British journal of anaesthesia
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Randomized Controlled Trial Clinical Trial
Does intrathecal fentanyl produce acute cross-tolerance to i.v. morphine?
We have examined the hypothesis that intrathecal fentanyl at operation can increase postoperative i.v. morphine requirements. We studied 60 patients undergoing Caesarean section. All received intrathecal 0.5% plain bupivacaine 2 ml combined with either fentanyl 0.5 ml (25 micrograms) (group F) (n = 30) or normal saline 0.5 ml (group S) (n = 30). ⋯ Up to 6 h after delivery there was no difference in postoperative morphine requirements or pain scores. Between 6 h and 23 h there was a 63% increase in morphine requirements in group F. We consider the most likely explanation for this finding to be that intrathecal fentanyl induced acute spinal opioid tolerance.
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Femoral nerve palsy has been reported after percutaneous ilioinguinal field infiltration with general anaesthesia for inguinal herniorrhaphy. The mechanism whereby this could occur was studied in cadaver dissections. ⋯ Femoral nerve palsy may result from infiltration of a sufficient volume of local anaesthetic into the plane between the transversus abdominis muscle and the transversalis fascia with tracking of the injectate deep to the iliacus fascia to affect the femoral nerve. This finding has important implications for the performance of a percutaneous ilioinguinal field block particularly in day surgery provision.
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Clinical Trial
Extracorporeal membrane oxygenation for transport of hypoxaemic patients with severe ARDS.
Conventional inter-hospital transfer of patients with severe acute respiratory distress syndrome (ARDS) in need of extracorporeal membrane oxygenation (ECMO) may be risky and in severe hypoxaemic patients may be associated with cerebral hypoxia and death. Therefore, we began a phase 1 study to evaluate the feasibility, complications and outcome of inter-hospital transport of these patients using veno-venous ECMO. Eight patients with severe ARDS and a PaO2/FIO2 < 6.7 kPa at a PEEP > or = 10 cm H2O were placed on a mobile ECMO at the referring hospital. ⋯ No significant complications occurred. Six patients survived and were discharged from hospital; two patients died because of multiple organ failure. We conclude that initiation of ECMO in hypoxaemic patients before inter-hospital transfer is feasible and enables safe transport to an ECMO centre.
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We describe an obstetric patient who developed incapacitating headache after inadvertent dural tap and was treated with repeated blood patching. She subsequently developed severe lumbar back pain which, after exclusion of suspected extradural abscess, was treated successfully with simple analgesics and physiotherapy. Two possible explanations are offered to account for her symptoms. We compare this case with others in the literature.
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To clarify the effects of the pregnant uterus on the extradural venous plexus in the supine and lateral positions, we studied magnetic resonance (MR) images of the lumbar spine in three parturients. T2-weighted axial MR images were obtained with the parturient in the supine and lateral positions. ⋯ When the parturient lay supine, the pregnant uterus compressed the inferior vena cava and almost totally obstructed it; the extradural venous plexus was engorged. On turning the parturient into the lateral position, the inferior vena cava was free from compression, and the engorged extradural venous plexus was found to shrink to the level of the non-pregnant state.