The analgesic efficacy of tramadol versus ketorolac in day-case laparoscopic sterilisation

We conducted a prospective, randomised, double-blind study to compare the analgesic efficacy of intravenous tramadol 1.5 mg.kg-1 and ketorolac 10 mg in 60 ASA grade 1 and 2 patients scheduled to undergo day-case laparoscopic sterilisation by application of Filshie clips. Patients who received tramadol had significantly less postoperative pain in the recovery room (p = 0.007) and at discharge from the day-surgery unit (p = 0.03), and they required rescue analgesia with morphine less often (p = 0.02) than patients who received ketorolac. No difference in either the incidence or severity of nausea and vomiting was observed between the two groups. Both analgesic drugs were well tolerated at the doses given in the study, although dry mouth was significantly more common after the administration of tramadol (p = 0.009). Three patients in the tramadol group and five in the ketorolac group required overnight admission due to pain or nausea and vomiting.

Effective time to satisfactory intubation conditions after administration of rocuronium in adults. Comparison of propofol and thiopentone for rapid sequence induction of anaesthesia

We determined the effective time to satisfactory intubation conditions after the administration of rocuronium 0.6 mg.kg-1 to 120 unpremedicated adult patients anaesthetised with propofol 2.5 mg.kg-1 or thiopentone 5 mg.kg-1. Intubation conditions were assessed in 10 subgroups of 12 patients at 30, 40, 50, 60 and 70 s. The effective times to satisfactory intubation conditions in 50 and 90% of patients were obtained by the method of maximum likelihood after log time-probit response transformations. Intubation conditions after induction of anaesthesia with propofol were satisfactory in 5/12 patients at 30 s, 7/12 at 40 s, 10/12 at 50 s, 11/12 at 60 s and 11/12 at 70 s compared with 1/12 patients at 30 s, 2/12 at 40 s, 5/12 at 50 s, 7/12 at 60 s and 8/12 at 70 s after induction with thiopentone. The effective times to satisfactory intubation conditions in 50% and 90% (95% confidence intervals) of patients after rocuronium 0.6 mg.kg-1 were 34 (26-40) s and 61 (50-81) s in patients given propofol compared with 57 (48-69) s and 101 (79-167) s in patients given thiopentone. We conclude that rocuronium 0.6 mg.kg-1 may be a suitable alternative to suxamethonium during rapid sequence induction of anaesthesia with propofol in situations where suxamethonium is contraindicated.

Diimidazo[1,2-c:4',5'-e]pyrimidines: N6-N1 conformationally restricted adenosines

Tethering the N6-substituents of N6-substituted adenosines to N1 has resulted in a series of conformationally restricted adenosine analogues. The resultant diimidazo[1,2-c:4',5'-e]pyrimidines were shown to be adenosine A1 selective.

Dose-response relationship and effective time to satisfactory intubation conditions after rocuronium in children

We assessed the neuromuscular blocking effects of, and intubation conditions following, rocuronium in 81 children aged 2-12 years. The study was conducted in three parts. Parts 1 and 2 were undertaken during anaesthesia with thiopentone, alfentanil and nitrous oxide. Neuromuscular blockade was evaluated by recording the force of contraction of the adductor pollicis in response to train-of-four stimulation at 2 Hz repeated every 10s. In Part 1 the potency of rocuronium was determined in 15 children using a single dose-response technique; in Part 2 onset and recovery times were determined in six children following rocuronium 0.6 mg.kg-1. In Part 3 of the study, intubation conditions were assessed in five groups of 12 children whose tracheas were intubated 30, 40, 50, 60 and 70s after rocuronium 0.6 mg.kg-1 during anaesthesia with thiopentone. The times to satisfactory intubation conditions in 50% and 90% of children were determined by probit analysis. The effective doses of rocuronium to produce 50% and 95% twitch depression were 151 micrograms.kg-1 (95% confidence intervals: 129-173 micrograms.kg-1) and 331 micrograms.kg-1 (95% confidence intervals: 249-543 micrograms.kg-1), respectively. The mean times (SD) to 90% and 100% depression of control twitch following rocuronium 0.6 mg.kg-1 were 42 (11.8) s and 60.3 (19.3) s, respectively. The times to 5%, 25%, 75% and 90% recovery were 20.5 (3.1) min, 26.1 (4.1) min, 35.1 (5.4) min, and 39.5 (6.4) min, respectively. Intubation conditions were satisfactory in 4/12 children at 30 s, 6/12 at 40 s, 8/12 at 50 s, 11/12 at 60 s and 12/12 at 70 s. The times to satisfactory intubation conditions in 50% and 90% of children after rocuronium 0.6 mg.kg-1 were 38 s (95% confidence intervals: 30-44 s) and 61 s (95% confidence intervals: 55-70 s), respectively.

