SummaryOesophageal Doppler monitoring allows non-invasive estimation of stroke volume and cardiac output. We studied the impact of Doppler guided fluid optimisation on haemodynamic parameters, peri-operative morbidity and hospital stay in patients undergoing major bowel surgery. Fifty-seven patients were randomly assigned to Doppler (D) or control (C) groups. All patients received intraoperative fluid therapy at the discretion of the non-investigating anaesthetist. In addition, Group D were given fluid challenges (3 ml.kg Surgical patients undergoing major bowel resection are at high risk of peri-operative complications and death. Centres in the UK report mortality rates in this group of between 4 and 9% [1, 2]. Many of these patients are elderly and suffer comorbid medical conditions as well as the local and systemic effects of colorectal disease. Studies of similar patient groups having major surgery have used fluid, inotrope and oxygen therapy to optimise cardiac output and oxygen delivery; these studies demonstrated reductions in mortality and length of hospital stay [3][4][5]. The method of cardiac output measurement in these reports, pulmonary artery catheterisation, is not commonly used for bowel surgery. Pulmonary artery catheter insertion can be time consuming and has been implicated with complications and excess mortality [6]. Furthermore some trials involving pulmonary artery catheter optimisation of oxygen delivery required pre-operative admission to intensive care which is currently not practical for colorectal resection.The minimally invasive oesophageal Doppler monitor permits real time assessment of cardiac output [7]. Haemodynamic parameters estimated by this device can be used to guide fluid therapy during surgery [8]. A study of patients undergoing repair of femoral neck fracture demonstrated a reduction in length of hospital stay when oesophageal Doppler was used to guide fluid therapy [9].The aim of this study was to examine the effect of oesophageal Doppler guided fluid administration during colorectal resection on haemodynamic performance, hospital stay and postoperative complications.

SummaryA common drawback of propofol is pain on injection and lidocaine is commonly mixed with propofol to reduce its incidence and severity. We conducted a randomised, prospective, doubleblind study to compare injection pain following the administration of two different formulations of propofol in 200 unpremedicated ASA I-III adult patients scheduled for elective surgery under general anaesthesia. Patients were allocated randomly into two groups to receive either Propofol-Ò Lipuro without added lidocaine or Diprivan Ò mixed with lidocaine 10 mg. Five ml of the study solution was injected at a constant rate over 15 s and patients graded any associated pain or discomfort using a four-point verbal rating scale. The incidence of propofol injection pain was virtually identical in both study groups with 37 ⁄ 98 (38%) patients experiencing pain or discomfort following Propofol-Ò Lipuro compared with 35 ⁄ 98 (36%) after Diprivan Ò (p = 0.88). We observed no significant difference in pain scores between the groups (p = 0.67). Moderate or severe injection pain was experienced by 12 ⁄ 98 (12%) patients given Propofol-Ò Lipuro compared with 8 ⁄ 98 (8%) given Diprivan Ò (p = 0.48).

We conducted a randomised prospective double-blind placebo-controlled study to assess the efficacy of oral midazolam premedication in 50 ASA I and II female patients scheduled to undergo day case breast surgery. Anxiety was assessed using 100-mm visual analogue scales (VAS) and The State-Trait Anxiety Inventory (STAI) psychometric questionnaire. Midazolam premedication did not significantly reduce either VAS or STAI score, although heart rate and systolic arterial pressure immediately before induction of anaesthesia were significantly lower in patients who received midazolam (p = 0.006 and 0.039, respectively). Induction of anaesthesia was achieved with a lower dose of propofol (p = 0.0009) and excellent (Grade I) conditions for insertion of a laryngeal mask airway were achieved more often after midazolam premedication (p = 0.038). Arterial desaturation during induction of anaesthesia and insertion of a laryngeal mask airway occurred more often in patients who received placebo (p = 0.022). There was a good correlation between VAS and STAI used to assess the anxiolytic effects of premedication. (Spearman coefficient 0.58, p < 0.0001).

We conducted a randomised prospective double‐blind placebo‐controlled study to assess the efficacy of oral midazolam premedication in 50 ASA I and II female patients scheduled to undergo day case breast surgery. Anxiety was assessed using 100‐mm visual analogue scales (VAS) and The State‐Trait Anxiety Inventory (STAI) psychometric questionnaire. Midazolam premedication did not significantly reduce either VAS or STAI score, although heart rate and systolic arterial pressure immediately before induction of anaesthesia were significantly lower in patients who received midazolam (p = 0.006 and 0.039, respectively). Induction of anaesthesia was achieved with a lower dose of propofol (p = 0.0009) and excellent (Grade I) conditions for insertion of a laryngeal mask airway were achieved more often after midazolam premedication (p = 0.038). Arterial desaturation during induction of anaesthesia and insertion of a laryngeal mask airway occurred more often in patients who received placebo (p = 0.022). There was a good correlation between VAS and STAI used to assess the anxiolytic effects of premedication. (Spearman coefficient 0.58, p < 0.0001).

To determine the optimal priming dose for administration in divided doses, atracurium was given to 77 patients either in a single dose of 0.5 mg X kg-1 or in an initial dose of 0.04, 0.05, 0.06, 0.07, 0.08 or 0.09 mg X kg-1, followed three minutes later by the remainder of the 0.5 mg X kg-1 dose. Patients were anaesthetized throughout the study. When atracurium was given as a single bolus of 0.5 mg X kg-1, the mean time to complete neuromuscular block was 141.5 seconds. Administration in divided doses accelerated the onset time (p less than 0.01), that is the time from the intubating dose to the complete suppression of train-of-four (TOF) response. The TOF ratio decreased slightly but statistically significantly following the priming doses. When the priming dose was 0.05 mg X kg-1, the mean onset time was 70.9 seconds and priming with larger doses did not add any further advantage. It is concluded that 0.05 mg X kg-1 appears to be the optimal priming dose for the administration of atracurium in divided doses. When 0.05 mg X kg-1 is given three minutes before the intubating dose, tracheal intubation can be accomplished in less than 90 seconds.