General Anaesthesia

Profound bradycardia during eye surgery is potentially serious event. In clinical practice this Oculocardiac Reflex (OCR) is most often encountered during squint surgery. The objective of this study was to assess the occurrence of OCR and prove the effect of anticholinergic premedication (atropine) to prevent OCR. This study comprises of sixty patients (age 2-30 years) operated for squint surgery under general anaesthesia. Cases were divided into two groups of thirty each. Group 1 was premedicated with intravenous injection of atropine and Group 2 did not receive any premedication. Patients were monitored during operation for any bradycardia or dysrhythmias. The observed data showed occurrence of 70% OCR in Group 2 as compared to only 10% in Group 1. Severe bradycardia in 40% cases of Group 2 needed intervention by IV injection of atropine. Our study showed that atropine premedication in the patients of squint surgery under general anaesthesia definitely obtunds OCR and prevents any...

Background. Anaesthesia and surgery are associated with impairment of the immune system expressed as an excessive proinflammatory immune response and suppression of cell-mediated immunity that may affect the course of the postoperative period. Addition of anaesthetic agents capable of attenuating the alterations in perioperative immune function may exert a favourable effect on patients' healing. We have assessed the effect of preoperative administration of a sub-anaesthetic dose of ketamine on the mitogen response and production of interleukin (IL)-1b, IL-2, IL-6, and tumour necrosis factor (TNF)-a by peripheral blood mononuclear cells (PBMCs), as well as natural killer cell cytotoxicity (NKCC) in patients undergoing abdominal surgery. Methods. Seventeen patients admitted for elective abdominal surgery were given ketamine 0.15 mg kg 21 i.v. 5 min before induction of general anaesthesia. Nineteen patients received a similar volume of isotonic saline 5 min before induction of the anaesthesia. PBMCs were isolated from venous blood before and 4, 24, 48, and 72 h after operation for IL-1b, IL-2, IL-6, and TNF-a secretion, and NKCC assessment. Results. Four hours after operation, the cells from patients in the ketamine group showed a significantly suppressed production of IL-6 (P,0.01) compared with controls. The production of IL-2 did not change from that of the preoperation samples. TNF-a secretion was significantly elevated in the control group 4 h after operation (P,0.05). Conclusions. Addition of small doses of ketamine before induction of anaesthesia resulted in attenuation of secretion of the proinflammatory cytokines IL-6 and TNF-a, and in preservation of IL-2 production at its preoperative level. It is suggested that this anaesthetic may be of value in preventing immune function alterations in the early postoperative period.

Service d'anesthésie-réanimation, hôpital des spécialités, Rabat, Maroc RÉ SUMÉ Objectif : Évaluer qualitativement et quantitativement l'activité anesthésique au Maroc afin d'identifier les problèmes prioritaires et les normes à recommander. Méthodes : L'enquête réalisée de juillet 1999 à décembre 1999 a porté sur sept jours, du mardi 8 heure au mardi suivant 8 heures. Un questionnaire a été adressé à chaque structure. Un responsable a été désigné par ville. Le traitement informatique des données a été effectué par un logiciel développé sous Microsoft Visual BasicT. Lieu : Tous les établissements marocains pratiquant l'anesthésie ; centres hospitaliers universitaires (CHU), hôpitaux publics (HP) et privés. Sélection des patients : Toutes les anesthésies réalisées par un anesthésiste-réanimateur ont été prises en compte. Les anesthésies pratiquées en cabinet médical ou dentaire ont été exclues. Résultats : 2 639 anesthésies ont été recensées. La répartition des anesthésies selon le type d'établissement a été la même HP= 35,7 %, CHU=34,3 % et privé=29,96 %. La consultation d'anesthésie a été réalisée chez 47 % des patients. La prémédication a été conduite dans 28,5 % des cas. L'anesthésie générale a représenté les ¾ des anesthésies. Le thiopental a été le produit le plus utilisé. La gallamine et la péthidine ont été encore utilisées dans les HP. L'anesthésie locorégionale a été réalisée dans 15 % seulement des anesthésies. La surveillance électrocardioscopique n'a pas été constante (65 %), la capnographie a été quasi-absente dans les HP, les oxymètres de pouls surtout utilisés dans les CHU et le privé. L'anesthésie ambulatoire a été réalisée dans 20 % des cas et l'anesthésie en urgence a représenté 30 % de l'activité anesthésique. Conclusion : Les résultats de cette enquête soulèvent une multitude de questions quant à la pratique de l'anesthésie, surtout concernant les produits anesthésiques utilisés et le monitorage peropératoire.

An undifferentiated abdominal sarcoma was removed surgically from a koi carp. The diagnostic procedures, including radiography and computed tomography, and the procedures for general anaesthesia and the surgical approach for a celiotomy in a fish are described. The gross and microscopic appearance of the tumour is described and lustrated.

Aims-To determine the adjuvant role of unilateral suborbicularis oculi fat (SOOF) lift in the periorbital rehabilitation of patients with chronic facial palsy. Methods-In a non-comparative prospective case series nine adult patients (seven male, two female) aged 34-90 years (mean 60.5) with chronic unrecovered facial palsy (over 1 year), who had not had any previous rehabilitative periorbital surgery, were studied. Lateral tarsal strip and adjuvant transconjunctival approach subperiosteal SOOF lift under local or general anaesthesia were performed; medial canthoplasty was performed where indicated. There was clinical observation of the long term (over 1 year) eVect on the ptotic palpebral-malar sulcus and lower eyelid retraction. Results-The patients were followed up for 12-24 months (mean 16). Seven patients (77%) had sustained clinical reduction of palpebral-malar sulcus ptosis. All patients had sustained reduction of lagophthalmos. Early postoperative complications included conjunctival cheimosis in 77%. Three patients with persistent keratitis required further surgical procedures on their upper eyelid to reduce the palpebral aperture. There were no cases of infraorbital nerve anaesthesia or recurrent lower eyelid retraction. Conclusions-The SOOF lift has an adjuvant role in chronic facial palsy with lower eyelid retraction and ptotic-palpebral malar sulcus. It supports the lower eyelid elevation and tightening achieved with the lateral tarsal strip. The best results were obtained in congenital facial palsy.

