Percutaneous retrograde placement of gastrostomy or gastrojejunostomy tubes safely and effectively provides long-term nutrition for children. A team approach is essential to provide service to this cumulative population.

SummaryA recent study performed in this department showed that a subcutaneous injection of local anaesthetic was significantly less painful than the insertion of a 22-gauge venous cannula. However, our colleagues remained sceptical that local anaesthetic infltration would eliminate the pain of cannulation. Consequently a further study was undertaken to compare the pain of cannulation with and without the use of local anaesthetic. The results show that pain of cannulation is significantly ( p < 0.003) reduced after subcutaneous infltration with I % lignocaine when compared to cannulation without local infltration. Persistent discomfort at the site of cannulation was eliminated by the use of local anaesthetic. Key wordsVeins; cannulation. Anaesthetics, local; lignocaine.A survey undertaken in this department revealed that most anaesthetists did not employ infiltration of local anaesthetic before insertion of an 18, 20 or 22-gauge intravenous cannula because they believed that cannulation was less painful than injection of lignocaine. We demonstrated [I] that intravenous cannulation with a cannula of 18,20 or 22 gauge was significantly (p < 0.006) more painful than a subcutaneous injection of 1 % lignocaine. These results were disseminated within our anaesthetic department, but most anaesthetists remained of the opinion that the combination of local anaesthetic infiltration and insertion of an intravenous cannula (which had not been investigated) was more painful than cannulation alone.This study was undertaken to establish whether prior injection of local anaesthetic significantly diminishes the pain of cannula insertion when using a small intravenous cannula (1 8-22-gauge). Patients and MethodsThe study was approved by the District Ethics Committee and written informed consent was obtained from all participants. Sixty adult patients, who were about to undergo surgery under general or regional anaesthesia, were included in the trial. Patients were allocated randomly (sealed envelope technique) into one of three groups, to receive intravenous cannulation with a Venflon cannula of 18 (group I), 20 (group 2) or 22-gauge (Group 3). Within each group, the side of local anaesthetic infiltration was randomised equally between left and right. Patients were premedicated or not as determined by the anaesthetist.The patient's eyes were closed throughout the procedure and a tourniquet was applied to both arms. A subcutaneous injection of 0.25 ml lignocaine I % through a 25-gauge needle was given into the dorsum of one hand and 1 min later a Venflon of predetermined size was inserted into the vein through the site of local infiltration. A Venflon of the same size was inserted into the corresponding site in the other hand. Cannulation was performed in the left hand first in all patients.The patients were then asked which procedure was the more painful and graded each insertion on a discrete pain scale of 1 to 10 ( I : no pain; 10: worst pain imaginable). All cannulations were successful at the first attempt. After a delay of ...

SummaryThe anaesthetist has less contact with the conscious patient than other professionals. The patient's perception of the anaesthetist may be influenced by the pre-operative visit. Studies of appearance show that some patients still prefer a more traditional dress for clinicians [4], while other patients are uninfluenced by doctors' appearance [5, 61. Rarely does the anaesthetist wear the 'regulation' doctor's white coat or name tag, both of which were thought desirable in a recent study [7]. That study also showed that the appearance of the anaesthetist was deemed unimportant to the success of the pre-operative visit, but it was not clear how many patients appreciated that the anaesthetist was medically qualified.Our study was designed to relate the appearance of the anaesthetist at the pre-operative visit to the patient's perception of the position and prestige held by anaesthetists among other medical and health service personnel. Patients and MethodsAdult patients, scheduled for operation within 24 h, were chosen at random from surgical and gynaecological wards.They had no inside knowledge of. or relation to. the medical services. Patients were allocated randomly to one of two groups. A or B and a representative cross-section of age and sex was included.All patients received a routine pre-operative visit by a male anaesthetist who was the same individual in all cases. He introduced himself by name and as an anaesthetist but gave no title and made no reference to his position. He undertook a predetermined standard pre-operative assessment. similar in all cases. When visiting patients in group A, he was dressed formally in a suit and tie, while for group B he wore jeans. trainers and an open-necked shirt.Within 30 min of the pre-operative visit, the patients were interviewed by a second individual and asked to complete a questionnaire in confidence. The interviewer introduced himself as a research student and no association was made with the anaesthetist.The patients were first shown two lists of adjectives that described the visit and the anaesthetist (Multiple Affect Adjectival Check Lists). They were asked to choose any of the adjectives which they felt were descriptive of the anaesthetist and his visit.The patients were then shown four questionnaires concerning the anaesthetist and his relationship with other professionals. The interviewer explained any terms not understood but refrained from using the terms Doctor, Specialist, Consultant, or any other term which might have influenced the patient. Finally, the patients were asked to

