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Introduction Turoctocog alfa pegol is a glycoPEGylated recombinant factor VIII (FVIII) with an extended half‐life developed for prophylaxis, treatment of bleeds and perioperative management in patients with haemophilia A. Aim Evaluate the efficacy and safety of turoctocog alfa pegol treatment for major and minor surgeries in the pathfinder 3 and 5 phase III trials. Methods Adults/adolescents aged ≥12 years with severe haemophilia A (FVIII 80% during major surgery (pathfinder 3). The primary end point was haemostatic efficacy during surgery; secondary end points were blood loss, haemostatic effect postsurgery, consumption, transfusions, safety and health economics. Children (0‐11 years) undergoing minor surgeries received 20‐75 IU/kg turoctocog alfa pegol at Investigator's discretion (pathfinder 5). Results pathfinder 3 included 35 patients undergoing 49 major surgeries. Haemostasis was successful in 47/49 (95.9%) surgeries; two had moderate haemostatic responses. Median (mean) blood loss during major surgery was 75 (322.6) mL. Four bleeds were reported postsurgery; three were successfully treated with turoctocog alfa pegol (one was not evaluated). On the day of surgery, overall mean (median) dose was 75.5 (74.5) IU/kg and mean (median) number of doses was 1.7 (2.0). Five procedures required 11 transfusions on the day of surgery or days 1‐6. No safety concerns or inhibitors were identified. Forty‐five minor surgeries in 23 children were performed without complications. Conclusion Turoctocog alfa pegol was effective for perioperative haemostatic management of major and minor surgeries in patients across age groups with severe haemophilia A.

Introduction Recombinant factor IX fusion protein concentrate (rFIXFc) is increasingly used for prophylaxis in people with haemophilia B (PWHB), but experience in the perioperative setting is limited. Aims To evaluate real-world perioperative factor usage, bleeding and complications in PWHB (≥18 years) who received rFIXFc for surgical haemostasis and to describe the treatment regimens used. Methods Single centre, retrospective review of all PWHB who underwent a major or minor surgical procedure between June 2017 and July 2020 and received rFIXFc perioperatively for maintenance of surgical haemostasis. Results A total of 56 PWHB (45 male and 11 female), including people with mild (n = 32), moderate (n = 4) and severe (n = 20) haemophilia B, underwent 11 major and 131 minor procedures with rFIXFc for surgical haemostasis. Haemostasis was rated as excellent (9/11) or good (2/11) in all major procedures. Median total rFIXFc consumption for orthopaedic surgeries was 972 IU/kg (range 812-1031 IU/kg) and for other major (non-orthopaedic) surgeries was 323 IU/kg (range 167-760 IU/kg). The median number of perioperative rFIXFc infusions was 19 (range 17-26) for orthopaedic surgery and 7 (range 5-17) for other major surgeries. The number of infusions in the postoperative period was determined by procedure and patient factors. Complications included bowel ileus and wound infection. Most minor procedures were managed with single infusion of rFIXFc, with no bleeding complications in 95% of minor procedures. There were no thromboembolic events or inhibitor formation. Conclusion This unique data provides real-world evidence that rFIXFc is safe and effective in achieving haemostasis in PWHB undergoing surgery.

Bartholin duct cysts and gland abscesses can affect a woman's day-to-day functioning and be challenging to manage. Many Bartholin duct cysts that are not infected remain asymptomatic and resolve spontaneously without intervention. However, an infected Bartholin duct cyst or glandular abscess should be drained when larger than 2 cm because such cysts or abscesses do not tend to resolve spontaneously and can recur. Management options fall under 3 broad categories: expectant, medical, or surgical. With special training, midwives and women's health nurse practitioners can manage many women who present with Bartholin duct cysts or gland abscesses. Rarely, a woman with a severe or recurrent infection will need referral to a surgeon. Knowing which management option to choose may be challenging at first; this article is aimed at providing evidence-based knowledge about Bartholin duct cysts and gland abscesses for clinicians so that they can make the diagnosis and management plan with confidence. A clinical case is used to illustrate the identification, diagnosis, and management of Bartholin duct cysts and gland abscesses. The range of interventions, from expectant management with comfort measures to surgical intervention, is be explored to assist the clinician in choosing the correct management approach.

