Twenty consecutive patients undergoing OLT without veno-venous bypass were studied. Anaesthesia was maintained with propofol, remifentanil and atracurium infusions. All patients were monitored with a modified pulmonary artery catheter (RVEF-PAC), which continuously measures the RVEF. Haemodynamic data were recorded at: baseline (TB), anhepatic stage (TA), and 1, 5, 10, and 30 min post-reperfusion of the graft.

The baseline RVEF was decreased [40% (sd 6)] and remained so throughout the OLT. A biphasic pattern was revealed, with the RVEF reaching its lowest values during TA [34% (7)] and gradually returning toward baseline at T30 [39% (8)]. Clinical significant RV dysfunction did not occur.

Although the baseline RVEF was decreased, it showed only minor alterations throughout the procedure, suggesting that the RV function is not significantly compromised during OLT under propofol anaesthesia.

A standard general anaesthetic was administered with patients breathing spontaneously via a laryngeal mask airway and i.v. fluids administered according to an algorithm guided by CVP measurements. CVP and EJVP catheters were placed on the right side of the neck where possible.

In the supine position, 185 paired measurements of CVP and EJVP and 79 in the lateral position were recorded by a blinded observer during surgery. In the supine position, the mean difference between CVP and EJVP was –0.3 mm Hg (limits of agreement –2.6 to +1.9 mm Hg, 95% confidence intervals for both upper and lower limits of agreement, respectively, were –2.9 to –2.2 and +1.6 to +2.2 mm Hg). In the lateral position, the mean difference was –1.2 mm Hg (limits of agreement –5.8 to +3.8 mm Hg, 95% confidence intervals –6.8 to –4.5 and +2.7 to +4.9 mm Hg).

These data suggest that EJVP is an acceptable estimate of CVP in the supine position. Agreement was poor in the lateral position but was stronger for estimates of trend rather than absolute values. This could be explained by the direct effects of posture.

Forty-four patients undergoing maxillofacial surgery at a university hospital were prospectively randomized to receive general anaesthesia with remifentanil combined with propofol or sevoflurane. Muscle microcirculation was investigated with near-infrared spectroscopy (NIRS) before general anaesthesia was induced and 30 min later. An NIRS device (NIMO, Nirox) was used to quantify calf deoxyhaemoglobin [HHb], oxyhaemoglobin [HbO₂], and total haemoglobin [HbT] concentrations, coupled to a series of venous and arterial occlusions to measure calf blood flow, muscle oxygen consumption, calf vascular resistance, microvascular compliance, and haemoglobin resaturation rate (RR).

In both the groups, general anaesthesia induced marked changes in muscle microcirculation: the tissue blood volume increased (+33% in remifentanil–sevoflurane and +45% with remifentanil–propofol groups), microvascular resistance decreased (–31% and –38%, respectively), and the post-ischaemic haemoglobin RR decreased (–48% and –36%, respectively). In the remifentanil–propofol group, the muscle blood flow increased (P<0.001), whereas in the remifentanil–sevoflurane group microvascular compliance and muscle oxygen consumption decreased (P<0.01).

Remifentanil-based general anaesthesia with propofol or sevoflurane altered the muscle microcirculation in different ways. Quantitative NIRS, a technique that takes into account the optical tissue properties of the individual subject, can effectively measure these changes non-invasively.

This study involves a prospective observational investigation of AWR in patients undergoing general anaesthesia. Blinded structured interviews were conducted in the postanaesthesia care unit, on postoperative day 7 and day 30. Definition of AWR was ‘when the patient stated or remembered that he or she had been awake at a time when consciousness was not intended’. Patient characteristics, perioperative, and drug-related factors were investigated. Patients were classified as not awake during surgery, AWR, AWR-possible, AWR-not evaluable. The perceived quality of the awareness episode, intraoperative dreaming, and sequelae were investigated. The anaesthetic records were reviewed to search for data that might explain the awareness episode.

The study included 4001 patients. Incidence of AWR was 1.0% (39/3921 patients). If high risk for AWR patients were excluded, the incidence was 0.8%. After the interview on the seventh day, six patients denied having been conscious during anaesthesia; hence, the incidence of AWR in elective surgery was 0.6%. Factors associated with AWR were: anaesthetic technique incidence of 1.1% TIVA-propofol vs 0.59% balanced anaesthesia vs 5.0% O₂/N₂O-based anaesthesia vs 0.9% other anaesthetic techniques (mainly propofol boluses for short procedures), P=0.008; age (AWR 42.3 yr old vs 50.6 yr old, P=0.041), absence of i.v. benzodiazepine premedication (P=0.001), Caesarean section (C-section) (P=0.019), and surgery performed at night (P=0.013). More than 50% of patients reported intraoperative dreaming in the early interview, mainly pleasant. Avoidable human factors were detected from the anaesthetic records of most patients. Subjective auditory perceptions prevailed, together with trying to move or communicate, and touch or pain perception.

