We performed a prospective, randomized study comparing the efficacy and safety of remifentanil, propofol or both for conscious sedation during eye surgery under retrobulbar blockade. Forty-five unpremedicated patients were assigned to receive remifentanil (group R) (n=15, mean dosage: 0.05±0.03 μg kg−1 min−1), propofol (group P) (n=15, 1.5±0.5 mg kg−1 h−1) or a combination (group RP) (n=15, R: 0.03±0.01 μg kg−1 min−1; P: 0.7±0.2 mg kg−1 h−1). Haemodynamic responses were comparable among all groups. Minimum values for respiratory rate were lower in R patients (R: 7 vs. P and RP: 10 breaths min−1). Peri-operative blood gas analysis showed differences in maximum carbon dioxide tensions (R: 51.5 vs. P: 48.3 vs. RP: 45.5 mmHg) and decrease in minimum pH values (R: −0.06 vs. P: −0.0 vs. RP: −0.01). All group P patients reported mild to intense pain during retrobulbar block, while 53% of the group R patients were free from pain. In group RP, 60% of patients experienced no pain and the remaining 40% reported mild pain only. Remifentanil, applied as the sole agent, provided superior pain relief and patient comfort when compared with propofol, but produced greater respiratory depression and postoperative nausea. The combination of remifentanil and propofol provided haemodynamic stability, adequate spontaneous respiration and pain relief, with a low risk of untoward side effects.

A prospective multicentre pilot study was undertaken in 20 Italian hospitals to assess the influence of a routine pre-operative chest radiograph on anaesthetic management and to characterise which patients might benefit from it. A total of 6111 patients undergoing elective surgery and submitted for routine pre-operative chest radiograph were enrolled. Abnormal pre-operative chest radiographs were reported in 1116 patients (18.3%). Pre-operative chest radiograph altered the anaesthetic management (i.e. useful pre-operative chest radiograph) in 313 patients (5.1%). Male sex, age >60 years, ASA classes ≥3, respiratory diseases, and the presence of two or more co-existing diseases were significantly related to the probability of a useful pre-operative chest radiograph using multivariate analysis (P<0.01). The classification of the surgical intervention and, of the co-existing diseases, the presence of cardiac disease had a very low influence when determining the probability that a pre-operative chest radiograph would be useful. A simple equation includes the effects of all the variables studied and allows calculation of the probability of a useful pre-operative chest radiograph. This study indicates that in healthy, female, ≤60-year-old patients, submitted for standard surgery, the probability of a useful pre-operative chest radiograph ranges from 0.2% to 3.5% according to the hospital. The probability increases in male or elderly subjects, or in the presence of co-existing respiratory diseases, or in ASA classes ≥3, but there is a wide variation between hospitals.

This prospective, randomized and double-blinded study was designed to evaluate the anti-emetic efficacy of a combination of ondansetron and metoclopramide in 100 ASA physical status I and II children of either sex and 1–15 years of age undergoing elective surgery for strabismus. A standardized anaesthetic technique and post-operative analgesia were used for all the children. Children were divided into four groups. They received saline, metoclopromide 250 μg kg−1, ondansetron 150 μg kg−1 or a combination of metoclopramide 150 μg kg−1 and ondansetron 100 μg kg−1 intravenously immediately after the insertion of an intravenous cannulae. There were no differences between the groups in their age, gender, weight, duration of surgery, number of muscles subjected to surgery or intravenous fluids received. In the first 24 post-operative hours, 18 (72%) patients in the placebo group, 15 (60%) patients in the metoclopramide group, 10 (40%) patients in the ondansetron group and 11 (44%) patients in the combination group had nausea or vomiting. The overall incidence of post-operative nausea and vomiting was significantly (P<0.05) lower in the combination group and in the ondansetron group compared with the placebo group. Nine (36%) patients in both the placebo and the metoclopramide groups and one (4%) patient in the ondansetron group required rescue anti-emetic treatment. None of the patients in the combination group required rescue anti-emetic and this was significantly less (P <0.01) when compared with the placebo and the metoclopramide groups. Recovery and sedation scores were comparable in all the four groups. A combination of metoclopramide 150 μg kg−1 and ondansetron 100 μg kg−1 administered prior to surgery was not found to be more effective than ondansetron 150 μg kg−1 alone for the prophylaxis of nausea and vomiting following surgical repair of strabismus in paediatric patients.

