Prevention of hypotension during spinal anaesthesia for caesarean section: ephedrine infusion versus fluid preload

We compared the efficacy of prophylactic ephedrine infusion over fluid preloading in prevention of maternal hypotension during spinal anaesthesia for Caesarean section. Forty-six women undergoing elective Caesarean section at term were allocated randomly to receive either intravenous fluid preloading with Hartmann's solution 20 ml.kg-1 (fluid group) or prophylactic intravenous ephedrine 0.25 mg.kg-1 (ephedrine group). Moderate hypotension was defined as > or = 20% reduction in systolic blood pressure and severe hypotension as > or = 30% reduction in systolic blood pressure. Maternal uterine circulation was measured using Doppler ultrasound in 11 parturients before and after spinal anaesthesia. There was a lower incidence of severe hypotension in the ephedrine group compared with the fluid group (35% vs. 65%, p = 0.04), although the incidence of moderate hypotension was similar. Mean umbilical venous pH was higher in the ephedrine group than in the fluid group (7.33 vs. 7.29, p = 0.02) and the number of patients shivering was lower in the ephedrine group (2 vs. 9, p = 0.02). No difference was found between pre- and postspinal uterine artery pulsatility indices in either group. We conclude that prophylactic ephedrine infusion alone is at least as good as fluid preload alone in combating the hypotension associated with spinal anaesthesia for Caesarean section.     

Small-dose hyperbaric versus plain bupivacaine during spinal anesthesia for cesarean section

In a double-blind, randomized trial, 98 parturients undergoing cesarean section received either hyperbaric or plain bupivacaine 6.6 mg combined with sufentanil 3.3 microg as part of a combined spinal-epidural procedure. To prevent hypotension, 1000 mL of lactated Ringer's solution, 500 mL of hydroxyethyl starch 6%, and ephedrine 5 mg were administered i.v. The height of the block was equal in both groups, but more patients in the plain group had blocks that were either too high or too low (P < 0.01). The number of patients requiring epidural supplementation was equal in both groups. Strict criteria were used to treat hypotension. The overall incidence of systolic blood pressure (<90 mm Hg) was 13%, whereas it was more pronounced in the plain group (21% vs 6% in the hyperbaric group, P < 0.05), which required more ephedrine (P < 0.05) and in which a greater incidence of nausea was noticed (P < 0.05). We conclude that the use of a small dose of intrathecal bupivacaine combined with sufentanil plus our described preloading regimen resulted in a lower incidence of hypotension. Further, we conclude that the use of hyperbaric bupivacaine in this manner provides a more reliable block and a lower incidence of hypotension than plain bupivacaine. Implications: A small dose of hyperbaric bupivacaine 0.5% combined with sufentanil used intrathecally during cesarean section offered a more reliable cephalad spread of the spinal block than the glucose-free combination, which was reflected in a lower incidence of hypotension and nausea.     

Epidural anaesthesia for caesarean delivery in triple and quadruple pregnancies

BACKGROUND: Mechanical and/or hormonal factors may increase the spread of epidural anaesthesia in pregnancy, and hormonal changes are more pronounced in high-order pregnancies. However, no previous study has evaluated the dose requirements and haemodynamic effects of epidural anaesthesia for caesarean delivery in this latter situation. METHODS: The anaesthetic requirements to obtain a T4 upper sensory level were retrospectively compared in triple (n = 19) or quadruple (n = 2) pregnancies to 31 singleton pregnancies who received epidural anaesthesia for elective caesarean delivery using 2% lidocaine with 1/200,000 adrenaline. RESULTS: In high-order pregnancies, the gestational age at delivery was lower than in singleton pregnancies (34.9 +/- 1.9 weeks vs 38.2 +/- 1.1 weeks; P = 0.0001) whereas maternal body weight (76.5 +/- 8.7 kg vs 73.4 +/- 14.8 kg; NS) and lidocaine requirements (428 +/- 95 mg vs 426 +/- 98 mg; NS) were similar. Moreover, although the overall incidence of hypotension was not different (multiple pregnancy; 65% vs 58% in singletons), ephedrine (5.4 +/- 5.3 mg vs 10.7 +/- 13.8 mg; P < 0.05) and additional fluid requirements during onset of the block (4.3 +/- 1.7 mL/kg vs 5.3 +/- 2.6 mL/kg; P = 0.03) were less than in singletons. CONCLUSION: We found surprisingly similar anaesthetic requirements for epidural anaesthesia in high-order and singleton pregnancies. Mechanical factors may have played an important role. Moreover, the need for ephedrine and fluids was less in high-order pregnancies. This could be related to more pronounced physiological changes or to different physician attitudes.     

