L. Lindgren

Sevoflurane mask induction of anaesthesia is associated with epileptiform EEG in children.

Background: Sevoflurane inhalation induction of anaesthesia is widely used in paediatric anaesthesia. We have found that this method is frequently associated with epileptiform electroencephalogram (EEG) in adults, especially if controlled hyperventilation is used.

Effects of carbon dioxide pneumoperitoneum for laparoscopic cholecystectomy

LAPAROSCOPY is ‘‘the golden standard’’ in treating symptomatic gallstones. Because the postoperative benefits are superior to open cholecystectomy, laparoscopy is today also used in patients with underlying diseases. To be able to treat this challenging patient population, we should be aware of physiological alterations caused by carbon dioxide (CO2) insufflation and elevated intra-abdominal pressure (IAP). It is now commonly accepted that pneumoperitoneum causes intraoperative adverse cardiovascular, respiratory and renal effects. Some of these effects are related to CO2 and some to elevated IAP. CO2 is the preferred gas for the creation of pneumoperitoneum because it is inexpensive, highly soluble, chemically stable, rapidly eliminated, physically inert, suppresses combustion and also provides fairly good illumination. CO2 is a normal product of human metabolism and at physiological levels non-toxic.

Pharmacokinetics and ventilatory effects of oxycodone before and after liver transplantation

The pharmacokinetics and ventilatory effects of oxycodone were studied in six volunteer patients with end‐stage liver cirrhosis before and after orthotopic liver transplantation. Plasma samples and urine were collected for 24 hours after intravenous administration of 0.05 mg/kg oxycodone hydrochloride. Concentrations of oxycodone and its metabolites, noroxycodone and oxymorphone, were measured in plasma and urine. The median elimination half‐life of oxycodone was 13.9 hours (range, 4.6 to 24.4 hours) in patients with cirrhosis before transplantation and 3.4 hours (range, 2.6 to 5.1 hours) after transplantation (p < 0.05). Correspondingly, oxycodone clearance increased from 0.26 L/min (range, 0.15 to 0.73 L/min) before transplantation to 1.13 L/min (range, 0.71 to 3.98 L/min) after transplantation (p < 0.05). Oxycodone depress edventilation more strongly before transplantation than after transplantation (p < 0.05). Care should be exercised when oxycodone is used in patients with end‐stage liver disease.

Magnesium depletion in chronic terminal liver cirrhosis.

Koivisto M, Valta P, Höckerstedt K, Lindgren L. Magnesium depletion in chronic terminal liver cirrhosis. Clin Transplant 2002: 16: 325–328.

Experience with albumin dialysis in five patients with severe overdoses of paracetamol

Five patients in whom the serum paracetamol levels or the amount of ingested paracetamol was high enough to cause severe liver injury were treated with N‐acetyl‐cysteine (NAC) and a molecular absorbant recirculating system (MARS). MARS treatment was started as early as possible in order to prevent or retard the development of hepatocyte necrosis. Four of our five patients survived without liver transplantation, and one died due to brain oedema. The early commencement with NAC and MARS treatments in paracetamol intoxication might give enough time for the liver to regenerate and thus avoid liver transplantation.

Pain after laparoscopic cholecystectomy

In order to create the surgical view, carbon dioxide (CO,) is insufflated into the abdominal cavity. CO, is a volatile acid. It may cause irritation of the diaphragm since the patients have to be operated on in the revere Trendelenburg position and COP as a gas moves upwards. C02 will probably be entrapped between the liver and the right diaphragm causing referred pain in the right shoulder (3). Furthermore, visceral pain from the site of surgery and from the holes made in the abdominal wall for the trocars will further increase the intensity of the postoperative pain. The degree of pain until the first postoperative moming has been shown to be strong or even unbearable in about half of the patients (3). Pain in the right shoulder has been reported to persist until the fourth postoperative day and the need for NSAIDs for 1 week (3). Instillation of a local anaesthetic bupivacaine in low concentrations into the abdominal cavity after surgery has been shown to be ineffective (3-6). In a Japanese study, right phrenic nerve block with 10 ml of 1% mepivacaine before laparoscopic cholecystectomy significantly prevented the occurrence of postoperative right shoulder pain (7). In everyday practice, the phrenic nerve block may not always be easy to perform. happy? There are plans to perform laparascopic cholecystectomy as day-case surgery in ASA 1 patients in the future. From the anaesthesiological and surgical points of view this plan may be justified. However, the patients’ postoperative discomfort can make this impossible. Therefore, we have to improve the treatment of pain after laparoscopic cholecystectomy. In the present issue of Acta Anaesthesiologica Scandinavica the postoperative pain after laparoscopic cholecystectomy has been reassessed in an elegant scheme by Mraovii. et al. (8). The authors instillated 15 ml of 0.5% bupivacaine before and again after surgery into the hepatodiaphagmatic space and on the surgical treatment area in a double-blind placebo-controlled study. Opioid analgesia was not given peroperatively. Bupivacaine was very effective in decreasing postoperative pain scores and consumption of analgesics significantly. The conclusion is simple: bupivacaine was given at high enough concentrations on the right sites at the correct time. The right diaphragm was blocked against noxious stimuli by CO,. As is common in scientific life, Pasqualucci et al. (9) at the same time reported 20 ml of 0.5% bupivacaine with adrenaline 1 :200 000 applied before and after surgery to the same sites as Mraovik et al. (8) to be effective against postoperative pain after laparoscopic cholecystectomy. The concentrations of cortisol indicating smaller stress were lower in the group treated with preand postoperative bupivacaine than in that with only postoperative bupivacaine and in the control group. The pre-emptive analgesic effect of preoperative bupivacaine also seems to be crucial in the light of these two studies. Intra-abdominal adminis-

