Eight physiological variables--tidal volume, breathing rate, end-tidal carbon dioxide fraction, oxygen fraction in the anesthetic circuit, oxygen saturation by pulse oximetry, systolic and diastolic blood pressure, and heart rate--recorded on-line by a commercially available automated system were compared with the same variables recorded on handwritten anesthesia records. We quantified the differences between the automated and handwritten records generated from the same 30 patients (2,412 minutes of general anesthesia for elective eye surgical procedures). Considering the design of the study, we claim that the differences between both records were caused by the incompleteness or inaccuracy of the handwritten records, except in two instances. The amounts of missing or erroneous data for these eight physiological variables were expressed as fraction ("error fractions") of the time being recorded, designated EFm and EFe, respectively. For the first five variables the EFm on the handwritten records ranged between 0.23 and 0.31, and the EFe ranged between 0.01 and 0.06. For the last three variables the EFm range was 0.08 to 0.13, and the EFe range was 0.05 to 0.11. Most of these missing or erroneous data occurred during the period of induction (first 15 minutes) and at the end of the case (last 10 minutes). The EFm and EFe during induction had increased to 0.62 and 0.26, respectively, and to 0.76 and 0.06, respectively, at the end of the case. Erroneous data were observed on the automated records for the tidal volume during induction (EFe = 0.0044) and for the oxygen fraction during maintenance (EFe = 0.0024). The effect of averaging by the recordkeeper is discussed. The results of this study indicate the clinical relevance of automated record keeping.

16 patients underwent acute hypervolaemic haemodilution with dextran 40 and Ringers lactate, to see whether this procedure could avoid preoperative blood transfusion. Packed cell volume (PCV) and oxygen extraction decreased, and cardiac index and pulmonary wedge pressure increased, although end-systolic area was unchanged. PCV was not significantly different between patients who lost less than or greater than 20% of their initial blood volume. This preoperative manoeuvre, which reduces loss of red blood cells, allowed major surgery to be completed safely without blood transfusion.

is an oral disease-modifying therapy (DMT) approved for relapsing multiple sclerosis (MS) that acts via modulation of the sphingosine-1phosphate (S1P) receptor. 1 Fingolimod also targets the cardiovascular system, frequently causing reduced heart rate after the first dose. 2 We describe a patient with MS who developed paroxysmal atrial fibrillation (PAF) after initiating fingolimod therapy.Case report. A 42-year-old man with no medical history other than MS presented with a persistently relapsing progressive course. Since other DMTs were discontinued because of adverse effects or lack of effectiveness (figure, A), we started the patient on fingolimod. Routine screening, consisting of an ECG showing a normal sinus rhythm of 62 beats per minute (bpm) and blood tests of serum liver functions and leukocyte count and differentiation, did not point to any contraindications. We prescribed fingolimod (0.5 mg/day) to be administered under cardiac surveillance. Approximately 2.5 hours after the first dose, the patient had 5 short episodes of narrow complex tachycardia within 10 minutes. Each episode lasted 6-15 seconds and consisted of an abruptly increased heart rate to 210 bpm alternating with a sinus rhythm at 75 bpm. Blood pressure remained stable around 130/70 mm Hg. The patient had palpitations, chest pain, paresthesia in his limbs, and a feeling of heat (core temperature 36.8°C) during these episodes and stated he had never experienced these before.Cardiologic examination revealed no abnormalities. ECG and blood tests for electrolytes, kidney function, and measures of infection were normal.The cardiologist diagnosed PAF, sometimes preceded by beats with abnormal QRS morphology (figure, B). This is most likely explained by the Ashman phenomenon; when lower heart rates are suddenly followed by tachycardia, it may take several heart beats before conduction velocity in the His-Purkinje system (HPS) has increased, resulting in transient aberrant intraventricular conduction. 3 A single dose of sotalol 40 mg was prescribed to urgently treat the high heart rate, at the risk of drug interaction with fingolimod.The patient had a few more PAF episodes the night following sotalol but none by the following day. A rechallenge with fingolimod was justifiable because a clinically relevant interactive effect of the low-dose sotalol was considered unlikely after 20 hours, and at this moment a causal relation with fingolimod was uncertain. However, approximately 2.5 hours after the second dose, a short series of PAF recurred during 30 minutes, with identical signs and symptoms as the initial episodes. They started with an episode of 30 seconds at 180 bpm, followed by episodes of 2-10 seconds alternating with a sinus rhythm at 78 bpm. Again at night a single episode occurred and none by the next day.Since arrhythmias reproducibly started 2.5 hours after fingolimod administration, we assumed causality and discontinued treatment.Following discharge, physicians from the cardiology clinic extensively evaluated the patient (including transt...

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