What is the future of advanced trauma life support training?

Within the past 20 years, advanced trauma life support has developed from a regional to an international educational programme, with 31 participating countries. Notwithstanding the general acknowledgement of the effectiveness of advanced trauma life support procedures for improving early hospital trauma management and the specific knowledge and skills of participants, some criticism has come from the community of British anaesthetists, regarding course contents, the possibility of participating, the significance of skills for trained anaesthetists, team-related concerns and, of course, costs. Now that we have 10 years' experience from European advanced trauma life support courses, we want to take the opportunity to assess the advantages and possible deficiencies of this programme.

Toxicity of spinal local anaesthetics.

Recent reports of severe neurological injury after spinal anaesthesia have generated concerns about the neurotoxic potential of local anaesthetics and, in particular, of lignocaine. Further, there is an increasing body of evidence indicating that transient neurological symptoms commonly occur after uneventful lignocaine spinal anaesthesia but not after bupivacaine. Results from an epidemiological study suggest that patient positioning and outpatient status are major co-factors.

Acute management of a cyanotic episode in an infant after a Norwood procedure.

In infants with a Norwood stage I reconstruction, the respiratory management to direct pulmonary to systemic blood flow ratio is of critical importance. Disturbance of this delicate blood-flow balance can occur causing rapid deterioration of the infant's condition requiring urgent interventions. However, the emergency staff personnel that are generally the first to be called may not be familiar with these patients' complex pathophysiology.

Effects of halothane, sevoflurane and propofol on left ventricular diastolic function in humans during spontaneous and mechanical ventilation.

Background: There is limited knowledge of the effects of anaesthetics on left ventricular (LV) diastolic function in humans. Our aim was to evaluate these effects in humans free from cardiovascular disease.

Methods: Sixty patients (aged 18-47 yr) who had no history or signs of cardiovascular disease were randomized to receive general anaesthesia with halothane, sevoflurane or propofol.

Effect of obesity and thoracic epidural analgesia on perioperative spirometry.

Background: Lung volumes in obese patients are reduced significantly in the postoperative period. As the effect of different analgesic regimes on perioperative spirometric tests in obese patients has not yet been studied, we investigated the effect of thoracic epidural analgesia and conventional opioid-based analgesia on perioperative lung volumes measured by spirometry.

Methods: Eighty-four patients having midline laparotomy for gynaecological procedures successfully completed the study.

Fulminant neuroleptic malignant syndrome after perioperative withdrawal of antiParkinsonian medication.

Neuroleptic malignant syndrome is a rare complication when using neuroleptic drugs. We report the case of a patient with severe Parkinson's disease who developed neuroleptic malignant syndrome after withdrawal of his antiParkinsonian medication for elective coronary artery bypass grafting. Sodium dantrolene may be a therapeutic option in severe cases.

Impact of spinal anaesthesia and obesity on maternal respiratory function during elective Caesarean section.

Spinal anaesthesia for Caesarean section has gained widespread acceptance. We assessed the impact of spinal anaesthesia and body mass index (BMI) on spirometric performance. In this prospective study, we consecutively assessed 71 consenting parturients receiving spinal anaesthesia with hyperbaric bupivacaine and fentanyl for elective Caesarean section.

Anesthesia affects olfaction and chemosensory event-related potentials.

Objective: Olfactory and trigeminal systems interact and contribute to the perception of odorants. This study was aimed at investigating the effect of local anesthesia on olfaction.

Methods: One percent of tetracaine on a cotton swab was applied intranasally at three different locations in 20 volunteers and 4% of lidocaine was applied to the olfactory cleft in a head-down position.

The effect of epidural analgesia in labour on maternal respiratory function.

Lumbar epidural analgesia during labour has gained widespread acceptance. The impact of epidural analgesia based on mixtures of low-dose local anaesthetic solutions and lipophilic opioids on most clinically relevant obstetric outcomes is minimal. Since the pregnant state per se is associated with important alterations in respiration, we assessed whether a subtle degree of motor blockade brought about by epidural analgesia might compromise respiratory function as assessed by spirometry.

Effect of three anaesthetic techniques on isometric skeletal muscle strength.

Background: Our aim was to quantify human involuntary isometric skeletal muscle strength during anaesthesia with propofol, sevoflurane, or spinal anaesthesia using bupivacaine.

Methods: Thirty-three healthy patients undergoing anaesthesia for elective lower limb surgery were investigated. Twenty-two patients received a general anaesthetic with either propofol (n=12) or sevoflurane (n=10); for the remaining 11 patients spinal anaesthesia with bupivacaine was used.

Effect of obesity and site of surgery on perioperative lung volumes.

Background: Although obese patients are thought to be susceptible to postoperative pulmonary complications, there are only limited data on the relationship between obesity and lung volumes after surgery. We studied how surgery and obesity affect lung volumes measured by spirometry.

Methods: We prospectively studied 161 patients having either breast surgery (Group A, n=80) or lower abdominal laparotomy (Group B, n=81).

Heart rate variability and cardiac troponin I are incremental and independent predictors of one-year all-cause mortality after major noncardiac surgery in patients at risk of coronary artery disease.

Objectives: The aim of this study was to determine whether perioperative measurements of heart rate variability (HRV) and cardiac troponin I (cTnI) add additional prognostic information to established risk scores for first-year mortality in patients at risk of coronary artery disease (CAD) undergoing major noncardiac surgery.