A relatively high incidence of AWR and dreams during general anaesthesia was found. Techniques without halogenated drugs showed more patients. The use of benzodiazepine premedication was associated with a lower incidence of AWR. Age, C-section with general anaesthesia, and surgery performed at night are risk factors.

Propofol (99.7%) was added directly to an aqueous solution of poly(N-vinyl-2-pyrrolidone)-block-poly(d,l-lactide)copolymers (PVP-PLA) block copolymers and stirred in order to obtain a clear solution. This formulation was filtered sterile and then lyophilized to its solid form Propofol-PM (propofol polymeric micelle) which reconstitutes to a propofol 1%w/v (10 mg ml^–1) clear aqueous solution of 30–60 nm propofol-containing micelles. Population pharmacokinetic data from whole blood and plasma were obtained by administering reconstituted Propofol-PM formulations and a 1% oil in water formulation, Diprivan^® to male Sprague–Dawley rats (n = 40) at a dose of 10 mg kg^–1. Preliminary recovery data were obtained from a further small study.

The pharmacokinetics were best described using a two-compartment mamillary population model, which incorporated sample matrix (blood or plasma) and propofol formulation (Diprivan^® or Propofol-PM) as covariates. Sample matrix was applied to all structural model parameters as a dichotomous covariate. An influence of propofol formulation was observed for all parameters (excluding distributional clearance) but only when plasma was used for propofol quantification. In this preliminary pharmacodynamic study, there was no statistically significant difference in the timing of the recovery endpoints between the Propofol-PM formulation and Diprivan^® groups.

Propofol-PM formulations produce anaesthesia in rats. Whole blood pharmacokinetics of Propofol-PM did not differ from those observed with Diprivan^®.

Eighty patients (44 female and 36 male) undergoing elective major abdominal surgery were randomly assigned to a control group [n=40, mean age 66 (sd 10), range 40–84 yr] or SPV group [n=40, age 61 (16), range 26–100 yr] in which intraoperative fluid management was guided by SPV (trigger: SPV>10%). Central venous O₂ saturation (ScvO₂), lactate and bilirubin, creatinine, indocyanine green plasma disappearance rate (ICG-PDR), and gastric mucosal CO₂ tension were measured after induction of anaesthesia, after 3, 6, 12, and 24 h.

Patient characteristics, duration of surgery [5.8 (2.5) vs 5.4 (2.5) h], and infusion volumes (median 4865 vs 4330 ml) were comparable between the groups. At 3 and 6 h, SPV (P=0.04, P=0.01) and down (P=0.005, P=0.01) were significantly higher in the control group. Oxygen transport and organ function were comparable: baseline and 24 h values for ICG-PDR: 28.5 (7.9) and 22.7 (7.8) vs 23.9 (6.9) and 26.1 (5.9)% min^–1, 77.7 (6.6) and 72.6 (5.5) vs 79.3 (7.1) and 72.8 (6.7)% for ScvO₂ and 1.0 (0.4) and 1.2 (0.6) vs 0.9 (0.2) and 1.3 (0.5) mmol litre^–1 for lactate. Length of mechanical ventilation, ICU stay, and mortality were comparable.

In comparison with routine care, intraoperative SPV-guided treatment was associated with slightly increased fluid adminstration whereas organ perfusion and function was similar.

Twenty-five patients were studied after induction of general anaesthesia. Haemodynamic data [cardiac index (CI), respiratory variations in arterial pulse pressure (PP), POP, and PVI] were recorded before and after volume expansion (500 ml of hetastarch 6%). Fluid responsiveness was defined as an increase in CI ≥15%.

Volume expansion induced changes in CI [2.0 (sd 0.9) to 2.5 (1.2) litre min^–1 m^–2; P<0.01], POP [15 (7)% to 8 (3)%; P<0.01], and PVI [14 (7)% to 9 (3)%; P<0.01]. POP and PVI were higher in responders than in non-responders [19 (9)% vs 9 (4)% and 18 (6)% vs 8 (4)%, respectively; P<0.01 for both]. A PVI >14% before volume expansion discriminated between responders and non-responders with 81% sensitivity and 100% specificity. There was a significant relationship between PVI before volume expansion and change in CI after volume expansion (r=0.67; P<0.01).