Effects of premedication on dose requirements for propofol: comparison of clonidine and hydroxyzine

The influence of a single dose of clonidine (5 micrograms kg-1) or hydroxyzine (1 mg kg-1) on intraoperative propofol requirements was determined in 28 male patients (ASA I) undergoing elective orthopaedic surgery. Patients were randomly allocated to receive either clonidine or hydroxyzine orally 2 h before induction of anaesthesia. After a loading dose of propofol (2.5 mg kg-1), mivacurium (0.2 mg kg-1) and alfentanil (15 micrograms kg-1), anaesthesia was maintained with a standardized propofol infusion supplemented with nitrous oxide (66%) in oxygen. During surgery, additional propofol boluses (1 mg kg-1) were administered when heart rate or mean arterial pressure increased by more than 10% compared with preinduction values. The clonidine group demonstrated a 14.5% decrease in total propofol requirements (P < 0.05) and a 52.2% reduction in additional propofol boluses (P < 0.02) in comparison with the hydroxyzine group. intraoperative heart rate and mean arterial pressure were significantly lower in the clonidine group but no patients needed treatment with ephedrine for hypotension or bradycardia. Recovery of psychomotor function and discharge from the recovery room were not delayed in the clonidine group. This study indicates that 5 micrograms kg-1 clonidine given as premedication in ASA I patients reduces intraoperative propofol requirements in comparison with 1 mg kg-1 hydroxyzine without inducing adverse effects on recovery or haemodynamic stability.     

The transcriptional switch between the Drosophila genes Pig-1 and Sgs-4 depends on a SEBP1 binding site within a shared enhancer region

Quantitative assessment of myocardial ischaemia during incremental spinal, single-dose spinal and general anaesthesia may provide guidelines for the choice of anaesthetic technique for osteosynthesis of hip fractures in the elderly atherosclerotic individual. Forty-three patients with coronary artery disease were allocated to receive either incremental spinal anaesthesia (bupivacaine 0.5% plain) (A), single-dose spinal anaesthesia (2.5 mL of bupivacaine 0.5% plain) (B) or general anaesthesia (fentanyl, thiopentone, atracurium, enflurane, N2O/O2) (C) for hip surgery. ST segment monitoring was performed from the induction of anaesthesia and for the following 48 h, and perioperative hypotension, blood loss and fluid therapy were recorded. ST depression developed in two out of 14 (A), seven out of 15 (B) and six out of 14 (C) patients (P = 0.14). In (A), a total of seven ST depressions occurred in the observation period as opposed to 125 in (B) and 16 in (C) (P < 0.05). Intra-operative ST depression only occurred in (B). Three (A), 33 (B) and 40 (C) hypotensive events were recorded (P < 0.002). Altogether, 56% of hypotensive patients developed ST depression compared with 10% of normotensive patients (P < 0.003). In (A), 1.6 mL of 0.5% bupivacaine were used as opposed to the fixed 2.5 mL dose in (B) (P < 0.001). In the first post-operative week, mortality was higher in (B) (P < 0.05) but, after 1 month, there was no significant difference in mortality between the three groups. The incidence of hypotension and myocardial ischaemia was lowest in the group receiving incremental spinal anaesthesia.     

Treatment of the hypertensive response during coronary surgery: comparison of high-dose propofol to propofol with nitroprusside

