The anaesthetist and the head-injured patient

Audit of transfer of head-injured patients to a stand-alone neurosurgical unit

An audit was conducted of all serious head injured patients received at Atkinson Morley's Hospital over 1 year. One hundred and fifty-four were received, of whom 65 (42.2 per cent) had multiple injuries; 137 (89 per cent) patients were intubated and the overall incidence of hypoxia was 9.7 per cent. The incidence of hypercarbia was 25.9 per cent and was unrelated to the mode of ventilation. Hypotension was present in 11 patients (7.1 per cent) and hypovolaemia in 16 (10.5 per cent). During transfer 39 (28.9 per cent) intubated patients received no sedation, although 29 (21.5 per cent) were given neuromuscular blocking agents alone. The incidence of actual cervical injury was 3.2 per cent and in all five patients the neck was adequately stabilized pre-transfer. The incidence of thoracid injury was 19.5 per cent and of these four patients (13.3 per cent) warranted thoracotomy. Abdominal trauma occurred in eight (5.2 per cent) patients and in only one patient was laparotomy not performed pre-transfer. The accompanying doctor was a SHO with less than 6 months experience in anaesthetics in 33 per cent of transfers. Arterial blood pressure was monitored in only 50 per cent of transfers. The initial management of patients was generally satisfactory, and in particular the avoidance of hypoxia by a high rate of intubation was a significant improvement over other studies.

Effect of hypercapnia or xylazine on lateral ventricle and lumbosacral cerebrospinal fluid pressures in pentobarbital-anesthetized horses

Facial artery pressure, central venous pressure, heart rate, and lateral ventricle cerebrospinal fluid (CSF) pressure (LV-CSFP) were measured in 10 pentobarbital-anesthetized horses at arterial partial pressure of carbon dioxide (PaCO2) values of 40, 60, and 80 mm Hg, produced by varying the inspired carbon dioxide concentration. Variables were recorded at 5-minute intervals for 15 minutes at each level of PaCO2. Arterial blood gas analysis was performed at the end of the 15-minute time period for each level of PaCO2. Lateral ventricle CSF pressure was significantly increased (p < .05) at a PaCO2 of 80 mm Hg. Cardiovascular variables were not significantly changed by changing PaCO2. The PaCO2 was returned to 40 mm Hg; 1.1 mg xylazine/kg body weight was injected intravenously in eight horses, and data were collected for 60 minutes. No significant changes were observed. No changes were observed in two control horses not receiving xylazine. Subsequently, placement of a lumbosacral subarachnoid catheter allowed simultaneous measurement of LV-CSFP and lumbosacral CSF pressure (LS-CSFP) at PaCO2 values of 40, 60, and 80 mm Hg. The Pearson Correlation Coefficient between LV-CSFP and LS-CSFP was 0.94 (p < .0001) It was concluded that changes in CSF pressure could be detected at the lateral ventricle and the lumbosacral space; increasing PaCO2 to 80 mm Hg resulted in significant increases in LV-CSFP; xylazine does not increase LV-CSFP in pentobarbital-anesthetized, normocapnic horses; and under the conditions of this experiment, LV-CSFP and LS-CSFP were closely correlated.

Acute airway management in the critically ill child requiring transport

Airway compromise was found to be a common problem in children requiring critical care transport to our hospital. This retrospective review of 39 infants and children was undertaken to assess the frequency and degree of airway compromise in these children, to document the management required and to determine who performed it. Ninety-seven per cent of children had airway difficulties associated with their disease, and one-third of these required further airway management on the arrival of the transport team. Airway specialists had not been involved in the care of these children before the arrival of the transport team. This indicates that greater attention should be paid to airway management as soon as children are identified as being sufficiently ill to require transport to a tertiary care facility.