Canadian journal of anaesthesia = Journal canadien d'anesthésie
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The use of an ultra-thin flexible fiberoptic bronchoscope with a single lumen diameter of 2.7 mm at the distal tip to assist intubation of paediatric patients with a difficult airway is reported. Two patients (ages 30 months and 18 months) with mandibular hypoplasia and one patient (three months) with the Pierre-Robin syndrome are reported. In each case two fiberoptic bronchoscopes were used. The first allowed introduction of topical local anaesthetic while the second and smaller one was used for tube placement.
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The effect of age on the onset and duration of action of a d-tubocurarine (DTC) neuromuscular blockade with and without pancuronium priming in children was examined. Sixty ASA physical status I or II patients in three age ranges (0-1 yr, 1-3 yr and 3-10 yr) were anaesthetized with thiopentone, halothane and nitrous oxide. Each patient received either a single paralyzing dose of DTC 0.4 mg.kg-1, or DTC 0.36 mg.kg-1 preceded three minutes earlier by pancuronium 0.007 mg.kg-1. ⋯ Time to ten per cent spontaneous recovery after single dose DTC was shorter in older individuals (r = 0.40, p less than 0.05), being 36.4 +/- 5.1 min in infants 0-1 yr, 30.6 +/- 4.6 min (1-3 yr), and 24.0 +/- 2.7 min (3-10 yr). Priming with pancuronium accelerated the onset significantly in all age groups with 90 per cent T1 depression occurring at 0.7 +/- 0.1 min (0-1 yr), 0.9 +/- 0.1 min (1-3 yr), and 2.1 +/- 0.6 min (3-10 yr). However, priming delayed recovery, especially in infants.(ABSTRACT TRUNCATED AT 250 WORDS)
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One must distinguish between what is medically safe and what is legally safe. The authors have the impression that in order to be "legally safe" one must perform a test dose. This is despite the fact that it has not been conclusively shown that the use of test doses improve the safety margin of epidural anaesthesia, when administered by a competent person, with the proper resuscitative equipment immediately available. ⋯ The literature suggests that lidocaine 1.5 per cent in dextrose 7.5 per cent should be the test dose of choice in obstetric epidural anaesthesia in an amount known to produce spinal anaesthesia (30-50 mg). The use of epinephrine in test doses in unpremedicated healthy women in active labour is neither sensitive nor specific in signalling intravascular injection, and it may also be detrimental to fetal wellbeing. Epinephrine 15 micrograms as a test dose for intravenous injection appears to create more problems than it solves.
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The management of a 28-year-old primigravida with placenta accreta diagnosed during Caesarean section is described. A hysterectomy was required to control massive haemorrhage, and the patient made a full recovery. The increased incidence of placenta accreta over the last three decades is thought to be associated with the concomitant increased frequency of Caesarean section, resulting in an increased incidence of placenta praevia (1.9 per cent to 3.9 per cent). ⋯ Management of placenta accreta is primarily by control of haemorrhage on delivery of the placenta. Control can be assisted by infrarenal cross-clamping of the aorta and/or intra-myometrial injection of prostaglandin F2 alpha which produces myometrial and vascular contraction. Identification of patients at increased risk, preparation for treatment and effective treatment of placenta accreta will minimize maternal morbidity and mortality.
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Randomized Controlled Trial Clinical Trial
Neostigmine, pyridostigmine and edrophonium as antagonists of deep pancuronium blockade.
To compare the ability of equipotent doses of neostigmine, pyridostigmine and edrophonium to antagonize intense pancuronium neuromuscular blockade, one hundred and twenty ASA physical status I or II patients scheduled for elective surgery received 0.06 mg.kg-1 pancuronium during a thiopentone nitrous oxide-enflurane anaesthetic. Train-of-four stimulation was applied every 12 s and the force of contraction of the adductor pollicis muscle was recorded. In the first 60 patients, spontaneous recovery was allowed until ten per cent of initial first twitch height. ⋯ These doses were given by random allocation to the next 60 patients, but at one per cent spontaneous recovery. Neostigmine, 0.04 mg.kg-1, produced a T1 of 73 +/- 4 per cent (mean +/- SEM), and a train-of-four ratio (TOF) of 39 +/- 3 per cent. This was significantly greater than with pyridostigmine, 0.2 mg.kg-1 (T1 = 50 +/- 6 per cent; TOF = 25 +/- 3 per cent), and edrophonium, 0.54 mg.kg-1 (T1 = 54 +/- 3 per cent; TOF = 17 +/- 2 per cent).(ABSTRACT TRUNCATED AT 250 WORDS)