OBJECTIVE: To determine the efficacy of high doses of propofol for controlling hypertension during coronary surgery and to compared cardiovascular stability with propofol to that observed under lower doses of propofol with nitroprusside. PATIENTS AND METHODS: Forty patients were studied prospectively. The patients had good ventricular function and were scheduled for coronary surgery, randomized to two groups. Group P (n = 20) received 0.3 mg/kg propofol plus a 10 mg/kg/h perfusion. Hypertensive responses were treated with boluses of 0.3 mg/kg of propofol and progressive increases in the perfusion dose of 2.5 mg/kg/h at intervals of 2 minutes (maximum 15 mg/kg/h). If hypertension persisted it was treated with nitroprusside. Group N (n = 20) received propofol in perfusion at a dose of 8 mg/kg/h and hypertension was controlled directly with nitroprusside. During extracorporeal circulation, the propofol dose was reduced to 3 mg/kg/h in both groups and was adjusted in response to changes in arterial pressure, with nitroprusside added as needed. We recorded the number of patients becoming hypertensive during sternotomy and mediastinal dissection, the maximum doses of propofol and nitroprusside and the time taken to achieve control of hypertension. Arterial pressure and heart rate were recorded at intervals of one minute throughout the operation. RESULTS: Eight patients in group P and eleven in group N suffered hypertension (NS). Increasing the dose of propofol in group P controlled arterial hypertension in one patient. We found no significant differences between groups in amount of nitroprusside needed or time taken to bring episodes under control. Differences between the two groups in rates of intraoperative hypertension (65% in group P and 85% in group N) and hypotension (75% in group P and 55% in group N) and in duration of episodes were not statistically significant. CONCLUSIONS: Using high doses of propofol rather than moderate doses in combination with nitroprusside in coronary surgery does not improve control of either hypertension or hemodynamic stability.     

Attenuation of the haemodynamic responses to noxious stimuli in patients undergoing cataract surgery. A comparison of magnesium sulphate, esmolol, lignocaine, nitroglycerine and placebo given i.v. with induction of anaesthesia

A study was conducted on 100 middle-aged to elderly patients (n = 52, healthy; n = 48, suffering from either diabetes, hypertension, ischaemic heart disease or a combination of these diseases) undergoing cataract extraction to assess the effects of laryngoscopy and tracheal intubation, anaesthesia and surgery, eye bandaging and tracheal extubation, saline (control), magnesium sulphate 40 mg kg-1, esmolol 4.0 mg kg-1, lignocaine 1.5 mg kg-1 and glyceryl trinitrate 7.5 micrograms kg-1 given i.v. at induction of anaesthesia on heart rate (HR), blood pressure (BP), rate-pressure product (RPP) and pressure-rate quotient (PRQ). Anaesthesia was standardized. Haemodynamic responses and requirements for atropine, ephedrine and labetalol to maintain HR and BP during surgery were similar in healthy and diseased patients, and in the test drug groups. Differences produced by the test drugs were evident until 5 min following intubation. Esmolol prevented rises in HR and RPP. Glyceryl trinitrate prevented a rise in BP, but was associated with tachycardia and a fall in PRQ to < 1.0. Magnesium sulphate and lignocaine did not prevent responses to laryngoscopy and tracheal intubation, and were associated with rises in RPP. Application of the eye dressing and tracheal extubation at the end of surgery each caused significant increases in HR, BP and RPP in all groups.     

Genital carcinoma secondary to pagetoid spread from a pagetoid urothelial carcinoma in-situ

PURPOSE: To compare and assess the efficacy of eye ointment and adhesive tape for protection of eyes under general anaesthesia. METHODS: One hundred and fifty patients (300 eyes) undergoing general anaesthesia for > 90 min for non-ophthalmic procedures were divided randomly into three groups (C, T & O). Eyes in group C were left as control, in group T hypoallergen tape was applied and in group O chloromycetin ointment was used. In all eyes basal tear production and visual acuity was assessed and corneal examination was carried out after fluorescein staining both before and after surgery. All the patients were subjected to a conventional general anaesthesia technique. RESULTS: General anaesthesia reduced basal tear production irrespective of the method of eye protection used (P < 0.0001). The overall incidence of corneal epithelial defects was 10%, of which 90% occurred in the control group, 6.6% in the tape and 3.3% in the ointment group. There was no difference between pre and post operative visual acuity (P : NS). Corneal injuries were more common in the dependent eye in the lateral position and the incidence of corneal epithelial defects did not alter with increase in duration of surgery. CONCLUSION: During general anaesthesia eyes need protection either by tape or ointment as incidence of corneal injuries is greater in unprotected eyes.     

