Anaesthesia
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This paper presents the findings from the second pilot study of the cost block method in 21 adult general intensive care units (ICUs). The aim of this study was to explore the possible reasons for the variation in cost identified in a previous pilot study of 11 ICUs. Data were collected for the six cost blocks for the financial year 1996/97. ⋯ Ninety-two per cent of the variation in nursing staff expenditure was explained by the number of ICU beds and the presence of an HDU. Hospital type and the number of patient days explained 76% of the variation in expenditure on consultant staff. Sixty-four per cent of the variation in drug and fluid expenditure was explained by the number of patient days.
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Randomized Controlled Trial Clinical Trial
Reversing sevoflurane-associated Q-Tc prolongation by changing to propofol.
Congenital or acquired forms of the long Q-T syndrome may result in ventricular tachycardia known as torsade de pointes. Many drugs including volatile anaesthetics modify the Q-T interval. Sevoflurane is known to prolong of the rate-corrected Q-T interval (Q-Tc). ⋯ Measurements were taken before, and 15, 20, 25 and 30 min after induction. Q-Tc prolongation was significantly reduced 5, 10 and 15 min after propofol had been substituted for sevoflurane. We conclude that the sevoflurane-associated Q-Tc prolongation is fully reversible within 15 min when propofol is substituted for sevoflurane.
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Seven cases are described in which neurological damage followed spinal or combined spinal-epidural anaesthesia using an atraumatic spinal needle. All patients were women, six obstetric and one surgical. All experienced pain during insertion of the needle, which was usually believed to be introduced at the L2-3 interspace. ⋯ The tip of the conus usually lies at L1-2, although it may extend further. Tuffier's line is an unreliable method of identifying the lumbar interspaces, and anaesthetists commonly select a space that is one or more segments higher than they assume. Because of these sources of error, anaesthetists need to relearn the rule that a spinal needle should not be inserted above L3.
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We have studied the reliability of two simple pre-induction tests used to select the more patent nostril for nasotracheal intubation by comparing their results with those obtained from fibreoptic examination of the nostrils, in 75 maxillo-facial patients requiring nasotracheal intubation under general anaesthesia, who had no history of nasal obstruction. The tests comprised (1) estimation of the rate of airflow through each nostril during expiration by palpating the passage of air when the contralateral nostril was occluded, and (2) asking for the patient's assessment of airflow through the nostrils, following the administration of a vasoconstrictor. After each test, noses were classified as left or right nostril clearer or nostrils equally clear. ⋯ There was no significant difference between the overall diagnostic success rates of the two tests (44% and 47%, respectively). In patients with intranasal abnormalities, the numbers of correct diagnoses made by the two tests were not significantly different and were also not significantly different from the number of correct selections made if only the right nostril or only the left nostril had been used for the intubation. In view of the relatively high diagnostic failure rates, anaesthetists should not rely on the two tests investigated when selecting the best nostril for nasotracheal intubation.
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When lumbar puncture is performed in the sitting position, the patient's thighs are usually at an angle of approximately 90 degrees to the trunk, whereas in the lateral position, hip flexion is employed by flexing the patient's knees to the chest. We measured the presumed but hitherto unquantified widening of lumbar interspinous spaces resulting from hip flexion. ⋯ Mean lumbar interspinous space width at L2-3, L3-4 and L4-5 increased by 7%, 11% and 21%, respectively, with the hips flexed. Hip flexion in the sitting position will anatomically optimise lumbar interspinous space width for needle passage, and statistically significant increases in space width have been demonstrated increasing progressively from L2-3 to L4-5.