OBJECTIVES Minor pediatric surgeries performed in the minor procedure room (MPR) may be more time efficient and less costly compared to those performed in the operating room (OR). STUDY DESIGN Retrospective review. METHODS This was a retrospective study on cost and efficiency differences of bilateral myringotomy with tube insertions performed in the MPR versus the OR. Charts were reviewed from June 2015 to May 2017. Cost data was based on supply cost and case costing of medical personnel including nurses, aides, and anesthesia assistants. RESULTS Two hundred eighteen patients were included in the study. The median age was 2.7 years (range: 0.8-16.7), and there were no differences in gender between locations. One hundred twenty-three patients had surgery in the MPR (56.4%), and 95 had surgery in the OR (43.6%). The median length of time in the procedure room was 11 minutes shorter for patients who underwent surgery in the MPR (12.0 minutes, range: 3.0-33.0) compared to patients in the OR (23.0 minutes, range: 11.0-52.0; P

Background Haemodynamic instability during the induction of anaesthesia and surgery is common and may be related to hypovolaemia caused by pre-operative fasting or chronic diuretic therapy. The aim of our prospective, controlled, randomized study was to test the hypothesis that a predefined fluid bolus given prior to general anaesthesia for minor surgery would increase haemodynamic stability during anaesthetic induction. Methods Two hundred and nineteen fairly healthy adult patients requiring minor surgery were enrolled. All received standard treatment, including a pulse contour analysing device for non-invasive measurement of cardiac index. Infusion therapy was started in all patients at induction. The intervention group (106 patients) was randomized to receive an additional fluid bolus of 8 mL/kg Ringer's acetate solution before the induction of anaesthesia. The primary endpoint was the incidence of haemodynamic instability, defined as a significant reduction of blood pressure or cardiac index during induction of anaesthesia. Results The interventional group had a lesser incidence of haemodynamic instability during induction (41.5% vs 56.6%, P = .025). This group also had higher cardiac index, stroke volume index, systolic and mean blood pressure and a greater left ventricular end-diastolic area. Conclusions A fluid bolus prior to anaesthesia reduced the incidence of haemodynamic instability during induction of general anaesthesia. The total fluid volume was slightly greater in the intervention group compared to the control group (1370 ± 439 mL vs 1219 ± 483 mL, P = .007). We conclude that a defined fluid bolus can help stabilizing haemodynamics in patients undergoing general anaesthesia.

Introduction To work in the National Health Service (NHS) as a dentist, the practitioner needs to be on the UK dental "performer's list". To apply for access to this list and work as a General Dental Practitioner (GDP), dentists must be qualified from the European Economic Area (EEA) or, those trained in the UK, must undertake Dental Foundation Training (DFT). Dentists interested in further taught learning or pursuing specialist training must continue working as "Dental Core Trainees" (DCTs). Most of these jobs are available in Oral and Maxillofacial Surgery (OMFS) Units and require dentists to undertake unsupervised surgical procedures. It is currently estimated that over 400 "junior dentists" undertake DCT a year. It is the aim of this study to ascertain whether confidence in simple surgical procedures improves when compared to GDPs of similar experience. Methods One hundred and two junior dentists, 34 DFTs, 20 DCT1s, 21 DCT2s and 27 second and third year post-DFT GDPs all working across the Midlands, UK, had Likert scale responses about confidence in 14 minor surgical skills assessed. Results were analysed to ascertain whether gender, year group and number of extractions had any effect on confidence. Conclusions We conclude that confidence in minor surgical procedures improves significantly when undertaking DCT OMFS posts, with the most significant improvement in confidence occurring within the first 6 months. Dental Core Trainees become significantly more confident in their surgical ability within the first 6 months when compared to GDPs with longer postgraduate experience.

AIM The COMFORT behavioural scale was developed to assess sedation, pain and distress in children unable to report pain. Our aims were to test construct validity of the scale in toddlers undergoing minor surgery and determine the inter-rater reliability of the scale. METHODS We consecutively enrolled 45 children aged 12-36 months from a Norwegian surgical outpatient care unit. The level of sedation, pain and distress was assessed before and after surgery with the COMFORT behavioural scale. Inter-rater reliability was estimated and construct validity was tested based on a priori defined hypotheses. A 2.5-point (15%) change in the scale was considered clinically important. RESULTS We obtained 307 scores covering most of the scale's range, but a floor effect was clearly present. Inter-rater reliability was high between assessors (intraclass correlation coefficient = 0.96; 95% CI 0.92-0.98). Clinically important differences were seen between baseline and light sedation (3.1 points, p

Summary Increased levels of exhaled nitric oxide (eNO) may be a more objective predictor in identifying children at higher risk of peri-operative adverse respiratory events than the presence of risk factors such as recent cold or wheeze. Children with either none or ≥ 2 risk factors had eNO measured before surgery and any peri-operative adverse respiratory events were recorded. We found that an elevated eNO level was only predictive of adverse respiratory events in children with ≥ 2 risk factors (OR 2.96 (95% CI 1.48–5.93), p = 0.002). The presence of risk factors had a better predictive capability than a raised eNO level (OR 3.83 (95% CI 1.85–7.95), p