The anti-emetic effects of ondansetron and droperidol were evaluated in 134 ASA Grade I and II female patients, scheduled for laparoscopic cholecystectomy and minor gynaecological laparoscopic surgery, who were randomly assigned to receive ondansetron 4 mg or droperidol 75 μg kg−1 intravenously immediately after induction of anaesthesia. The patients were assessed 1, 6, 12 and 24 h after surgery for intensity of nausea and number of vomiting episodes. In the case of the patients undergoing laparoscopy, vomiting episodes occurred in a similar proportion in patients treated with ondansetron or droperidol, with the probability of the Type I error of 0.05 and the Type error II of 0.1. Although there was no difference between the two groups in emetic episodes following all laparoÍscopic procedures and gynaecological laparoscopic surgery, there was a significant difference between these parameters after laparoscopic cholecystectomy. The patients treated with ondansetron experienced a lower intensity of nausea (P=0.04) after laparoscopic cholecystectomy, less frequent severe nausea (P=0.02) and episodes of vomiting (P=0.04) when compared with those in the droperidol group. We conclude, that despite the result the droperidol prophylaxis appears to be an effective alternative to ondansetron in all patients undergoing laparoscopy, the ondansetron prophylaxis is superior to droperidol in patients undergoing laparoscopic cholecystectomy.

To evaluate the quality of intra-operative anaesthesia and recovery characteristics of two different anaesthesia regimens, 60 healthy women undergoing ultrasound guided oocyte retrieval for in vitro fertilization procedures were randomly allocated to receive either a propofol/fentanyl or a midazolam/remifentanil based anaesthesia. The surgical procedure was successful in all patients and no severe side effects were reported by any patient. Four patients in the midazolam/remifentanil group (13%) would not accept the same anaesthetic procedure for further in vitro fertilization treatment due to intra-operative awareness, while all propofol/fentanyl patients were prepared to accept the same procedure again (P < 0.05). Patients in the propofol/fentanyl group required manual ventilation more frequently through a facemask than those patients treated with the midazolam/remifentanil combination (50% and 30%, respectively; P < 0.05). The time to achieve an Aldrete's score of 10 was shorter in the midazolam/remifentanil patients (2±2 min) than in those who received propofol/fentanyl (4±2 min) (P < 0.001), but no differences were observed in the time required to be ‘fit to discharge’ from the post-anaesthesia care unit. We conclude that the use of a midazolam/remifentanil regimen is as effective and safe as a fentanyl/propofol regimen in patients undergoing transvaginal oocyte retrieval for in vitro fertilization procedures.

In this study, we have sought to establish whether N2O and ketamine alter the bispectral index during propofol–fentanyl anaesthesia. Fourteen surgical patients were randomly assigned to one of two groups: the N2O group (n=7) and the ketamine group (n=7). In both groups, anaesthesia was induced with propofol 1.5–2 mg kg−1 and fentanyl 2 μg kg−1 and maintained with propofol 5–7 mg kg−1 hr−1 to target the bispectral index between 40 and 50. After the bispectral index value had stabilized the propofol infusion rate was fixed. In the N2O group, the following concentrations of N2O were subsequently inhaled at 20-min intervals; 20, 40, 60 and 70%, and then N2O was terminated. In the ketamine group, ketamine (0.4 mg kg−1+1.0 mg kg−1h−1) was given. The bispectral index and 95% spectral edge frequency were recorded 20 min after each change in concentration of N2O or ketamine infusion. The bispectral index and 95% spectral edge frequency did not change significantly in the N2O group, but increased significantly from 44.1±0.7 and 16.0±0.5 to 58.6±1.4 and 19.5±0.3 (P <0.01), respectively, in the ketamine group. Additional N2O or ketamine did not decrease the bispectral index and 95% spectral edge frequency values. The depth of sedation should be assessed carefully using a bispectral index monitor when these anaesthetic agents are used together.

In order to compare interscalene brachial plexus block performed with ropivacaine or bupivacaine, 45 healthy, unpremedicated patients, undergoing elective shoulder surgery, were randomly allocated to receive interscalene brachial plexus anaesthesia with 20 mL of either ropivacaine 0.75% (n=15), ropivacaine 1% (n=15), or bupivacaine 0.5% (n=15). Readiness for surgery (loss of pinprick sensation from C4 to C7 and inability to elevate the limb from the bed) was achieved later with bupivacaine 0.5% (28±15 min) than with ropivacaine 1% (10±5 min) (P=0.005) and ropivacaine 0.75% (15±8 min) (P=0.0005). No differences in success rate were observed between the three groups; however, seven patients receiving bupivacaine 0.5% required intra-operative analgesic supplementation (fentanyl 0.1 mg intravenous) compared with one patient receiving ropivacaine 0.75%, and two patients treated with ropivacaine 1% (P=0.02). The time from the block placement to first request for pain medication was similar in the three groups (10.7±2 h, 11±2.4 h, and 10.9±3.9 h after 0.75% and 1% ropivacaine or 0.5% bupivacaine, respectively). We conclude that interscalene brachial plexus block performed with 20 mL of either 0.75% or 1% ropivacaine allows for a prolonged post-operative pain relief, similar to that provided by bupivacaine 0.5%, with short onset time of surgical anaesthesia.