Background. Lateralization of cerebral blood flow and EEG activity is known to vary during cognition, sleep and waking. In spite of this, electrode placement for the cerebral state index (CSIÔ) monitor is not specified to a particular side of the brain. This study is designed to determine if pairwise registrations differ for CSI measured simultaneously from the left or right sides of the brain. Methods. In total, 25 ASA I-II patients undergoing elective day surgery under general anaesthesia were recruited. Pairwise recordings were made every minute from two CSIÔ monitors (Cerebral State Monitor, Danmeter A/S; Odense, Denmark) connected to the left and the right side of the head. Sedation was graded according to the observer's assessment of alertness/ sedation rating scale and correlated with CSI. Results. A large overlap of indices, of similar magnitude, for each side of the brain was seen between different levels of sedation. The agreement between pairwise registrations was high, correlation between the 584 CSI pairs of recordings left/right was r 2 =0.92. Conclusions. Despite known lateralization of the EEC, this study found a very high correlation in CSI derived simultaneously from the left and right sides of the brain by two independent monitors.

Background. The purpose of this study was an anatomical and clinical evaluation of ultrasonography-guided rectus sheath blocks in children. Method. A total of 30 children were included in the sono-anatomical part of the study. The depth of the anterior and posterior rectus sheath was evaluated with a portable SonSite 180 plus ultrasound machine and a 5-10 MHz linear probe. In total, 20 consecutive children undergoing umbilical hernia repair were included in the clinical part of this study. After induction of general anaesthesia children received a rectus sheath block under real-time ultrasonographic guidance by placing 0.1 ml kg À1 bilaterally in the space between the posterior aspect of the sheath and the rectus abdominis muscle. Results. Ultrasonographic visualization of the posterior rectus sheath was possible in all children. The correlation between the depth of the posterior rectus sheath and weight (adjusted r 2 =0.175), height (adjusted r 2 =0.314) and body surface area (adjusted r 2 =0.241) was poor. The ultrasoundguided rectus sheath blockade provided sufficient analgesia in all children with no need for additional analgesia in the perioperative period. Conclusion. The bilateral placement of levobupivacaine 0.25% 0.1 ml kg À1 in the space between the posterior aspect of the rectus sheath and the rectus abdominis muscle under real-time ultrasonographic guidance provides sufficient analgesia for umbilical hernia repair. The unpredictable depth of the posterior rectus sheath in children is a good argument for the use of ultrasonography in this regional anaesthetic technique in children.

Objective: To evaluate clinical aspects, results and the economic impact of the outpatient thoracic surgery programme (OTSP) developed in our Department. Methods: Prospective study of 300 patients who entered in the OTSP from April 2001 to March 2005. The procedures performed were videomediastinoscopy (MC), videothoracoscopic lung biopsy (LB) and videothoracoscopic bilateral thoracic sympathectomy (TS). All procedures were performed under general anaesthesia and patients were discharged in 4-6 h. We analyse demographic data, the substitution index (SI), the admission rate (AR) and readmission rate (RR) after the procedure. We calculate the economic impact of stay expenses on our hospital and on other Spanish hospitals. Results: The female/male ratio of the 300 patients was 83/217, with a mean age of 58.1 years (range: 15-85 years). There were no deaths. Mediastinoscopy was performed as outpatient procedure in 210 patients (mean age: 65.6 years) out of 244 total MC (SI = 86.1%). Two patients were admitted (AR = 0.95%) to observe a minimal pneumothorax and because of late night end. There were no readmissions after MC (RR = 0%). We included 32 ambulatory patients for lung biopsy (mean age: 61.5 years) out of 64 total LB (SI = 50.0%). One patient was admitted because of air leak (AR = 3.1%) and there were no readmissions after LB (RR = 0%). Fifty-eight patients were included in the OTSP for bilateral sympathectomy (mean age: 27.1 years) out of 83 total TS (SI = 69.9%); there were no admissions (AR = 0%) and one patient was readmitted after 9 days because of a hemothorax (RR = 1.7%). Sixty-four patients out of the 91 not included in the OTSP were included in an 'afternoon surgical programme' and dismissed the morning after surgery, without contraindication for their inclusion in the OTSP. The hospital's total stay saving was s12,668 (s88,226 if performed elsewhere), s42 per patient (s294 per patient if performed elsewhere). Conclusion: Videoassisted mediastinoscopy, lung biopsy and bilateral sympathectomy can be included safely in outpatient thoracic surgical programmes. The impact of the economic benefit of OTSP over the conventional hospitalisation depends on the Department's previous policy on hospital stays. Further experience is needed to increase the substitution index and expand the OTSP to other procedures.

Background: This report describes the case management of a 32 year old special needs patient with life-threatening odontogenic infection. The combination of schizophrenia, Down and Eisenmenger syndromes presented significant challenges to managing his oral health, particularly within the rural context. In this case, dental treatment was limited to a full dental clearance during a high risk general anaesthesia session. Method: A comprehensive work-up prior to general anaesthesia was an essential aspect of care. This included a full medical history and examination, communication between medical specialists, the dentist and family consultation. The anaesthetic procedure was undertaken using a careful regimen of drugs and monitoring to minimize the impact on his cardiovascular system. Techniques to minimize bleeding from extraction sites were also important. Results: Three weeks postsurgically the patient was reviewed and his family reported that he was interacting positively with them after years of surliness and conflict. This was attributed to a managed psychotropic medication regimen and improved dental condition, which has led to a sustained improvement in quality of life. Conclusions: The management of acute odontogenic infection for special needs patients in the rural setting requires a local interdisciplinary team approach, careful consideration of related pathophysiology and its potential impact on general anaesthesia, and close consultation with family and carers.