A comparison of acceleromyography and mechanomyography for determination of the dose-response curve of rocuronium in children

In order to compare an acceleromyograph (TOF-Guard) with a mechanomyograph (Grass FT03), the dose-response relationship of rocuronium was simultaneously determined in both arms of 15 children aged 3-11 years during anaesthesia with thiopentone, alfentanil and nitrous oxide. Three subgroups of five children received rocuronium 120, 180 or 240 micrograms.kg-1 randomly. The effective doses to produce 50% and 95% depression of the first twitch of the train-of-four determined by acceleromyography were 206 and 337 micrograms.kg-1, respectively, while these values determined by mechanomyography were 151 and 331 micrograms.kg-1, respectively. The dose-response curve obtained by acceleromyography was steeper and shifted to the right compared with that obtained by mechanomyography (p < 0.0001). The difference between the effective dose producing 50% twitch depression determined by the two devices was highly significant (p < 0.0001). In 13 out of 15 children, the acceleromyograph control train-of-four ratio was significantly greater than unity. Although there was a good correlation (r = 0.85) between simultaneous pairs of measurements of neuromuscular block, the acceleromyograph exhibited a bias of -25% relative to the mechanomyograph with wide limits of agreement (-62 to +12%). We conclude that acceleromyographic and mechanomyographic measurements should not be used interchangeably when determining the potency of muscle relaxants.

The prognostic value of serial measurements of serum albumin concentration in patients admitted to an intensive care unit

The prognostic value of serial measurements of serum albumin concentration during the first 72 h after admission to a general adult intensive care unit was retrospectively reviewed in 348 consecutive critically ill patients over a one year period. The accuracy of the admission APACHE II (Acute Physiology And Chronic Health Evaluation) score in correctly predicting patient outcome was compared with the serum albumin concentration measured at different times after intensive care unit admission. Multiple logistical regression analyses were performed to evaluate whether combining APACHE II and serum albumin into a unified risk index improved prognostic accuracy. Serum albumin concentration on admission was lower in non-survivors than in survivors and decreased more rapidly in non-survivors (p < 0.001). The admission serum albumin concentration was found to be an insensitive prognostic indicator. However, serum albumin measured after 24 h was as accurate as the admission APACHE II score in correctly classifying patients according to outcome. There was a good correlation between the admission APACHE II score and serum albumin measured after 24 h but not between the admission APACHE II and the admission serum albumin. Combining the APACHE II score and serial albumin concentrations into a unified risk of death equation did not improve the accuracy of outcome prediction.

Dose-response and minimum time to satisfactory intubation conditions after mivacurium in children

We assessed neuromuscular blocking effects and tracheal intubation conditions following mivacurium in 121 anaesthetised children aged 1-10 years. The study was conducted in three parts. Parts 1 and 2 were undertaken during thiopentone-alfentanil-nitrous oxide anaesthesia; neuromuscular blockade was evaluated by recording the force of contraction of the adductor pollicis in response to train-of-four stimulation at 0.1 Hz. In part 1 the potency of mivacurium was determined in 15 children using a single dose-response technique; in part 2 onset and recovery times were determined in six children following a dose of mivacurium 0.2 mg.kg-1. In part 3 of the study, clinical intubation conditions were assessed in two groups of 50 children whose tracheas were intubated 60 or 90 s after injection of mivacurium 0.2 mg.kg-1 during thiopentone-nitrous oxide anaesthesia. The ED50 and ED95 of mivacurium were 54 and 105 micrograms.kg-1 respectively. The times to 90% and 100% depression of control twitch were 1.3 (0.3) and 1.9 (0.5) min; times to 5%, 25%, 75% and 90% recovery were 6.4 (1.0), 8.4 (1.1), 12.5 (1.1) and 14.4 (1.9) min, respectively. Intubation conditions were rated satisfactory in 33/50 children (0.66, 95% confidence interval 0.51-0.79) at 60 s and in 49/50 children (0.98, 95% confidence interval 0.89-1.0) at 90 s (p = 0.0001). Intubation conditions 90 s after mivacurium 0.2 mg.kg-1 were significantly better than those obtained in 10 patients given anaesthetic drugs alone (p = 0.002).

