SummaryA double-blind, randomised clinical study was undertaken to compare the efSect of temperature on the incidence and severity of the pain experienced on injection of propofol. The number of patients who experienced pain and the severity of the pain were reduced signijicantly when propofol was administered at a temperature of 4°C. The eficacy of propofol as an induction agent appeared to remain unaltered. Key wordsAnaesthetics, intravenous; propofol. Complications; pain.It is well recognised that propofol may cause pain or discomfort on injection when administered intravenously, especially into a vein on the dorsum of the hand. Studies have shown that the incidence may be as high as 45%.' Premedication has little influence on the incidence of pain but may reduce its severity.2 Other important factors are known to be the site and speed of injection3-' and the use of analgesics and local anaesthetics in combination with p r o p o f~l .~-~ This study was designed to assess whether the temperature of propofol affects the incidence or severity of pain on injection. Patients and methodsThe study was performed on 71 adult patients of ASA class 1 and weight 50-85 kg who presented for minor, elective surgery. Informed consent was obtained. All patients received lorazepam 0.5 mg/lO kg to a maximum of 4 mg, 90 minutes before surgery. A 22-gauge cannula was inserted into the largest apparent vein in the dorsum of the hand. The patients were then allocated randomly to one of two groups.General anaesthesia was induced with intravenous propofol 2.5 mg/kg. Patients in group 1 received propofol that had been taken directly from the refrigerator (4-5°C). Those in group 2 received propofol maintained at room temperature (20-23°C). The speed of injection was controlled carefully. One quarter of the total calculated dose was given over the first 5 seconds; after this period, the injection was stopped for 5 seconds to allow assessment of discomfort by the method outlined below. An initial pain score was obtained. Induction was then continued and the second quarter of the total induction dose was administered over a further 5-second period. The patient was questioned again and a second pain score obtained. Finally, the remainder of the induction dose was administered.The level of pain was assessed by a second, independent anaesthetist who was unaware of the group to which the patient had been allocated. The pain score was obtained by asking the patient a standard question about the comfort of the injection and the verbal response, together with behavioural signs such as facial grimacing, arm withdrawal or tears. A score of 0 to 3, which corresponded to no pain, mild, moderate and severe pain, respectively, was recorded ( Table 1). ResultsThe second pain score was higher in all cases and this score was used for later analysis. The results are shown in Table 2. The overall incidence of pain in group 2 was 46% compared with 23% in group 1 (p < 0.05). In addition, less patients in group 1 experienced severe pain (3% versus 21 Yo; p <...

This study reveals that in an intensive care unit important diagnostic discrepancies were found in 19.6% of patients who underwent a post mortem examination. In a fifth of these (4.1%), survival may have been adversely affected. Haemorrhage was the most commonly missed diagnosis. Despite technological advances in intensive care medicine the post mortem examination continues to have an important role in auditing clinical practice and diagnostic performance.

Observations were recorded from two hundred consecutive insertions of the laryngeal mask airway (LMA). They were undertaken by 27 anaesthetists most of whom had no previous experience of its use. A clinically patent airway was obtained in 94% of patients and in the majority of these (76%) the LMA was positioned correctly at the first attempt. There were twelve cases of failed insertion. Nine of these were as a result of an inability to pass the LMA correctly into the hypopharynx while in the remaining three cases complete airway obstruction was reported. The insertion technique was easily acquired and trainee anaesthetists achieved a success rate of84%for their firstfive attempts. Success with the LMA was related to experience: anaesthetists who had used the LMA over 15 times had no failures in 67 insertions. Twenty-two patients coughed and six developed mild laryngospasm at insertion. The incidence of postoperative sore throat was 8%.

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