Background  Postoperative delirium can result in increased postoperative morbidity and mortality, major demand for postoperative care and higher hospital costs. Hypnotics serve to induce and maintain anaesthesia and to abolish patients' consciousness. Their persisting clinical action can delay postoperative cognitive recovery and favour postoperative delirium. Some evidence suggests that these unwanted effects vary according to each hypnotic's specific pharmacodynamic and pharmacokinetic

Background. This study investigated the cost-effectiveness of ultrasonographic-guided interscalene brachial plexus blockade (ISB) in comparison with general anaesthesia (GA) for arthroscopic shoulder surgery. Methods. Forty patients undergoing arthroscopic shoulder surgery received either an ultrasonographic-guided ISB or GA. ISB was performed outside the operation room (OR) and patients were transferred in the OR at the earliest 20 min after block performance. All drugs and disposables were recorded to evaluate the costs for both techniques. The following anaesthesia-related times were defined: ready for surgical preparation (from arrival in the OR until end of anaesthesia induction), OR emergence time (from end of dressing until leaving the OR), anaesthesia control time (from patient's arrival in the OR until readiness for positioning plus time from the end of surgery to patient's discharge from the OR), and post-anaesthesia care unit (PACU) time (from patient's arrival in the PACU to the eligibility for discharge to normal ward). Personnel costs were excluded from statistical analysis. Results. The total costs were [mean (SD)] 33 (9)E for patients with ISB and 41 (7)E for those who received GA (P,0.01). The anaesthesia-related workflow was improved in the ISB group when compared with the GA group [ready for surgical preparation 8 (3) vs 13 (5) min, P,0.001; OR emergence time 4 (3) vs 10 (5), P,0.001; anaesthesia control time 12 (4) vs 23 (6), P,0.001; and PACU time 45 (17) vs 70 (20), P,0.001]. Conclusions. Ultrasonographic-guided ISB is a cost-effective method for arthroscopic shoulder surgery.

Objective: to relate changes in somatosensory-evoked potentials (SEPs) with onset of neurological deficits in patients having carotid endarterectomy (CEA) under locoregional anaesthesia. Methods: a prospective study of 50 consecutive patients. Results: SEPs yielded an accuracy of 98%, specificity 100%, and sensitivity 89%. In all concordant cases the onset of a neurological deficit in awake patients corresponded to a 30-40% reduction in amplitude of N20-P25 waveforms. After shunting, the N20-P25 took 2-3 min to return to normal. Conclusions: SEPs are associated with a 2% false negative rate. Their threshold for detecting cerebral ischaemia is lower than the currently reported value for patients under general anaesthesia. The time needed for evoked potentials (2-3 min) to return to normal after shunting limits their usefulness in verifying effective shunting.

tory ensheathing cells from the nasal olfactory lamina propria have the ability to promote spinal cord regeneration when transplanted 4 weeks after complete transection. Olfactory ensheathing cells are accessible and available in the human nose; the present study further supports clinical use of these cells in repairing the human spinal cord via autologous transplantation.

Patients with myasthenia gravis receive pyridostigmine, an anticholinesterase agent, as a part of therapy. These patients demonstrate a heightened sensitivity towards non-depolarising muscle relaxants. Continuing pyridostigmine till the day of the surgery or omitting it on the night before surgery could provide variable results with regards to the effect of vecuronium. Myographic evaluation of a dose of vecuronium in patients with myasthenia gravis on pyridostigmine therapy. A randomised, double-blind, clinical study conducted in a teaching hospital. Medically (oral pyridostigmine) well-controlled adult patients with myasthenia gravis who were posted for thymectomy, were randomly divided into two groups. Patients in Group 1 received their last dose of pyridostigmine on the night before surgery while those in Group 2 received even the morning dose of the drug on the day of surgery. Neostigmine (1-2 mg) intravenously was used as rescue medication. Vecuronium (0.01 mg/kg) was used for ...

Insertion Ventilation Tube In Patients With Otitii Media And Care Otitis media is a disease which is seen frequently in childs and adults. As ventilation tube ventilates the middle ear, it could prevent recurrent otitis media, provide a regression in otitis media and improve the hearing function average as 12 dB. Ventilation tube insertion is usually performed under a general anaesthesia in child, local anaesthesia in adults and it is programmed as day surgery. Patients are usually ready to go home within two to four hours after the surgery. Surgical nurses have important responsibilities on patients' discharge education and their daily activities to return and adapt to their new lives. It is clear the importance of education of the patients who have been inserted ventilation tube or parents during the preoperative and postoperative periods and then prepare them for home-care. In this article, the preoperative and postoperative care applications for the patients - having adenoi...

Exogenous morphine downregulates the activity of immunocompetent cells such as lymphocytes, granulocytes and macrophages. Furthermore, morphine increases the secretion of CRH, ACTH and glucocorticoids, i.e. substances with inhibitory effects on the immune system. In the present study we tested the hypothesis that endogenous morphine production is increased as part of the antiinflammatory response to cardiac surgery. Sixteen patients submitted to elective coronary artery bypass grafting (CABG) surgery were randomized to either thoracic epidural analgesia combined with general anaesthesia (group I) or high-dose fentanyl anaesthesia (group II). Patients in group I did not receive morphine while patients in group II received systemic morphine for postoperative pain relief. From each patient 18 blood samples were taken perioperatively and tested for morphine. Furthermore, monocyte function with respect to motility and shape was determined by computer-assisted image analysis. A steep increase in plasma morphine concentrations was demonstrated on the first postoperative day in patients in group I (not given morphine). Plasma morphine levels remained significantly elevated during the following five postoperative days. Patients in group II given morphine as pain treatment showed a larger and earlier morphine peak related to the morphine administration. Computer-assisted image analysis of leukocyte behaviour revealed a biphasic increase in cell motility. In conclusion, we demonstrate for the first time that endogenous morphine levels increase after the trauma of surgery. We surmise that morphine is part of the antiinflammatory response to cardiac surgery.