Respiratory compliance during orthotopic liver transplantation

After liver transplantation, respiratory complications are frequent. The purpose of this study was to assess if intraoperative monitoring of respiratory compliance is of clinical value in predicting such complications.

Measurement of the abdominal circumference for the detection of intra‐abdominal hemorrhage has no diagnostic value

Background:u2002 Measuring the circumference of the abdomen is still commonly used when treating a patient with suspicion of intra‐abdominal bleeding. In the present study the usefulness of this method for a diagnostic purpose is questioned because of the assumed method‐related interindividual variation.

How to reduce the persistent shortage of organ donors in Scandinavia.

THE POSITIVE impact of organ transplantation should be constantly brought up and discussed. The improving patient and graft survival and the costeffectiveness strongly favour transplantation over conservative treatment. Most importantly, the quality of life after transplantation is similar to that of the general population (1). Kidney transplantation saves money and offers better quality of life than any replacement therapy. The long-term results are strikingly good in kidney, liver and heart transplant patients. A real eye-catching event is the World Transplantation Olympics for transplant patients from numerous countries in all five continents. The key word for rewarding organ transplantation is the availability of donor organs. Without the legislation on brain-death organ harvesting from heartbeating donors would not be possible. Finland was the pioneering country and the first in the world to accept brain-death as clinical death in 1971. Today the legislation on organ donation is similar in Scandinavia, with only minor differences between the countries. However, there is still a major problem: the shortage of organ donors. In Europe, the situation is best in Spain with 30 donors/million people. The second best are Austria and Finland, both with about 20 donors/ million people in 1998. Unfortunately, the organ donation rates in Denmark and Sweden are clearly below the average in Europe. A donor card is available in all Nordic countries; however, there is huge variation in its use among the countries. Yet, as the donor card is found in the pockets of only a few percent of donors this is not the solution. Only Sweden has had a special donor registry since 1996. This system has not been popular, and there has been a loud opposition. Negative feedback has had a negative impact on the function of the donor registry. In Sweden, financial support to donor hospitals to cover the costs of the donation procedure

ECG T-wave amplitude changes during thiopentone induction with or without alfentanil

The T‐wave amplitude of ECG is thought to reflect the sympathetic tone of the heart but anaesthesia studies on this topic are rare. Haemodynamic and ECG T‐wave amplitude changes were studied during induction of anaesthesia in 24 ASA I‐II patients. Twelve patients were given alfentanil 30 μg kg‐1 at induction while physiologic saline was given to the rest (control). Thiopentone was then administered at the rate of 5 mg s‐1 until eyelash reflex disappeared. Vecuronium 0.1 mg kg‐1 was given thereafter. No anticholinergics were used. The lungs were ventilated with 40% oxygen in air. Haemodynamic parametres and T‐wave amplitude were measured before induction, before intubation, 30 s, 3 min and 5 min after intubation. A significandy higher amount of thiopentone was needed to abolish the eyelash reflex in the control group than in the alfentanil group (P<0.001). There were no changes in heart rate (HR) in the alfentanil group during the trial. Systolic and diastolic arterial pressures (SAP and DAP) were continuously below the preinduction levels in the alfentanil group. After baseline HR, SAP and DAP were significantly higher in the control group than in the alfentanil group at each data point. T‐wave amplitude flattened significantly (P<0.001) after intubation in the control group while no significant changes were seen in the alfentanil group. T‐wave flattening correlated to the increases in HR (P<0.01) and SAP (P<0.01). Three control patients with flattened T‐wave had a transient bigeminia period after intubation. It is concluded that ECG T‐wave amplitude flattening was associated with pressure and heart rate response to laryngoscopy and intubation. Alfentanil blunted these responses and prevented T‐wave changes after intubation.