P. Pere

Comparison of 27-gauge (0.41-mm) Whitacre and Quincke spinal needles with respect to post-dural puncture headache and non-dural puncture headache.

Background:  The incidence of headache after spinal anaesthesia has varied greatly between studies. We compared the incidence of postoperative headache in general and postdural puncture headache (PDPH) when using 27‐gauge (G) (outer diameter 0.41 mm) Quincke and Whitacre spinal needles in ambulatory surgery performed under spinal anaesthesia.

Comparison of airway management with the intubating laryngeal mask, laryngeal tube and CobraPLA® by paramedical students in anaesthetized patients

Background:  Because of the importance of airway management in emergency care, alternative methods with shorter learning curves for inexperienced personnel have been looked for as a substitute for endotracheal intubation (ETI).

Effect of paracetamol and coxib with or without dexamethasone after laparoscopic cholecystectomy.

Background: Pain after laparoscopic cholecystectomy (LCC) is multifactorial. Effective post‐operative pain control is necessary in LCC performed as day‐case surgery. We studied the efficacy of paracetamol or valdecoxib with or without dexamethasone after LCC.

Pharmacokinetics of ropivacaine in patients with chronic renal failure

BACKGROUND As ropivacaine and its metabolites are excreted by the kidneys, we studied their disposition in subjects with renal dysfunction. METHODS Twenty patients with moderate or severe renal insufficiency and 10 healthy volunteers received ropivacaine 1 mg kg(-1) i.v. over 30 min. The concentrations of ropivacaine and its main metabolites, pipecoloxylidide (PPX) and 3-hydroxy-ropivacaine, were measured in plasma and urine for 16-48 h. The relationship between pharmacokinetic parameters and creatinine clearance (CL(CR)) was assessed. A model for estimating non-renal clearance of a metabolite of ropivacaine is described. RESULTS Renal dysfunction had little or no influence on the pharmacokinetics of ropivacaine. The median plasma concentrations of unbound ropivacaine were similar in uraemic and non-uraemic subjects. Renal clearance of PPX correlated significantly with CL(CR) (R(2)=0.81). Lack of correlation between total PPX exposure, expressed as area under the total plasma concentration-time curve from zero to infinity, and CL(CR) suggests that the clearance of PPX also includes non-renal elimination. However, in two uraemic patients, there was increased exposure to PPX resulting from low non-renal elimination. CONCLUSIONS The pharmacokinetics of ropivacaine is not affected by renal failure. Although the renal clearance of PPX correlates with CL(CR), non-renal elimination seems to compensate for reduced renal clearance in most patients. PPX may accumulate in plasma during long-term postoperative infusions, in particular in patients with co-existing low non-renal elimination. Systemic toxicity is still unlikely because PPX is markedly less toxic than ropivacaine.

Comparison of hyperbaric and plain articaine in spinal anaesthesia for open inguinal hernia repair.

BACKGROUND Fast onset and short duration are prominent properties of the amide-type local anaesthetic articaine. Similar to bupivacaine, a hyperbaric solution of articaine may produce faster onset and shorter duration of spinal anaesthesia than a plain solution. METHODS Patients undergoing open inguinal hernia repair received in random order articaine 84 mg in either hyperbaric (HyperA, n=49) or plain solution (PlainA, n=48) intrathecally. A blinded observer tested the dermatomal spread (pinprick) and motor block (Bromage scale). RESULTS Median (range) onset time to the T(10) dermatome was 2 (2-8) (n=46) and 6 (2-30) min (n=39) (P<0.001), and the duration of the sensory block at (or above) the T(10) dermatome was 86 (39-148) and 69 (15-118) min (P=0.007), in Groups HyperA and PlainA, respectively. Peak sensory block was greater in Group HyperA T(4) (L(2)-C(2)) than in Group PlainA T(8)-T(7) (L(3)-T(3)) dermatome, median (range), P<0.001. Spread of the block to the cervical dermatomes associated with hypotension occurred in three patients of Group HyperA (one patient C(2) and two C(4)). The sensory block resolved to the S(2) dermatome significantly faster in Group HyperA, 2.5 (1.5-4.5) h, than in Group PlainA, 3.5 (2.0-4.5) h (P<0.001). Median duration of the motor block was significantly shorter in Group HyperA, 2.0 (1.3-3.5) vs 3.0 (1.5-4.0) h (P<0.001). CONCLUSIONS Hyperbaric articaine 84 mg had a faster onset and shorter duration of spinal anaesthesia than the plain solution.

Hyperbaric articaine with or without fentanyl in spinal anaesthesia: patient and observer blinded comparison.

The rapid and short‐acting local anaesthetic articaine is a feasible spinal anaesthetic for day‐case open inguinal herniorrhaphy (OIH). We hypothesised that similarly to other spinal local anaesthetics, the addition of fentanyl may prolong articaine spinal analgesia without prolonging motor block.