SummaryA survey was conducted on 100 consecutive patients who underwent spinal anaesthesia in our urology operating theatres. Details of' the spinal technique were recorded in the operating theatre. In 25% of patients, more than one attempt at subarachnoid puncture was required and 16% of this group went on to require general anaesthesia. The patients were visited between 24 and 48 h postoperatively by one of the authors. On questioning, 24% ofpatients reported a headache, which had the characteristics associated with dural puncture; 62% of these headaches were described as moderate or severe and lasted between I2 and 24 h. Patients were sign$cantly ( p < 0.05) more likely to develop a postdural puncture headache i f more than one attempt at subarachoid puncture was made. Key wordsAnaesthetic techniques regional; spinal. Complications; headache.It is common practice among anaesthetists to use spinal anaesthesia for some urological procedures, particularly transurethral resection of prostate (TURP) or of tumour (TURT). In obstetric practice, there has been a great deal of interest in the occurrence of headaches after spinal anaesthesia, and in methods of minimising their incidence. There has been much less interest in examining these problems in the urological patient. A previous study [I] reported a 4% incidence of postdural puncture headache in patients aged over 60 years.The majority of anaesthetists in our department believe that postdural puncture headache in this age group is rare if a 26-gauge Yale spinal needle is used. However, there is no firm evidence to support this belief. We therefore carried out an audit of urological spinal anaesthetics in an attempt to provide further information on this topic. MethodsDetails of 100 consecutive patients who underwent spinal anaesthesia for urological procedures were recorded by the anaesthetist in the operating theatre. The following information was obtained for each patient: age; gauge and type of spinal needle; number of attempts at dural puncture; success or failure of the technique. No attempt was made to standardise the technique used to perform the spinal anaesthetic, or the subsequent management. All the patients were visited between 24 and 48 h postoperatively by one of the authors. Specific enquiry was made regarding the occurrence and duration of a postoperative headache which was characteristic of dural puncture, i.e. a postural headache aggravated by standing, relieved by lying down and fronto-occipital in distribution. Severity of the headache was assessed as described in a recent report [2]: slight, patient able to walk and requiring occasional analgesics; moderate, preventing activity and requiring analgesic therapy; severe, preventing the patient from getting up, and associated with nausea and photophobia.Patients were also asked about their overall satisfaction with the anaesthetic technique used. ResultsAll of the 100 patients were visited postoperatively. A total of 98 were male and the age range was from 50-88 years (mean 71 years). A 26-gau...

SummaryHigh continuousflow breathing systems are now available to provide fresh gasflows well in excess of 100 I.min-I in continuous positive airway pressure systems used for respiratory support. The performance of two commonly used intensive care humidifiers. the Kendal Conchatherm and the Fisher and Paykel FP310 have been assessed a t j o w s of 50, 75, 100, I25 and 150 I.min-'. Their performance when using two humidifiers connected in parallel and in series was also studied. A t a fresh gasflow of 100 I.min-I the single Conchatherm gave an absolute water vapour concentration of 15.6 g.m-' and the single FP310 11.9 g.m-3. At allflows the best results were achieved using two Conchatherm humidijiers in series. It is concluded that with high continuous flow breathing systems the humidification achieved with conventional humidifiers may be inadequate and it may be necessary to combine two humidifiers to obtain clinically useful humidification. Key wordsEquipment; humidifiers, anaesthetic breathing systems. Humidijication. Ventilation; continuous positive airway pressure.The upper airway normally warms, moistens and filters inspired gas. If this mechanism is bypassed for any length of time, such as by tracheal intubation, then it is accepted that some means of artificial humidification is required. Inspired air is warmed and humidified by the nasooropharynx to reach the upper airway with a relative humidity (RH) of about 90% and a temperature of 32-36°C. Normal nasal breathing adds about 75% of total water content before the inspired gas reaches the larynx. A temperature at the mouth of approximately 32°C and a mean absolute humidity of 27.3 g.m-3 is considered optimal in a patient receiving ventilatory support [I]. Humidification of inspired gases to this level should preserve mucociliary and pulmonary function in most patients. In intubated patients or those with a tracheostomy, the naso-oropharynx is bypassed and the RH falls to 50% or less. Presentation of dry, cold gases direct to the trachea has several adverse effects which include an increase in mucus viscosity, reduced ciliary function, microatelectasis due to obstruction of small airways and larger airway obstruction from tenacious sputum [2]. An ideal humidifier should therefore deliver inspired gases to the tracheal mucosa close to saturation at body temperature.The set temperature should remain constant and both temperature and humidity should be unaffected over a large range of gas flows.Continuous Positive Airway Pressure (CPAP) systems are presently available which utilise high flows in excess of 100 1.min-I [3], greatly in excess of flows used in other systems. There are advantages in using these high flow systems over low flow systems with reservoir bags or ondemand systems [4-61. If the high continuous flow CPAP systems are to be used in the intensive care unit then adequate humidification is required. This study assesses the performance of two humidifiers, the Kendal Conchatherm (Concha) and the Fisher and Paykel FP310 (F&P) over a range of fl...