SummaryThere must be a,deJined, predisposing condition to furfil the criteria of brainstem death in the UK. A patient presented recently in coma and with absent brainstem reflexes, but no diagnosis was initially obvious. A subsequent diagnosis of Guillain-BarrP syndrome was made, and the patient made a full recovery. Key wordsBrain; brainstem function tests. Nerve; neuropathy.A 43-year-old man was admitted recently to our intensive care unit from another hospital where he had been admitted after a 10-day history of an influenza-like illness, and a 4-day history of diplopia, and weakness in the arms and legs. The weakness had progressed rapidly after admission and the onset of respiratory failure necessitated the use of artificial ventilation. He was transferred to our intensive care unit when it was noticed that his pupils were dilated and unresponsive to light. The differential diagnosis, made by the consultant physician at the referring hospital, included Guillain-Bark syndrome and brainstem death. On arrival, brainstem function tests were performed as part of a full neurological examination. The absence of pupillary response to light was confirmed, and testing by a consultant from the intensive care unit revealed absent corneal reflexes, absent vestibulo-ocular reflexes after the injection of 20 ml of iced water into each external auditory meatus (having first confirmed that both tympanic membranes were visible), no response to a suction catheter passed down the trachea, and no response to painful stimuli anywhere on the face. The patient was then disconnected from the ventilator for 10 minutes with oxygen delivered at 6 litres/minute through a suction catheter passed through the tracheal tube. No respiratory movements were observed despite an increase in Paco, from 5.2 to 7.9 kPa. The patient's temperature was 36.5"C, the urea and electrolyte concentrations were normal, blood glucose was 7.8 mmol/litre and the acid-base status was normal. No hypnotic drugs had been received by the patient for 48 hours. Tests indicated the absence of all brainstem reflexes but in view of the fact that no diagnosis had been made it was decided to carry out further diagnostic tests whilst continuing full care. Computerised tomography and magnetic resonance imaging of the brain were both normal. An electroencephalogram (EEG) showed a normal a rhythm which was unusually dominant and unresponsive to stimulation, suggestive of a brainstem lesion. The protein concentration in cerebrospinal fluid was high ( 2 g/litre; normal < 0.4) with normal cell numbers. All other results, including a full toxicology screen and tests for porphyria and Wernicke's encephalopathy, were normal. A provisional diagnosis of Guillain-Barre syndrome was made because of the patient's presenting history and the high CSF protein concentration, and full active treatment was continued. There was no change in the patient's condition for the next few days, but it was noticed on day 5 that his pupils reacted to light. A repeat EEG performed at this time showed a m...

SummaryThe MI air crash provided an enormous challenge to the anaesthetic and intensive care services of the hospitals which admitted the survivors, many of whom had serious injuries. This account describes some of the problems which were encountered in two of the hospitals, details the workload imposed on the anaesthetists and the staff of the Intensive Therapy Units and identijies factors which, if improved, might advance the management of multiple casualties admitted from the scene of a major disaster.

Blood loss during suction termination of pregnancy was estimated in patients anaesthetised with intravenous ketamine (n = 25) and compared with those anaesthetised with intravenous methohexitone (n = 25). Both groups received midazolam 0.15 mg/kg intravenously 3 min prior to induction of anaesthesia. No statistically significant difference was found in blood loss between the two groups (P = 0.66). There was no incidence of dreaming or psychomotor disturbances with ketamine in our study.

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