Postoperative pain after Caesarean section under spinal anaesthesia was not reduced by the addition of oral dextromethorphan to a multimodal approach including intrathecal morphine.

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Case reportA 7 l-year-old female was admitted electively for a left upper Iobectomy and possible pneumonectomy. An asymptomatic mass had been discovered in the left lung on a routine chest radiograph. The patient had a 25 pack-year smoking history and was a non-insulin dependant diabetic controlled on oral chlorpropamide 250 mg per day for the previous five years. The patient described mild orthostatic dizziness and occasional palpitations associated with anxiety. She denied any other cardiorespiratory symptoms. The patient had had two previous general anaesthetics for gynaecological surgery without complications. There was no history of drug or alcohol abuse. The patient's height was 1.53 m and her weight 45 kg. There were no abnormalities on physical examination. Preoperative ECG revealed sinus rhythm at 75 min-i with non-specific ST-segment changes and occasional unifocal premature ventricular contractions (PVC's). Chest x-ray showed a 3 cm diameter mass in the left mid-lung field. Spirometry, arterial blood gas analysis, haemoglobin, urinalysis and liver enzymes were all within mormal limits. Key wordsThe patient was premedicated with promethazine 25 mg and glycopyrrolate 0.2 mg IM one hour preoperatively. On arrival in the operating room the heart rate was 110 min -I, blood pressure 125/75 mmHg and the ECG revealed unifocal PVC's at a rate of 10 min -I. An IV line was placed and diazepam 5 mg and fentanyl 100 I~g administered. Subsequently, a radial artery line was placed and general anaesthesia induced with fentanyl 100 p~g, thiopentone 225 mg and the lungs were ventilated with isoflurane two per cent in oxygen. After pancuronium 5 mg and lidocaine 60 mg, a #35Fr right doublelumen bronchial tube was placed. Following intubation the heart rate was 100 min -I, blood pressure 108/64 mmHg and there were no PVC's. A further 3.5 mg pancuronium was admimistered incrementally during the four-hour anaesthetic to maintain >95 per cent thumb twitch depression and anaesthesia was maintained with isoflurane in oxygen.After induction of anaesthesia the patient was placed in the right lateral decubitus position and the position of the bronchial tube was verified by bronchoscopy. Prior to skin incision one further dose of fentanyl 50 I~g was given. Heart rate decreased to 80 min -1 and blood pressure decreased to 90/45 mmHg after thoracotomy which required a brief infusion of phenylephrine 40 Ixg ml -~. During the anaesthetic the heart rate remained between 80-96 min -~ without PVC's and the systolic blood pressure remained between 90-140 mmHg. The oxygen saturation during both two-lung and one-lung ventilation remained >97 per cent as determined by pulse oximetry and intermittant arterial blood gas analyses.From the time of induction until the initiation of one-lung ventilation (105 min) a Penlon AM 1000 anaesthetic machine was used in combination with a Penlon PPV isoflurane vaporizer and a Nuffield 400 CAN J ANAESTH 1990 / 37 : 2 / pp 258-61

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