A 36-year-old grand multiparous midwife presented to the gynaecological unit of the University of Uyo Teaching Hospital with the string of an intrauterine contraceptive device (IUCD) protruding from her anus. She had had a copper IUCD inserted at a health centre 8 years earlier. However, 4 months later she noticed that she no longer felt its strings and had another IUCD inserted in the same facility when the first device was not located. Four months prior to presentation, she presented to a private clinic when she no longer felt the strings of the second IUCD. The device in the uterus was removed in the private clinic and she was referred to the teaching hospital. At the teaching hospital rectal examination and plain x-ray revealed the presence of a device. Under general anaesthesia, the device was successfully removed in theatre through the rectum with no postoperative complications. BACKGROUND Perforation of the rectum with the strings of an IUCD protruding from the anus is very rare and to the knowledge of the authors has not previously been reported in Nigeria. 1 In addition, this case highlights certain pitfalls in the management of the patient.

Major breast cancer surgery is associated with a high incidence of postoperative nausea, vomiting and pain. Regional anaesthesia, with bztraoperative sedation, would seem an ideal alternative to general anaesthesia for this type of surgery. We report our initial experience using paravertebral blocks (PVB) to provide anaesthesia for major breast surgery. Methods: Twenty-five patients" agreeing to have surgery performed under paravertebral blocks were studied. Procedures performed varied from simple lumpectomy with axillary dissection to modified radical mastectomy with axillary dissection. During monitored sedation, blocks opposite spinous processes of C7-T6 were performed using bupivacaine 0.5% with epinephrine, 3-4 ml per segment. Patients were evaluated for 72 hr and were requested to document:(i) when sensation returned (ii) incidence and frequency of nausea or vomiting (iii) degree of discomfort and medication taken. Results: Twenty patients had blocks that required no supplementation. Five patients had blocks that were incomplete. No complications were attributed to the blocks. Post-operatively, patients with successful blocks had minimal nausea, vomiting and pain. No patients Jbund the procedure unsatisfactory. Patients with successful blocks were all very satisfied. Conclusion: Our initial results show that PVB for breast cancer surgery can be successfully performed in a majority of patients with few side effects. All patients with successful blocks were returned to the ambulatory care unit, bypassing the recovery room. That breast cancer surgery under regional anaesthesia can be safely performed as an ambulatory procedure has the potential for accomplishing major cost-saving.

MRI is a common medical imaging investigation. Patients, including young children, can be required to keep still for up to 60 min for the study to be completed successfully. Children often find the confined space, noise, need to lie still and possibility of intravenous administration of contrast agent anxiety-provoking and sometimes so distressing that they are unable to cope and require general anaesthesia. A practice MRI intervention was introduced at the Royal Children's Hospital in Melbourne, Australia. The program is conducted by educational play therapists in conjunction with the Department of Medical Imaging. This study explored the effectiveness of this intervention. The intervention was conducted in a practice MRI unit devoid of magnets. Data were collected as a clinical audit with respect to age, gender, times of scans, position in bore, diagnostic scans and movement artefact. Epidata and Stata were used to analyze the data. A total of 291 children were included; their...

The mechanisms through which general anaesthetics, an extremely diverse group of drugs, cause reversible loss of consciousness have been a long-standing mystery. Gradually, a relatively small number of important molecular targets have emerged, and how these drugs act at the molecular level is becoming clearer. Finding the link between these molecular studies and anaesthetic-induced loss of consciousness presents an enormous challenge, but comparisons with the features of natural sleep are helping us to understand how these drugs work and the neuronal pathways that they affect. Recent work suggests that the thalamus and the neuronal networks that regulate its activity are the key to understanding how anaesthetics cause loss of consciousness.

Objective. In mechanically ventilated patients a high fraction of the pressure can be dissipated to overcome the viscoelastic components of the respiratory system. Recently it was demonstrated that sigh improved oxygenation in mechanically ventilated ARDS patients. We evaluated if, in acute lung injury (ALI) patients, the sigh can be used to measure the respiratory viscoelastic properties. Methods. Ten consecutive normal subjects undergoing general anaesthesia for minor abdominal surgery and ten ALI patients admitted to the ICU, were studied. Three sighs were administered every minute during the measurement period. The viscoelastic constants (E 2 , R 2 and (2) were determined by (i) a series of end-in£ation airway occlusions (multiple breath method, MBM) and (ii) ¢tting the time course of the slow decay in pressure during end inspiratory pause of the sigh (sigh method, SM). The ruslts were compared by means of the limits of agreement as modi¢ed for small sample sizes. Results. Viscoelastic parameters were similar to those obtained in other studies. In normal subjects the mean di¡erences (AE SEM) of (2, R 2 , and E 2 given by the SM and the MBM were 0 AE 0.04 s, 0.37 0.20 cmH 2 O L À1 s, and 0.21 AE 0.26 cmH 2 O L À1 , respectively. The mean di¡erences (AE SEM) of (2, R 2 , and E 2 in ALI patients were 0.02 AE 0.02 s, 0.45 0.31 cmH 2 O L À1 s, 0.34 AE 0.36 cmH 2 O L À1 , respectively. No lack of agreement could be detected between the two methods in all variables in normal subjects and ALI patients. Conclusions. The long in£ation time characteristic of the sigh allowed the determination of the viscoelastic constants by means of a simpler and faster method. Moreover it does not require very small tidal volumes, which can increase reabsorption atelectasis in ALI patients and can improve alveolar recruitment and oxygenation in these patients.

