Anaesthesia
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Review
Neuromuscular transmission and its blockade. Pharmacology, monitoring and physiology updated.
The role of two recently introduced muscle relaxants--atracurium and vecuronium--in contemporary anaesthetic practice is assessed. Recent advances in the physiology of neuromuscular transmission, particularly the roles of calcium and calmodulin, are reviewed, and new ideas concerning the reversal and monitoring of neuromuscular blockade are discussed.
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Four cases of air embolism which occurred during neurosurgical procedures in the sitting position are described, in whom the signs could be due to air in the coronary or cerebral arteries. It is suggested that, during venous air embolism in the sitting position, a significant number of patients are haemodynamically at risk from paradoxical air embolism, and that the serious consequences of venous air embolism in neurosurgery may be due to this.
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The history of tracheal intubation has been described before, but earlier accounts have overlooked several aspects and, in particular, the part played by Kuhn, who also deserves to be recognised for a number of other original contributions to anaesthesia.
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The metabolic response to surgery causes sodium and water retention. It does not seem logical to pour crystalloid solutions into patients in the peri-operative period, particularly when these solutions can cause deterioration in lung function. Plasma volume must be maintained to prevent a decreased blood flow to vital organs such as the kidneys. ⋯ Patients undergoing minor to moderate surgery when they are likely to be drinking within 24 hours do not usually require any intravenous infusion. Moreover, to administer intravenous fluids to these patients may cause harm. No fluid regimens should be inflexible and the patient's size, age and fluid losses should be taken into account.