Summary

SummaryWe studied tracheal intubation conditions produced by the muscle relaxant, cisatracurium, following induction of anaesthesia with fentanyl (2 mg.kg ÿ 1 ) and thiopentone (6 mg.kg ÿ 1 ). Sixty patients were randomly assigned to receive cisatracurium in a single bolus dose of either 0.15 or 0.20 mg.kg ÿ 1 . Tracheal intubation was commenced 120 s after injection of the relaxant. The mean (SD) time taken to achieve intubation was significantly shorter in the 0.20 mg.kg Cisatracurium is an isomer of atracurium. It is a highly potent, nondepolarising muscle relaxant (ED 95 estimated to be 50 mg.kg ÿ 1 ) which does not provoke histamine release [1]. Doses of 3 × or 4 × ED 95 of cisatracurium produce satisfactory intubating conditions when propofol is used as the induction agent [2][3][4]. Since propofol itself can provide satisfactory intubating conditions [5, 6] it may affect the quality of the intubating conditions produced by a muscle relaxant. We studied the intubating conditions produced by two different doses of cisatracurium after induction of anaesthesia with thiopentone. Patients and methodsAfter ethics committee approval and the patients' informed consent, 60 ASA grade 1 or 2 patients, aged over 18 years, requiring tracheal intubation for low-or moderate-risk surgical procedures, were studied. Patients were not studied for the following reasons: anticipated difficult intubation; body weight greater than 30% of ideal; clinically significant neurological, muscular or cardiovascular disease; impairment of hepatic or renal function; a personal or family history of malignant hyperthermia, drug or alcohol abuse, asthma or sensitivity to neuromuscular blocking agents.Anaesthesia was induced with fentanyl 2 mg.kg ÿ 1 followed 2 min later by thiopentone 6 mg.kg ÿ 1 . After loss of the eyelash reflex patients received a single bolus of either 0.15 mg.kg ÿ 1 (group A) or 0.20 mg.kg ÿ 1 (group B) cisatracurium by random allocation by a nonblinded investigator. The start of the injection was designated as time zero. Ninety seconds after the cisatracurium injection a further bolus of thiopentone 1 mg.kg ÿ 1 was given. Oral tracheal intubation was commenced 120 s after injection of the muscle relaxant by one of two anaesthetists who did not know the dosage of cisatracurium administered. The intubating time was designated as the time at which the tracheal tube was correctly positioned in the trachea.Intubating conditions were graded on a scale from 1 to 4 (1 representing excellent conditions; 2 -good; 3 -poor and 4 -intubation not possible) according to the observed state of relaxation of the vocal cords and the severity of coughing on passing the tracheal tube [4]. If intubation failed at the first attempt, further attempts were made after 10-20 s or more and the total time taken was recorded.Heart rate, arterial blood pressure and oxygen saturation . Neuromuscular block was allowed to recover spontaneously or was antagonised at the discretion of the anaesthetist involved.The parametric data were subjected to anal...

A randomised, single-blind study was conducted on 802 parturient women who required epidural analgesia, to compare open-end (single hole) with closed-end (three lateral holes) epidural catheters. The complication rate after catheter insertion was not statistically drferent between the two groups, but the number of unsatisfactory blocks was significantfy higher in the open-end group (p < 0.001). The closed-end catheters were easier and less painful to place, but gave a higher incidence of bloody taps. The open-end catheters caused sensory blockade to be more frequently unilateral and more frequently missed sensory segments. This resulted in a significantly higher number of open-end catheters that required replacement (p < 0.001). Open-end catheters despite their theoretical advantages in the detection of intravenous and subarachnoid placement caused an unacceptably high incidence of unsatisfactory sensory blockade.

MS aS MRCOGPurpose: To describe the management problems presented by a case of acute massive pulmonary embolism in a labouring woman. Clinical Features: A case of massive pulmonary embolism is described in a woman who presented in early labour at thirty-eight weeks gestation. Immediate management involved the administration of oxygen and intravenous heparin, and transfer to the regional cardiothoracic centre. Pulmonary angiography confirmed the diagnosis of massive pulmonary embolism, but attempts at percutaneous catheter disruption of the clot were of only temporary benefit. The patient subsequently underwent Caesarean section under general anaesthesia, followed minutes later (because of an abrupt deterioration in her condition) by surgical pulmonary embolectomy. The outcome was successful for both mother and child. Conclusion:In cases of acute massive pulmonary embolism presenting in late pregnancy and in labour, the risks and benefits of surgical embolectomy, pharmacological thrombolysis, or attempts at mechanical clot disruption have to be weighed on an individual basis. Management at the referral centre was facilitated by having cardiothoracic and obstetric facilities on the same site.Objecdf: DEcrire les probl~mes de traitement d'une embolie pulmonaire massive d'apparition brutale chez une parturiente en travail.Aspects cliniques : Un cas d'embolie pulmonaire massive est d&rit chez une femme qui s'est prEsentEe trente-huit semaines de grossesse, en travail obstetrical prematurE. Le traitement immEdiat a consistE ~ administrer de I'oxygEne et de I'hEparine intraveineuse et de diriger la patiente vers le centre cardiothoracique rEgional. I'angiographie pulmonaire a confirmE le diagnostic d'embolie pulmonaire massive, mais des essais pour rompre le caillot ~ I'aide de catheter percutanE front eu que des effets temporaires. La patiente a subi ensuite une cEsarienne sous anesthEsie gEnErale, suivie quelques minutes plus tard (~ cause de la dEtErioration soudaine de son Etat) d'une embolectomie pulmonaire rEussie avec succ& pour la m&e et I'enfant.Conclusion : Lors d'une embolie pulmonaire massive d'apparition brutale, qui se pr&ente vers la fin de la grossesse et pendant le travail, les risques et les avantages de I'embolectomie, la thrombolyse pharmacologique ou les essais de rupture m&anique du caillot doivent &re EvaluEs sur une base individuelle. Le traitement au centre sp&ialisE a EtE facilitE ici par le fait d'avoir les services cardiothoraciques et obst&ricaux au m~me site.