This paper describes two otherwise unrelated cases of fatal haemopericardium resulting directly from attempted cannulation of the right subclavian vein. Although this is an extremely rare complication, it is essential that all physicians involved in establishing central venous access are aware of the danger of causing this condition, and how the use of a careful technique of insertion can minimize the risk.

Hereditary angio-oedema is an autosomal dominant condition resulting in a deficiency of C1 esterase inhibitor protein in serum. The condition is characterized by oedematous attacks in the skin, mucous membranes and gastrointestinal tract triggered by mental and physical stress. We present the rare case of a young girl with known hereditary angio-oedema and spina bifida occulta being admitted for an elective pilonidal sinus excision. This case presented different challenges for the anaesthetists and surgeons.

A 74-year-old woman was scheduled for surgical treatment of a carpal tunnel syndrome. An intravenous (i.v.) regional anaesthetic was performed using 1% prilocaine standard technique. Three minutes after injection of the local anaesthetic mild to moderate central nervous system symptoms developed, along with tachycardia, sweating and peri-oral paraesthesia. The evolution was favourable, no convulsions or other more serious events occurred. Despite showing adequate pressure inflation the tourniquet failed to accomplish its purpose. The patient recovered well without any sequelae.

This study was undertaken to determine whether epidural analgesia has any benefit for post-operative pain relief in patients undergoing laparoscopic cholecystectomy. Patients were randomly assigned to receive post-operative epidural analgesia with a morphine–bupivacaine combination (Group A, n=22) or placebo (saline) (Group B, n=22). The same standard general anaesthetic technique, which consists of nitrous oxide and isoflurane in oxygen was used. Analgesia was assessed using visual analogue pain scores (0–10 cm). The evaluation was carried out 24 and 48 h post-operatively. At 24 h after anaesthesia, pain scores in Group A (2.3±1.2) were lower than those in Group B (4.4±1.5) (P<0.05). However, at 48 h post-operatively, no difference in scores was observed between the two groups. In conclusion, epidural analgesia with a morphine–bupivacaine combination improves pain relief during the first 24 h following laparoscopic cholecystectomy.

The medical literature sometimes reports neurological complications after spinal or epidural anaesthesia. In a few cases, the onset of symptoms can be a sign of a pre-existing disease without a primary connection with regional anaesthesia. In the following case report, the patient complained of paraesthesias in both legs after a failed spinal anaesthesia, even though the needle had been placed intrathecally. Only neurological examination and nuclear magnetic resonance imaging revealed the presence of syringomyelia.

Cardiac and major abdominal surgery are associated with granulocytosis in peripheral blood. The purpose of the present study was to describe the granulocyte and monocyte oxidative burst and the expression of adhesion molecules following cardiac surgery with cardiopulmonary bypass and abdominal surgery. The ability to respond with an oxidative burst was measured by means of flow cytometry using 123-dihydrorhodamine. The adhesion molecules CD11a/CD18, CD11c/CD18, CD44 were measured using monoclonal antibodies. Blood samples from eight patients undergoing open-heart surgery were taken before surgery, 1, 5, 10 and 20 min after aortic clamping, and then 1, 5, 10 and 20 min and 1, 2 and 3 h after declamping. Samples from eight patients undergoing abdominal surgery were taken before surgery, at the end of surgery, and 2 and 3 h post-operatively. A decrease in number of granulocytes and monocytes during cardiopulmonary bypass was observed. The percentage of CD11a-positive granulocytes increased from 30% preoperatively to 75% following cardiopulmonary bypass, while CD44-positive granulocytes increased from 5% to 13%. Despite the extent of the changes, these were not significant. The oxidative burst of the granulocytes and monocytes decreased after declamping to 15% and 27% of initial values in vitro. Several hours after surgery, there was no significant difference between the two groups. These results can be explained by a granulocyte and monocyte refractory response developing subsequent to an increased per-operative oxidative burst activity, and the induction of adhesion molecules on granulocytes associated with the cardiopulmonary bypass and surgery. In conclusion, open-heart surgery with cardiopulmonary bypass was associated with a rapid and pronounced activation of leukocytes which may play a role in reperfusion injury.

Airway management is a major concern in Robin sequence, where micrognathia, glossoptosis and a cleft of the soft palate exist. The management of an infant with a potentially difficult airway is discussed where tracheal intubation was aided by the use of a 2.2-mm fibrescope mounted with a 3-mm endotracheal tube passed through a size 1 laryngeal mask airway.

A 36-year-old female presented with seizures and transient dysphasia in her 31 week of pregnancy. Neuro-radiological investigations revealed a large falx meningioma. A decision was taken to deliver the infant and excise the tumour before term because of the risk of an increase in the size of the tumour and the risk of sinus thrombosis. Therefore, she underwent in her 32 week of pregnancy an elective Caesarean section followed by a craniotomy to remove the meningioma. There were no neonatal complications and she made an uneventful recovery. The final pathology report confirmed the diagnosis of meningioma with progesterone positive receptors.

We report the case of a 33-year-old woman who developed a dense hemiplegia immediately after an uncomplicated general anaesthetic for diagnostic laparoscopy. She had a history of recurrent hemiplegic migraine with a strong family history. Her migraine was normally associated with visual disturbances and a unilateral headache followed by a left-sided weakness such that she was unable to walk. Symptoms would last up to 24 h. Her post-operative state was atypical of her normal migraine, in that she had no headache or visual disturbance and initially all four limbs were affected.