Comparison of continuous spinal anaesthesia using a 32-gauge catheter with anaesthesia using a single-dose 24-gauge atraumatic needle in young patients

One hundred and twenty-eight ASA I-III patients less than 40 yr of age, undergoing orthopaedic or trauma lower limb surgery, were allocated randomly to receive either continuous spinal anaesthesia (CSA) using a 32-gauge polyimide microcatheter with a permanent stylet (Rusch/TFX Medical, Duluth, GA, USA) or single-dose spinal anaesthesia (SDSA) with a 24-gauge x 103-mm Sprotte spinal needle (Pajunk, Germany). Plain bupivacaine (0.5%) was used as the local anaesthetic. The initial doses were 1 ml (5 mg) of CSA and 3 ml (15 mg) of SDSA, while the re-injection doses were 1 ml (5 mg) in the CSA group. SDSA was quicker to perform: mean 4.4 (SD 1.6) min compared with 6.2 (2.6) min for CSA (P < 0.01). Times to onset and surgical anaesthesia were also significantly greater in the CSA group (P < 0.01). The quality of the block was better in the SDSA group (P < 0.05), but was associated with greater haemodynamic instability (P < 0.05). The segmental level of analgesia was significantly lower in the CSA group (median T10 (range T12-T8)) than in the SDSA group (T9 (T11-T5)) (P < 0.05). There were no significant differences in the incidence of postoperative complications, with two mild spinal headaches in both groups. We conclude that CSA using a microcatheter in young patients is difficult to perform and affords no advantages over SDSA with a small gauge atraumatic needle.     

Ropivacaine 7.5 mg/ml for elective caesarean section. A clinical and pharmacokinetic comparison of 150 mg and 187.5 mg

BACKGROUND: The new, long-acting local anaesthetic ropivacaine has shown less systemic toxicity than bupivacaine and a concentration of 7.5 mg/ml can therefore be used for epidural anaesthesia in Caesarean section. The present pilot study was undertaken to find indications for an optimal dosage by comparing the clinical effects, quality of anaesthesia and pharmacokinetics of ropivacaine 150 mg (lower dose = LD) vs 187.5 mg (higher dose = HD) for women undergoing elective Caesarean section under epidural anaesthesia. METHODS: Sixteen full-term women scheduled for elective Caesarean section in two equal-sized consecutive groups received 20 or 25 ml ropivacaine epidurally in this non-randomised, open study. Study parameters included sensory and motor blockade, circulatory response, intraoperative pain and discomfort, neonatal evaluation and pharmacokinetic determinations. RESULTS: Block height varied between T5 and T2 in the LD group, whereas the HD group produced 4 unnecessarily high blocks (C8 in 3 women and C7 in 1 woman). Surgical anaesthesia was excellent in both groups. Circulatory stability was pronounced in the LD group (no ephedrine given), while 4 women required ephedrine in the HD group. Neonatal outcome as judged by Apgar scores; umbilical blood gas determinations and NACS scores were excellent in both groups. The plasma concentration-time profiles indicated linearity in the concentration range studied, with similar clearance values to those reported previously. Placental drug equilibrium was rapid; however, the foetal drug exposure depended on intrauterine exposure time. CONCLUSIONS: 20-25 ml ropivacaine 7.5 mg/ml produced very satisfactory conditions for elective Caesarean section under epidural anaesthesia. In this small population, 150 mg ropivacaine seemed optimal, while 187.5 mg produced unnecessarily extended block height in 50% of the women.     

Haemodynamic heterogeneity and treatment with the calcium channel blocker nicardipine during phaeochromocytoma surgery

BACKGROUND: Favourable outcome of phaeochromocytoma surgery requires that paroxysmal hypertension and arrhythmia be controlled, and that hypotension be prevented. Is nicardipine, a calcium channel blocking drug, always adequate? METHODS: Nineteen consecutive patients underwent surgery for phaeochromocytoma. Management was standardised with regards to anaesthesia and antihypertensive treatment. Nicardipine was used as a vasodilator and was given in order to maintain systemic vascular resistance lower than 1600 dyn.s.cm-5. RESULTS: Hypertension did not occur at any time during surgery in 6/19 patients. Blood pressure rose acutely in 3/19 patients at the time of tracheal intubation or surgical approach to the tumour, and was controlled by increased depth of anaesthesia. Hypertensive episodes occurred in 11/19 patients during tumour manipulation. Nicardipine always succeeded in maintaining low systemic vascular resistance but its dosage varied widely between patients (0.5 to 70 mg), a fact that may be accounted for by the striking intersubject variability of haemodynamic behaviour during surgery. In 7/11 patients, despite nicardipine treatment, sustained increase in blood pressure persisted with increased cardiac index, but low systemic vascular resistance. Following tumour removal, transient serious hypotension (MAP < 60 mmHg) occurred in 4 patients, and was corrected by fluid volume expansion. Perioperative incidence of hypertension or hypotension was not related to preoperative clinical status. CONCLUSION: Adequate management of patients operated upon for phaeochromocytoma requires invasive monitoring, since the mechanisms underlying hypertensive crises are heterogeneous with regards to systemic vascular resistance and not predictable from preoperative data. Nicardipine provides a good control of vasoconstriction during phaeochromocytoma surgery with limited risk of serious hypotension after tumour removal.     

