Anaphylactic reactions to anaesthetic and associated agents used during the perioperative period have been reported with increasing frequency in most developed countries. Any drug administered in the perioperative period can potentially produce life-threatening immune-mediated anaphylaxis. Most published reports on the incidence of anaphylaxis come from France, Australia, the UK and New Zealand. These reflect an active policy of systematic clinical and/or laboratory investigation of suspected immune-mediated reactions. The estimated incidence of anaphylaxis ranges from 1 : 10 000 to 1 : 20 000. Muscle relaxants (69.1%) and latex (12.1%) were the most frequently involved drugs according to the most recent French epidemiological survey. Clinical symptoms do not afford an easy distinction between immune-mediated anaphylactic reactions and anaphylactoid reactions resulting from direct non-specific histamine release. Moreover, when restricted to a single clinical symptom, anaphylaxis can easily be misdiagnosed. Pre- and postoperative investigation must be performed to confirm the nature of the reaction, the responsibility of the suspected drugs and to provide precise recommendations for future anaesthetic procedures. These include plasma histamine, tryptase and specific IgE concentration determination at the time of the reaction and at skin tests 6 weeks later. In addition, since no specific treatment has been shown reliably to prevent the occurrence of anaphylaxis, allergy assessment must be performed in all high-risk patients. Treatment of anaphylaxis is aimed at interrupting contact with the responsible antigen, inhibiting mediator production and release, and modulating the effects of released mediators. It must be initiated as quickly as possible and relies on widely accepted principles. Finally, the need for proper epidemiological studies and the relative complexity of allergy investigation should be underscored. They represent an incentive for further development of allergo-anaesthesiology clinical networks to provide expert advice for anaesthetists and allergologists.

Background and objective: Recent clinical studies comparing ropivacaine 0.25% with bupivacaine 0.25% reported not only comparable analgesia, but also comparable motor block for epidural analgesia during labour. An opioid can be combined with local anaesthetic to reduce the incidence of side-effects and to improve analgesia for the relief of labour pain. The purpose of the study was to evaluate the effects of epidural bupivacaine 0.2% compared with ropivacaine 0.2% combined with fentanyl for the initiation and maintenance of analgesia during labour and delivery.

Methods: Sixty labouring nulliparous women were randomly allocated to receive either bupivacaine 0.2% with fentanyl 2 μg mL−1 (B/F), or ropivacaine 0.2% with fentanyl 2 μg mL−1 (R/F). For the initiation of epidural analgesia, 8 mL of the study solution was administered. Supplemental analgesia was obtained with 4 mL of the study solution according to parturients’ needs when their pain was ≥4 on a visual analogue scale. Analgesia, hourly local anaesthetic use, motor block, patient satisfaction and side-effects between groups were evaluated during labour and at delivery.

Results: Sixty patients were enrolled and 53 completed the study. No differences in verbal pain scores, hourly local anaesthetic use or patient satisfaction between groups were observed. However, motor block was observed in 10 patients in the B/F group whereas only two patients had motor block in the R/F group (P < 0.05). The incidence of instrumental delivery was also higher in the B/F group than in the R/F group (P < 0.05).

Conclusions: The results suggest that epidural bupivacaine 0.2% and ropivacaine 0.2% combined with fentanyl produced equivalent analgesia for pain relief during labour and delivery. It is concluded that ropivacaine 0.2% combined with fentanyl 2 μg mL−1 provided effective analgesia with significantly less motor block and need for an instrumental delivery than a bupivacaine/fentanyl combination at the same concentrations during labour and delivery.

Background and objective: Epidural analgesia is the most effective method for pain relief during labour. The aim was to elucidate the efficacy of ropivacaine 0.05% and bupivacaine 0.05%, which were both combined with fentanyl 0.00015% to provide analgesia in labour.

