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Introduction: Exposure to cold temperature is a serious but often neglected problem in prehospital care. It not only is an uncomfortable, subjective experience, but it also can cause severe disturbances in vital functions, gradually leading to hypothermia., Objective: The aim of this study was to examine healthy subjects' physiological and subjective reactions to cold exposure (30 minutes at -5 degrees C in the a climatic chamber) while they were lying in a protective covering., Methods: Healthy volunteers (n = 20) participated in the experiment, which consisted of a 10-minute stabilization period of vital functions at room temperature (23 degrees C), 30 minutes of cold exposure (-5 degrees C), and a 30-minute recovery period at room temperature. Subjects lay supinely in protective covering during the entire experiment. Skin temperatures, oxygen saturation, pulse rates, pulse wave amplitude in the middle finger, and surface electromyography (EMG) activity of the major pectoral muscle were recorded continuously during the test. Before and immediately after the cold exposure, tympanic membrane temperatures were measured. In addition, subjects were asked to estimate cold using a standard scale., Results: During the cold exposure, the decrease in tympanic membrane temperature was not significant. The pulse wave amplitude in the finger decreased sharply upon entering the cold chamber. Skin temperatures, especially of the fingers and toes, decreased during the cold exposure. There were no clear signs of shivering in electromyographic recordings. Subjective cold feelings followed decreasing skin temperatures. Skin temperatures did not return quickly. Even 30 minutes after the exposure, all the skin temperatures still had not returned to normal levels. However, subjective cold feeling was relieved immediately., Conclusions: Cold exposure provoked immediate protective vasoconstriction in the peripheral compartment, which caused linear decreases of local skin temperatures. This probably was triggered from the unprotected face and upper respiratory areas.

This is a review of the facilities and programmes of the Finnish National Centre for Emergency Services in Kuopio, Finland. It includes the Emergency Services College that provides all of the training for emergency service workers in Finland and provides some services for the international community. There are needs for training by the medical community in Finland that relate both to skills and knowledge. Education and training focus on the demonstration of evidence-based competence. The facility includes a training ground for the provision of immediate emergency medical care, scene safety, extrication, industrial accidents, and water rescue. It is used for the training of paramedic students, nurses, medical students, firefighters, dispatch center staff, and officers. Computer-aided simulations are used to enhance the learning process. Plans are underway for adding tele-education and/or virtual-reality facilities. Close liaison is maintained with the University of Kuopio, Kuopio University Hospital, and with the Pohjois-Savo Polytechnic Institute.

Introduction: It is important to know which level of tactical preparedness is reached after completing lectures and training included in a medical curriculum. A computer-based interactive programme aimed for tactical training of emergency care tactics at the scene (Matimed, Matimed Ltd, Kuopio, Finland) was used in testing the skills of 20 medical students., Method: In this standardised test, every student first received guided introduction on the technical use of the programme. The test included four severely injured victims. The traumas used were hepatic rupture, flail chest, haemothorax, and femoral fracture. The students were tested in making decisions on the priority of care and transportation and in keeping the patients alive with appropriate emergency care until they were transported to a trauma centre., Results: Only five of 20 (25%) succeeded in this task, 50% lost one victim and 25% lost two. The results show that the tactical preparedness of medical students is far from what is presumed. A more detailed analysis shows serious deficiencies in decision-making, priority order of actions, and in the use of available resources., Conclusions: This type of interactive computer-aided training of tactics appropriately supplements theoretical lectures, and partially fills the need for practical training.