Caudal clonidine and bupivacaine for combined epidural and general anaesthesia in children

BACKGROUND: Clonidine produces analgesia by actions on alpha 2-adrenoceptors and enhances both sensory and motor blockade from epidural injection of local anaesthetics. Low-dose clonidine has been used so far for caudal injection in children. Our aim was to study the perioperative effects of high-dose caudal clonidine when added to low concentration of bupivacaine for combined epidural and general anaesthesia in children. METHODS: After induction of general anaesthesia caudal block was performed either with 1 ml.kg-1 bupivacaine 0.175% with the addition of clonidine 5 micrograms.kg-1 (n = 20), or with 1 ml.kg-1 bupivacaine 0.175% (n = 20). The intraoperative anaesthetic requirements, the perioperative haemodynamic effects, respiratory rate, sedation score, postoperative pain scores and side effects were assessed by a blinded observer. A patient-controlled analgesia system was used for postoperative pain relief. The quality of postoperative pain relief was assessed using Smiley's pain analogue scale. RESULTS: Intraoperative haemodynamic responses did not differ between the groups. However, during emergence from general anaesthesia children in the clonidine group had significantly lower heart rates and blood pressure compared to children in the control group. In addition, heart rates and blood pressures were also lower in the clonidine group in the early postoperative period (P < 0.05). Postoperative analgesia was significantly better in the clonidine group as evidenced by the total number of requests (3 vs 12, P < 0.05) and the total amount of tramadol (20.5 mg vs 72.8 mg, P < 0.05) administered. The duration of the caudal analgesia was significantly longer in the clonidine group (20.9 +/- 7.4 h vs 14.4 +/- 10.9 h, P < 0.05). CONCLUSION: Our results suggest that caudal clonidine 5 micrograms.kg-1 enhances and prolongs caudal blockade with bupivacaine (1.175% in children. It also blocks sympathoadrenergic responses during emergence from anaesthesia. Sedation and cardiovascular effects are observed up to 3 h into the postoperative period.     

Indoor radon prediction from soil gas measurements

We have studied the intubating conditions in 60 ASA I or II patients, after induction of anaesthesia with propofol 2 mg kg-1, allocated to one of the following three groups: group 1, remifentanil 1 microgram kg-1; group 2, remifentanil 1 microgram kg-1 and lignocaine 1 mg kg-1; group 3, remifentanil 2 micrograms kg-1. No neuromuscular blocking agents were administered. Intubating conditions were assessed using a four-point scoring system based on ease of laryngoscopy, jaw relaxation, position of vocal cords, degree of coughing and limb movement. Overall intubating conditions were acceptable in 35% of patients in group 1, 100% of patients in group 2 and 85% of patients in group 3. There was a statistically significant drop in blood pressure after induction in groups 2 and 3, and two patients in each group required ephedrine 6 mg i.v. boluses, as dictated by the intervention criteria (mean arterial pressure fall > 25% from baseline). Similarly, there was a drop in heart rate in groups 2 and 3, but this did not reach statistical or clinical significance, and no patient required atropine.     

Effects of sulpiride isomers in the control of blood pressure in man

The effects of d-Sulpiride (25 mg i.v.) and 1-Sulpiride (25 mg i.v.) administration in the control of arterial blood pressure (ABP) and PRL-GH secretion have been analyzed in five normal male volunteers. It was observed a quite different action on ABP, 1-Sulpiride causing a long lasting hypotension and d-Sulpiride a short-lived hypertension. The correlation between ABP, heart rate and PRL-GH levels suggests a probable central cation for 1-Sulpiride and a possible peripheral action for d-Sulpiride effects on ABP.     

