Lung morphology at zero end-expiratory pressure predicts the response to recruitment maneuvers. Patients with focal lung morphology are at risk for significant hyperinflation during the recruitment maneuvers, and lung recruitment is rather limited.

SummaryWe compared the duration of analgesia produced by a mixture of lignocaine and bupivacaine, either alone or combined with morphine (75 mg.kg ¹1 ), buprenorphine (3 mg.kg ¹1 ) or sufentanil (0.2 mg.kg ¹1 ) in 80 patients after brachial plexus block for orthopaedic surgery of the upper limb. The characteristics of analgesia were evaluated hourly using a visual analogue scale. The analgesia was considered satisfactory for scores of 30 or less. The median duration (range) of satisfactory analgesia was: 11.5 (8-15) h without an opioid, 21 (9-27) h with morphine, 20 (14-34) h with buprenorphine and 24.5 (11-38) h with sufentanil. We conclude that the addition of an opioid to a local anaesthetic mixture lengthens the duration of analgesia. The demonstration that opioid receptors are present in the peripheral nervous system [1] prompted recent investigations of the effects of using opioids, alone or combined with local anaesthetics, for regional analgesia procedures like brachial plexus block. Several authors have investigated the efficacy of injecting opioids into the brachial plexus sheath [2][3][4][5][6][7][8][9][10][11][12][13][14], but the results remain inconclusive. Some authors did not observe any benefit from adding opioids [6,7,[9][10][11], but the drugs and doses of opioids and local anaesthetics and the populations of patients, were different in the various studies. Lipid solubility and the affinity of the different opioids for their receptors seemed to be important factors [1]. The aim of this study was to evaluate the effects of different opioids which have either different receptor affinities or different lipid solubilities in patients scheduled for osteosynthesis of a fractured upper limb, without any signs of inflammation. For this purpose, we compared the quality and the duration of the analgesia produced by a brachial plexus block with a mixture of lignocaine and bupivacaine, either alone or combined with morphine, buprenorphine or sufentanil. MethodsThe study was approved by our local ethics committee and informed consent was obtained from the 89 participating ASA grade 1 or 2 patients who were less than 65 years old. They were scheduled to undergo osteosynthesis of the upper limb under brachial plexus anaesthesia. After oral medication with hydroxyzine 100 mg given 2 h before surgery, the brachial plexus block was performed with the aid of a nerve stimulator, using the supraclavicular technique. The patients were randomly allocated into four groups: the control group (group C), which was given a mixture of 1 mg.kg ¹1 of bupivacaine 0.5% and 2 mg.kg ¹1of lignocaine 1% with 1 : 200 000 adrenaline and groups M, B and S, which were all given the same mixture, combined with either morphine 75 mg.kg ¹1 , buprenorphine 3 mg.kg ¹1 or sufentanil 0.2 mg.kg ¹1 . The opioids were diluted in the bupivacaine, in order to obtain the same volume per kilogram in all the groups. In all cases, there was an interval of more than 45 min between the injection of the anaesthetic solution and the surgical procedure.

In the absence of alveolar recruitment and improvement in arterial oxygenation, RM decreases the rate of alveolar fluid clearance, suggesting that lung overinflation may be associated with epithelial dysfunction.

SummaryA 77-year-old female was admitted in our hospital for uterine prolapse surgery. She developed ventricular tachycardia during induction of general anaesthesia and after initial symptomatic measures, she was transferred to the coronary care unit. Heart failure persisted and electrocardiographic changes mimicking acute myocardial infarction appeared. Coronary angiography was normal and left ventriculography revealed akinesis of the apical region of the left ventricle and apical ballooning during systole, with relative sparing of the base of the heart. Complete recovery of left ventricular function occurred 8 days after the initial onset of symptoms. A diagnosis of Takotsubo syndrome was made on the basis of consistent clinical and laboratory findings, typical echocardiography and angiography findings, and reversible course. This case emphasises the importance of being aware of uncommon causes of cardiac dysfunction in stressful situations, especially during induction of general anaesthesia. Takotsubo cardiomyopathy, or transient left ventricular apical ballooning syndrome, was first described in Japan as acute systolic heart failure caused by transient left ventricle apical akinesis [1]. This syndrome is usually triggered by stressful situations, and mainly affects elderly female patients [2]. The peri-operative period is wellknown to induce stress in patients, and this diagnosis should be considered when a patient presents with left ventricular dysfunction or electrocardiographic changes mimicking acute myocardial infarction in stressful situations [3,4], especially during the induction of general anaesthesia. We report the case of a 77-year-old female with Takotsubo syndrome that revealed itself during the induction of general anaesthesia. Case reportA 77-year-old female was admitted to our hospital for vaginal repair of uterine prolapse. She had a history of facial neuralgia treated by clonazepam, venous insufficiency, previous laparotomy under general anaesthesia and bilateral cataract surgery under peribulbar anaesthesia. There were no anaesthetic complications during these procedures. Pre-operative evaluation including electrocardiography was unremarkable, arterial pressure was 150 ⁄ 80 mmHg, and cardiopulmonary auscultation was normal. The patient decided against spinal anaesthesia, and it was therefore decided to administer a targetcontrolled infusion (TCI) of propofol, combined with regional anaesthesia (bilateral paracervical and pudendal nerve blocks). Before transfer to the operating room, the patient received 50 mg hydroxyzine. In addition to standard monitoring, anaesthesia depth monitoring was performed during surgery to measure bispectral index (BIS). Her arterial pressure was 195 ⁄ 92 mmHg, and heart rate was 70 beats.min )1 . Oxygen saturation was 95% with the patient breathing air. Pre-oxygenation was administered until the expired oxygen reached a fraction of 0.9.

Continuous fascia iliaca block with 0.2% bupivacaine reduces opioid requirements and improves range of motion in the immediate postoperative period compared with a placebo and 0.1% bupivacaine. Plasma levels are below the toxic range with this dose. Only 40% of the catheters are positioned in the ideal location. With the smaller dose of bupivacaine, the success rate with this block is small.