Summary

Sepsis is an infection-induced syndrome characterized by a generalized inflammatory state. The normal reaction to infection involves a series of complex immunological processes. A potent, complex immunological cascade ensures a prompt protective response to microbial invasion in human beings. Although activation of the immune system during microbial invasion is generally protective, septic shock develops in a number of patients as a consequence of excessive or poorly regulated immune response to the offending organism. This unbalanced reaction may harm the host through a maladaptive release of endogenously generated inflammatory compounds. Early recognition of the syndrome is of key importance to promptly start appropriate management. Timely, aggressive resuscitation to preserve organ function remains a fundamental principle in the care of septic patients. The specific treatment is directed at identifying and treating the underlying disorder. The physician should investigate diligently for the presence of active infection using modern imaging methods and other diagnostic studies to localize the site of infection and to obtain adequate culture specimens from potential infective sources. Early administration of appropriate, effective antibiotic therapy is important in the management of septic patients. Infected fluid collections and/or infected necrotic tissues should be drained or debrided without delay. Adequate nutritional support is indicated in the management of the septic patient. A number of adjuvant therapies, aimed at blunting/downregulating the host immune response to bacterial infection are currently under intensive investigation; however, the complexity of immunological defences and the potential for complementary interaction of the different components of the inflammatory cascade make the development of these pharmacological interventions difficult.

Summary

Background and objective: To evaluate the capability of first responders to ensure an airway and ventilate the lungs of a patient employing a bag-valve device and two oxygen-driven resuscitators.

Methods: Prospective, controlled, blinded, single-centre clinical trial using a bag-valve device and one of two FR-300® devices, with 20 cmH2O working pressure, flows of 24 and 30 L min−1. One-hundred-and-four patients were analysed. Induction of anaesthesia was followed by ventilation of the lungs with a bag-valve device and an Oxylator® (CPR Medical Devices Corp., Markham, Ontario, Canada) in manual and automatic modes. Each series was repeated twice by a fireman first responder using a hand-held mask to seal the airway, once under anaesthesia and then again under anaesthesia with muscle relaxation.

Results: Patients’ mean age 49 ± 17 yr; 47% male, 48–132 kg. Only 29% had optimal facial and airway physiognomy. Airway management was significantly poorer when the bag-valve device was used than with either Oxylator® mode (P < 0.0001); 23% of cases were not manageable with the bag-valve device. Gastric insufflation was markedly less with the Oxylator® (P < 0.02).

Conclusions: The use of an oxygen-driven device improves the ability of first responders to secure an airway and reduce gastric insufflation, even when distracted. Oxylators® perform significantly better (P < 0.0001) than the bag-valve device.

Summary

Background and objective: To evaluate the capability of first responders to achieve and maintain normal ventilation of the lungs of victims employing a bag-valve device and two oxygen-driven resuscitators.

Methods: Prospective, controlled, blinded, single-centre clinical trial using a bag-valve device and one of two FR-300® devices, with 20 cmH2O working pressure, and flows of either 24 or 30L min−1. One hundred and four patients were analysed. Induction of anaesthesia followed by ventilation of the lungs with a bag-valve device and an Oxylator® in manual and automatic modes performed by a fireman first responder. Each series was repeated for three conditions (anaesthesia; anaesthesia plus muscle relaxation, both with facemask; anaesthesia plus relaxation using an endotracheal tube).

Results: Patients age 49 ± 17 yr; 47% males, 48–132 kg. Normocapnia was achieved and maintained in 66% (bag-valve device), 82% (Oxylator®).

Conclusions: The use of an oxygen-driven device improves the ability of first responders to achieve and maintain normocapnia even when distracted. Use of the Oxylators® improves performance (P < 0.001) vs. the bag-valve device significantly.

Summary

Background and objective: Hitherto, neither desflurane nor sevoflurane, with similar physicochemical properties, have been compared with regard to their effects on the central nervous system. We compared the effects of desflurane and sevoflurane on electrical cortical activity and sensory transmission at two anaesthetic concentrations in patients undergoing hysterectomy.

Methods: The 1 and 2 MAC in nitrous oxide/oxygen (55%/45%) of desflurane or sevoflurane were administered while electroencephalographic power spectra and the somatosensory-evoked potentials were measured and correlated with cardiovascular effects.

Results: Both volatile agents induced a concentration-related increase of power in the slow delta-band and a concomitant decrease of power in the fast beta-domain. There was a close correlation with regard to the decrease in beta-power and heart rate (r2 = 0.988) and systolic blood pressure (r2 = 0.952) following both agents. Desflurane and sevoflurane had little effect on the early N20-peak, but affected the late N100-peak. There was a concentration-related increase in latency and a depression of amplitude height. Changes were not significantly different between both agents.