Comparison of detomidine/ketamine and guaiphenesin/thiopentone for induction of anaesthesia in horses maintained with halothane

This prospective clinical study compared the physiological effects of two commonly used anaesthetic induction techniques in horses maintained with halothane. One hundred horses admitted for elective surgery were randomly allocated to receive either guaiphenesin (to effect) and thiopentone (5 mg/kg), or detomidine (20 microg/kg) and ketamine (2 mg/kg) for the induction of anaesthesia after acepromazine premedication. Anaesthesia was maintained with halothane in oxygen. There were no significant differences in breed, age, sex, weight, type of surgery and duration of anaesthesia between the groups. Immediately after induction of anaesthesia heart rate was higher after guaiphenesin and thiopentone, and arterial blood pressure was higher after detomidine and ketamine. Thereafter hypotension, often necessitating an infusion of dobutamine, developed in both groups. Arterial blood gases and respiratory rates were similar in the two groups. There were no significant differences between the groups in the subjectively scored quality of induction and recovery, or in recovery time.     

Primary Sj?gren''s syndrome presenting as autonomic neuropathy. Case report

A study conducted at P.G.I., Chandigarh to find out the effect of spinal anaesthesia on arterial blood gases, blood glucose, and pyruvate-lactate during spinal anaesthesia. All patients received night sedation of oral diazepam in dose of 0.2 mg/kg body weight. No narcotic/antisialogogue premedication was given to any patient. All patients received spinal anaesthesia with 5% lignocaine (hyperbaric), in lateral position. All patients received normal saline intravenously as a maintenance fluid. Blood samples for the measurement of blood pyruvate, lactate levels and arterial blood gas analysis were collected preoperatively, 10 minutes after the administration of spinal anaesthesia after fixation of drug, and half hour after the end of operative procedure. Even though there was continued rise in blood sugar levels intraoperatively, which persisted in postoperative period, the values were within normal clinical range. Blood lactate levels and blood pyruvate levels remained unchanged. Hypocapnoea observed intra-operatively in our report is attributed to hyperventilation. There was 12.44% fall in bicarbonate level. (P > .001) which even though statistically significant did not alter the pH. We conclude that spinal anaesthesia up to T8 level does not affect the metabolic processes.     

The influence of intrathecal fentanyl on the characteristics of subarachnoid block for caesarean section

Forty healthy parturients scheduled for elective Caesarean section were randomly allocated to receive either 0.3 ml 0.9% saline (control group, n = 20), or 15 micrograms (0.3 ml) fentanyl (treatment group, n = 20) added to 2.5 ml 0.5% hyperbaric bupivacaine given intrathecally in the sitting position. A sensory block to T4 was achieved after 6.5 min in those who received fentanyl compared to 8.0 min in the control group; this was not significantly different. The highest level of sensory block achieved in both groups was similar. Ephedrine was required earlier (p < 0.05) in those who received fentanyl but the total requirement of ephedrine intra-operatively was similar. Fentanyl significantly improved the quality of intra-operative surgical anaesthesia as none of the patients in the treatment group complained of discomfort compared with seven in the control group (p < 0.05). Similarly those in the treatment group had better comfort scores as evaluated by visual analogue score (p < 0.01). Regression of anaesthesia to T12 took longer (184 vs 156 min, p < 0.05) in those who received fentanyl but this did not affect the total requirement of morphine in the first 24 h after operation. There was no difference in the incidence of side effects in the mother and no adverse effects were detected in the baby. The results indicate that adding 15 micrograms fentanyl to hyperbaric bupivacaine for spinal anaesthesia markedly improves intra-operative anaesthesia for Caesarean section.     

Long-term bone marrow culture profiles in patients with myelodysplastic syndromes are not explicable by defective apoptosis

