R. J. Marks

Predicting outcome in intensive therapy units —a comparison of Apache II with subjective assessments

In a prospective study 568 patients admitted to a mixed medical and surgical intensive therapy unit (ITU) were assessed using the Apache II severity of illness score to predict outcome. Their outcome was also predicted subjectively by a doctor and nurse on admission. There were 260 deaths in the group. The subjective predictions were compared with the Apache II predictions using logistic regression analysis and receiver-operating-characteristic curve measurement. The subjective assessments were found to be a more powerful predictor of outcome in this group of patients than the Apache II scores and predicted risk of death. Although the predictions could be succesfully applied to the population as a whole, none of the tests were suitable for predicting outcome on an individual patient.

Simulation technique for difficult intubation: Teaching tool or new hazard?

This investigation evaluated the risks of a simulation drill designed to improve the skill of anesthesia personnel in dealing with an unexpected difficult intubation. In a controlled prospective study, 40 patients with normal airways scheduled to undergo noncardiothoracic surgery were randomized into two groups of 20 patients. In the control group, intubation was performed by standard techniques. In the simulation group, intubation of a difficult airway was simulated and performed with the aid of an endotracheal tube introducer. Heart rate (HR); systolic, mean, and diastolic blood pressures (BPs); and arterial oxygen saturation were measured noninvasively during the preinduction period and 1 minute postintubation. A record was kept of all adverse events, including electrocardiogram (EKG) evidence of myocardial ischemia or cardiac arrhythmias, esophageal intubation, pulmonary aspiration, or tracheal injury. There were no significant differences in percent changes in HR, BP, or oxygen saturation between the two groups. There were five uncomplicated esophageal intubations in the simulation group compared with none in the control group (p = 0.001). No other adverse events were recorded. The potential hazards of esophageal intubation should be considered before this simulation drill is performed.

Anaesthesia for transoral craniocervical surgery

Transoral surgery on lesions in the craniocervical region has been performed on 25 patients in this unit. The anaesthetic management is presented. Tracheostomy and nasotracheal intubation have both been used. Peroperative monitoring of cord compression remains an important and only partly solved problem. There were two deaths as a result of anaesthesia and surgery, and these are discussed.

Ritodrine-induced pulmonary oedema in labour Successful management using epidural anaesthesia

A case is described in which unusually high doses of intravenous ritodrine were used for 6 weeks to postpone premature labour. Treatment was complicated by tachydysrhythmias and pulmonary oedema. Epidural analgesia was used successfully for pain relief during labour and Caesarean section. The pathophysiology is discussed.

Dangers of cocaine and adrenaline paste. Exceeding the recommended dose may have serious sequelae.

Exceeding the recommended dose may have serious sequelae EDITOR,--K E A Nicholson and J E G Rogers report serious complications associated with the use of topical cocaine with adrenaline,1 but they draw inappropriate conclusions about the evidence they present and …