The percentage use of regional anaesthesia (RA) and failure rate of RA for different grades of caesarean section (CS) has become a marker of quality for obstetric anaesthesia service. The objective of our prospective observational study is to find out the technique of anaesthesia used in different grades of CS, reasons for choosing general anaesthesia (GA) and failure rate of RA in our hospital setting. This prospective cross sectional study was carried in the obstetric unit of Aga Khan University Hospital from 1st January 2010 to 31st May 2011. The anaesthetist performing the procedure filled out the data collection proforma .Suggested Indicators were percentages of Grade 1-4 CS done under RA and GA, percent of failed regional, percent of failed regional in different grades of CS. A total of 407 patients having undergone Caesarian Section (CS) were reviewed. General Anaesthesia (GA) was used in 201(49%) patients and Regional Anaesthesia (RA) in 206 (51%) patients. There was no sign...

Use of prompt and efficient anesthetic management of an actively convulsing gravid to term female in the OPD. In this case report, we present a successful anesthetic induction and management in a case of gravid to term female with active convulsions and complaints of vomiting and headache, later diagnosed as Posterior Reversible Encephalopathy Syndrome under General anesthesia.

Background. Non-selective cyclooxygenase (COX) inhibitors or non-steroidal anti-in¯ammatory drugs (NSAIDs) are frequently omitted for perioperative pain relief because of potential side-effects. COX-2-selective inhibitors may have a more favourable side-effect pro®le. This study tested the hypothesis that the COX-2-selective inhibitor rofecoxib has less in¯uence on platelet function than the NSAID diclofenac in gynaecological surgery. In addition, analgesic ef®cacy and side-effects of the two drugs were compared. Methods. In this single-centre, prospective, double-blind, active controlled study, women undergoing vaginal hysterectomy (n=25) or breast surgery (n=25) under general anaesthesia received preoperatively 50 mg of rofecoxib p.o. followed 8 and 16 h later by two doses of placebo or three doses of diclofenac 50 mg p.o. at the same time points. We assessed arachidonic acid-stimulated platelet aggregation before and 4 h after the ®rst dose of study medication, estimated intraoperative blood loss, and haemoglobin loss until the ®rst morning after surgery. Analgesic ef®cacy, use of rescue analgesics, and side-effects were also recorded. Results. In the rofecoxib group, stimulated platelet aggregation was disturbed less (P=0.02), and estimated intraoperative blood loss (P=0.01) and the decrease in haemoglobin were lower (P=0.01). At similar pain ratings, the use of anti-emetic drugs was less in the rofecoxib group (P=0.03). Conclusion. Besides having a smaller effect on platelet aggregation, one oral dose of rofecoxib 50 mg given before surgery provided postoperative analgesia similar to that given by three doses of diclofenac 50 mg and was associated with less use of anti-emetics and less surgical blood loss in gynaecological surgery compared with diclofenac.

In search of the neuronal substrate for motion analysis in the ferret (Mustela putorius furo), we extracellularly recorded from extrastriate visual cortex in five pigmented and two albino ferrets under general anaesthesia and paralysis. Visual stimulation consisted of large area random dot patterns moving either on a circular path in the frontoparallel plane or expanding and contracting radially. Strongly direction-selective neurons were recorded in a circumscribed area in and just posterior to the suprasylvian sulcus, thus named by us the posterior suprasylvian area (area PSS). Altogether, we recorded 210 (90%) and 95 (72%) PSS neurons in pigmented and albino ferrets, respectively, that were direction selective. In these neurons responses during random dot pattern stimulation in the preferred direction were at least twice as strong than stimulation in the non-preferred direction. Response strength in preferred direction and tuning sharpness of PSS neurons in albinos were significantly reduced when compared to pigmented animals (median values: 34.1 versus 14.8 spikes/s and 142 versus 165°for pigmented and albino ferrets, respectively). Inter-spike-intervals during visual stimulation were significantly shorter in pigmented (median 9ms) than in albino PSS neurons (median 14ms). Our data indicate that area PSS may play a crucial role in motion perception in the ferret.

accepted by the surgeon worldwide e.g. especially laparoscopic cholecystectomy, with published reports describing the benefits of less postoperative pain, reduced hospital stay and an earlier return to work. The hall mark of laparoscopic surgery is the creation of pneumoperitoneum with pressurized CO 2 . The high solubility of CO 2 increases systemic absorption by the vasculature of the peritoneum. This, combined with smaller tidal volumes because of poor lung complication, leads to increased arterial CO 2 levels which is known as hypercarbia. If hypercarbia allowed to develop, will stimulate the sympathetic nervous system and thus increase heart rate, blood pressure, and the risk of dysrhythmias. These effects can prove especially challenging in patients with restrictive lung disease, impaired cardiac function, or intravascular volume depletion 1 .

GENERAL ANAESTHESIA continues to be widely used for Caesarean section. Despite the reduction of neonatal depression and the decreased risk of maternal aspiration with regional anaesthetic techniques, 1,2 there are many indications for general anaesthesia for Caesarean ...

Background. There is limited knowledge of the effects of anaesthetics on left ventricular (LV) diastolic function in humans. Our aim was to evaluate these effects in humans free from cardiovascular disease. Methods. Sixty patients (aged 18-47 yr) who had no history or signs of cardiovascular disease were randomized to receive general anaesthesia with halothane, sevoflurane or propofol. Echocardiography was performed at baseline and during spontaneous respiration at 1 minimum alveolar concentration (MAC) of the inhalational agents or propofol 4 mg ml À1 (step 1), and repeated during positive-pressure ventilation with 1 and 1.5 MAC of the inhalational agents or with propofol 4 and 6 mg ml À1 (steps 2A and 2B). Analysis of echocardiographic measurements focused on heart rate corrected isovolumic relaxation time (IVRT c) and early diastolic peak velocity of the lateral mitral annulus (E a). Results. IVRT c decreased from baseline to step 1 in the halothane group (82 [95% CI, 76-88] ms and 74 [95% CI, 68-80] ms respectively; P=0.02), remained stable in the sevoflurane group (78 [95% CI, 72-83] ms and 73 [95% CI, 67-81] ms; n.s.) and increased in the propofol group (80 [95% CI, 74-86] ms and 92 [95% CI, 84-102] ms; P=0.02). E a decreased in the propofol group only (18.8 [95% CI, 16.5-19.9] cm s À1 and 16.0 [95% CI, 14.9-17.9] cm s À1 ; P=0.003). From step 2A to step 2B, IVRT c increased further in the propofol group (109 [95% CI, 99-121] ms and 119 [95% CI, 99-135] ms; P=0.04) but remained stable in the other two groups. E a did not change from step 2A to step 2B. Conclusions. Halothane and sevoflurane did not impair LV relaxation, whereas propofol caused a mild impairment. However, the impairment by propofol was of a magnitude that is unlikely to cause clinical diastolic dysfunction.

