Cardiac output is frequently monitored to maintain and improve cardiac function with the primary goal of adequate tissue perfusion. The pulmonary artery catheter is considered to be the gold standard although several non-invasive devices are being introduced and gaining attention. To evaluate the accuracy of the ultrasonic cardiac output monitor (USCOM)-1A (Pty Ltd, Coffs Harbour, NSW, Australia), a non-invasive cardiac output device including its capability to differentiate between different shock states in haemodynamically unstable ICU patients was used in this single-centre, prospective, observational study.

Cardiac output was measured with a pulmonary artery catheter and transcutaneously via a suprasternal approach with the USCOM-1A by continuous-wave Doppler ultrasound in 25 adult patients in a mixed medical and surgical ICU in a major teaching hospital in the Netherlands.

A total of 1315 USCOM-1A cardiac output measurements were performed. In order to reduce time-variability, the mean of five consecutive USCOM-1A measurements was calculated. Total 263 values were compared with 263 thermodilution cardiac output measurements performed with a pulmonary artery catheter. Data were analysed for systematic error, precision and correlation. Systematic and random errors were found. On average USCOM-1A values were 12% lower than thermodilution measurements (systematic error), while the random error was 17% (coefficient of variation). The error comprised an inter-operator variability of 3%, an inter-patient variability of 11% and residual variability of 15%. The correlation coefficient of the calculated cardiac index with the USCOM-1A and the pulmonary artery catheter was r = 0.8024 and 0.6438, respectively. Temperature and gender did not influence correlations. The learning curve for USCOM-1A skill acquisition was steep.

The correlation between the two techniques was acceptable, although relevant systematic and variable errors were detected. USCOM-1A provided adequate data to distinguish non-invasively different shock types in ICU patients.

When intrathecally or epidurally administered, α2-adrenoceptor agonists produce potent antinociception by affecting the activity of primary afferent fibres and spinal cord neurons. Recent reports have indicated that in dorsal root ganglion neurons, tetrodotoxin-resistant Na+ channels play important roles in the conduction of nociceptive sensation. We therefore investigated the effects of α2-adrenoceptor agonists on tetrodotoxin-resistant Na+ currents.

Using the whole-cell patch-clamp technique, we recorded tetrodotoxin-resistant Na+ currents from rat dorsal root ganglion neurons.

Both clonidine and dexmedetomidine reduced the peak amplitude of the tetrodotoxin-resistant Na+ current concentration- and use-dependently. The concentration required for a half-maximal effect was significantly lower for dexmedetomidine (58.0 ± 10.2 μmol) than for clonidine (257.2 ± 30.9 μmol) at holding potential −70 mV. The current inhibitions induced by these agonists were not prevented by 1 μmol yohimbine, an α2-adrenoceptor antagonist. Both clonidine and dexmedetomidine shifted the inactivation curve for the tetrodotoxin-resistant Na+ current in the hyperpolarizing direction. The combinations clonidine with lidocaine and dexmedetomidine with lidocaine produced an additive blockade-type interaction on the tetrodotoxin-resistant Na+ current.

The results suggest that a direct inhibition of tetrodotoxin-resistant Na+ channels may contribute to the antinociceptive effects of clonidine and dexmedetomidine when used as additives to regional anaesthesia.

We surveyed delegates at the Group of Anaesthetists in Training (UK) meeting to investigate evidence of a training-gap (number of fibreoptic intubations believed to bestow competence vs. number actually performed).

Questionnaires were distributed to and collected from delegates in person. Questions covered six areas, including experience of fibreoptic intubation and cricothyrotomy, fibreoptic intubation as a specialist skill and ethical issues.

We received 221 replies (76%). All trainees believed competence to be achievable with 10 intubations (interquartile range (IQR) 10–20); the median number performed was 2 (IQR 0–4). This was statistically significant for the groups senior house officers, 1st and 2nd year registrars and 3rd and 4th year registrars; P < 0.0001. Many final year trainees (12/20, 60%) also failed to achieve their competency target. Few trainees had seen or performed any cricothyrotomies (medians 0, IQRs 0–1 and 0–0). Most (195/208, 94%) believed that fibreoptic intubation was a core skill and 199/212 (94%) believed that all should be competent by completion of training. Ten percent (n = 208) felt it unethical to perform an awake training intubation with full consent and 10% believed it acceptable without explanation. Most (82.7%) would fibreoptically intubate an asleep patient (requiring intubation) without consent.

Trainees reported a gap between their perception of competence and achievement in awake fibreoptic intubation. Simple and complex simulations and structured training programmes may help. Anaesthetists must address the ethics of clinical training in advanced airway management.

The kind of fluid for correcting hypovolaemia is still a focus of debate. In a prospective, randomized, controlled and double-blind study in patients undergoing major abdominal surgery, a total balanced volume replacement strategy including a new balanced hydroxyethyl starch (HES) solution was compared with a conventional, non-balanced fluid regimen.