PVI, an automatic and continuous monitor of POP, can predict fluid responsiveness non-invasively in mechanically ventilated patients during general anaesthesia. This index has potential clinical applications.

Ten patients undergoing lung surgery were included in the study. They received anaesthesia with continuous i.v. propofol at an average rate of 10 mg min^–1. During surgery and 60 h thereafter, we sampled blood and urine. Propofol and its metabolites were measured using gradient high performance liquid chromatography (HPLC).

In nine patients, propofol and its glucuronides were found in the plasma over the first 15 h. In the urine, however, even after 60 h, propofol and its quinol glucuronides were still detectable. One patient had a markedly different pharmacokinetic profile, showing a limited renal excretion or absorption of 12% of the dose.

After an infusion of propofol, patients excrete propofol and its metabolites in the urine over a period in excess of 60 h. We hypothesize that (re)absorption of propofol and its metabolites by the kidney is a major process in elimination and that the reabsorbed compounds are gradually conjugated in the kidney and excreted in the urine. One patient showed a different pharmacokinetic profile for which we currently have no explanation.

Multi-channel EEG recorded from 12 ASA 1 (American Society of Anesthesiologists physical status 1) patients during low-dose, target effect-site controlled propofol infusion was used for this analysis. The initial target effect-site concentration was 0.5 µg ml^–1 and increased at 4 min intervals in increments of 0.5 to 2 µg ml^–1. EEG parameters were calculated for 2 s epochs in the frequency ranges 0.5–32 and 0.5–47 Hz. All parameters were calculated in the channels: P4–O2, P3–O1, F4–C4, F3–C3, F3–F4, and Fp1–Fp2. Sedation was assessed clinically using the OAA/S (observer’s assessment of alertness/sedation) scale.

Relative beta power and spectral entropy increased with increasing propofol effect-site concentration in both the 0.5–47 Hz [F(18, 90) = 3.455, P<0.05 and F(18, 90) = 3.33, P<0.05, respectively] and 0.5–32 Hz frequency range. This effect was significant in each individual channel (P<0.05). No effect was seen of increasing effect-site concentration on relative power in the alpha band. Averaged across all channels, spectral entropy did not outperform relative beta power in either the 0.5–32 Hz [Pk=0.79 vs 0.814 (P>0.05)] or 0.5–47 Hz range [Pk=0.81 vs 0.82 (P>0.05)]. The best performing indicator in any single channel was spectral entropy in the frequency range 0.5–47 Hz in the frontal channel F3–F4 (Pk=0.85).

Relative beta power and spectral entropy when considered over the propofol effect-site range studied here increase in value, and correlate well with clinical assessment of sedation.

Patients undergoing elective Caesarean section were assigned alternately to one of two groups. In Group 1, all blood and AF was collected with one suction. In Group 2, AF was aspirated to waste with a second separate suction device before collection of any blood.

In both groups, alpha-fetoprotein (AFP), squames cells, and heparin were significantly reduced (P<0.001) by the washing and filtering process. Mean AFP levels post-filtration were 2.58 IU ml^–1 in Group 1 and 3.53 IU ml^–1 in Group 2. Squames cells were completely removed in all but two cases. Fetal red blood cells were still present in the final product, range 0.13–4.35%. In Group 1, haemoglobin and haematocrit were higher than in Group 2, with lower white blood cell, AFP, and fetal red cell counts.

This study adds to the growing body of evidence that there is little or no possibility for AF contamination to enter the re-infusion system when used in conjunction with a leucodepletion filter.

Eighty-four patients (aged 2–12 yr) undergoing strabismus surgery were randomly allocated to one of the three groups (n=28 for each) according to target BIS value of 40, 50, and 60. The end-tidal sevoflurane concentration with 50% N₂O/O₂ was adjusted towards target BIS. The incidence of OCR and the lowest heart rate (HR) were recorded in relation to the end-tidal sevoflurane concentration.

The incidence of OCR was higher in Group BIS-60 (71.4%) than in Groups BIS-40 (10.7%) (P<0.001) or BIS-50 (32.1%) (P=0.003), with no difference between Group BIS-40 and Group BIS-50. The lowest HR [beats min^–1, mean (sd)] during traction on the extraocular muscle was lower in Group BIS-60 [112.3 (sd 17.8)] compared with Group BIS-40 [129.3 (11.2)] (P<0.001), with no difference between BIS-40 and BIS-50 [121.4 (16.3)], and between BIS-50 and BIS-60. The end-tidal sevoflurane concentration was different between the three groups (P=0.001).