Background: The number of skin conductance fluctuations (NSCF) expresses sympathetic skin nerve activity. The response entropy (RE) measures electromyographic and electroencephalographic activity in the forehead. The state entropy (SE) measures mainly electroencephalographic activity. When the suppression of frontal muscular activity is complete, RE is equal to SE. RED is defined as SE minus RE. The purposes of this study were to examine whether NSCF and RED correlate with signs of clinical stress during intubation and tetanic noxious stimulation and to elucidate how rapidly and accurately entropy and NSCF react during emergence from general anaesthesia. Methods: Twenty women scheduled for gynaecological laparotomy were studied. During intubation in remifentanil and propofol general anaesthesia, NSCF and RED were correlated with the clinical stress score. After a wash-out period, two series of tetanic stimuli were given, the first with (Rþ) and the second without (R-) remifentanil infusion. The tetanic pre-stimuli periods were compared with the tetanic post-stimuli periods, and Rþ was compared with R-. During emergence, the responses of entropy and skin conductance were related to the time of extubation. Results: NSCF correlated well with the clinical stress score during intubation (r 2 ¼ 0.73, P < 0.0005). RED showed a weaker correlation (r 2 ¼ 0.33, P ¼ 0.007). During tetanic stimuli, the NSCF pre-stimuli level was lower than the post-stimuli level (P < 0.001), and the NSCF Rþ response was lower than the NSCF R-response (P ¼ 0.002). RED did not show similar differences. During emergence, RE reacted before NSCF and SE (P ¼ 0.003). Conclusion: NSCF was better than RED for the measurement of clinical stress during intubation, and was sensitive to tetanic stimuli at different opioid analgesic levels, by contrast with RED. Both modalities were able to predict emergence at the end of anaesthesia, but RE was more rapid.

While peripheral polyneuropathy is a well-known complication in diabetes mellitus, and the subject of a great deal of study, the clinical importance of autonomic diabetic neuropathy is increasingly recognised. Using an animal model, where the pupil diameter of the eye serves as a parameter of autonomic function, we produced an age and weight curve of pupil diameter and studied the development of autonomic neuropathy in rats with streptozotocin-induced diabetes. We show that diabetic rats develop significantly (P &lt; 0.009) smaller pupils compared with controls, most probably due to a defective sympathetic input, caused by sympathetic neuropathy. Treatment with the neurotrophic peptide Org 2766, a synthetic ACTH4-9 analogue, prevents the occurrence of this sympathetic neuropathy, as the pupil diameters in the ACTH4-9 analogue-treated group are significantly (P &lt; 0.05) larger than the pupils of placebo-treated rats, and are comparable to the pupil diameters of the rats in the cont...

The course of a pregnancy in a woman with syringomyelia is presented. She was ®rst admitted at 28 weeks' gestation suffering neurologic symptoms associated with a spinal cord injury, which had happened in the past. The disease was diagnosed with a magnetic resonance imaging (MRI). Delivery was accomplished by elective caesarean section under general anaesthesia at 37 weeks, in order to avoid straining during the second stage of an imminent labour.

Inhalation of foreign body into the tracheobronchial tree is a medical emergency sometimes resulting into sudden death. The current mortality rate due to foreign body inhalation ranges from 0% to 1.8%. Children with or without positive history of aspiration were examined and diagnosis was made on the basis of history, clinical fi ndings, radiological evaluation and strong index of suspicion. A review of 30 cases of suspected foreign body aspiration revealed, children between 6 months were found to be very vulnerable to aspiration. Majority of children were boys. 80% of the patients had positive history of inhalation. Only 50% of the patients presented immediately i.e. within 24 hours after aspiration. Common symptoms were cough and respiratory distress. Decreased air entry was the signifi cant clinical sign (50%). Obstructive emphysema and mediastinal shift were found in the majority of cases (50%). Rigid bronchoscopy under general anaesthesia and patient ventilating using a jet ventilator is a very safe and effective technique.

Background. There is limited knowledge of the effects of anaesthetics on left ventricular (LV) diastolic function in humans. Our aim was to evaluate these effects in humans free from cardiovascular disease. Methods. Sixty patients (aged 18-47 yr) who had no history or signs of cardiovascular disease were randomized to receive general anaesthesia with halothane, sevoflurane or propofol. Echocardiography was performed at baseline and during spontaneous respiration at 1 minimum alveolar concentration (MAC) of the inhalational agents or propofol 4 mg ml À1 (step 1), and repeated during positive-pressure ventilation with 1 and 1.5 MAC of the inhalational agents or with propofol 4 and 6 mg ml À1 (steps 2A and 2B). Analysis of echocardiographic measurements focused on heart rate corrected isovolumic relaxation time (IVRT c) and early diastolic peak velocity of the lateral mitral annulus (E a). Results. IVRT c decreased from baseline to step 1 in the halothane group (82 [95% CI, 76-88] ms and 74 [95% CI, 68-80] ms respectively; P=0.02), remained stable in the sevoflurane group (78 [95% CI, 72-83] ms and 73 [95% CI, 67-81] ms; n.s.) and increased in the propofol group (80 [95% CI, 74-86] ms and 92 [95% CI, 84-102] ms; P=0.02). E a decreased in the propofol group only (18.8 [95% CI, 16.5-19.9] cm s À1 and 16.0 [95% CI, 14.9-17.9] cm s À1 ; P=0.003). From step 2A to step 2B, IVRT c increased further in the propofol group (109 [95% CI, 99-121] ms and 119 [95% CI, 99-135] ms; P=0.04) but remained stable in the other two groups. E a did not change from step 2A to step 2B. Conclusions. Halothane and sevoflurane did not impair LV relaxation, whereas propofol caused a mild impairment. However, the impairment by propofol was of a magnitude that is unlikely to cause clinical diastolic dysfunction.

