SummaryWe investigated the use of measurements of serum concentrations of the cardiac proteins troponins I and T as biochemical markers of myocardial cell damage in 80 patients undergoing vascular or major orthopaedic surgery. Holter electrocardiographic monitoring was carried out before surgery and for 3 days after surgery. Blood samples for troponins I and T and creatine kinase-MB isoenzyme were taken on each of these 4 days. Outcome was assessed at 3 months using a patient questionnaire, general practitioner follow-up and case notes review. Silent postoperative myocardial ischaemia was detected in 21 patients; increases in troponins I and T and creatine kinase-MB occurred in four, six and 17 of these patients, respectively. Eight patients suffered major postoperative complications (cardiac death, myocardial ischaemia, congestive cardiac failure, unstable angina and cerebrovascular accident) and 21 minor complications (poorly controlled hypertension needing increased or new additional treatment, palpitations, increased tiredness or shortness of breath in the absence of known respiratory disease). There were no associations between postoperative ischaemia and cardiac protein concentrations. The relative odds for the associations of major adverse outcome at 3 months after surgery and postoperative ischaemia or increased serum concentrations of the three proteins were 5.39 [95% confidence intervals 1.16±27.67] for postoperative ischaemia; 5.64 [1.07±31.00] for creatine kinase-MB isoenzyme; 17.00 [2.20±116.54] for troponin T and 13.20 [1.12±135.00] for troponin I. We found troponin T to be the only prospective marker for both major and minor cardiovascular complications (relative odds 10.65 [1.26±252.88]).

We studied 160 patients undergoing elective Caesarean section under spinal anaesthesia who received a preloading volume of 15 ml kg-1 of 10% pentastarch in 0.9% saline, or Hartmann's solution, in a prospective, randomized, double-blind study. We compared the incidence of spinal-induced hypotension in each group. Hypotension was defined as a decrease in systolic arterial pressure to less than 70% of baseline values or < or = 90 mm Hg, whichever was the greater. The groups were comparable in physical characteristics and there was no serious morbidity. Fetal outcome was similar in both groups. Significantly more patients in the Hartmann's group (n = 38, 47.5%) developed hypotension than in the pentastarch group (n = 10, 12.5%) (P < 0.0001). Linear regression analysis showed that the only significant variable was type of fluid used. Blood glucose concentrations were not related to the presence of hypotension. We conclude that starches may be suitable for preloading in Caesarean section under spinal anaesthesia and provide an alternative to the aggressive use of vasoconstrictors.

Case reports operation because of the extensive adhesions. Subsequent reoperation was necessary because additional bezoars were left in the stomach and later caused a new obstruction.Small bowel obstruction by phytobezoar after gastric operation is a preventable complication. The surgeon, the gastro-enterologist and the general physician must instruct patients to avoid consumption of persimmons, and to reduce the consumption of fibre-rich fruits and vegetables.

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In the UK, when the standard brain death criteria are met, further investigations are not necessary. Confirmatory tests can be useful, however, when it is not possible to carry out all of the brainstem tests. We report the case of a patient with multiple trauma and a high spinal cord injury who was apnoeic. Confirmatory tests (EEG, brainstem, auditory evoked potential) were essential in supporting the diagnosis of brainstem death to allow withdrawal of artificial ventilation, as organ donation was being considered.