Superior wound healing with excellent cosmesis is critical in superficial dermal wounds created when cosmetically unacceptable lesions are removed from the body. Dermatologists frequently remove seborrheic keratoses, nevi, and angiomas from the body with a superficial shave excision. The excision is designed to minimize dermal scarring while removing the unsightly skin growth. This study was undertaken to evaluate the ability of an onion extract gel to improve the appearance of scars following excision. Sixty subjects with symmetrical seborrheic keratoses at least 8 mm in diameter on the right and left upper chest were enrolled. The lesions were removed with a scalpel shave, following local anesthesia with 2% lidocaine plus epinephrine. The surgical sites were allowed to heal for 2 to 3 weeks, at which time the subjects returned to the research center for randomization to either the onion gel treatment group or the no-treatment group. Forty-seven subjects in the active treatment group were further randomized as to the site of study product application. Thirteen control subjects applied nothing to either side. Subjects returned to the study center at weeks 2, 4, 6, and 10 for photography, subject evaluations, and investigator assessments. The study showed that the onion extract gel significantly improved scar softness, redness, texture, and global appearance at the excision site at study weeks 4, 6, and 10 as assessed by the blinded investigator.

Probit analysis was used to predict an optimal dose of fentanyl, co-administered with propofol 2.5 mg.kg(-1), when inserting the laryngeal mask airway. In all, 21 male and 54 female healthy Chinese patients, aged 18-63 years, requiring anaesthesia for minor surgery were recruited. They were assigned to one of five groups: placebo, 0.5, 1.0, 1.5 and 2.0 microg.kg(-1). Insertion was performed 90 s after administration and insertion conditions assessed using a six-category score. Dose-response curves could only be drawn for swallowing and movement categories, and only the ED(50) could be predicted with certainty. To provide optimal conditions in over 95% of patients, fentanyl doses well above the clinical range were required. A standard fentanyl dose of 1 mug.kg(-1), co-administered with propofol 2.5 mg.kg(-1), provided optimal conditions in 65% of cases. Ninety seconds may have been insufficient time for fentanyl to reach its peak effect.

Summary Background: Rapid sequence induction (RSI) is the ‘gold standard’ technique for preventing aspiration of gastric contents during induction of anesthesia in unfasted patients. We conducted a survey to discover whether the conduct of RSI in children varies amongst anesthetists and if practice alters in relation to the time since training or degree of ongoing experience. Methods: Six hundred and fifteen questionnaires were sent to anesthetists in the south-west of England. Results: The response rate was 61%. Preoxygenation was utilized by 83% of anesthetists for infants whereas 94% preoxygenated schoolchildren, P

Objective. The aim of this paper was to determine the use of theatre time for all procedures performed under general anaesthetic on a paediatric dental list. Methods. A prospective study of paediatric dental general anaesthetic procedures was undertaken at Ninewells Hospital and Medical School, NHS Tayside, Dundee, UK. Data were collected prospectively for 71 operating lists over a 3-year period from April 2003 to March 2006. Both operator status and the procedure being undertaken were recorded. In addition, pre-anaesthetic, anaesthetic, operating and disconnection times were recorded. Results. Of the 71 lists examined, 61 either finished early or on time, with a median unused time of 32.50 min (interquartile range = 19.50, 50.00 min), whilst 10 lists finished late with a median overrun time of 30.50 min (interquartile range = 9.25, 45.50 min). Comparing lists which finished late with those which were completed within time, the median pre-anaesthetic time was significantly longer (Mann–Whitney U-test, W = 20.05, P = 0.048). Overall, the theatre was in use for 78.22% of time combining pre-anaesthetic, anaesthetic, operating and disconnection times; hence, there was poor time utilization of theatre for 21.78% of the total theatre time. Conclusions. Overall, 85.9% of theatre sessions for dental procedures under general anaesthetic in children finished early or on time. Where lists finished late, the duration of the pre-anaesthetic time appeared to be the significant factor.

Objective We aimed at treating complicated pilonidal sinus (PS) patients by a simple and effective surgical procedure. Method Between 2000 and 2004, 24 selected complicated PS patients were treated with ‘limited separate elliptical excision and primary closure’. Patients with extensive or bilateral gluteal involvement, having more lateral, caudal or cephalic sinuses, multiple recurrences and unhealed chronic wounds after pilonidal surgery were included. Asymmetric excision and primary closure was performed to main diseased tissue in the midline. Additionally, small separate elliptical excisions with primary closure were performed in other involved tissues. The fistula tract or granulation tissue were excised subcutaneously if present. All patients were operated under local anaesthesia. The fascial attachments between the skin and coccyx were released at the deep point in the midline and at one side of wound. Suction drains and prophylactic antibiotics were used; subcutaneous tissues were closed with running polyglactin sutures and skin with polypropylene subcutaneously. Results The mean age of patients was 28.4 years (range 18–38). The mean follow-up time was 2.8 years. One recurrence, one seroma, one wound infection and one wound breakdown were recorded. Healing was always by first intention except in patients with wound infection and breakdown. Conclusion Most of the complicated PS patients can be operated with acceptable rates of recurrences and complications by using ‘limited separate elliptical excisions with primary closure’.