Conclusions: Both desflurane and sevoflurane possess a similar profile with regard to their hypnotic effects and a similar outline in depressing propagation within the sensory nervous system. Cortical nervous effects are mirrored closely in heart rate and systolic blood pressure.

Summary

Background and objective: Unplanned hospital admission is a measure of quality of care in the setting of day-case surgery. We set out to identify the incidence and causes of unplanned hospital admission in a paediatric day-case unit.

Methods: A retrospective survey to determine the incidence and causes of unplanned hospital admissions in children undergoing day-case surgery. The survey covered the period from January 1996 until December 1999 inclusive in a university affiliated children’s hospital. This hospital is the second largest paediatric referral centre in Ireland with total admissions across all specialities during the study period of 42 738.

Results: During the study period 10 772 children underwent day-case surgery, of whom 242 (2.2%) experienced unplanned hospital admission. The reasons for admission were surgical 146 (54%), anaesthetic 44 (16%), social 38 (14%), medical 31 (11%) and unclassified 10 (4%). Pain, surgical complications and/or further management, admission for observation, extensive surgery and oozing were the commonest surgical reasons. Postoperative nausea and vomiting, anaesthetic-related complication and somnolence were the commonest anaesthetic causes responsible for admission. Surgery performed after 15:00 h was an important factor associated with admission for social reasons. Orthopaedic surgery accounted for the largest absolute number of unplanned admissions with 61 (25%), followed by urology with 46 (19%) and general surgery with 46 (19%). However, measured as percentage of caseload, urology had the highest proportion of unplanned hospital admissions.

Conclusion: This study demonstrated that the incidence and causes of unplanned hospital admission following day-case surgery in children are similar to those for adults.

Summary

Background and objective: Arterial catheters are routinely used to sample blood for clotting studies in most cardiothoracic intensive care units. The clotting profile in surgical bleeding after cardiac surgery influences further management. Aspiration and discard of a certain amount of blood from the line, prior to sampling, are assumed to clear heparin contamination. We have investigated this assumption through analysis of the clotting profile by simultaneous arterial line and peripheral venous samples.

Methods: The morning following cardiac surgery, simultaneous arterial line and peripheral venous blood samples were taken for activated plasma thromboplastin time (APTT) ratio and international normalized ratio (INR) in 49 randomly selected patients. Also, a thromboelastogram analysis (TEG) (n = 7) was made. A survey of 22 UK cardiothoracic intensive care units was carried out to determine the practice for the withdrawal of blood for clotting studies.

Results: The median arterial APTT ratio value was 1.32 ± 0.52 as compared to the median peripheral APTT ratio value which was 1.1 ± 0.24 (P < 0.001). INR values were statistically similar by both routes. Heparin contamination was confirmed by TEG which revealed that the R-value for arterial catheter blood samples without heparinase in the cup was higher (406.00 ± 64.44 s) compared with the value for arterial samples with heparinase in the cup (318.28 ± 47.26 s, P < 0.05). The survey of 22 UK cardiothoracic intensive care units showed that heparinized arterial lines were by far the commonest ports used for blood withdrawal for the measurement of APTT ratio results.

Conclusions: Samples withdrawn from heparinized arterial lines cannot be relied upon for APTT ratio results.

Summary

Background and objective: A randomized, blind study to evaluate the effects on β-endorphin and substance P release after washing acid burns with 0.9% saline, calcium gluconate or diphoterine in a model of chemical burn in rats.

Methods: Twenty Sprague–Dawley rats (approximate weight 250 g) were anaesthetized with ketamine (30 mg kg−1 intramuscularly) and then given an acid injury on the back skin with 0.5 mL of hydrochloric acid 52%. The rats were then randomly allocated to receive no washing (control group, n = 5), washing with normal saline (0.9% NaCl) (n = 5), 10% calcium gluconate (n = 5) or diphoterine (n = 5). Blood concentrations of substance P and β-endorphin were measured 6 h, 48 h and 7 days after the chemical burn. An independent blinded observer evaluated wound healing at the 7th day.

Results: Seven days after burn wound healing was almost complete only in rats treated with diphoterine. Plasma concentrations of substance P were lower in rats receiving skin flushing with diphoterine compared to the other groups at 6 and 48 h after acid burn (P < 0.05 and P < 0.05, respectively); this was also associated with higher concentrations of β-endorphin at day 7 (P < 0.05).

Conclusions: Skin flushing with diphoterine reduced substance P release during the first 48 h after burn, and was associated with better wound healing and higher concentrations of β-endorphin 7 days later when compared with normal saline or 10% calcium gluconate.

Summary

Background and objective: A retrospective analysis of applicants to Specialist Registrar training posts in anaesthesia in the Wessex Region of the UK was undertaken.

