C. Aps

Anaesthetic management and postoperative care of cardiac surgical patients in a general recovery ward

The postoperative care of 143 cardiac surgical patients has been successfully conducted in a general surgical recovery ward. Admission was limited to overnight stay only and all but two patients were returned to the general ward the following day. There were no deaths. The intra‐operative anaesthetic management was considered to have played an important part in the success of this technique.

Peritoneal closure and atracurium

Federal Drug Administration (FDA) in the United States, to the effect that there have been at least 12 maternal deaths identified as being due to cardiac arrest caused by the drug when used for extradural block. Others may wish to comment upon the absence from the literature of reports of such occurrences. In common with other centres in the UK we used 0.75% bupivacaine plain for extradural analgesia for Caesarean section during a period of several months after it became generally available last year. We have abandoned its use again in common with others because of evidence of an associated incidence of toxic response although these were related to the central nervous system rather than to the cardiovascular system. As far as I am aware there have been no fatalities in this country comparable to those referred to in the FDA report. It is, however, obvious that, if only for medicolegal reasons, the administration of 0.75% of bupivacaine extradurally should be discontinued in obstetric practice. The puzzle remains regarding why its use extradurally in other branches of anaesthetic practice should continue to be countenanced.

Experiences with fibre-optic bronchoscopic positioning of single-lumen endobronchial tubes.

The use of flexible fibre‐optic devices for positioning single‐lumen endobronchial tubes in one‐lung anaesthesia has been assessed. The technique is safe, easily learnt and provides a useful alternative to existing methods of establishing one‐lung anaesthesia.

Hypotension following cimetidine administration during cardiopulmonary bypass.

Intravenous administration of cimetidine may occasionally cause profound hypotension. Cimetidine 200 mg was administered as a bolus injection to patients whilst on cardiopulmonary bypass and subsequent changes in systemic arterial pressure were recorded. A statistically significant fall in arterial pressure was observed (P < 0.001), which was attributable to a fall in systemic vascular resistance.

Hypoxaemia after premedication in cardiac patients. Glycopyrronium compared with hyoscine

Arterial blood gases were analysed before and approximately one hour after premedication in two groups of 10 patients awaiting cardiac surgery. One group received intramuscular papaveretum and hyoscine, the other papaveretum and glycopyrronium. Similar, small but statistically significant reductions in mean arterial oxygen tension and oxygen saturation, and increases of arterial carbon dioxide tension occurred in both groups. Hypoxaemia in individual patients was unpredictable and in some was clinically relevant.

An aid for double-lumen intubation

my, we found that the drain would have entered the chest one finger’s breadth from the diaphragm and two finger’s breadth from the apex of the left ventricle. We feel therefore that this is an unduly hazardous site at which to attempt pleural drainage. In addition, a drain inserted anteriorly will not be basal. It is safer to insert intrapleural drains through the fourth intercostal space in the mid-axillary line or through the fifth or sixth spaces in the posterior axillary line. Visceral injury should not occur in patients with a non-adherent pleura if drainage is attempted in a reasonable manner at these sites. Unfortunately, the widely used Argyle trocar chest drain (Sherwood Medical Industries, Crawley) is often inserted in a cavalier fashion, with predictable consequences on occasion. As anaesthetists may have occasion to use these otherwise excellent drains, we would like to describe a safe method for their insertion. The site for insertion of the drain is carefully identified and marked. The area is prepared draped, and anaesthetised. A 1.5-2 cm incision is made with a scalpel through the skin and superficial fascia. Two stitches of stout nylon or silk are inserted (a simple stitch to hold the drain in place and a vertical mattress stitch for closure of the incision when the drain is removed). This latter stitch should be knotted to prevent its inadvertent removal. Before proceeding further the correct size of drain is selected and the drainage bottle and connections checked. As a guide to si7e. the drain should havc a diameter equal t o the width of the intercostal space. This would be a 28F drain for an adult. Do not attempt to penetrate the chest wall using the trocar provided with the drain. Considerable force is necessary and, when the pleural space is entered, the tube may go in much further than intended. Instead we recommend that the axillary fascia and intercostal muscles are dissected with the blunt tips of a Spencer Wells forceps. Jt is impossible for the tips of this instrument to penetrate more than a few centimetres inside the chest. When the pleura has been entered, the jaws of the forceps are ‘sprung’ several times to enlarge the track sufficient to admit the drain. All that remains is for the drain to be guided along the track into the pleural space. The trocar can be used to direct the drain towards the lung apex by angling the trocar cranially and advancing the plastic tube over it. The trocar is removed and the tube clamped briefly whilst it is tied securely and connected to an underwater seal. The clamp is gradually released allowing blood and air to escape from the pleural space. Suction can then be applied to the drainage bottle. We hope that these comments may prove helpful and go some way towards preventing the all to frequent tragedies which occur when intrapleural drains are inserted at injudicious sites, or in a manner akin to bayonet practice.