We confirmed that OCR is relevant to the depth of anaesthesia. BIS values of 40–50 seem adequate for the inhibition of OCR. The results suggest that BIS may be a valuable tool during sevoflurane anaesthesia for strabismus surgery in children.

We investigated 500 infants and children, prospectively. Premedication consisted of i.v. midazolam 0.1 mg kg^–1. Sedation was induced with i.v. nalbuphine 0.1 mg kg^–1 and propofol 1 mg kg^–1, and maintained with propofol 5 mg kg^–1 h^–1. Outcome measures were induction time, sedation time, recovery time, need for additional sedation, respiratory events, cardiovascular events, paradoxical reactions, and sedation failure.

Data were obtained from 53 infants and 447 children. Median (IQR) age was 5.3 (4.5, 6.1) yr and body weight was 19.3 (16.5, 24.7) kg. The induction time was 2 (1, 2) min, sedation time 55 (45, 65) min, and recovery time 8 (8, 9) min. Additional sedation was necessary in 11 patients (2.2%), mild respiratory events occurred in five patients (1%). All MRI examinations could be completed without paradoxical reaction or sedation failure.

This sedation regimen provides the shortest induction time so far described, a rare demand for additional sedation, a low incidence of respiratory events, and a rapid recovery.

Patients with severe symptoms of FBSS who did not respond to other treatments were included. Lumbar epiduroscopy was performed via interlaminar approach through a 14 G epidural needle under fluoroscopy. A flexible, 0.77 mm, endoscope was introduced through a 4F catheter into the epidural space and advanced in a cephalad direction. Flushes of normal saline through the catheter (via a Y-adapter/haemostasis valve) enabled distension of the space. Adhesions were mechanically mobilized under direct vision. A mixture of triamcinolone 60 mg, hyaluronidase 600 IU, and bupivacaine 0.0625% was instilled.

Nineteen patients were included. The mean number of operations at lumbar level was 2.26. Major findings included adhesions, inflammation, stenosis, and nerve root hypotrophia. The visual analogue scale (VAS) score was 7.89 at baseline, 5.95 (P<0.001) 3 months later, and 6.05 (P<0.001) 6 months later. Six patients (31.6%) did not show any improvement, and six other patients showed a very significant improvement (at least three points reduction in the VAS) 3 months later. We had four cases of dural puncture, but only one patient required hospital admission.

We have described a new procedure for epiduroscopy with approximately 50% reduced outer diameter of the catheter, which allows interlaminar approach. Its diagnostic efficacy is clear and there were a significant number of patients who had improved outcome.

Patients who received a continuous lumbar plexus nerve block for postoperative analgesia and received warfarin after total hip surgery between August 2002 and June 2007 were included in this retrospective study. PT and INRs were recorded before surgery and every day after operation along with any post-surgical nerve injury and bleeding related to the removal of the perineural catheter.

Six hundred and seventy patients met the inclusion criteria. Almost all lumbar plexus catheters (89%) were removed on postoperative day 2. At the time of the perineural catheter removal, 36.2% of patients had an INR >1.4 (range: 1.5–3.9). One case of local bleeding was recorded at the time of the catheter removal with an INR of 3.0. This was managed with a direct pressure at the site.

Although in this retrospective analysis, we demonstrated that lumbar plexus catheters were removed with an INR ≥1.5, additional data are required to confirm the safety of such an approach.

Fifty-four patients (three groups, n=18 each) undergoing urological surgery in lumbotomy position were studied in Groups T (Th7–8) and L (L3–4), epidural anaesthesia was performed with initial doses obtaining sensorial block at Th4 (sd 1) followed by 7 ml h^–1 infusion; Group C received no epidural anaesthesia intraoperatively. The ID (BIS <45) and MD (BIS: 40–50) of propofol and recovery (BIS >80) and extubation times were recorded.

