a prospective observational study. A reinforced LMA, sizes 3–5, was used during surgery and removed with its cuff inflated, in recovery, when the patients awoke. The LMA was examined on its laryngeal aspect for contamination of blood and secretions and scored (0–3) independently by two observers according to soiling (score of 0 =no blood;score of 1 =staining on the cuff;score of 2 = staining on the inside of mask;score of 3 =blood in the tube).ResultsThe contamination scores were [n (%)]: 0 = 174 (87%); I = 22 (11%); 2 = 4 (2%); 3 = 0 (0%).ConclusionNinety-eight percent of patients had no or minimal contamination of the LMA. The 2% incidence of grade 2 LMA soiling is low and probably acceptable, since it did not result in symptoms of airway contamination. We suggest that the use of the LMA for nasal surgery may be appropriate.RésuméObjectifLe masque laryngé (ML) est utilisé en chirurgie nasale, mais on craint une contamination trachéale ou laryngée par le sang et les sécrétions. Nous avons évalué la capacité du ML à prévenir la contamination des voies aériennes avant le retour à la conscience.MéthodeDeux cents adultes, ASA I–III, devant subir une intervention chirurgicale nasale sous anesthésie générale, ont participé à une étude prospective par observation. Un ML renforcé, de taille 3–5, a été utilisé pendant l’opération et retiré avec son ballonnet gonflé, au réveil du patient. La surface laryngée du ML a été examinée pour y déceler toute trace de contamination par le sang et les sécrétions et cotée (0–3) par deux observateurs indépendants selon le degré de souillure (0 = pas de sang; 1 = coloration sur le ballonnet; 2 = coloration à l’intérieur du masque; 3 = sang dans le tube).RésultatsLes scores de contamination ont été [n (%)]: 0 = 174 (87 %); 1 = 22 (11 %);2 = 4 (2%); 3 = 0 (0 %).ConclusionQuatre-vingt-dix-huit pour cent des patients n’ont subi aucune contamination ou une contamination minimale du ML. L’incidence de 2 % de souillure de classe 2 du ML est faible et sans doute acceptable, puisqu’elle ne cause pas de symptômes de contamination des voies aériennes. Nous croyons que le ML est approprié pour la chirurgie nasale.

An epidural scoring scale for arm movements (ESSAM) in patients receiving high thoracic epidural analgesia for coronary artery bypass grafting.

Thoracic epidural analgesia appears to improve the outcome of patients undergoing coronary artery bypass graft surgery. Cranial extension of nerve blockade involving the third, fourth and fifth cervical nerve roots can cause apnoea. However, progressive paraesthesia and weakness due to cephalad spread of thoracic epidural analgesia will affect the arms before the diaphragm. A scale was designed to test three active movements of the arms bilaterally: hand grip (T1/C8), wrist flexion (C8/7) and elbow flexion (C6/5). This epidural scoring scale for arm movements (ESSAM) consists of four grades (0–3) based on the number of absent movements, and suggests appropriate action. The reliability of this scale was tested in 40 patients undergoing coronary artery bypass surgery. Twelve of the 40 patients had their epidural infusion reduced on the basis of the scale. Of these 12 patients, eight had a worst ESSAM score of 1, three had a worst score of 2 and one had a worst score of 3. In each patient, motor power returned following the reduction in infusion rate, taking between 30 min and 3 h. This scale appears to be a simple and reliable method for the early detection of the cephalad spread of thoracic epidural analgesia.

Delayed vascular puncture following axillary brachial plexus sheath cannulation.

We were interested to read the article by Hill and Campbell on the use of the loss of resistance technique for identifying and blocking the brachial plexus (Anaesthesia 1992; 47: 207-9). We have used this technique successfully on a number of occasions and are writing to comment on a recent complication. A 29-year-old male patient presented for exploration of his right thumb. The axillary sheath was successfully cannulated the the first attempt with a 20 G Medicut cannula using the loss of resistance to saline technique. The cannula was advanced smoothly off the needle for about 2 cm. A T-piece extension set was attached and the cannula taped in place. After careful aspiration at regular intervals 30 ml of plain 1 % lignocaine was injected into the sheath. Good anaesthesia and motor block was achieved within 15 min. There was no blood seen on aspiration at any time and the cannula was left in situ. Unfortunately there was a 1 h delay in commencing surgery and some motor power returned to the thumb. We decided to top-up the block with 1 % lignocaine with 1 :200000 adrenaline. However, on aspiration, blood flowed out freely. A I ml test dose resulted in the patient complaining, within seconds, of facial fullness, palpitations and a feeling of ‘rush’. The pulse oximeter showed his heart rate increased from 75 to 116 beat.min-’. This continued for approximately 1 min and gradually decreased. The skin incision to the thumb was pain free. A deeper incision was painful, but responded to local infiltration with anaesthetic solution. We are aware that venous or arterial puncture during any local anaesthetic procedure is well known. In our case the cannula was not intravascular initially and yet obviously was 1 h later. We assume that the vascular puncture occurred during minor movements of the shoulder joint. This case illustrates forcefully the need for aspiration of cannulae prior to injection of local anaesthetic, not only at first injection but also when performing subsequent topups. The delayed vascular puncture maqy have caused problems if we had commenced an infusion.

Current BNF recommendations on peri‐operative cessation of clopidogrel

general anaesthesia at our hospital, the fetus is monitored using a Phillips Avalon Fetal Monitor FM30 machine (Fig. 4), which uses exactly the same caution and emergency audible alarms as the MP70 anaesthetic monitor, and indicates problems such as abnormal fetal heart rate or loss of contact, both common occurrences in this setting. The Fetal Monitor alarm distracts the anaesthetist from his ⁄ her current task, and further, when trying to locate the source of the alarm, potentially affects the quality of clinical care provided. In addition, anaesthetists familiar with this type of false alarm become desensitised to the alarm sound and risk ignoring an important warning. We believe that when designing equipment, manufacturers must consider the likelihood of concurrent use with other monitors in the same clinical area and ensure that each machine’s alarms are distinctive and unique. C. Pollit G. Graham St Thomas’ Hospital, London, UK Email: chris.pollitt@nhs.net

spraying the cords

dard airway exchange catheter (e.g. the Cook Airway Exchange Catheter®, Bloomington, IN) can be inserted easily through the AIC after removal of the bronchoscope (Fig. 1). This can provide an additional 25–28 cm of length and might be a suitable solution when a double lumen tube is indicated. Preliminary experience with the Aintree Catheter suggests that it may be a very useful addition to the difficult airway armamentarium [4,5]. Beyond its reported use with the LMA and fibreoptic bronchoscope in patients found difficult to intubate, we add to this its use as a unique adjunct to awake fibreoptic intubation in the very large patient. Of note, it has proven easy to learn and to use in our hands as well as others [4,5]. We expect further reports of this valuable device in other airway situations will be forthcoming. Meanwhile, we offer this simple advice: get to know the AIC; you will not be disappointed.