Evaluation of the Pneupac Ventipac portable ventilator: comparison of performance in a mechanical lung and anaesthetized patients

The performance of the Pneupac Ventipac portable gas-powered ventilator was evaluated in two stages. The accuracy of delivery of the ventilator was assessed using a mechanical lung model at different combinations of compliance and airway resistance to simulate normal and diseased lungs. The performance of the ventilator was then assessed in 20 anaesthetized patients. The tidal volume delivered by the ventilator in airmix mode (nominal inspiratory oxygen fraction (FIO2) 0.45) was between -20 and +30% of the preset tidal volume with the mechanical lung model adjusted to normal adult values of compliance and airway resistance. The corresponding value with the ventilator set to deliver 100% oxygen was between -22 and -7% of the preset tidal volume. The performance of the ventilator decreased when either compliance was reduced or airway resistance was increased in the mechanical lung model; this effect was greater in airmix mode. Delivered tidal volume was between -19 and +12% of the present tidal volume in the group of anaesthetized patients using the ventilator in airmix mode. The ventilator was reliable and simple to use, and performance was within acceptable limits in the anaesthetized patients. However, we recommend that a means of verifying the adequacy of ventilation should always be used when transporting critically ill or anaesthetized patients with any portable ventilator, particularly when lung compliance or airway resistance may be abnormal.

Oral administration of midazolam as a premedicant for paediatric day-case anaesthesia

Fifty-four children aged 1-10 years, scheduled for day-case anaesthesia were prescribed either oral midazolam 0.5 mg.kg-1 or a placebo preparation 30-60 min pre-operatively on a double-blind basis. On arrival at the induction room, anxiolysis was satisfactory in 23 out of 24 (96%) children who received midazolam compared with 12 out of 27 (44%) of those who received placebo (p < 0.001); at induction of anaesthesia these proportions were 21 out of 24 (88%) and nine out of 27 (33%) respectively (p < 0.001). The time to early recovery from anaesthesia was somewhat longer in children premedicated with midazolam compared with controls (28.2 vs 21.9 min) (p < 0.05). Similarly, the time to hospital discharge was longer in the midazolam group (244 vs 185 min) (p < 0.01). Analysis of behavioural questionnaires completed by parents 2 weeks after hospitalisation indicated that there were fewer postoperative behavioural disturbances in children premedicated with midazolam compared with controls (p < 0.05).

Microtubule-associated protein 2: monoclonal antibodies demonstrate the selective incorporation of certain epitopes into Alzheimer neurofibrillary tangles

Neurofibrillary tangles (NFT) are the principal structural alteration of neuronal cell bodies in Alzheimer disease as well as in normal aging of the human brain. While the ultrastructure of these intraneuronal lesions has been extensively studied, the biochemical composition of the fibers comprising the NFT is unknown. We report the production of three monoclonal antibodies against the microtubule-associated protein 2 (MAP-2), one of which intensely labels Alzheimer NFT. All three antibodies specifically recognize MAP-2 on immunoblots and stain brain tissue in a characteristic dendritic pattern. The three antibodies are directed against at least two different antigenic sites on the MAP-2 molecule, and one appears to recognize a phosphorylation site on MAP-2. That only one of the three antibodies immunolabels NFT suggests that the formation of the tangle involves some modification of the MAP-2 molecule. Our findings suggest that one aspect of Alzheimer-type neurofibrillary pathology is an aggregation of MAP-2 or MAP-2 fragments with altered neurofilamentous elements present in NFT. Normal interactive function, which putatively occurs between neurofilaments and MAP-2, may thus be disrupted in Alzheimer disease.