Materials and Methods: Cardiovascular effects of two local anesthetic agent solutions containing 2% lidocaine with 1:80,000 epinephrine (LE) and 3% prilocaine with 0.54 microgram/ml felypressine (PF) used separately and in combination were observed. We made 38 separate monitoring sessions (30 minutes each) with healthy voluntary dental students. Participants were monitored with Cardiocap multiparameter physiological monitor. The monitored values were heart rate, systolic and diastolic blood pressure, SaO2 and peripheral blood flow. Values were registered into computer memory for further analysis. Group 1 received 7.2 ml of PF to the buccal sulcus just distal of the second upper right molar and 7.2 ml of LE to the left buccal sulcus ten minutes later. Group 2 had the same injection positions but they received 3.6 ml of PF to both sides of maxilla and then, ten minutes later, 3.6 ml of LE to each side., Results: There were no radical changes in systolic or diastolic blood pressure. The blood oxygen saturation values were constant and the displayed SaO2 values were between 96-98% during the measurement period. Mean heart rate decreased about 10 beats/min after PF injection and increased about 10 beats/min after injection of LE in both groups. The peripheral blood flow (pbf) was the most sensitive parameter in our measurements. In general, pbf diminished in the period preceding the injection. It showed lowest values during the injection phases in both groups., Conclusions: Despite large doses of local anesthetics SaO2, systolic and diastolic blood pressure showed no clinically important changes, which suggests that local anesthetics have only a minimal effect on parameters mentioned above. This means that if the effect of one local anesthesia preparate (PF) is not sufficient, it is possible to safely reinforce the anesthesia with another substance (LE) in young healthy patients. Additionally, heart rate and pbf demonstrated quite clearly the symphatetic stimulation effect of the stress of injection and the stimulating action of epinephrine was seen clearly in heart rate values in both groups.

This paper describes three cases of early detection of hypoxia with pulse oximeter during intravenous sedation. In the main study group over 40 patients were monitored by pulse oximetry during large dental operation under i.v.-sedation. Diazepam with soybean oily solvent and midazolam were used as intravenous sedative agents in this study. The first signs of hypoxia were seen by pulse oximetry. In three healthy patients some periods of remarkable hypoxia was detected and those cases are reported in this paper. Two of the patients were treated by a surgical operation and one patient underwent large conservative dental treatment under sedation because of dental care phobia. During the dental treatment period external oxygen was added for all these three patients to avoid more complications as a result of hypoxia. Two of the patients received an injection of benzodiazepine antagonist, too. One patient needed further follow up but non of these patients developed any additional complications. As a conclusion pulse oximetric monitoring was found to be extremely sensitive as a predictor for coming complications as well as allowing early intervention in ventilation problems.

The effects of dihydroergotamine (DHE) on the circulation of the leg during combined epidural and general anaesthesia were studied to determine if DHE would enhance leg blood flow and prevent postoperative deep vein thrombosis in a double-blind trial of 40 elderly female patients subjected to cholecystectomy. Central and big toe temperature, arterial blood pressure, heart rate, calf volume and arterial inflow of the leg by electrical impedance plethysmography and the venous outflow by Doppler method were measured. DHE 0.5 mg subcutaneously reduced the volume of the leg, i.e. increased the electrical impedance, probably due to venous vasoconstriction. Simultaneously the need for etilefrine hydrochloride was reduced. No significant changes in the pulsatile inflow of the leg or the outflow were detected. Deep vein thrombosis (DVT) was detected by fibrinogen uptake test in five patients (three in DHEH and two in the control group) and verified by ascending phlebography in four patients. Intraoperative characteristics in patients with postoperative DVT were tachycardia (P < 0.001), enhanced need for etilefrine (P < 0.01) and a more rapid increase in big toe temperature (P < 0.05) after induction of epidural analgesia, compared with patients without DVT. Femoral vein flow velocity remained at the preinduction level, whereas pulsatile arterial inflow slightly increased. Together with a low basal impendance of the leg, the changes were indicative of a more intense vasodilatation, probably leading to stagnant flow and development of postoperative deep vein thrombosis.