In Group A (n = 15), a new balanced 6% HES 130/0.42 was given along with a balanced crystalloid solution; in Group B (n = 15), an unbalanced conventional HES 130/0.42 plus an unbalanced crystalloid (saline solution) were administered. Volume was given when mean arterial pressure (MAP) was <65 mmHg and central venous pressure (CVP) minus positive end-expiratoric pressure (PEEP) level was <10 mmHg. Haemodynamics, acid–base status, coagulation (thrombelastography (TEG)) and kidney function (including kidney-specific proteins, N-acetyl-beta-d-glucosaminidase (beta-NAG) and alpha-1-microglobulin) were measured after induction of anaesthesia, at the end of surgery, 5 and 24 h after surgery.

Group A received 3533 ± 1302 mL of HES and 5333 ± 1063 mL of crystalloids, in Group B, 3866 ± 1674 mL of HES and 5966 ± 1202 mL of crystalloids were given. Haemodynamics, laboratory data, TEG data and kidney function were without significant differences between the groups. Cl− concentration and base excess (−5 ± 2.4 mmol L−1 vs. 0.4 ± 2.4 mmol L−1) were significantly higher in patients of Group B than of Group A.

A complete balanced volume replacement strategy including a new balanced HES preparation resulted in significantly less derangement in acid–base status compared with a non-balanced volume replacement regimen. The new HES preparation showed no negative effects on coagulation and kidney function.

Volatile anaesthetics have gained more popularity recently due to the potential for cardiac protection. Ultra-fast-track anaesthesia implies the immediate extubation after cardiac surgery. The purpose of this prospective randomized double-blind controlled study is to compare the cardioprotective effects of sevoflurane and isoflurane in off-pump cardiac bypass surgery.

Forty patients undergoing elective off-pump cardiac bypass surgery with high thoracic epidural analgesia and immediate extubation at the end of surgery were randomized into two groups. During surgery, anaesthesia was provided with either 1 minimum alvelolar anaesthetic concentration of sevoflurane or 1 minimum alvelolar anaesthetic concentration of isoflurane. Troponin-T, creatine kinase-MB, left ventricular wall motion anomalies, time to extubation, respiratory functions and haemodynamic parameters were compared between the two groups by analysis of variance.

All patients were successfully extubated in the operating theatre with minimal postoperative pain. Serial creatine kinase-MB and troponin-T concentrations were not significantly different between the two volatile agents. Haemodynamic stability throughout surgery and contractility was not different between groups. However, extubation time was significantly shorter with sevoflurane (10 ± 5 min) compared to isoflurane (18 ± 4 min).

This study indicates that during off-pump cardiac bypass surgery, sevoflurane and isoflurane provide the same ischaemic cardioprotective effects. There is no difference for heart contractility and haemodynamic values during and after off-pump cardiac bypass surgery between the two agents. Sevoflurane allows a more rapid recovery from anaesthesia, but this does not translate into better pulmonary function or haemodynamics. Both agents are similar in ultra–fast-track off-pump cardiac bypass surgery.

Levobupivacaine in combination with sufentanil may be used for labour or postoperative regional analgesia. The risk of bacterial growth within these contained solutions for several hours at room temperature is unknown. We investigated the in vitro antimicrobial effect of levobupivacaine and sufentanil against common micro-organisms encountered during regional anaesthesia.

Standardized suspensions of Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli were incubated for 1, 3, 6 and 24 h at 25°C, with saline (as control), sufentanil 0.5 or 0.75 μg mL−1, levobupivacaine hydrochloride 5.6 mg mL−1 and concentrations of 1.4, 2.8 and 5 mg mL−1 of levobupivacaine hydrochloride with sufentanil 0.5 μg mL−1. Colony counts were compared after 24 h incubation at 37°C.

No bacterial growth was observed on any bacterial strain for any solution tested throughout the experiment.

Our results suggest that solutions of levobupivacaine combined with sufentanil may be used for 24 h at room temperature during regional anaesthesia with no risk of bacterial growth.

Respiratory variations in pulse oximetry plethysmographic waveform amplitude (ΔPOP) are related to respiratory variations in arterial pulse pressure (ΔPP) in the critical care setting. The aims of this study were to test the hypothesis that in mechanically ventilated patients undergoing general anaesthesia, ΔPOP calculation is feasible and can detect changes in preload.

Twenty-five mechanically ventilated patients were studied immediately after induction of general anaesthesia. Haemodynamic data (mean arterial pressure [MAP], central venous pressure [CVP], ΔPP and ΔPOP) were recorded at baseline, before and after tilting the patient from anti-Trendelenburg to Trendelenburg position in order to induce preload changes.

Change from anti-Trendelenburg to Trendelenburg position induced changes in MAP (58 ± 9 to 67 ± 10 mmHg, P < 0.05), CVP (4 ± 4 to 13 ± 5 mmHg, P < 0.05), ΔPP (14 ± 8 to 7 ± 5%, P < 0.05) and ΔPOP (17 ± 12 to 9 ± 5%, P < 0.05). There was a significant relationship between ΔPOP in anti-Trendelenburg position and percent change in MAP after volume expansion (r = 0.82; P < 0.05).