Summary Background: Emergence agitation (EA) is a common postoperative problem in young children who have received sevoflurane and isoflurane for general anesthesia. This randomized, double-blinded study evaluated the efficacy of intraoperative clonidine in reducing EA, and describes its recovery profile. Methods: With Institutional Review Board approval and informed consent, children undergoing brief, minimally painful procedures were studied. All children received preemptive analgesia with acetaminophen and ketorolac, sevoflurane for induction, and isoflurane for maintenance of anesthesia. Children received either 2 lgAEkg )1 clonidine or placebo intravenously (i.v.) following induction of anesthesia. Children were observed postoperatively for behavior and side effects, and their parents were telephoned the next day to determine postdischarge recovery characteristics. Results: One hundred and twenty children were included in this study: 59 of whom received clonidine, and 61 placebo; 41% of those in the placebo group exhibited moderate–severe EA compared with only 22% of those in the clonidine group (P < 0.03). Compared with those who received placebo, children who received clonidine awakened more slowly (22 min vs 14 min), had a longer postanesthesia care unit stay (57 min vs 46 min), and experienced sleepiness more frequently after discharge (75% vs 39%; all comparisons significant at P < 0.03). There were no adverse cardiorespiratory events in either group. Conclusions: Findings demonstrate that i.v. clonidine administered after induction of anesthesia significantly reduces the incidence of EA in young children, but is associated with sleepiness postoperatively.

Summary Background : Oral Transmucosal ketamine (lollipop) has been shown to be an effective, harmless preoperative medication for children. However, its efficacy was not compared with commonly used premedication drugs. We, therefore, compared the efficacy of oral transmucosal ketamine with oral midazolam for premedication in children. Methods : Fifty-five children (2–6 years of age) were randomized to receive orally either a lollipop containing 50 mg of ketamine (the group K; n = 27) or syrup containing 0.5 mg·kg−1 of midazolam (the group M; n = 28) before minor surgery. A five points-sedation score (1 = asleep to 5 = agitated; scores 2 and 3 were defined as ‘effective’) on arrival in the operating room and a three points-acceptance score of separation from the parents and a three points-mask cooperation score at induction of anesthesia (1 = easy to 3 = markedly resistant; score 3 was defined as ‘poor’) were used. Results : Sedation scores in group K were significantly higher than those in group M (P = 0.012), and the incidence of ‘effective’ in sedation was significantly lower in group K than in group M (P = 0.036). The incidence of ‘poor’ at separation from the parents and for mask cooperation was significantly higher in group K than in group M (P = 0.017, P = 0.019, respectively). Conclusion : These results indicate that a relatively low dose of oral transmucosal ketamine premedication provides no benefits over oral midazolam in children.

Summary Background: Thromboelastography (TEG) is an established way of monitoring the coagulation status of children and adults requiring blood products during surgery. Serial measurements are performed using a nearside machine and blood product prescription may be titrated against changes in TEG. There may also be useful applications when the patient is remote from the TEG machine but these are limited because TEG is usually performed on fresh native whole blood within 6 min of venepuncture. Citrated whole blood can be used for TEG if transport time is more than 6 min. We wished to establish whether TEG parameters for citrated whole blood were comparable with those of native whole blood in healthy children. Methods: Blood was obtained from 14 healthy children undergoing minor surgical procedures, at the time of intravenous cannula insertion for anaesthesia. Each sample was divided: TEG was performed on part of the sample in its fresh native state at 6 min and second portion of the sample was citrated, kept at room temperature and TEG was performed at 30 min after recalcification. Results: There was a significant difference in TEG parameters (r, k, a, MA and LY30) for fresh native whole blood and recalcified citrated whole blood (paired t-test). Conclusions: The normal range for fresh native whole blood TEG parameters is well established, which is routinely used in practice. There was a significant difference between TEG parameters for fresh native whole blood and citrated whole blood. We recommend that a specific normal range be established for citrated whole blood to enable it to be used in clinical practice.

