SummaryGuidelines are presented for the organisational and clinical peri‐operative management of anaesthesia and surgery for patients who are obese, along with a summary of the problems that obesity may cause peri‐operatively. The advice presented is based on previously published advice, clinical studies and expert opinion.

We found a nonsignificant difference in outcome between NAC and placebo-treated patients. Our results suggest that the initiation of NAC treatment >24 hrs after hospital admission may potentially be harmful, and further studies should be undertaken to investigate the clinical use of the early application of NAC in critically ill patients.

We have investigated the use of microalbuminuria as a predictor of outcome in a pilot study involving 50 critically ill patients in a six-bed hospital intensive care unit (ICU). Urinary microalbumin:creatinine (M:Cr) ratios measured only 6 h after admission to the ICU demonstrated a significant difference (P = 0.01) between survivors and non-survivors, allowing rapid identification of patients at increased risk of developing organ failure and at greater risk of death. This work suggests that earlier identification of these patients using a rapid, simple, inexpensive biochemical test is possible; if confirmed in a larger study, it may be that clinical interventions can be targeted at those most likely to benefit.

No abstract

SummaryTwo cases cfsevere hrudycardiu are described which occurred during elevations of zygomatic fractures. The twa patients and the possible mechunisms involved are discussed. Key wordsComplications; bradycardia. Surgery; faciomaxillary.The oculocardiac reflex is a phenomenon well known to anaesthetists engaged in ophthalmic work. We report two cases that demonstrated what we believe to be a hitherto unreported variation of this reflex: that elicited by elevation of zygomatic fractures. Case histories Case IThis was a healthy, 43-year-old man who weighed 79 kg and had sustained a depressed left zygomatic fracture in an affray 5 days prior to hospital admission. He was medically fit, had no previous anaesthetic history and was unpremeditated. Anaesthesia was induced with thiopentone 425 mg followed by suxamethonium 75 mg. The trachea was intubated with an oral 9.5-mm cuffed tracheal tube. On return of some movement, atracurium 0.5 mg/kg was given and anaesthesia maintained with 0.5% halothane and 66% nitrous oxide in oxygen (fresh gas flow 6 litres/minute) using a Manley Servovent ventilator. Monitoring was by means of an ECG and oscillotonometer.Surgery proceeded uneventfully with the systolic blood pressure (BP) maintained at 120 mmHg and pulse at 80 beatsjminute in sinus rhythm. The pulse decreased to 60 beats/minute (sinus rhythm) a t the first attempt to elevate the fracture and recovered to 80 beats/minute immediately on cessation of the stimulus. The second and successful attempt to elevate the fracture caused the pulse to decrease to 30 beatsjminute with a junctional rhythm and then to sinus arrest for 4 seconds. This reverted spontaneously to a junctional rhythm at 30 beats/minute. Intravenous atropine 600 pg converted this to a sinus tachycardia of 120 beats/ minute with frequent ventricular ectopics. This gave way to a bigeminal rhythm which itself reverted spontaneously to a sinus tachycardia. This whole episode lasted one minute. The rest of anaesthesia was uneventful. Reversal of residual neuromuscular blockade was with neostigmine 2.5 mg and glycopyrronium 0.5 mg. A postoperative ECG was normal.