Background: In cardiac-risk patients undergoing major noncardiac surgery, the short- and long-term prognoses are mainly influenced by perioperative cardiac complications. Heart rate variability and cTnI are important prognostic markers in patients with congestive heart failure and myocardial infarction.

Use of myocardial tissue Doppler imaging for intraoperative monitoring of left ventricular function.

Background: Detection of myocardial ischaemia during surgery is usually by assessment of regional wall motion using two-dimensional transoesophageal echocardiography (TOE). Tissue Doppler imaging (TDI) may assist this assessment and improve its accuracy.

Methods: We measured peak myocardial velocities in the anterior mid-wall of the left ventricle by TOE and pulsed-wave TDI in addition to transmitral flow velocity, two-dimensional echocardiography and cardiovascular variables.

B-lymphocytes from malignant hyperthermia-susceptible patients have an increased sensitivity to skeletal muscle ryanodine receptor activators.

Malignant hyperthermia (MH) is a pharmacogenetic disease triggered by volatile anesthetics and succinylcholine in genetically predisposed individuals. The underlying feature of MH is a hypersensitivity of the calcium release machinery of the sarcoplasmic reticulum, and in many cases this is a result of point mutations in the skeletal muscle ryanodine receptor calcium release channel (RYR1). RYR1 is mainly expressed in skeletal muscle, but a recent report demonstrated the existence of this isoform in human B-lymphocytes.

Reference values for left ventricular function in subjects under general anaesthesia and controlled ventilation assessed by two-dimensional transoesophageal echocardiography.

Background And Objective: Transoesophageal echocardiography is increasingly used for evaluation and monitoring of left ventricular function in anaesthetized patients. However, the only available reference values for transoesophageal echocardiography were derived from studies in awake subjects.

Methods: We determined left ventricular dimensions and systolic function in 45 patients without clinical evidence of heart disease who voluntarily underwent transesophageal echocardiography under conditions of balanced general anaesthesia, controlled fluid administration, supine position, muscle relaxation and controlled ventilation.

Competence of the internal jugular vein valve is damaged by cannulation and catheterization of the internal jugular vein.

Background: Experimental results suggest that the competence of the internal jugular vein (IJV) valve may be damaged when the IJV is cannulated for insertion of a central venous catheter. It has further been hypothesized that the risk of causing incompetence of the proximally located valve might be reduced by using a more distal site for venous cannulation. The present study evaluated these hypotheses in surgical patients.

Inspired oxygen fraction after cardiopulmonary bypass: effects on pulmonary function with regard to endothelin-1 concentrations and venous admixture.

Twenty consecutive patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) were allocated at random to group 1 (n = 10, high inspired oxygen fraction (FIO2) after CPB), or group 2 (n = 10, moderate FIO2 after CPB). The effects of each FIO2 on arterial and mixed venous concentrations of endothelin-1 (ET-1) and its precursor, Big ET-1, were measured. Venous admixture was calculated to assess the efficiency of pulmonary gas exchange.

News in autoimmune disease.

The diversity of strategies reflects as much the lack of ideal treatments as it does the imagination of the investigators. Many aspects such as manipulation of apoptosis and extracorporeal removal of autoantibodies have been omitted due to space restrictions. Although most successful treatment strategies have been based on proven basic research principles, most require well performed, prospective, randomised clinical trials before optimistic anecdotes translate to clinical practice.

Teaching the use of fiberoptic intubation in anesthetized, spontaneously breathing patients.

Unlabelled: In patients with difficult airways, the standard of care involves fiberoptic intubation under spontaneous ventilation. However, the safety and feasibility of a fiberoptic intubation teaching program has only been documented in paralyzed and apneic patients, whereas data obtained in patients under spontaneous respiration are limited and conflicting. We evaluated 100 anesthetized patients undergoing orotracheal fiberoptic intubation.

Mechanism of antinociceptive action of clonidine in nonmyelinated nerve fibres.

Despite a large body of clinical evidence in favour of a local anesthetic effect of clonidine, the underlying mechanism has not yet been elucidated. In this study we have used the sucrose-gap method to measure the effects of clonidine on the electrophysiological properties of nonmyelinated nerve fibers in the rabbit vagus nerve. The results showed that clonidine enhanced the hyperpolarizing and reduced the depolarizing afterpotential that follow compound action potentials during electrical activity.

High incidence of intravenous thrombi after short-term central venous catheterization of the internal jugular vein.

Study Objective: To assess incidence and characteristics of intravenous (i.v.) thrombi associated with short-term central venous catheterization through the internal jugular vein.

Gastric intramucosal pH as a monitor of gut perfusion after thrombosis of the superior mesenteric vein.

Gastric intramucosal pH (pHi) when measured by a tonometer is a simple and minimally invasive method to determine gut ischemia. In a case of severe mesenteric venous thrombosis, we measured pHi intra- and postoperatively over a period of five days. The goal was to monitor improvement or deterioration of gastrointestinal perfusion in the intensive care unit and to perform a second-look laparotomy if the condition worsened.

General anaesthesia for surgery can influence circulating melatonin during daylight hours.

Background: Both melatonin and anaesthetics have been shown to affect sleep and behaviour. The effect of general anaesthesia on circulatory melatonin has not been reported, but anaesthetic-related alterations in hormone profiles are known. We hypothesize that differences in recovery from anaesthesia may be associated with differences in circulatory melatonin levels because of melatonin's sedative effect in humans.