BACKGROUND The objective was to examine whether or not ketoprofen enters the cerebrospinal fluid after a single oral dose of 1 mg.kg-1 syrup, and to find out what is the lowest plasma concentration that will achieve a measurable level in the cerebrospinal fluid. METHODS We measured ketoprofen concentrations both in plasma and cerebrospinal fluid of 10 young and healthy children (aged 9-86 months) after surgery with spinal anaesthesia. Samples of cerebrospinal fluid were collected 30 min after drug administration, at the same time as venous blood samples. A validated high-performance liquid chromatography method with a lower limit of 0.02 microg x ml(-1) was used to detect ketoprofen concentrations in cerebrospinal fluid and plasma. RESULTS Ketoprofen was detectable in the cerebrospinal fluid only in the child who had the highest plasma concentration, 7.4 microg x ml(-1), while at plasma concentrations 6.5 microg x ml(-1) or less, cerebrospinal fluid (CSF) concentrations remained unmeasurable. The detected CSF/plasma ratio was 0.008. CONCLUSIONS These results indicate that ketoprofen at a dose of 1 mg x kg(-1) is too low to produce measurable CSF levels within 30 min of oral administration.

Background: The cuffed oropharyngeal airway (COPA) is a device which has already been demonstrated to be suitable for anaesthetized adult patients undergoing either spontaneous or mechanical ventilation. There are few reports on the use of the COPA in children. In this study, the authors assessed the COPA in paediatric patients undergoing minor surgery. Methods: The same anaesthesiologist inserted the COPA in 40 consecutive paediatric patients, ASA I and II, aged 1.8–15.3 years. (7.4 ± 3.9), after induction of anaesthesia with N2O/O2/sevoflurane. COPA size was chosen by measuring the distal tip of the device at the angle of the jaw with the COPA perpendicular to the patient's bed. The proper positioning of the COPA was assessed by observing thoracoabdominal movements, regular capnograph trace, the reservoir bag movements and SpO2 > 94% with a fraction of inspired oxygen of 0.5. Anaesthesia was maintained with 1 MAC halothane, sevoflurane, or isoflurane in N2O/O2 (50%) and the patients were spontaneously breathing. The stability of the COPA following changes in head, neck and body position was tested. We recorded the duration time for COPA insertion, the side-effects of placement of the COPA and during the intraoperative period, the number of attempts, the type of manipulation in order to provide an effective airway and postoperative symptoms, such as the presence of blood on the device, sore throat, neckache, jaw pain and PONV. Results: Successful COPA insertion at the first attempt was 90% and at the second attempt in the remaining 10%. The most frequent airway manipulations were head tilt in 27.5% (obtained by a pillow under shoulders) and chin lift in 5%. No complications both at COPA placement nor during the intraoperative period were observed. On the basis of weight and age, the COPA size was no. 8 in 50%, no. 9 in 30%, no. 10 in 12.5%, and no. 11 in 7.5%. The COPA demonstrated stability after changes in head, neck and body position. Postoperative complications were the presence of blood stains in one case and PONV in six cases (15%). Conclusions: The COPA is an extratracheal airway device suitable in paediatric patients undergoing general anaesthesia with spontaneous ventilation for minor surgery and other painful procedures. This study shows that for paediatric patients: (i) complications seem to be rare; (ii) the COPA allows hands free anaesthesia; (iii) specific indication for the COPA could be obese patients with a small mouth; and (iv) COPA sizing can be easily established by the weight or age of the patients.

A eutectic mixture of local anesthetics (EMLA), prepared as a cream, is an oil-in-water emulsion of 2 anesthetic agents—lidocaine and prilocaine. Several clinical applications of EMLA cream, its effectiveness as a topical anesthetic, and its safety profile have been previously reported. We report our experience with EMLA cream in 17 adult and 24 pediatric patients. We find EMLA to be the preferred anesthetic for performing minor outpatient otologic procedures in adults. We also find EMLA to be a safe, well-tolerated alternative to general anesthesia in some pediatric patients. Potential cost savings of EMLA cream during pediatric myringotomies in the clinic are also discussed. (Otolaryngol Head Neck Surg 1999;121:38-42.)

In a double-blind, randomised study of patients scheduled for minor hand surgery 0.5% 2-chloroprocaine (n = 30) and 0.5% prilocaine (n = 30) in a volume of 40 ml were compared for intravenous regional anaesthesia. The onset of sensory and motor block and recovery of sensory block were determined, and the occurrence of side-effects was noted. Twenty-four patients in the 2-chloroprocaine group and 17 in the prilocaine group developed complete sensory block by 15 min after injection (p0.05). Complete recovery of sensation was faster after prilocaine (7.1 min) than 2-chloroprocaine (9.8 min) (p0.01). Venous irritation and/or urticaria after tourniquet release was observed on 10 occasions in those receiving 2-chloroprocaine and twice in those receiving prilocaine. An increase in heart rate of20% above control values occurred in three patients, all of whom had been given 2-chloroprocaine. Clinically, local anaesthetic properties of 0.5% 2-chloroprocaine and prilocaine were similar, but there were more side-effects with the former drug.