Methods: Applicants whose primary medical qualification was obtained in the European Economic Area were compared to applicants whose primary medical qualification was obtained outside it. The time since qualification, the time spent in anaesthesia, the time spent in other specialities, the post currently held and the success of the application were recorded.

Results: For doctors with a primary medical qualification from outside the European Economic Area, the median time since obtaining that qualification was 12.0 yr compared with 6.0 yr for doctors qualifying within it (P = 0.0001, U-test). Thirteen out of 89 (15%) doctors whose primary medical qualification was from outside the European Economic Area and 39 out of 61 (64%) doctors whose primary medical qualification was from within it were shortlisted for interview (P = 0.0001, χ2-test). Six out of 13 (46%) shortlisted doctors from outside the European Economic Area were appointed at interview compared with 24 out of 39 (62%) shortlisted doctors who qualified within it (P = 0.33, χ2-test).

Conclusions: In the Wessex Region of the UK, applicants whose primary medical qualification is obtained within the European Economic Area are approximately four times as likely to be shortlisted than doctors qualifying outside it. However, after shortlisting, both categories are equally likely to be successful at interview.

Summary

Background and objective: The perception of a looming manpower shortage led the French College of Anaesthesiologists (CFAR) and the French Society of Anaesthesia and Intensive Care (SFAR), with assistance from the National Institute for Demographic Studies (INED), to conduct a national survey of French anaesthesiologists in order to determine precise physician characteristics data, analyse professional practices and project future service provision.

Methods: The survey was based on self-administered individual questionnaires, approved by the National Committee on Informatics and Freedom (CNIL). The survey was carried out at the end of 1998 among 1484 hospitals (590 public and 894 private), under the supervision of local referees and regional co-ordinators.

Results: Of 9741 anaesthesiologists' posts, 5694 (58%) are in public hospitals, 3569 (37%) in private practice and 478 (5%) in private hospitals within the National Health Service, i.e. the participant au service public hospitalier (PSPH). Complex validation of the results was necessary to account for the missing responses and multiple sites of activity. The survey identified 8876 specialists practising anaesthesia and intensive care in France at the beginning of 1999, including 216 in French overseas territories. This figure is consistent with that published by the Medical Council (Ordre des Médecins) on 1 January 1999, identifying 8950 anaesthesiologists in France, including 234 in the overseas territories. Annual growth in the anaesthesiologist population has fallen from 9% pre-1989 to 0% in 1999. Male anaesthesiologists outnumber females (35.7%). The average age has risen from 42.8 yr in 1989 to 45.9 yr in 1999. The age distribution of anaesthesiologists has become bell shaped, reflecting reduced numbers of younger practitioners. There are currently 14.75 anaesthesiologists per 100 000 people (compared to 12.9 in 1989), a figure slightly above the European average, but there is considerable geographical inequality between the north and south of France, with increased concentrations in large cities that contain university hospitals.

Conclusions: Future service provision must take account of falling numbers of new anaesthesiologists and an increase in retirements, but must also include changes in working practices, such as the European Working Time Directive. If anaesthesia manpower shortages are to be avoided, there must be a restructuring of the workplace, a redefinition of tasks and improved management of working time.

Summary

Background and objective: This study was designed to determine which single bolus dose of remifentanil in combination with propofol and nitrous oxide is best to control the haemodynamic, autonomous and somatic responses in patients scheduled for dilatation and curettage of the uterine cervix. We evaluated the adequacy of different bolus doses of remifentanil, associated with propofol and nitrous oxide, for dilatation and curettage in a prospective double-blind study.

Methods: After institutional approval and informed consent, 34 healthy females undergoing curettage to remove material from the uterus after spontaneous abortion were randomized to receive remifentanil 0.5 μg kg−1 intravenously (i.v.) (Group A; n = 4), 1 μg kg−1 i.v. (Group B; n = 15) or 1.5 μg kg−1 i.v. (Group C; n = 15), with propofol 2 mg kg−1 i.v. in all groups. Anaesthesia was maintained with 60% nitrous oxide in oxygen. Haemodynamic, somatic and autonomic signs of light anaesthesia were registered to assess the response to surgical stress. Recovery times and Aldrete score were recorded at the end of the procedure.

Results: The groups were similar with regard to biometric data and duration of surgery. The poor results using the lowest dose of remifentanil obliged us to abandon this dose. The total dose of remifentanil was larger in Group C (100 ± 5.7 μg vs. 65 ± 4.1 μg in Group B; P < 0.05), but more patients required extra bolus injections in Group B (69% vs. 38% in Group C; P < 0.01). Recovery times were significantly shorter in Group C. Aldrete scores when leaving the operation room was similar.

Conclusions: Remifentanil 1.5 μg kg−1 i.v. with propofol 2 mg kg−1 i.v. and 60% nitrous oxide in oxygen provided the best anaesthetic control with the fastest recovery times.