The effect of three bolus doses of remifentanil on the pressor response to laryngoscopy and tracheal intubation during rapid sequence induction of anaesthesia was assessed in a randomized, double-blind, placebo-controlled study in four groups of 20 patients each. After preoxygenation, anaesthesia was induced with thiopental 5-7 mg kg-1 followed immediately by saline (placebo) or remifentanil 0.5, 1.0 or 1.25 micrograms kg-1 given as a bolus over 30 s. Cricoid pressure was applied just after loss of consciousness. Succinylcholine 1 mg kg-1 was given for neuromuscular block. Laryngoscopy and tracheal intubation were performed 1 min later. Arterial pressure and heart rate were recorded at intervals until 5 min after intubation. Remifentanil 0.5 microgram kg-1 was ineffective in controlling the increase in heart rate and arterial pressure after intubation but the 1.0 and 1.25 micrograms kg-1 doses were effective in controlling the response. The use of the 1.25 micrograms kg-1 dose was however, associated with a decrease in systolic arterial pressure to less than 90 mm Hg in seven of 20 patients.

We describe the case of a pregnant woman, 35 weeks' gestation, with primary pulmonary hypertension and coarctation of the aorta requiring emergency Caesarean section under general anaesthesia. The patient had a pulmonary artery catheter inserted before operation which revealed pulmonary artery pressures in excess of 80/40 mm Hg. These were lowered using an infusion of glyceryl trinitrate. After delivery of the baby and administration of oxytocin, pulmonary artery pressures were more difficult to control. An infusion of prostacyclin was substituted which stabilized pulmonary pressures. After operation, she was transferred to the intensive care unit where prostacyclin was administered by an "aerosolized" route. Her trachea was extubated after 48 h and she made an uneventful recovery.

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This study investigates the effect on the heart and blood vessels of various rates of administration of boluses of a relatively new potent opiate, remifentanil, to patients with coronary artery disease. The results show that remifentanil should be given only by slow infusion to such patients.

Percutaneous tracheostomy using a graded dilatation technique was described by Ciaglia in 1985 [1]. The description of other techniques using special forceps to dilate the trachea followed. The safety and low early complication rate of percutaneous tracheostomy compared with open surgical tracheostomy have been established by several prospective studies [2][3][4][5][6][7].The long-term complications, such as tracheal stenosis, remain a source of controversy. Conventional surgical tracheostomy has been associated with a long-term tracheal stenosis rate of between 16 and 64% [2, 8]. Studies using tomography [2] and fibreoptic laryngotracheoscopy [9, 10] have shown low stenosis rates with percutaneous tracheostomy.This postal survey was designed to assess the practice and attitudes to percutaneous tracheostomy in intensive care. Questions were included on the use of fibreoptic bronchoscopy and long-term follow-up. MethodsIn 1997, a postal survey was sent to the clinical directors of 231 general intensive care units in England and Wales.Specialist units, such as pure neuro-surgical or cardiac units were not surveyed. The recipients were requested to fill in a short and simple questionnaire (Appendix). The results were statistically analysed using the Chi-squared test. A p value less than 0.05 was considered statistically significant. ResultsQuestionnaires were returned by 176 out of 231 intensive care units, yielding a 76% response rate. Of the 176 directors who replied, 129 (73.3%) used percutaneous tracheostomy as the method of choice for tracheostomies on their unit (Table 1). Only 32 (18.2%) had never used it. Six (3.4%) had stopped using the technique. In all, 78.4% were using the technique of percutaneous tracheostomy on their ICU patients. FibreoscopyIn seventy-one (49.3%) units, fibreoscopy did not feature as a routine part of the technique of percutaneous tracheostomy (Table 2) and in only 45 (31.3%) was it used routinely.