The utility of preoperative ketorolac administration to reduce the intensity and duration of postoperative pain was compared with placebo in a randomized double-blind design of 60 ASA 1-2 patients scheduled for minor orthopaedic surgery. No opioids nor local anaesthetic blocks were used during surgery. The patients received either 30 mg ketorolac IV before surgery followed by a placebo injection after surgery or the reverse. Postoperative pain intensity was assessed repeatedly for 6 h using a visual analogue scale. No differences in pain intensity were observed between the two groups except for the initial 15-min postoperative assessments in the ketorolac group. The time to first rescue morphine administration and the total morphine consumption during the 6-h observation period were similar. It is concluded that the preoperative administration of ketorolac did not provide a significant preemptive analgesic benefit with regard to postoperative pain relief and opioid dose-sparing effect.

This paper describes the evaluation of a two-day minor surgery training course for general practitioners and vocational trainees. The course was developed by a team from a wide range of specialties. A pilot run of six of these courses was held in various locations in the United Kingdom during 1994, organized by the Royal College of General Practitioners and supported by the Department of Health. The courses were attended by 144 participants in total: 52 general practitioners and 92 vocational trainees. The evaluation addressed (a) the process of training which resulted in substantial changes being made to the original design and content of the courses; and (b) the outcome of the training in terms of knowledge, confidence and competence. A central feature of the course was the use of sophisticated simulated tissue. Participant feedback indicated that although the simulated tissue was not considered to be very realistic it substantially increased levels of confidence and competence to carry out minor surgery. Knowledge on various aspects of minor surgery increased significantly. The feedback from the evaluation was forwarded to a minor surgery working party at the Department of Health whose remit was to prepare guidelines for teaching, authorising and carrying out minor surgery in general practice.

The azeotropic mixture of halothane and diethyl-ether has been claimed to be a suitable anaesthetic agent for use during difficult conditions because of its negligible effect on circulation and ventilation. The purpose was to evaluate the effect of halothane-diethyl-ether azeotrope (HE) and isoflurane (ISO) on ventilation. 12 patients scheduled to undergo minor orthopaedic surgery and belonging to ASA 1, were randomly allocated to the HE group or the ISO group. Evaluation of resting ventilation and ventilation stimulated by hypercarbia and hypoxaemia was done on three occasions: (A) before anaesthesia, (B) after inhalational induction of anaesthesia and intubation without muscle relaxants when the level of anaesthesia was 1 MAC and (C) half an hour after operation and during recovery. Resting ventilation and the ventilatory response to hypercarbia during anaesthesia were maintained in the HE group but not in the ISO group, whereas the ventilatory response to hypoxaemia during anaesthesia was absent in both groups. The responses had returned to normal values in both groups during recovery. We conclude that halothane-diethyl-ether azeotrope is comparatively safe during anaesthesia with spontaneous breathing provided arterial oxygenation is adequate. This makes this azeotrope suitable for use by anaesthetists with limited experience and during difficult conditions such as civil disaster or war.

Study objective: To evaluate the performance of the reusable intermediate–volume low–pressure cuffed “Super Safety Yellow” (Willy Rusch AG, P. O. Box 1620, D–71332 Waiblingen, Germany) endotracheal tube with regard to cuff seal, tube tip position, and incidence of postoperative throat complaints. The “Super Safety Yellow” was compared with the “Super Safety Clear” (W. Rusch AG), the “lo–pro” (Mallinckrodt Laboratories, Cornamady, Athlone County, Ireland), and the “red rubber” (W. Rusch AG) tubes. Methods: Two hundred adult patients scheduled for minor surgery under standardized general anaesthesia were allocated to one of these tubes. Past–cuff leakage (indicator: orally instilled 0.2% indigocarmine) as well as intratracheal tube tip position (degree of being centred) were assessed by fibre–optic tracheoscopy. The semi–standardized interviews for the recording of postoperative sore throat were performed in double–blind fashion once a day, starting on the day of operation till p.o. day 3. Statistics: x2–test; significance: P < 0.05. Main Results: A past–cuff leakage was found in three “red rubber” tubes. There were significant differences in tube tip position with the “Super Safety Clear” being best, and the “Super Safety Yellow” being worst centred (P = 0.010). The incidence of postoperative throat complaints showed a nonsignificant tendency in favour of the PVC–tubes. A significant number of such complaints were observed in women (P = 0.0004) and in obese patients (P = 0.011). By contrast, this incidence did not significantly differ with age, tracheal cross–sectional shape, tube tip position, use of atropine, and duration of intubation. Conclusion: Although resembling the “red rubber” tube in the incidence of postoperative throat complaints, the “Super Safety Yellow” may be an alternative to the currently used disposable tubes in anaesthesia. Its performance is comparable with regard to cuff seal and intra–cuff pressure. Additionally, it helps in reducing PVC waste and may lessen costs.

