We studied 60 children, aged 12 months to 8 yr, undergoing plastic surgery under general anaesthesia supplemented by regional anaesthesia. Patients were allocated randomly to have the laryngeal mask airway removed either on awakening or while anaesthetized. Subsequent observation of respiratory factors and oxygen saturation showed a significant difference between the groups for coughing (P < 0.001), with a greater incidence (17 of 33) in the awake group compared with those from whom the laryngeal mask airway was removed while anaesthetized (two of 27). There were no differences in the incidences of laryngospasm, desaturation (< 95%) and excess salivation between the groups. Removed of the laryngeal mask airway during deep anaesthesia reduced coughing in the immediate postoperative period.

We studied the effect of P6 acupressure on 46 women undergoing laparotomy for major gynaecological surgery who received patient-controlled analgesia. Half the patients received acupressure at the P6 site, the remainder received acupressure at a "sham" site. There was a reduction in the requests for anti-emetic therapy in the group receiving P6 acupressure but there was no difference in the incidence of nausea and vomiting. There was no difference in total morphine consumption between the two groups.

Major surgery induces profound physiological responses; frequent sequelae include pain, nausea, ileus, increased cardiac demands, and impaired pulmonary function. These complications can lead to delayed mobilization, prolonged hospital stay, and significant postoperative complications. 'Fast-track' surgery was pioneered by Professor Henrik Kehlet in Denmark in the early 1990s. 1,2 The term refers to a multimodal package of techniques which aim to decrease post-surgical organ dysfunction and complications, and hence to improve postoperative recovery. The centres that have pioneered this approach have achieved impressive reductions in hospital stay and surgical morbidity. The core principles of fast-track surgery (or enhanced recovery) programmes, as applied to major abdominal surgery, are reviewed here. Each aspect uses evidence gleaned from the literature on perioperative medicine, and attempts to integrate these ideas into a seamless programme of clinical care. For this to be a success, the multidisciplinary team involved should be fully informed and educated about their roles within the programme. Well-organized prospective audit is an important part of the process. Preoperative management Preoperative assessment Postoperative organ dysfunction and complications are related to preoperative co-morbidity. Preoperative assessment allows estimation of risk and an opportunity to stabilize co-existing disease and optimize organ function before surgery. Preoperative assessment also provides an opportunity for patient education. In fast-track programmes, patients are given information about their anticipated postoperative course, analgesia, mobilization programme, and discharge. Several studies have demonstrated that such information can reduce anxiety, analgesic requirements, and length of hospital stay.

CPET provided the only means in this study of predicting both 30-day outcome and 30-month mortality. CPET could therefore become an increasingly important tool in determining the optimum management for AAA patients.

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