Conventional lateral radiography was used in 18 elderly male patients to investigate the changes induced by general anaesthesia in the upper airway. The effect of tongue traction under anaesthesia was studied similarly in another 11 patients. Following induction of anaesthesia, there were highly significant approximations to the posterior pharyngeal wall of the soft palate (median change 1.3 mm, 95% confidence interval (Cl) 0.3-2.6 mm; P = 0.006), tongue base (mean change 6.5 mm, 95% Cl 5.3-7.7 mm; P less than 0.001) and epiglottis (mean change 3.8 mm, 95% Cl 3.1-4.5 mm; P less than 0.001). Apparent radiographic occlusion of the airway occurred most consistently at the level of the soft palate (17 of 18 patients), sometimes at the level of the epiglottis (four patients), but the tongue base did not touch the posterior pharyngeal wall in any patient. Traction on the tongue failed to clear the nasopharyngeal obstruction. Attempted inspiration under anaesthesia caused major secondary collapse of the pharynx, with multiple sites of obstruction, similar to that found in obstructive sleep apnoea.

SummaryThree adults are described who developed life-threatening hypotension following intravenous codeine phosphate. It is recommended that codeine phosphate should not be given intravenously to adults. Key wordsAnalgesics; codeine phosphate. Complications; hypotension.Codeine phosphate has retained a place in the treatment of moderate pain, despite the availability of new, highly potent synthetic opioids with minimal unpredictable adverse effects. In addition it is a popular analgesic for neurosurgical patients because of its relative lack of sedation and interference with pupillary size. The parenteral preparation of codeine phosphate currently available bears a label listing the intravenous route of administration as an alternative to intramuscular injection. Adverse reactions to intravenous codeine phosphate have been described in children, in whom its use is not recommended [ l]. We describe three adults who developed severe hypotension following intravenous codeine phosphate. Case histories Case IA 17-year-old male, weighing 51 kg, was scheduled for six dental extractions, as a day case. He had previously been investigated for short stature but no cause had been found. He had received two uneventful anaesthetics for squint correction and tonsillectomy some years before.He was prescribed no premedication. Anaesthesia was induced with alfentanil, thiopentone and suxamethonium, and following tracheal intubation was allowed to breathe spontaneously an oxygen/nitrous oxide/enflurane mixture. The patient remained stable throughout surgery, and at the end of the procedure his systolic blood pressure was 120 mmHg, which was identical to the pre-induction value. Codeine phosphate injection 50 mg (McCarthy 60 mg.ml-I) was then given, undiluted, intravenously as a bolus. Almost immediately the patient became pulseless and grey, but the electrocardiograph (ECG) continued to show sinus rhythm at a rate of 90 beat.min-l. The patient's lungs were ventilated with 100% oxygen and external cardiac massage started. Adrenaline (I mg) was given intravenously. After 60 s the pulse became palpable and systolic blood pressure was measured at 40mmHg. The patient remained in sinus rhythm at a rate of 90beat.min-'. Ephedrine 15 mg and atropine 0.6 mg were administered intravenously and 4 min later the systolic blood pressure was 70mmHg, but a further 5 min elapsed before the systolic blood pressure reached 100 mmHg (Fig. 1). At no time did any bronchospasm or rash develop, and there was no increase in body temperature. The patient's trachea was extubated and he was admitted for observation overnight. He remained stable and his ECG was normal. He was discharged the next day, fully recovered, with written instructions that he was allergic to codeine phosphate injection. Case 2A previously fit, 16-year-old female was scheduled for myringoplasty. She was premedicated with lorazepam. Anaesthesia was induced with thiopentone and vecuronium and maintained with enflurane in nitrous oxide and oxygen

The twelfth rib syndrome appears to be a fairly common and underdiagnosed chronic pain syndrome. It is more common in women than men (3:1) and is usually described as a constant dull ache or sharp stabbing pain that may last from several hours to many weeks. Lateral flexion, rotation of the trunk, and rising from a sitting position classically aggravate the pain. Manipulation of the affected rib and its costal cartilage reproduces it exactly. The diagnosis of this syndrome is clinical, requires exclusion of specific etiologies, and should only be made when the patient's symptoms can be exactly reproduced by manipulation of the affected rib. If symptomatology is complicated, it may be necessary to use an image intensifier for accurate location of the pain locus. Patients with this syndrome can be overinvestigated and have even undergone surgical procedures when this diagnosis has been overlooked. To describe the varied presentation of this syndrome, we describe the clinical manifestations in six patients.

Pain in neurological disease displays great diversity in putative mechanisms and clinical presentation. Rational management requires an analysis of likely mechanisms of pain generation as a guide to treatment. Some common neurological disorders are briefly discussed, primarily to provide an indication of the range of pain phenotypes observed across the spectrum of neurological disease. Treatments are reviewed with an emphasis on systemic drugs and the current best evidence for their use.

Body temperature, respiratory gas exchange, and plasma catecholamines were determined before and after surgery in three groups [control (C), warmed (W), and epidural (E) who received local anesthetic at T4-S5 dermatomes during and for 24 h after surgery] of patients undergoing colonic surgery under general anesthesia. At the end of surgery, group W were nursed in an ambient temperature of 28-30 degrees C, whereas the others were at 20-23 degrees C for a period of 24 h. Core (Tc) and dorsal hand temperature decreased during surgery in both C and E (P less than 0.05) but not in W. After surgery, Tc increased similarly in C and E and by a smaller amount in W. Plasma catecholamine concentrations increased significantly in C and W but not in E (P less than 0.001), with the greatest response occurring in C. Postoperative oxygen consumption and carbon dioxide production exceeded preoperative values (P less than 0.01) in C but not in W or E. After surgery, plasma albumin fell and C-reactive protein increased similarly in all three groups. Thus body heat conservation or epidural blockade attenuates or abolishes the rise in plasma catecholamines and oxygen consumption postoperatively but does not prevent the increase in Tc or the acute phase protein response.