Neutrophils have been implicated in the pathogenesis of the adult respiratory distress syndrome (ARDS). We have measured concentrations of the neutrophil attractant interleukin-8 in blood and bronchoalveolar lavage fluid (BAL) from patients at risk of ARDS. We studied 29 patients from three groups at risk of developing ARDS: multiple trauma (n = 16), perforated bowel (n = 6), and pancreatitis (n = 7). ARDS developed in 7 of these patients. Interleukin-8 in BAL and blood samples taken on initial hospital presentation was measured by a sandwich enzyme-linked immunosorbent assay. The mean BAL interleukin-8 concentration was significantly higher for the patients who subsequently progressed to ARDS than for the non-ARDS group (3.06 [SE 2.64] vs 0.053 [0.010] ng/mL, p = 0.0006). There was no difference between the groups in plasma interleukin-8 (6.23 [2.60] vs 5.12 [2.22] ng/mL, p = 0.31). Immunocytochemistry suggested that the alveolar macrophage is an important source of interleukin-8 at this early stage in ARDS development. This study provides evidence of a relation between the presence of interleukin-8 in early BAL samples and the development of ARDS. The early appearance of interleukin-8 in BAL of patients at risk of ARDS may be an important prognostic indicator for the development of the disorder and reinforces the likely importance of neutrophils and the effects of their accumulation and activation in the pathogenesis of many cases of ARDS.

Liver transplantation (LT) may be life-saving in severe acute liver failure (ALF). The aim of this study was to compare the utilization of LT in acetaminophen and non-acetaminophen ALF. Between 1992 and 2006, 469 patients with ALF were admitted, and 104 underwent LT. Acetaminophen was the most common etiology, but LT proceeded more frequently in the non-acetaminophen cohort (acetaminophen: 45/326 patients received LT, 13.8%; non-acetaminophen: 59/143 patients received LT, 41.3%; P Ͻ 0.01). A retrospective analysis of the individual steps in the management of patients revealed more ALF patients in the non-acetaminophen cohort fulfilled the King's College Hospital poor prognostic criteria (non-acetaminophen: 91/143, 63.6%; acetaminophen: 165/326, 50.6%; P Ͻ 0.01), more patients had contraindications to LT in the acetaminophen cohort (acetaminophen: 99/165, 60%; non-acetaminophen: 21/91, 23.1%; P Ͻ 0.01), and survival on the LT waiting list was reduced in the acetaminophen cohort (acetaminophen: 45/66, 68.2%; non-acetaminophen: 59/70, 84.3%; P Ͻ 0.05). Post-LT survival was similar in the 2 groups. An analysis of cohorts admitted in 1993-1996 and 2002-2005 revealed that LT proceeded less commonly in acetaminophen ALF in the later cohort (1993( -1996 4/81 LT, 5%; P Ͻ 0.01) in comparison with the non-acetaminophen cohort, in which transplantation proceeded more commonly in the later cohort (1993( -1996 24/49 patients, 49.0%; P Ͻ 0.01). This was due to an increase in the number of patients with psychiatric contraindications to transplantation (predominantly resistant and severe alcohol dependence). In conclusion, at all decision steps between admission and emergency LT, LT is favored in non-acetaminophen patients, and nonoperative management is favored in acetaminophen ALF patients. Liver Transpl 15: 600-609, 2009.

Ninety-one patients were allocated randomly to three groups to receive 1% ropivacaine 10 ml, 0.5% ropivacaine 20 ml or 0.5% bupivacaine 20 ml extradurally. Intermittent sensory (pinprick) and motor (Bromage scale) assessments of the block produced were recorded, with an assessment of the quality of the block and the requirement for supplementary analgesia. There was little difference between the groups in frequency, onset, duration or spread of sensory block. However, the motor block produced by 0.5% ropivacaine was less intense and of shorter duration than that with bupivacaine. The block produced by the smaller volume of ropivacaine was less reliable clinically than the larger, more dilute, solution and more anaesthetic supplements were required in that group. Cardiovascular changes were similar in all three groups. The peak plasma concentration of ropivacaine was significantly greater and T1/2 significantly shorter than those of bupivacaine, although no patient showed any features of systemic toxicity. The systemic kinetics of ropivacaine were not influenced significantly by varying the concentration or volume administered.

SUMMARYDefinitive airway control which may require endotracheal intubation with or without an induction agent and muscle relaxant is an essential component of trauma resuscitation. We reviewed the delivery of advanced airway care in the resuscitation room of a regional trauma centre. This prospective survey suggests that in the absence of an experienced anaesthetist, A&E staff with a background of suitable training and experience may undertake the anaesthetic responsibility associated with securing a definitive airway when the situation demands.