Spinal analgesia with hyperbaric bupivacaine: effects of volume of solution

The effects of 0.5% bupivacaine 1.5, 2 and 3 ml in 8% glucose was compared in a double-blind study involving 30 patients undergoing spinal analgesia. The time to the onset of maximum segmental spread of analgesia was approximately 15 min for all three volumes. Cephalad spread of analgesia was related to the volume used: 1.5 ml reached T10, 2 ml T8 and 3 ml T7. The duration of analgesia increased with increasing volume, 3 ml producing analgesia in T8-T12 for 1.5-2 h, and in the lumbar region for 2.5-3 h. Increasing the volume increased the extent of motor blockade and speeded up its onset. Significant decreases in arterial pressure were observed in the 2- and 3-ml groups. The changes in heart rate were moderate and not correlated with the amount of drug. Spinal headache occurred in two patients.

Epidural block during labour in a patient with spina bifida cystica

A case report is presented of a patient in whom a lumbosacral meningocele had been successfully removed in the neonatal period and who later received a lumbar epidural block for pain relief during labour. Although a high level was chosen for the puncture, deficiency of the dorsal interspinous layer of ligaments complicated the localisation of the epidural space when the 'loss of resistance' technique was applied. Analgesia was achieved more rapidly and with a lower dose of analgesic drug than is normally necessary for satisfactory relief of pain in labour.

Assessment of cerebral injury with spinal fluid creatine kinase (CSF-CK) in patients after cardiac resuscitation

Serial determinations of creatine kinase in cerebrospinal fluid (CSF) were made in eighty-two patients, that were comatose after cardiac resuscitation because of ventricular fibrillation. In all patients who remained unconscious creatine kinase (CSF-CK) increased from less than 2 U/L to 11 U/L or more with maximum CSF-CK averaging 53 +/- 6 U/L 48-72h after resuscitation. In patients who recovered consciousness maximum CSF-CK activity never exceeded 11 U/L. However, maximum CSF-CK activity between 5 and 11 U/L was always associated with some permanent cerebral dysfunction. Complete cerebral restitution was only observed when maximum CSF-CK was 5 U/L or less. In some patients a maximum CK activity of 4 U/L was associated with depressed memory functions. The blood-brain barrier was impermeable to CK as evidenced by isoenzyme analysis and lack of correlation between CK activity in CSF and peripheral blood. CSF-pressure rose slightly to 217 +/- 11 mmH2O in patients with CSF-CK above 10 U/L and to 197 +/- 15 mmH2O when CSF-CK was below 5 U/L. The results indicate that high CSF-CK activity, whether appearing early or late after successful cardiac resuscitation, effectively predicts an unfavourable outcome of global cerebral ischemia. No rise in CSF-CK was always indicative of full cerebral recovery.

On the technique of external cardiac compression

ECG, arterial flow and pressure were recorded during external cardiac compression (ECC) in a patient whose heart had ceased beating. The patient was a 68-year-old female who remained comatose for 2 weeks after an emergency laparotomy for perforated diverticulitis of the colon. She developed sepsis, renal failure, and cardiopulmonary failure. During ECC, the pressure on the sternum was maintained for about 0.5 sec (sustained pressure technique), flow and mean arterial pressure were improved by 32 and 20%, respectively, as compared with flow and pressure obtained with a quick and more jerky compression. During spontaneous heart activity with a low blood pressure, a superimposed ECC improved both flow and mean arterial pressure. Calcium chloride and adrenaline injected into the right atrium increased the tone and contractile power of the heart and greatly improved flow and pressure when the heart was subsequently compressed during asystole.