The first 24 hours of the postoperative course of 2153 consecutive patients who had operations at the Nottingham Hospitals were studied in detail. Five per cent of patients had serious complications during this period; 15% of those having major operations, 1.8% having intermediate operations and 1.4% having minor operations. Thus, a significant number of patients were in an unstable condition for many hours after they were discharged from the main theatre recovery areas to the surgical wards. In 17 out of 23 patients who died and six out of six patients who suffered severe disability as a result of their surgery, the final outcome was a direct result of a sequence of events which began with an initial deterioration within 24 hours of surgery. We considered that, for at least 10 of these 29 patients, the outcome might have been different had more sophisticated postoperative facilities been available. In the light of this study we have identified the operations for which high dependency facilities are most likely to be required.

Based on plasma levels determined with a radioreceptor assay and following a single oral (50 pgikg) and intravenous (5 pg/kg) administration of glycopyrrolate in six healthy children operated twice during a several weeks period, a negligible and variable oral bioavailability was found (3.3; 1.3-1 3.3%) (median;range). No significant changes in heart rate after oral or intravenous administration of the drug could be seen. Oral glycopyrrolate appears to have no place in paediatric premedication. Anticholinergic drugs have been commonly used in paediat- ric anaesthesia to prevent from harmful vagal reflexes and to avoid excessive secretions in the small airways (Mirakhur et al. 1978). The most effective way to attain these goals is intravenous administration of either atropine or glyco- pyrrolate briefly before induction of anaesthesia. Several authors have demonstrated that oral atropine (20 pg/kg) is an acceptable alternative to parenteral administra- tion of anticholinergic premedication (Miller & Friesen 1988; Cartabuke

Postoperative morbidity and serum osmolality were studied in 46 patients who were encouraged to drink water until 3 h pre-operatively and 49 receiving the normal fasting regimen prior to minor surgery. There was significantly less thirst in the postoperative period in those patients allowed to drink and subjectively better recovery than after previous anaesthesia. There was no morbidity from ingestion of up to 11 of water 2.5 h pre-operatively. Although there was only a moderate improvement in postoperative recovery we feel that allowing patients to drink water pre-operatively improves patient comfort, especially since patients may have to fast for much longer than guidelines recommend, simply because of the traditional organisation of operating lists.

Summary Twenty patients scheduled for minor gynaecological surgery were studied. Anaesthesia was induced with propofol and maintained either with enflurane/oxygen/nitrous oxide or propofol/oxygen/nitrous oxide. The rate of gastric emptying was measured indirectly by the paracetamol absorption model. The results showed that there was no significant difference in gastric emptying rate between the two groups. Recovery in the propofol group was more rapid in that paracetamol ingestion occurred earlier in the recovery period compared with the enflurane group.

Objective To determine the current practice among British urologists for obtaining written consent for flexible cystoscopy and other minor procedures under local anaesthesia. Methods Postal questionnaires were sent to full members of The British Association of Urological Surgeons practising in the UK asking if they obtained written informed consent for local anaesthetic procedures, e.g. flexible cystoscopy, urethral dilatation, and urethral catheterization for retention, for urodynamics or for intravesical chemotherapy. They were also asked whether they recorded that the risks and benefits of the procedure had been explained to the patient. Results Respondents were divided on whether they obtained written consent for flexible cystoscopy and urethral dilatation. Most did not obtain written consent for catheterization for retention, urodynamics, intravesical chemotherapy or suprapubic catheterization. The policy was inconsistent both between and within urologists. Conclusion Given the medicolegal importance of informed consent, consensus among urologists is required so that national guidelines can be developed and a more rational policy applied.

Twenty patients, scheduled for minor gynaecological surgery, were studied. Anaesthesia was induced with propofol and maintained with oxygen, nitrous oxide and enflurane. Patients were randomly allocated to two groups: group 1 were given alfentanil 0.2 mg; group 2 were given morphine 5 mg. The rate of gastric emptying was measured indirectly by the paracetamol absorption technique. The results showed that morphine caused greater delay in gastric emptying compared with alfentanil (p < 0.05). The observed effect on gastric emptying rate may potentially affect the risk of peri-operative regurgitation and aspiration. This study provides further evidence that in short day-case procedures, when oral medication may be required postoperatively, alfentanil may be preferable to morphine as an intra-operative opioid.