Methods: Forty nulliparous females were enrolled into the study. After insertion of an epidural catheter, patients were randomly assigned into two groups. Once the os uteri had dilated to 4–5 cm, a bolus of bupivacaine 0.125% 10 mL + fentanyl 50 μg (1 mL) in Group 1 patients, and ropivacaine 0.125% 10 mL + fentanyl 50 μg (1 mL) in Group 2 patients was administered via the epidural catheter. Then, patient-controlled epidural analgesia was started with a basal infusion of bupivacaine 0.05% 10 mL h−1 + fentanyl 0.00015% 1.5 μg mL−1 in Group 1, and ropivacaine 0.05% + fentanyl 1.5 μg mL−1 in Group 2. When needed, a 10 mL bolus infusion could be given and the lockout time was 20 min. Maternal and fetal haemodynamic variables were monitored before induction and subsequently at 5 min intervals. Using a visual analogue scale assessed the degree of pain.

Results: Maternal haemodynamic variables and Apgar scores were not different between the two groups. The second stage of the labour was shorter in Group 2 (P < 0.01). There were no significant differences in patients’ assessment of motor block or mode of delivery between groups.

Conclusions: An epidural infusion (10 mL h−1) of bupivacaine 0.05% or ropivacaine 0.05% together with fentanyl 1.5 μg mL−1 provided good and safe analgesia during labour.

Background and objective: Cardiac surgery with cardiopulmonary bypass triggers an inflammatory response involving pro-inflammatory cytokines such as tumour necrosis factor-α (TNF-α), interleukin 6 (IL-6) and interleukin 8 (IL-8). We investigated whether different anaesthetic techniques alter the pro-inflammatory cytokine response to cardiac surgery.

Methods: Thirty patients scheduled for elective coronary artery bypass grafting (CABG) surgery were randomized into three groups of 10 patients. They received either volatile inhalation induction and maintenance (Group 1) or total intravenous anaesthesia with propofol and a minimal dose sufentanil (Group 2) or a moderate dose midazolam-sufentanil (Group 3). The effect of the different anaesthetic techniques on plasma levels of TNF-α, IL-6 and IL-8 were examined during and after anaesthesia.

Results: Concentrations of TNF-α, and IL-8 were comparable in the three groups throughout all measurements. Before the start of cardiopulmonary bypass, IL-6 was significantly higher in Group 1 than in Group 2 (P = 0.009) or Group 3 (P = 0.030), but there were no differences between groups after cardiopulmonary bypass or postoperatively. In the three groups there was a positive correlation between aortic clamping time and serum concentrations of IL-6 (r = 0.54) and IL-8 (r = 0.62). Length of stay in intensive care was correlated with high levels of TNF-α (r = 0.78).

Conclusions: Albeit there is difference between the volatile induction and maintenance of the anaesthesia method and the total intravenous anaesthesia technique on the pro-inflammatory cytokine response to surgical stimulation before starting of cardiopulmonary bypass, neither technique can modify the pro-inflammatory cytokine response to ischaemia-reperfusion or extracorporeal circulation.

Background and objective: The role of sevoflurane has not been studied in relation to awareness during anaesthesia. We observed the effect of sevoflurane on the incidence of awareness during cardiopulmonary bypass for open-heart surgery.

Methods: Fifty-nine patients of age >17 yr undergoing open-heart surgery with cardiopulmonary bypass were randomly assigned to two groups. In both groups, induction was with etomidate, dehydrobenzperidol and fentanyl; anaesthesia was maintained with sevoflurane, fentanyl and N2O; vecuronium was used for muscular paralysis. Group 1 (30 patients) received dehydrobenzperidol and fentanyl during cardiopulmonary bypass; Group 2 (29 patients) received sevoflurane and fentanyl. Patients were given different auditory inputs during different phases of surgery. All patients were interviewed with standard questions 8 and 24h postoperatively for evidence of explicit awareness.

Results: Five patients in the dehydrobenzperidol group gave a history of awareness (16.67%) as opposed to none in the sevoflurane group. The difference in the incidences of awareness was significant (P < 0.05), but no differences were found between the interviews conducted at 8 and 24h. Sevoflurane and opioid combination reduced the incidence of awareness in open-heart surgery.