ΔPOP can be determined in the operating room and is influenced by changes in preload. This new index has potential clinical applications for the prediction of fluid responsiveness.

Electroencephalographic entropy is used to measure the degree of brain hypnosis and anaesthesia depth. Two parameters are displayed in the monitor, state entropy (SE) and response entropy (RE). Ageing leads to reduction in liver mass as well as hepatic blood flow, which decreases clearance of propofol and increases the risk of cardiovascular adverse effects. The aim of this study is to demonstrate the effect of electroencephalographic entropy on propofol requirement and haemodynamic parameters during induction of anaesthesia in elderly patients.

We studied 72 elderly patients. Standard monitoring was performed for all patients together with entropy monitor. Patients were allocated randomly either to the control group, which were given the recommended induction dose of propofol, or to the entropy group which was induced with propofol based on entropy reading where the end-point was SE 50 and SE-RE difference less than 10. Propofol induction doses and haemodynamic changes were recorded. Anaesthesia was maintained using sevoflurane and O2 air mixture.

After induction of anaesthesia, the systolic, diastolic, mean arterial pressure, RE and SE were significantly lower in the control group (P value < 0.05). Total dose of propofol and the dose kg−1 were significantly reduced by 37.1% and 31.8%, respectively, in the entropy group (P value < 0.01).

The use of electroencephalographic entropy during induction of anaesthesia in elderly patients reduces propofol requirements and maintains cardiovascular stability.

The purpose of this study was to examine the effects of intravenous dexmedetomidine on the duration of bupivacaine-induced epidural anaesthesia and level of wakefulness and the respective side-effects.

Sixty ASA I–II patients were included in the study. Consecutive patients were allocated to groups according to the last digit (odd/even) of their admission numbers. All patients had epidural anaesthesia with bupivacaine 0.5% performed by the same experienced anaesthesiologist. In the first group, the patients were administered intravenous dexmedetomidine infusion just after the epidural block and continued during the operation, while those in the second group were administered physiologic saline infusion at the same amount and duration.

The recovery time of sensory block was significantly longer in the first group. The bispectral index values were lower in the first group than in the second. Also, heart rate was significantly lower in Group I than in Group II. Regarding side-effects, shivering was significantly less frequent in the first group, whereas there was a significant increase in the requirement of atropine in the first group as dexmedetomidine caused bradycardia.

Intravenous administration of dexmedetomidine prolonged the duration of epidural anaesthesia, provided sedation and had few side-effects.

We compared the efficacy of intravenous lornoxicam vs. dipyrone in patient-controlled analgesia for postoperative analgesia.

The study included 105 patients who had undergone elective septorhinoplasty after receiving general anaesthesia. Patients were divided into three groups to receive lornoxicam (24 mg day−1), dipyrone (5 g day−1) or placebo. Pain was evaluated using a 0–100 mm visual analogue scale at 2, 4, 6, 8, 12, 16, 20 and 24 h postoperatively. Pethidine (1 mg kg−1) was administered intramuscularly to patients requiring rescue analgesia. Pethidine requirements were recorded during the first 24 h postoperatively, and treatment-related adverse effects were noted.

Postoperative pain scores were significantly lower with lornoxicam compared with dipyrone at 8 h (P = 0.016). No significant differences regarding pain scores at 2, 4, 6, 12, 16, 20 and 24 h were found. Significantly fewer patients in the lornoxicam group required rescue analgesics (vs. dipyrone, P = 0.046; vs. placebo, P = 0.001); fewer patients in the dipyrone group required rescue analgesics compared with placebo (P = 0.008). Significantly fewer patients in the lornoxicam group had nausea (vs. dipyrone, P = 0.022; vs. placebo, P = 0.006); no significant differences were found between the other two groups. Antiemetic use was significantly lower in the lornoxicam group (vs. dipyrone, P = 0.002; vs. placebo, P = 0.001).

Lornoxicam has better tolerability and is a more effective analgesic than dipyrone when administered by patient-controlled analgesia for postoperative analgesia after septorhinoplasty.

Intrathecal opioids are now used routinely in the UK for intra- and postoperative analgesia. The opioids of choice have altered over recent years and the dosage regimens used can vary between institutions. Concerns over safety have been reduced probably because much lower doses of opioids are now being used. This survey explored the practice of intrathecal opioid usage in the UK.

We sent a questionnaire survey to 270 anaesthetic departments and received 199 replies, a response rate of 73.7%.

Intrathecal opioids were used in 175 (88.4%) departments. Of these departments, 107 (61.1%) had local guidelines or protocols in place. Opioids such as diamorphine (used in 136 (78.2%) of departments) and fentanyl (129 (74.1%)) with a shorter duration of action are now more commonly used than morphine (37 (21.3%)) for intrathecal analgesia. In 96 (54.5%) departments, patients were nursed on regular surgical wards following administration of spinal opioids.

The use of low-dose lipophilic intrathecal opioids for postoperative analgesia is widespread in the UK. Patients are commonly nursed in low-dependency post-anaesthetic care areas. The low incidence of adverse events reported by the respondents along with the popularity of the technique suggests that low-dose spinal opioid administration is safe.