Summary Temazepam, a benzodiazepine, hitherto used only as a hypnotic, was studied as a pre-anaesthetic medication in adult women undergoing minor gynaecological surgery in a dose of 30 mg and compared to 10 mg of diazepam. The sedative effect of temazepam was found to be superior to that of diazepam, using both objective and subjective criteria for assessment. There was also a highly significant degree of patient acceptance of the drug. It is suggested that temazepam is a suitable drug for premedication for minor surgery.

Althesin anaesthesia alone had no significant effect on plasma cortisol concentration. When Althesin induction was followed by maintenance with N2O and halothane there was a statistically insignificant fall, but with N2O, pancuronium and I.P.P.V there was a tendency for plasma cortisol concentrations to rise. This, too, was statistically not significant. A significant elevation in the mean plasma cortisol concentration was only found in patients during abdominal surgery.

Serum phenylalanine values were measured in 10 PKU patients who had minor operations. No individual value exceeded 17 mg/dl and the interpolated mean did not exceed 10 mg/dl on any postoperative day. These data confirm the consensus that minor surgery does not cause major and long-lived perturbations of serum phenylalanine levels in PKU and requires no special dietary measures.

The traditional domain of the operating room nurse is the operating room suite in a hospital. But recent advances in health care delivery are changing this. Today the OR nurse may be working in a nonhospital facility offering outpatient surgery and postanesthesia observation. This article describes our experience as OR nurses at Surgicenter, an independently owned outpatient surgical facility in Phoenix.

The outcome of day-care versus inpatient surgery for two equivalent groups of children is examined. Ratings were made of medical outcome, behaviour change in the children at 1 week and 3 mths post-discharge from a pre-admission criterion, convenience and subjective anxiety for parents, and relative costs of the two procedures. Results showed trends in favour of the day-care procedure. Argument is made that day-care should be the preferred option for minor surgery in young children.

SUMMARY The blood concentration of Marcaine® after axillary nerve blocks, intercostal nerve blocks and lumbar epidural anaesthesia was determined in man. The blood concentration remained low when Marcaine was injected with adrenaline. Slow onset and long duration of anaesthesia coincided well with a slow increase to peak concentration, low peak concentration and slow decrease thereafter. ZUSAMMENFASSUNG Nach der Vornahme von Nervblockaden, axillar und intercostal, sowie lumbalen Epiduralanaesthesien wurde die Blutkonzentration von Marcain beim Menschen bestimmt. Wenn Marcain gemeinsam mit Adrenalin injiziert worden war, blieb der Blutspiegel niedrig. Langsamer Wirkungseintritt und lange Dauer der Anaesthesie waren in guter Ubereinstimmung mit dem lang-samen Anstieg zur Hochstkonzentration, der niedrigen Hochstkonzentration und dem langsamen anschliessenden Abfall derselben.

Summary In 38 patients subjected to minor surgery, totally intravenous anaesthesia with low dose ketamine and Althesin produced adequate operating conditions in 92% of patients with minimal cardiorespiratory disturbance. Problems arose from muscular hyper tonus, spontaneous movement and occasionally salivation. Initial recovery was quicker and the incidence of side-effects lower, than those reported when ketamine was used as the sole agent. The technique could be useful in difficult situations as an alternative to inhalation anaesthesia or other intravenous techniques.

The use of dermabrasion for correction of acne scarring and treatment of actinic damaged skin is well known. The usefulness of this type surgery for the treatment of other conditions like seborrheic keratoses, lentigines, milia, tattoos, and superficial scars is explained.

Approximately 45% of asthmatic families and 47% of non-asthmatic families had consulted an alternative-medicine practitioner at some time. The most popular form of alternative medicine was chiropractic (21.1% and 26.4%, respectively), followed by homoeopathy/naturopathy (18.8% and 12.7%, respectively), acupuncture (9.4% and 10.9%, respectively), and herbal medicine (4.7% and 6.4%, respectively), while the remainder (20.3% and 11.8% respectively) was distributed among iridology, osteopathy, hypnosis, faith healing and megavitamin therapy. More families were satisfied with orthodox medicine (87.1% and 93.6%, respectively) than with alternative medicine (84.2% and 75.1%, respectively). Crosstabulation analysis of pooled data both from asthma and from non-asthma groups showed that 76.4% were satisfied both with orthodox and with alternative medicine, and 16.4% were satisfied with orthodox, but not with alternative, medicine. In contrast, only 2.7% were dissatisfied with orthodox medicine and satisfied with alternative medicine (chi2 = 9.33; P less than 0.01). These findings do not support the view that patients who use alternative medicine are those who are disgruntled with orthodox medicine.

Paracetamol absorption after oral administration was studied in eleven patients immediately after a short general anaesthetic for cystoscopy and also in eight healthy volunteers. There were no statistical differences between the rate of paracetamol absorption in the two groups. This suggests that oral medication may be given immediately following a short general anaesthetic when opioid drugs are avoided.