PURPOSE: To compare intraoperative anaesthetic and haemodynamic effects of clonidine-bupivacaine, morphine-bupivacaine and placebo-bupivacaine combinations during continuous spinal anaesthesia. METHODS: Thirty six geriatric patients, undergoing knee replacement using continuous spinal anaesthesia were randomly assigned to: Placebo (n = 12), clonidine (n = 12) and morphine (n = 12), where 1 ml saline, 0.15 mg clonidine or 0.15 mg morphine were mixed with 10 mg bupivacaine 0.5%. Anaesthetic variables studied were maximal sensory level and degree of motor block, duration of surgical analgesia and duration of anaesthesia. Changes in systolic arterial pressure and vasopressor requirements were evaluated. RESULTS: Maximal sensory level and degree of motor block were comparable among the groups. Before surgery two patients in the placebo group, three in the clonidine and one in the morphine group received one additional ml bupivacaine 0.5% because of inadequate anaesthesia and were not considered for determination of duration of surgical analgesia. In the remainder, 1/9 in the clonidine group, 8/10 in placebo and 8/11 in morphine (P < 0.05) received reinjection of bupivacaine for surgical pain. These injections were given about 2 1/2 hr after the initial intrathecal injection, the duration of anaesthesia being about four hours. During the first 30 min after the initial injection the decrease in systolic pressure was greater in the clonidine and morphine than in the placebo group (P < 0.05). Thereafter, vasopressor requirements were higher only in the clonidine group (P < 0.05). CONCLUSION: In elderly patients 0.15 mg clonidine but not 0.15 mg morphine prolonged surgical analgesia when added to 10 mg plain bupivacaine.     

The teaching of all-ceramic restorations in North American dental schools: materials and techniques employed

BACKGROUND: Essential hypertension is a risk factor for cardiovascular disease. Atenolol, a cardio-selective beta-blocker, has been shown to be a safe and effective antihypertensive agent. The extended-release form of felodipine (felodipine ER), a vascular-selective dihydropyridine calcium blocker, is extensively used in Caucasians. However, its effectiveness, tolerability and adverse side-effect have not been assessed in Chinese populations. METHODS: Sitting blood pressure (BP), heart rate, body weight, adverse reaction and serum biochemistry were assessed in 70 patients with mild-moderate essential hypertension treated either with felodipine ER (37 patients), or atenolol (33 patients) for 10 weeks. Each patient was prescribed 5 mg of felodipine ER or 50 mg of atenolol once daily and this daily dosage was doubled to twice daily if necessary. RESULTS: Six patients who received felodipine ER and 3 who received atenolol withdrew from the treatment because of intolerable side effects. Within ten weeks, 81.1% of the patients had responded to a total daily dosage of 5-10 mg of felodipine ER and 81.8% to a daily dose of 50-100 mg of atenolol. By the end of treatment, the mean BP in the felodipine ER group had decreased from 176/104 mmHg at baseline to 145/85 mmHg, while the BP in the atenolol group had dropped from 173/103 mmHg to 145/84 mmHg (NS between the two groups). Heart rate declined in the atenolol group but did not change in patients who received felodipine ER. Overall, patients in the felodipine ER group had a higher rate of adverse reaction (70.3% vs. 39.4%; p < 0.001), and 16.2% of the patients in the felodipine ER group experienced symptoms of hypotension. CONCLUSION: Equivalent doses of felodipine ER and atenolol are effective first-line monotherapeutic agents for the treatment of mild-moderate essential hypertension.     

Candida parapsilosis fungemia associated with implantable and semi-implantable central venous catheters and the hands of healthcare workers

Hypertension in the elderly features differently from its younger counterpart in terms of diagnosis, associated condition, atypical manifestation, management and complication. Epidemiological study in this increasing age group in the community is, therefore, needed. 334 elderly subjects living in various parts of Bangkok were randomly recruited by appointment at 7 geriatric day centers situated in local health offices of Bangkok Metropolitan Authority. Each subject received blood tests before being interviewed and measured by digital sphygmomanometer. Blood pressure and heart rate changes were recorded during lying, sitting and standing. The prevalence of hypertension was 36.5 per cent, 33.2 per cent were already aware of its existence while 3.3 per cent were newly detected by the survey. Isolated systolic hypertension, a unique subtype found in the elderly, was 4.5 per cent of all or 37.5 per cent among the hypertensive group. The associated medical conditions among the case group were diabetes mellitus 22.9 per cent, hyperlipidemia 13.9 per cent, hyperuricemia 33.3 per cent and heart disease 18.0 per cent. As far as postural hypotension is concerned, 14.8 per cent of case group whereas 11.3 per cent of the control group were affected. On the other hand, the symptom of postural dizziness was found to be 31.1 per cent and 55.2 per cent in the case and control group respectively. Following the statistical logistic regression analysis, the independent associated factors in the hypertension group were: history of hyperlipidemia, increased serum uric acid and poor heart rate response after standing. These findings, as parts of the multiple pathology and potential complications prevalent among this group, should be of concern by any physician looking after the elderly.