studv the ,frequency of criticd incidents and factors associated with them. Eighty-six mishaps were reported in the first period, the majority o j which wew because of' human error (80.3%);the most common were the transmission of gases and vapours and errors in drug admrnistrulion. Fuclors frequently associated with these mishaps were.failure to perform a normal check and lack of'familiarity with vquipnient or technique. An anaesthesia equipnzent checklist was incorporated in the survey during the second period and 43 mislirips were reported. This decrease in incidence maj* have resulted from the anaesthesia apparatus checklist, awareness of mishops since they were discussed regularly at departmental meetings. and new anaesthesia machines (eight older machines were replrrrrd during the,first period and I J at the beginning of' the second).

SummaryA subarachnoid-cutaneous fistula developed in two children after the placement of a catheter in the subarachnoid space for drainage of cerebrospinal fluid. The management of this iatrogenic compiication with epidural blood patch is described. Key wordsAnaesthetic technique, regional; epidural, blood patch. Complications; fistula.The drainage of cerebrospinal fluid (CSF), by placement of a catheter in the subarachnoid space is often performed to allow surgical exposure and to prevent leakage of CSF from dural wounds.'-' A rare but a distressing complication of this technique is the development of subarachnoid cutaneous fistula. Epidural blood patch has been successfully used to treat CSF fistula in adult patient^,^-^ and we report its use in the management and treatment of two children with this type of fistula. Case histories Patient 1A 6-year-old boy was struck near the left orbit with a golf club. There was no history of loss of consciousness or any other neurological symptoms except for several bouts of vomiting in the emergency room. X ray of the skull showed a nondisplaced left blow-out fracture of the orbit and ethmoid bone associated with pneumocephalus along the left hemisphere and suprasellar cistern.The patient underwent emergency exploration and repair of the laceration on the eyelid. A CSF leak was observed, during exploration, from the undisplaced fracture in the ethmoid. Remaining surgery was uneventful and the patient was confined to bed after operation, with the head of the bed elevated at 45-60" for 36 hours. CSF continued to drain from the nose and a 16-gauge plastic catheter was placed via a 14-gauge needle in the interspace between the third and fourth lumbar vertebrae to drain CSF. The CSF leak from the nose ceased 6 days after the placement of the catheter, which was removed 3 days later, but a clear fluid (glucose positive) continued to drain from the catheter placement. The CSF leak from the lumbar region persisted for 2 days despite strict bedrest. The child's neurological examination remained normal throughout this period, and he denied having any headaches. The drainage was estimated at approximately l00ml per 8 hours by weighing wet dressings.The patient was referred to the pain clinic for epidural blood patch on the third day after removal of the catheter and was sedated with 400mg of rectal 2.5% methohexitone, and 30pg of intravenous fentanyl. A 2.5inch 20-gauge Tuohy needle was placed in the L,, interspace, and the epidural space identified by the loss of resistance technique. Seven ml of autologous blood were injected into the epidural space under aseptic conditions. The patient was confined to bed for the next 24 hours, during which CSF continued to leak from the lumbar region, but in smaller amounts as judged by fewer changes of dressings. The epidural blood patch was repeated the next day, after sedation with fentanyl 60pg, midazolam 1.5 mg and ketamine 45 mg titrated intravenously over 5-10 minutes. The L,, interspace was used on this occasion and 8.5ml of autologous bl...

SummaryThis study compares the response of the muscles of the hand to those of the face during non-depolarising neuromuscular blockade. It was found that observation of the facial muscles was misleading both in terms of degree of neuromuscular blockade and adequacy of reversal. Key words Neurornuscular relaxants. Measurement techniques; neuromuscular blockade.The correlation between the response of the hand muscles to those of respiration in relation to the action of nondepolarising muscle relaxants (NMR) is well described. One can expect that the effect of the NMR will have diminished sufficiently, that respiratory function should be adequate and that recurarisation should not occur, if the patient has a sustained response to tetanic stimulation or a train-of-four (TOF) ratio above 0.7. This information was developed using either the flexors of the digits or thc adductor of the thumb. The action of NMRs on facial muscles has not been well studied although it has been demonstrated that not all muscle groups respond to NMRs to the same degree., It is necessary in certain surgical situations to have both hands at the side. It is the practice of many anaesthetists in these circumstances, to stimulate the hcial nerve and observe the response of the facial muscles to determine both the degree of relaxation achieved and the adequacy of reversal. Our clinical experience suggested that observation of facial muscles does not provide adequate information and a study was designed to test this hypo1 hesis. MethodsTwenty patients undergoing elective abdominal surgery consented to participate in this protocol approved by our institutional review board. All patients were premedicated with morphine (0.14.15 mg/kg) and atropine (0.04 mg/kg) 45-60 minutes before surgery and anaesthesia was induced with thiopentone and isoflurane in 70% N,O. Tracheal intubation was accomplished aided by suxamethonium and end tidal anaesthetic concentration monitored using a mass spectrometer and maintained within 0.6 of 1.25 MAC. Both the facial and ulnar nerves were stimulated with a train-offour pattern using separate clinical nerve stimulators. The electromyograph (EMG) was recorded from the thenar eminence (adductor pollicis muscle) and one of the facial muscles (either the circumoral or circumorbital muscle groups). Transcutaneous electrodes were used to stimulate nerves and to record the EMG, which was registered on either an ink jet oscillograph or photographed from an oscilloscope trace. Pancuronium was administered in increments to generate a cumulative dose-response curve for each patient. The train-of-four ratio and the T1:TO ratio were observed in both muscle groups; the anaesthetist was asked to observe both groups and note the occurrence of TOF decrement during onset and reversal of neuromuscular blockade. Values were compared using Student's t-test. (p < 0.05 was accepted as significant). ResultsDecrement of EMG train-of-four ratio develops in both muscle groups at approximately the same dose (p > 0.05) but can be seen much earlier ...

A multicenter study was conducted to determine the patient and physician acceptability of transdermal fentanyl in the management of cancer-related pain. In this study, 10 cancer patients at the University of Iowa received transdermal fentanyl after discontinuing their prior opioid analgesic; 7 patients completed questionnaires before and at 2 and 4 wk following transdermal fentanyl application. There was no significant difference in visual analogue scale scores for pain or mood. Verbal pain descriptor scores improved at 2 wk (P less than .05). There was a nonsignificant tendency toward increased depression and nausea; however, patients spent less time thinking about their illness and felt their cancer was less disruptive to their closest friends/relatives. Constipation, appetite, drowsiness, and concentration were not statistically different. Patients reported improved sleep habits at 2 wk (P less than .05) and tended to require less help with eating, dressing, washing, and using the bathroom. All patients completing the study chose to continue transdermal fentanyl for their cancer pain management. In summary, these data demonstrate the analgesic efficacy of the transdermal fentanyl system and suggest that some patients with cancer-related pain could benefit from its use.

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