Conclusions: PEG is associated with significant morbidity. Neurologically impaired children are at risk of acquiring symptomatic GOR, but the risk does not warrant routine fundoplication. Major complications are common and need urgent surgical consultation with many requiring secondary surgical procedures. PEG in paediatric patients should be considered a major surgical undertaking.

Chapter 1 Introduction Chapter 2 Detecting recurrent laryngeal carcinoma after radiotherapy: room for improvement Chapter 3 Systematic review: Accuracy of imaging tests in the diagnosis of recurrent laryngeal carcinoma after radiotherapy Chapter 4 Improved detection of recurrent laryngeal tumor after radiotherapy using 18 FDG-PET as initial method Chapter 5 The cost-effectiveness of 18 FDG-PET in selecting patients with suspicion of recurrent laryngeal carcinoma after radiotherapy for direct laryngoscopy Chapter 6 Screening for distant metastases in patients with head and neck cancer: what is the current clinical practice? Chapter 7 Screening for distant metastases in patients with head and neck cancer: is chest computed tomography sufficient? Chapter 8 Screening for distant metastases in patients with head and neck cancer: Is there a role for 18 F D G-P E T ? Chapter 9 Summary and future prospects Chapter 10 Samenvatting en vooruitzichten List of publications, Dankwoord en CV 1.1.2 Staging and treatment Staging of HNSCC is performed according to the TNM system of the International Union Against Cancer / American Joint Committee on Cancer [23]. This classification describes the anatomical extent of the primary tumour as well as the involvement of regional lymph nodes and distant metastases [24]. Based on this classification, clinical stages I-IV can be assessed. About one-third of the patients present with early stage (I-II) disease and two-thirds with advanced stage (III-IV) [25]. Patients with early stage HNSCC can usually be treated with either surgery or radiotherapy, while patients with advanced stage disease mostly need a combination of treatment modalities. assessment of the presence or absence of cervical lymph node metastasis is 20 to 30%. Histopathological evaluations have demonstrated that both the false-positive and the false-negative rate are unsatisfactorily high, causing over-and undertreatment in many patients. Modern imaging techniques, such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound (US) and the subglottic region are rare [43,44]. When treating patients for laryngeal cancer, the goal is not only curation but also preservation of its unique functions; phonation, breathing and swallowing. Early stage laryngeal cancer can usually be managed successfully with either radiotherapy or surgery. Advanced stage disease is often treated with a combination of modalities: surgery with or without postoperative radiotherapy or (chemo)radiation with salvage surgery. With the aim of preservation of organ and function without jeopardising Patients with distant metastases are generally not considered curable and almost always receive only palliative treatment [64]. Development of distant metastases is related to the site and stage of the primary tumour. Several clinical risk factors for development of distant metastases were identified: three or more neck metastases, bilateral or low-jugular metastases, metastases larger than 6 centimetres, primary site or neck recurrences or second 2.3.1 18 FDG-PET in head and neck Research is being conducted to determine the optimal use of 18FDG-PET in head and neck tumours. Occult primary tumours: Lymph node metastasis in the neck is the first symptom. In most patients a primary tumour is identified through extensive diagnostics. In 1.5-3% of HNSCC patients, however, the primary tumour remains occult. 18 FDG-PET studies show additional value for detecting a primary tumour in 21-47% of these patients [73,74]. Lymph node metastases: Detection of lymph node metastases in the neck in patients with a biopsy proven primary head and neck tumour is an important step in deciding the best possible treatment for a patient. Using 18 FDG-PET in this setting yields a sensitivity of 74-93% with a specificity of 93-94%. In comparison to CT, MRI and a role for 18 FDG-PET in detecting recurrent carcinoma in this setting. Distant metastases and second primary tumours: Detecting distant metastases or second primary tumours may alter the choice of treatment in patients with head and neck carcinomas. Since PET is a whole body technique, 18 FDG-PET may be helpful in screening for distant metastases. Planning of radiotherapy: In radiotherapy, setting exact limits for the target-volume, has become even more important with the introduction of 'three-dimensional conformal radiation therapy' and 'intensity-modulated radiation therapy', to reduce the impact on healthy surrounding tissue. Comparing tumour-volumes estimated by In the adult population in The Netherlands, nationwide screening programmes are active for breast and cervical cancer, as in many countries in Western Europe and the USA [87,89,90]. There is still an ongoing discussion about the effect, risks and harms of these screening programmes. The discussion based on the aforementioned known biases focuses on the health and survival benefits of screening for both the

To identify specific fears being entertained about general anaesthesia. People who do work in any medical facility were targeted in this prospective questionnaire-based study. All respondents were literate. The questionnaire was divided into two sections; (a) The baseline information, which included age, sex, marital status, occupation, previous exposure to anaesthesia and patient preference for anaesthesia technique. (b) Fear about risks associated with general anaesthesia; respondents were expected to pick one of four options (very concerned, somewhat concerned, not concerned and not sure), to indicate how they feel about each of the eight risks listed in the questionnaire. The data obtained was analyzed using SSPS version 10 for Windows. In a bivariate analysis, marital status, occupation and previous exposure to anaesthesia are not associated with the expressed fear by the respondents. Respondents had the highest concern for the fear of death (82%), followed by fear of postopera...