This paper describes three cases of early detection of hypoxia with pulse oximeter during intravenous sedation. In the main study group over 40 patients were monitored by pulse oximetry during large dental operation under iv-sedation. Diatsepam with soybean oily solvent and midatsolam were used as intravenous sedative agents in this study. The first signs of hypoxia were seen by pulse oximetry. In three healthy patients some periods of remarkable hypoxia was detected and those cases are reported in this paper. Two of the patients were treated by a surgical operation and one patient underwent large conservative dental treatment under sedation because of dental care fobia. During the dental treatment period external oxygen was added for all these three patients to avoid more complications as a result of hypoxia. Two of the patients received an injection of bentsodiatsepine antagonist, too. One patient needed further follow up but non of these patients developed any additional complications. As a conclusion pulse oximetric monitoring was found to be extremely sensitive as a predictor for coming complications as well as allowing early intervention in ventilation problems.

Objective: To compare the conventional method for cannulation of the internal jugular vein with the ultrasound-aided technique., Design: Prospective, randomized trial., Setting: Medical and surgical patients requiring central cannulation in a university hospital., Patients: Consecutive medical and surgical patients in whom central venous cannulation was indicated., Interventions: Cannulation of the internal jugular vein was performed by one anesthesiologist. During the first 6 months, the ultrasound-aided technique (n = 29) was used, and during the second 6 months, the conventional technique (n = 27) was applied., Measurements and Main Results: The venous lumen was reached with fewer punctures (1.2 +/- 0.5 vs. 3.3 +/- 3.0 punctures per patient) and the cannulation time was shorter (35 +/- 19 vs. 198 +/- 211 secs) while using the ultrasound-aided technique. The ultrasound-aided method showed that the large-bore (diameter greater than 2.0 mm) needles invariably perforated the medial wall of the internal jugular vein, increasing the risk of perforating the adjacent carotid artery., Conclusions: Ultrasound guidance reduces both the duration of time and the number of punctures required to cannulate the internal jugular vein. The Seldinger technique appears safer for catheterization of the internal jugular vein.

Transdermal hyoscine (Scopoderm, Ciba-Geigy) has been compared with placebo in 283 female patients. The hyoscine patch had no significant effect on postoperative nausea or vomiting. In contrast with earlier studies, there was no correlation between previous experiences of nausea (motion, pregnancy or surgery related) and nausea caused by the surgery or anaesthetic in this study. No correlation was found between nausea or vomiting and the type of operation.

Six healthy male subjects were given in a crossover fashion medium molecular weight (HES 125) and low molecular weight (HES 40) hydroxyethyl starch, dextran, and balanced salt solution by intravenous infusion. The plasma volumes were determined using labeled albumin and plasma protein measurements. Three properties of factor VIII protein complex and indices of blood coagulation and hemostasis were measured before and after the infusions. Both the salt solution and HES 40 increased plasma volume, but their effect wore off within 3 hours. Dextran and HES 125 increased plasma volume significantly (P less than 0.001) more than the salt solution did, and the expansion was maintained for 24 hours. Plasma volume increases (dextran and HES 125) were associated with high nonglucose carbohydrate levels in plasma and low levels in urine. No or slight increases in plasma volumes (HES 40), on the other hand, were associated with low and high carbohydrate levels in plasma and urine, respectively. Serum alpha-amylase activity increased significantly after both HES preparations as compared to salt solution. Dextran and HES 125 decreased all the three values of factor VIII, these decreases being maximal 3 to 6 hours after administration and highest (about 25 per cent) for F VIII R:Ag and F VIII R:cof. It is concluded that HES 125 and dextran are equally effective plasma expanders.

Flunitrazepam premedication administered orally or intramuscularly was compared in 41 surgical patients. The effect of the premedication was assessed both subjectively and objectively. The plasma concentrations were determined just before induction. The mean (+/-SD) plasma concentration in the oral premedication group was 8.2 +/- 2.2 ng/ml and 7.9 +/- 4.6 ng/ml in the intramuscular premedication group. There was a highly significant correlation (p less than 0.001) between the sedative effect and plasma concentration of flunitrazepam in all patients. Oral flunitrazepam was equal to i. m. flunitrazepam as an anxiolytic and sedative with a rapid onset of action. However, the oral route of administration of flunitrazepam is preferable because it is painless and easy to administer.