The volume to obtain a block was significantly lower in Group T than in Group L [10.7 (1.5) vs 14.7 (1.0) ml; P<0.001]. ID was significantly higher in Group C compared with that in Groups T and L [2.16 (0.15) vs 1.33 (0.19) vs 1.46 (0.14) mg kg^–1, respectively; P<0.001] with no significant difference between Groups T and L. For MD, there were significant differences between all groups [3.82 (0.9) vs 5.8 (1.32) vs 9.21 (0.55) mg kg^–1 h^–1 in Groups T, L, and C, respectively; P<0.001]. For recovery and extubation times, Group T<Group L<Group C [1.4 (0.5) vs 3.3 (1.2) vs 8.1 (0.99) min, respectively, P<0.001; and 3.4 (0.52) vs 5.8 (1.32) vs 11.4 (1.96) min, respectively; P<0.0001].

Similar segments blocked with epidural anaesthesia have resulted in similar ID. During maintenance, identical amounts of bupivacaine applied from different levels have resulted in different MD of propofol. The concentration of the epidural anaesthesia appears to play a more important role than the applied amount of the local anaesthetic.

A total of 19 randomized, double-blind, cross-over study patients suffering from chronic tinnitus were given a 30 min i.v. infusion of ropivacaine or lidocaine 1.5 mg kg^–1 at an interval of 2–3 months. The intensity of tinnitus was evaluated on tinnitus handicap inventory (THI) scale and on the visual analogue scale (VAS). Plasma ropivacaine and lidocaine concentrations were determined.

In both treatments, the infusion decreased the VAS score significantly. At the end of infusion, a ≥50% reduction in VAS score was observed in five patients by ropivacaine and in one patient by lidocaine, but this effect was sustained for 1 h only in three patients. However, the THI scores did not differ significantly within or between treatments. On the post-infusion day, three patients after ropivacaine and five after lidocaine treatment had ≥30% improvement in the THI score. Four weeks later, one patient after ropivacaine and two after lidocaine had a ≥30% reduction in the THI score. One patient developed seizures soon after ropivacaine infusion from which he recovered uneventfully. His plasma concentration of ropivacaine was 1817 ng ml^–1. The highest individual ropivacaine and lidocaine concentrations were 3483 and 1680 ng ml^–1, respectively.

Temporary clinically significant alleviation of tinnitus was observed only in a few individuals after both i.v. ropivacaine and lidocaine. The toxicity of ropivacaine limits its usefulness.

We conducted a national survey exploring airway management and ventilation during elective laryngeal surgery, focusing primarily on injector and jet ventilation (i.e. high-pressure source ventilation: HPSV).

Responses were received from 229 centres (75%). Several hospitals reported major complications during HPSV in the previous 5 yr, including three deaths. Complications during manual techniques led to seven discharge delays, three critical care admissions and three deaths. During the use of a high-frequency jet ventilation (HFJV), complications led to one discharge delay, two critical care admissions and no deaths. Complications were evenly spread between supraglottic, subglottic and transtracheal techniques. All deaths occurred in departments without HFJV. Three centres perform more than 100 transtracheal jet ventilation cases per year. None of these hospitals reported serious complications. Respondents in hospitals reporting serious complications were more likely to have plans to change practice (P=0.03). Elective laryngeal surgery is performed in 62% hospitals, of which 67% use HPSV. Supraglottic, subglottic and transtracheal techniques are used by 86, 50 and 35%, respectively. Manual ventilation devices are used widely. Only 17% of those using HPSV use an HFJV. Two-thirds of respondents initiate manual ventilation with pressures above 2 atm and only 6% start at ≤1 atm. I.V. cannulae are used for direct tracheal access by 18% and subcricoid insertion by 9%.

HPSV may cause serious complications and there are wide variations in clinical practice. This is an area where guideline development and examination of outcome data are warranted.

A total of 60 patients were randomly assigned to receive saline (Group S), remifentanil (Group R), or landiolol (Group L). Anaesthesia was induced by propofol target-controlled infusion. Two minutes after the induction of anaesthesia, infusion with vecuronium bromide and remifentanil, landiolol, or saline was initiated. Tracheal intubation was performed 7 min after anaesthesia induction. Arterial pressure, heart rate (HR), bispectral index (BIS), and entropy indices were recorded.

In Group S, RE increased significantly after tracheal intubation, but there was no significant increase in BIS or SE. These increases in RE were abolished in Groups R and L. RE–SE increased significantly after tracheal intubation in Group S, whereas no increase in RE–SE was observed in Groups R and L. Increases in mean arterial pressure and HR after tracheal intubation were suppressed in Groups R and L compared with Group S.

RE increased in response to tracheal intubation, whereas BIS and SE did not. Landiolol and remifentanil suppressed the increase in RE after tracheal intubation with significant inhibition of RE–SE difference.