Droperidol and dimenhydrinate are inexpensive anti-emetic drugs. Droperidol, especially, has been studied extensively, but there are no studies on the combination of both drugs for prevention of post-operative nausea and vomiting. One hundred and forty male hospitalized patients undergoing nasal surgery were randomized to receive one of four anti-emetic regimes: placebo, dimenhydrinate (1 mg kg−1), droperidol (15 μg kg−1), or the combination of both drugs (droperidol 15 μg kg−1+dimenhydrinate 1 mg kg−1) administered after induction of anaesthesia. Patients in the dimenhydrinate-group and the combination-group received a second dose of dimenhydrinate 6 h after the first administration to mitigate the short half-life of the drug. For general anaesthesia a standardized technique, including benzodiazepine premedication, propofol, desflurane in N2O/O2, vecuronium, and a continuous infusion of remifentanil, was used. Post-operative analgesia and anti-emetic rescue medication were standardized. Episodes of vomiting, retching, nausea, and the need for additional anti-emetics were recorded for 24 h. The main endpoint of this study was the number of patients who were completely free of post-operative nausea and vomiting (Fisher's Exact Test) Furthermore, the severity of post-operative nausea and vomiting was analysed using a standardized scoring algorithm. The incidence of patients completely free of post-operative nausea and vomiting was 62.9% in the placebo-group, 77.1% in the dimenhydrinate-group (P =0.21), and 82.9% in the droperidol-group (P =0.07). This increased to 94.3% in the combination-group (P =0.0015). In all three treatment groups the severity of post-operative nausea and vomiting was reduced significantly compared with placebo treatment (P =0.0003). The incidence of side effects was similar in the four groups. Dimenhydrinate was ineffective in reducing the incidence of post-operative nausea and vomiting and droperidol only reduced the severity of post-operative nausea and vomiting. However, the combination of both drugs significantly reduces the incidence of post-operative nausea and vomiting when compared with placebo treatment.

An 86-year-old man on whom a transurethral resection of prostate was performed under spinal anaesthesia developed profound bradycardia and hypotension with disturbance of consciousness during transfer to the recovery room. Initial treatment with atropine produced rapid improvement in cardiovascular and cerebral function. A further hypotensive episode (without bradycardia) occurred approximately 1 h later but responded rapidly to methoxamine. The patient made a full recovery during an overnight stay on the High Dependency Unit. Possible mechanisms for this event are discussed, with the proposal that the concomitant administration of captopril and the relative unavailability of Angiotensin II may have significantly contributed to the problem.

In the management of adult respiratory distress syndrome pressure limited mechanical ventilation may protect the lungs from overdistention injury. Unacceptable hypoxia may be avoided by adding nitric oxide to the inspiratory gas, and thus make pressure limited ventilation easier to perform. There exists no consensus about an acceptable lower limit of SaO2, and in the present case we gave preference to pressure limitation at the cost of oxygenation. A young woman with severe adult respiratory distress syndrome was set on pressure limited mechanical ventilation with peak pressures of 35–38 cm H2O, PEEP of 10–12 cm H2O, and FiO2 of 0.95 with 20 ppm nitric oxide. SaO2 varied between 75 and 85%, and cardiac output ranged between 5.2 and 7.5 L min−1. Oxygen consumption was in the upper normal range, and she did not became acidotic. After 3 days, she started to improve. In conclusion, it seems that hypoxia might be well tolerated as long as the circulation is not compromised. It might prove benefical to accept some hypoxia to avoid ventilator induced lung damage.

This report describes two cases of central anticholinergic syndrome, the first after general anaesthesia and the other during a prolonged stay in the intensive care unit. The symptoms in both patients resolved soon after physostigmine administration. There was a delay in the diagnosis of central anticholinergic syndrome, which resulted in acute lung injury and unanticipated intensive care unit admission. It is suggested that in cases of abnormal mental recovery after anaesthesia or sedation, the diagnosis of central anticholinergic syndrome should be considered.

The intra-operative management of two patients with chronic obstructive pulmonary disease and cardiovascular pathology, who underwent peripheral reconstructive vascular surgery under continuous spinal anaesthesia, is described. Furthermore, continuous intrathecal analgesia was also continued in the post-operative period and provided effective pain relief that was reflected by the favourable surgical outcome.