A comparison has been made between the effects of the administration of flunitrazepam 1 mg i.v. and diazepam 10 mg i.v. in 90 female patients undergoing abdominal surgery. The drugs were given immediately before the skin incision as a booster to the induction agent thiopentone. The response to the incision, the quality of anaesthesia and the need for supplementary medication during maintenance were monitored. A standard post-anaesthesia interview was performed to evaluate the amnesic action and patient acceptability. The skin incision caused only slight increase in arterial pressure and heart rate in both groups. Only six patients of the diazepam group reacted to the incision with defensive movements. The overall quality of anaesthesia was better (P less than 0.05) and the need for supplementary doses of pethidine lower (P less than 0.01) in the flunitrazepam group. Recovery was equally good and the duration of sleep after operation was the same in both groups. The frequency of nausea after operation was low. The post-anaesthesia interview revealed that flunitrazepam possesses a more specific anterograde amnesic action than diazepam. Acceptability of the anaesthesia to the patient was equally good in both groups.

The efficacy of midazolam vs lorazepam and placebo was studied in 60 patients in a comparative, double-blind study. Midazolam 15 mg and lorazepam 2.5 mg were given orally in a single dose the night before operation. Sleep latency was shortest on midazolam but the mean duration of sleep longest on lorazepam. Four patients on lorazepam complained of headache and one reported tinnitus. Three patients receiving midazolam complained of headache. Headache was observed also in one patient given placebo and another experienced tachycardia. Midazolam administered the night before surgery is a preferable hypnotic for transient insomnia caused by preoperative anxiety.

Sixty female patients were given, in random order, under double-blind conditions, either midazolam or fat-emulsion diazepam, intramuscularly, as premedication, 1 h before general anaesthesia. The dose of midazolam used was 0.13 mg/kg and that of diazepam 0.17 mg/kg. The degree of sedation, mood of the patient, and time at which onset of effect was perceptible were assessed before induction of anaesthesia, together with skin temperature and concentrations of midazolam or diazepam in plasma. Patients were interviewed postoperatively to discover their subjective evaluation of the premedication and to assess its amnesic effects. Midazolam was significantly superior (P less than 0.05) to diazepam as regards sedation. There were no differences in effects on mood of the patients between the two groups. Sixteen patients in the diazepam group and four in the midazolam group had no perception of onset of effect. The difference is significant (P less than 0.01). The skin temperature was, on average, 2 degrees C higher in the midazolam group than in the diazepam group (P less than 0.005). The mean plasma concentration was 67.8 +/- 24.5 micrograms/l in the midazolam group and 44.8 +/- 25.7 micrograms/l in the diazepam group. In only two cases was the concentration of diazepam above 100 micrograms/l (arbitrarily defined as the minimum sedative concentration). Subjective evaluation of efficacy significantly (P less than 0.002) favoured midazolam. Local pain was evident in two patients in the diazepam group, and three patients experienced nausea immediately after administration of the drug.(ABSTRACT TRUNCATED AT 250 WORDS)

Xylitol has been suggested as a more advantageous calory source for intravenous administration than glucose in certain clinical situation, but the general suitability of intravenous xylitol infusion has not been confirmed. Thirty-middle-aged women were infused with 100 g of xylitol as postoperative fluid therapy after gynaecological laparotomy and general anaesthesia. Another 10 women received 50 g of glucose in a similar manner and served as a reference group. Infusion of xylitol both at the rate of 0.25 g/kg/h (1000 ml 10% xylitol in approx. 8 h) and 0.5 g/kg/h (1000 ml 10% xylitol in approx. 4 h) caused a distinct increase in the serum concentrations of lactic acid, pyruvic acid, and uric acid; such an increase was not seen with glucose infusion. The faster infusion of xylitol also distinctly increased serum bilirubin concentrations. Because of the possibility of lactic acidosis and urate deposits in kidneys, infusion of 100 g or more of xylitol at a rate of 0.25 g/kg/h or faster is not safe for postoperative fluid therapy in routine clinical work.