To test the accuracy of a new combined oxygen saturation and cutaneous carbon dioxide tension (SPO2-PCO2) sensor in a routine adult clinical environment. This probe provides a non-invasive and continuous monitoring of the arterial oxyhaemoglobin saturation, arterial carbon dioxide tension and pulse rate at the ear lobe. The sensor is intended to measure both relevant respiration/ventilation parameters in one single probe. Ten adult patients were consecutively studied during general anaesthesia. During the first 5 min after sensor placement at the ear lobe, arterial blood samples were drawn each minute. Carbon dioxide tension and oxygen saturation measurements were obtained simultaneously at 1-min intervals. After this period, patients were hyper-, normo- and hypoventilated. After 15 min at each setting, the simultaneously obtained cutaneous and arterial carbon dioxide tension values were compared. A total of 80 comparisons between ear lobe SpO2-PCO2 measurement, finger clip pulse ox...

One hundred patients with an incomplete abortion, 14 patients with retained products of conception after a second trimester termination, 5 patients with missed abortion and 2 patients with secondary postpartum haemorrhages (making a total of 121 patients) had a uterine evacuation in a treatment room using the portable Karman curette equipment. No general anaesthesia was used but patients were given intravenous pethidine or papavaretum (Omnopon) and diazepam. Four patients found the procedure painful but only two of them would have preferred general anaesthesia. There were no immediate complications but three patients required re-evacuation of the uterus.

Purpose: The aim of the study was to assess and compare in analogous controlled experimental conditions, the anaesthetic sparing and analgesic effects of the same dose of clonidine administered by the intramuscular (ira) and epidural (ep) routes. Methods: We used a randomized, double blind and placebo controlled protocol. Sixty patients undergoing abdominal hysterectomy were distributed into three groups who, 30 rain before surgical incision, received: 300 IJg ep clonidine plus im saline; ep saline plus 300 lag im clonidine; or ep and im saline (ss). General anaesthesia was maintained with 60% N20 in 02, and isoflurane administered at concentrations to maintain mean arterial pressure (MAP) and heart rate (HR) within 20% of basal values, lsoflurane requirements (mass spectrometry), cardiovascular variables (MAP, HR), and plasma concentrations of glucose, cortisol and prolactin were evaluated at criti-cal time points. In the recovery room (RR), sedation (Ramsay) and pain intensity (VAS) were estimated at the time of analgesia request (TAR). Results: Intramuscular and ep clonidine decreased isoflurane requirements similarly by about 85% (P < 0.00t). Patients in the ep group had lower MAP (P < 0.03) and FIR (P < 0.00t) than in the im group, but im and ep clonidine similarly blunted the plasma prolactin increase induced by intubation. In RR, ep but not im clonidine (P < 0.01) induced postoperative analgesia demonstrated by a prolonged TAR 80.8 • Z3 (ep) 35.9 • 3.2 (im) and44.5 +_ 5.1 (ss) min and a lower VAS (P < 0.05). Conclusions: Epidural and intramuscular clonidine decreased isoflurane requirements similarly, but only the epidural route provided postoperative analgesia, suggesting a spinal site for the analgesic action.

Background To compare the success rate of monocanalicular intubation (MCI) compared with bicanalicular silicone intubation (BCI) in congenital nasolacrimal duct obstruction (CNLDO) in infants and toddlers. Methods In a prospective, nonrandomized, comparative study, MCI (n=35 eyes) through the inferior canaliculus or BCI (n=35 eyes) were performed under general anaesthesia in children aged 10 to 36 months with CNLDO. The tubes were removed 3-4 months after tube placement, and the children were followed up for 6 months after the removal of tubes. Therapeutic success was defined as the fluorescein dye disappearance test grade 0-1, corresponding with a complete resolution of previous symptoms. Partial success was defined as improvement with some residual symptoms. Results Complete and partial improvement was achieved in 31/35 (88.57%) in the BCI group and 34/35 (97.14%) in the MCI group. The difference between the two groups was not significant (p=0.584). Complications occurred in both groups. Dislodgement of the tube and premature removal was observed in four BCI cases, and loss of the tube was observed twice in the MCI group. Canalicular slitting was observed in five eyes in the BCI group. Granuloma pyogenicum observed in 2 cases with MCI revealed a few weeks after the tube removal. Corneal erosion in the inferior medial quadrant was observed in one MCI eye and revealed in a few days after the local treatment without tube removal. Conclusions Both MCI and the BCI are effective methods for treating CNLDO. MCI has the advantage of a lower incidence of canalicular slit and easy placement.

Background. Different methods and propofol formulations have been used to decrease propofol injection pain, but it remains an unresolved problem. We aimed to investigate the effect of i.v. acetaminophen pretreatment on the propofol injection pain. Methods. One hundred and fifty ASA I-II patients undergoing general anaesthesia were randomly allocated into three groups. A 20-gauge catheter was inserted into a superficial radial vein of the left hand, and after the occlusion of venous drainage, Groups I, II, and III were pretreated with 40 mg of lidocaine in saline, 50 mg of i.v. acetaminophen, and 5 ml of saline, respectively. The occlusion was released after 2 min and one-fourth of the total propofol dose was injected into the vein over a period of 5 s. During the injection of both pretreatment solution and propofol, patients' pain was assessed and recorded as 0-3, corresponding to no, mild, moderate or severe pain, respectively. x 2 and Kruskal-Wallis tests were used for the statistical analysis. For all analyses, differences were considered to be significant at P,0.05. Results. Patient characteristics were similar among the groups. Incidence of pain on injection of propofol in control, i.v. acetaminophen, and lidocaine groups was 64%, 22% and 8%, respectively (P,0.05). Conclusions. Pretreatment with i.v. acetaminophen seems to be effective in attenuating pain during i.v. injection of propofol.