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

Two consecutive ruptures of the upper cuff of disposable laryngeal tubes during anaesthesia of a single patient

Sir, The Laryngeal Tube (VBM Medizintechnik GmbH, Sulz a.N, Germany) is a new supraglottic ventilatory device for airway management., It has been shown to be effective and safe both in spontaneously breathing (1) and in mechanically ventilated (2—5) patients even when using nitrous oxide (2, 4, 5). We wish to present our experience with a 60-year-old female (ASA II, 164 cm and 67kg) scheduled for day-case surgery under general anaesthesia. Insertion of the first laryngeal tube was slightly difficult and there was a considerable leakage of gas when the patient was ventilated via the tube. Inspection of the tube revealed a 1-cm tear in the upper cuff, probably caused by contact with the patient’s teeth. Another laryngeal tube was introduced without any problems. Both cuffs were sequentially inflated with air using the volume recommended by the manufacturer (80ml) but without a manometer. The patient was ventilated using volume-controlled mechanical ventilator Aestiva/5 (DatexOhmeda, Helsinki, Finland). The fresh gas settings were oxygen 1 lmin , nitrous oxide 2 lmin 1 and sevoflurane 3%. Ten minutes after the insertion of the second laryngeal tube, the upper cuff ruptured with an explosion-type sound, which was heard even outside the operating room. Instantly, a gurgling sound was heard from the patient’s throat. The tube was removed and the upper cuff was found to be totally ruptured. There were no signs of an airway trauma during the laryngoscopy nor difficulties in intubation. In the postanaesthesia care unit (PACU) the patient started complaining of a sore throat. However, she was able to drink some water. On the first postoperative day, the patient reported that she had difficulties in speaking and drinking. Inspection of her throat revealed a haematomatic tongue and some inflamed mucosal injuries 1 cm in diameter deeper in the pharynx. Full recovery took 7days. In all studies thus far describing the use of the laryngeal tube during general anaesthesia the cuffs have been inflated using a manometer (1—5). The manufacturer’s standard recommended volume for sequential inflation of both cuffs of the size 4 tube is 80ml and use of a manometer is not required. In their recent study (6), Asai and Shingu demonstrated time-related changes of the intracuff pressure after 20min of ventilation with 66% N2O. Our patient had been ventilated with 66% N2O for 10min before the cuff was ruptured. The role of N2O in our patient remains controversial, but it must be assumed that it was an important contributing factor to the clinically significant rupture of the cuff. In conclusion, a manometer should be used when inflating the cuffs of disposable laryngeal tubes. There are interindividual variations in size and shape of the pharynx between individuals of the same height and weight. A slight overinflation of the cuff may result in a rupture with potentially harmful consequences to the patient. Special caution should be taken when a disposable laryngeal tube is used during anaesthesia with N2O until the material of the cuffs has been improved

Authors’ reply (to: teaching airway management is dependent on the knowledge of the teachers)

1 The aim of our study, as clearly stated in the paper, was to evaluate the usefulness of the three devices in the hands of clinically inexperienced paramedical staff. The students received an equal amount of introduction and training for each device. None of the instructors were particularly familiar with any of these devices. 2 All attending anaesthesiologists were experienced senior staff, but none had specialized training in the use of any particular pharyngeal device. In fact, they were equally familiar with the CobraPLA, the intubating laryngeal mask [not the classic laryngeal mask airway (LMA) as stated in the letter] and the laryngeal tube. We do agree that choosing the correct size is critical, but that holds true for all devices. If difficulties are encountered, choosing a smaller device is recommended by the manufacturer of the CobraPLA, but still the patient’s weight is recommended for basic decision making regarding the size, also available from the manufacturer’s web-page. We found this a particular problem when choosing the correct size of the CobraPLA. This was not encountered with the use of the other two devices. When used by inexperienced pre-hospital staff, picking the correct size should be fast, easy and reliable. 3 You did not comment in your letter regarding the fact that gastric insufflation related to the use of the CobraPLA has been noticed elsewhere, too (1,2). A study from the UK comparing the classic LMA and the CobraPLA in anesthetized patients had to be discontinued after two cases of significant pulmonary aspiration in connection with the use of the CobraPLA (2). It was strongly emphasized, both during the basic training and during the focused training on the use of the test devices, that the difficulties with ventilation after insertion of a supraglottic device must not be solved by increasing the force of ventilation but by repositioning the device. 4 Comparison of the insertion success rates of airway management devices between experienced anaesthesia staff and inexperienced pre-hospital staff is unjustified and biased. We wanted to evaluate the performance of the CobraPLA in this latter group and it was indeed in that group that we found the