Background and objective: The feasibility of monitoring measured intravascular volumes and the cardiac filling pressures were compared to reflect the optimal volume status of postoperative patients.

Methods: In a prospective clinical study, 14 hypovolaemic adult patients were included after cardiac surgery. All patients received 1000 mL hydroxyethyl starch after meeting the authors’ criteria for hypovolaemia. Pressures were measured by use of a pulmonary artery catheter and volumes were determined by double-indicator dilution technique.

Results: Stroke volume index (SVI), central venous pressure (CVP), pulmonary artery occlusion pressure (PAOP), intrathoracic blood volume index (ITBVI) and total circulating blood volume (TBVIcirc) increased significantly after volume loading (30.7 ± 9.8 to 41.7 ± 9.6 mL m−2, 4.9 ± 1.7 to 9.1 ± 2.3 mmHg, 6.6 ± 1.3 to 10.6 ± 1.9 mmHg, 858 ± 255 to 965 ± 163 mL m−2, and 1806 ± 502 to 2110 ± 537 mL m−2, respectively). During the subsequent 1 h steady-state period, CVP and PAOP decreased significantly (9.1 ± 2.2 to 7.4 ± 2.2 mmHg and 10.6 ± 1.9 to 9.2 ± 2.0 mmHg, respectively), whereas SVI and intravascular volumes remained unchanged. The changes of CVP and PAOP did not correlate with changes in stroke volume during volume loading (r2 = 0.06 and 0.03, respectively) and during steady-state (r2 = 0.17 and 0.00 respectively). On the other hand, a significant correlation was found between changes of the intrathoracic blood volume and changes in stroke volume during the volume loading (r2 = 0.67) and also during the steady-state phase (r2 = 0.83).

Conclusions: Intrathoracic blood volume reflects more accurately the preload dependency of cardiac output in postoperative patients than left/right-sided cardiac filling pressures.

Background and objective: Drug mixtures containing sufentanil may be unstable owing to absorption into the drug reservoirs of patient-controlled epidural analgesia systems that contain polyvinylchloride. The stability of sufentanil in a mixture of ropivacaine 0.2% in a 750 mL reservoir was therefore investigated.

Methods: During simulated epidural infusions of 5 mL h−1 at 25°C, sufentanil concentrations were measured for 96 h. Samples were taken from the reservoir and from the end of the epidural catheter under the following conditions: into glass or polyvinylchloride reservoirs containing ropivacaine 0.2% with sufentanil 1, 0.75 or 0.5 μg mL−1; and into polyvinylchloride reservoirs with ropivacaine 0.2% and sufentanil 1 μg mL−1 which were stored for 4 weeks at 8°C.

Results: The different solutions remained stable over the observation period of 96h. Using the same solutions, independent samples’ ANOVA showed no difference in the sufentanil concentrations between the glass and polyvinylchloride reservoirs, or between the polyvinylchloride reservoirs when stored for 4 weeks. Correlations between the concentrations at the different measurement times were extremely high for the reservoir (rmin = 0.98, rmax = 1.00) and the catheter end (rmin = 0.86, rmax = 1.00).

Conclusions: Sufentanil citrate at 0.5–1.0 μg mL−1 in an admixture of ropivacaine 0.2% for 5 days, which is the usual period for postoperative epidural analgesia, remains stable in a polyvinylchloride reservoir. There is no change in the drug concentration even if the reservoir is stored for 4 weeks at 8°C.

The intubating laryngeal mask airway is a modification of the conventional laryngeal mask and is used as a tool for difficult intubation. It can be inserted without placing the head and neck in the Magill position and has been used successfully in cervical spine injuries. Reported is a case of successful insertion of the intubating laryngeal mask and subsequent intubation through it in a patient with ankylosing spondylitis with cervical involvement resulting in a fixed flexion deformity who underwent coronary artery bypass grafting.