The present report describes a case of cardiac arrest and subsequent death as a result of hyperkalaemia following the use of suxamethonium in a 23-year-old Malawian woman. Five days after the onset of the symptoms of meningitis, the patient aspirated stomach contents and needed endotracheal intubation. Forty seconds after injection of suxamethonium, bradycardia and cardiac arrest occurred. Attempts to resuscitate the patient were not successful. The serum level of potassium was observed to be 8.4 mequiv L−1. Apart from the reduction in the patient's level of consciousness, there were no signs of motor neurone damage or of any of the other known predisposing conditions for hyperkalaemia following the administration of suxamethonium. It is postulated that her death was caused by hypersensitivity to suxamethonium, associated with her 5-day immobilization.

While Horner's syndrome is a rare and occasionally reported complication of epidural ‘top-ups’ administered for labour and Caesarean delivery, the case reported here followed a low-dose epidural infusion of bupivacaine. Low-dose epidural infusions have generally been regarded as a safer alternative to bolus doses in labour. It is also the case that close supervision is deemed unnecessary in some centres where the mother is receiving such an epidural infusion. This case is reported in order to highlight the potential dangers of a low-dose regime which in spite of the lack of early warning signs may be associated with a high block.

A 17-nation survey was undertaken with the aim of studying the availability of acute pain services (APS) and the use of newer analgesic techniques, such as epidural and patient-controlled analgesia (PCA). A questionnaire was mailed to selected anaesthesiologists in 105 European hospitals from 17 countries. Depending on the population, between five and ten representative hospitals from each country were selected by a country coordinator. A total of 101 (96.2%) completed questionnaires were returned. A majority of respondents were dissatisfied with pain management on surgical wards. Pain management was better in post-anaesthesia care units (PACUs); however, 27% of participating hospitals did not have PACUs. There were no organized APS in 64% of hospitals, although anaesthesiologists from chronic pain centres were available for consultation. In the hospitals that had APS, the responsible person for the APS was either: (1) a junior anaesthesiologist (senior anaesthesiologist available for consultation); or (2) a specially trained nurse (supervised by consultant anaesthesiologists). Many anaesthesiologists were unable to introduce techniques such as PCA on wards because of the high equipment costs. Although 40% of hospitals used a visual analogue scale (VAS) or other methods for assessment of pain intensity, routine pain assessment and documenting on a vital sign chart was rarely practised. There was a great variation in routines for opioid prescription and documentation procedures. Nursing regulations regarding injection of drugs into epidural and intrathecal catheters also varied considerably between countries. This survey of 105 hospitals from 17 European countries showed that over 50% of anaesthesiologists were dissatisfied with post-operative pain management on surgical wards. Only 34% of hospitals had an organized APS, and very few hospitals used quality assurance measures such as frequent pain assessment and documentation. There is a need to establish organized APS in most hospitals and also a need for clearer definition of the role of anaesthesiologists in such APS.

In this case report, the anaesthetic management for a removal of phaeochromocytoma undertaken immediately following Caesarean section is described. A 32-year-old female patient was given epidural anaesthesia for Caesarean section, and thereafter, general anaesthesia for a resection of phaeochromocytoma. During surgery, phentolamine, nitroglycerine and prostaglandin E1 were electively administered to decrease blood pressure and heart rate. A live infant was delivered and the supra-adrenal tumour was excised successfully. The patient's post-operative recovery was uneventful.

Familial amyloid polyneuropathy (FAP) type I is a rare disease characterized by sensorimotor polyneuropathy, and autonomic nervous system and cardiac conduction system dysfunction. Severe bradyarrhythmia and hypotension may occur during anaesthesia and surgery in patients with the FAP type I. Only one report has been published of a patient with FAP type I who was managed with epidural anaesthesia. The present authors report a 38-year-old Japanese man with a permanent pacemaker because of advanced FAP type I who underwent rotation flap of the gluteus maximus muscle to cover a trophic ulcer in the sacral region under lumbar epidural anaesthesia. Ten millilitres of adrenaline (1:200 000) was injected around the ulcer prior to surgical manipulation. Neither bradycardia nor hypotension developed during the procedures. The haemodynamic changes under lumbar epidural anaesthesia in FAP type I are discussed.

We describe a case of transient neurological deficit that occurred after unilateral spinal anaesthesia with 8 mg of 1% hyperbaric bupivacaine slowly injected through a 25-gauge pencil-point spinal needle. The surgery and anaesthesia were uneventful, but 3 days after surgery, the patient reported an area of hypoaesthesia over L3–L4 dermatomes of the leg which had been operated on (loss of pinprick sensation) without reduction in muscular strength. Sensation in this area returned to normal over the following 2 weeks. Prospective multicentre studies with a large population and a long follow-up should be performed in order to evaluate the incidence of this unusual side effect. However, we suggest that a low solution concentration should be preferred for unilateral spinal anaesthesia with a hyperbaric anaesthetic solution (if pencil-point needle and slow injection rate are employed), in order to minimize the risk of a localized high peak anaesthetic concentration, which might lead to a transient neurological deficit.