A form of combination anaesthesia using ketamine, diazepam, alcuronium and nitrous oxide was used in 41 patients over 65 years requiring abdominal surgery. The patients were premedicated with droperidol 2.5-7.5 mg im. At induction the patients received diazepam 5 mg. ketamine 2 mg/kg and alcuronium 0.2 mg/kg. Anaesthesia was maintained with a continuous, steady injection of ketamine 2.5 mg/kg/h and nitrous oxide-oxygen with controlled ventilation. Four minutes before incision the patients received 1 ml of coded solution and at the end of anaesthesia the same solution, which contained either 5 mg/ml diazepam or its solvent only. There were no statistically significant differences between the two groups, i.e. patients receiving either 15 or 5 mg of diazepam. The incidence of bad dreams was 5 per cent, i.e. one patient in each group. Only one patient vomited and one had pronounced nausea in group D5. According to the anaesthesiologist's, the anaesthesia nurse's and the patient's subjective evaluations this type of combination anaesthesia was found to be highly acceptable. Despite there being no statistically significant differences between the patients who received 5 + 5 + 5 mg of diazepam compared to those receiving 5 + 0 + 0 mg, the figures in results per se incline in favour of the use of 5 + 5 + 5 of diazepam.

Carbonated bupivacaine and bupivacaine hydrochloride were used for epidural anaesthesia in patients undergoing surgery of the lower extremities. Thirty patients received 20 ml 0.5% bupivacaine hydrochloride and 32 patients 20 ml 0.42% carbonated bupivacaine. Carbonated bupivacaine had a more rapid onset of action and spread of both sensory and motor blockade than its hydrochloride salt. The differences were statistically significant.

The absorption of rectal diazepam solution was studied in 22 children aged 1-9 yr by measuring serum concentrations. The mean dose was 0.27 +/- 0.09 mgkg-1. The mean serum concentration was 98.5 +/- 53.5 ng ml-1 4 min after administration and 206.7 +/- 105.8 ng ml-1 at 11 min. The correlation between dose and serum concentration was statistically significant at both times. With a dose of 0.4-05 mgkg-1 an adequate serum concentration was achieved within 5-6 min. No side-effects were observed. A rectal solution provides a faster, more effective and reliable alternative to tablets and suppositories, and to the uncertain i.m. injection of diazepam. Meticulous nursing is important.

The occurrence of deep vein thrombosis (DVT) was studied by the 125-I-fibrinogen uptake test in 38 patients subjected to retropubic prostatectomy. The patients were randomly allocated to two groups: continuous lumbar epidural analgesia for up to 24 hours and general anaesthesia with intermittent positive pressure ventilation. Two of the 17 patients in the epidural group (12%) developed DVT in contrast 11 of the 21 patients in the general anaesthetic group (51%). The difference between the groups was significant. It is concluded that epidural analgesia offers a protection against postoperative DVT and is worth further investigation.

Carbonated local anesthetics are less acidic than the hydrochlorides and require less buffering by the tissues. Rapid buffering and diffusion of the carbon dioxide enables free base to be deposited in high concentrations on nerve fibres. Carbon dioxide increases the intracellular hydrogen ion concentration, thus increasing the amount of active cation at the receptor site. The interscalene approach to the brachial plexus was chosen for comparison of bupivacaine hydrochloride 0.5% and carbonated bupivacaine 0.5%. The interscalene route has many potential advantages, including anesthesia of the shoulder and reliable block of the musculocutaneous nerve, but large volumes of local anesthetic solutions are needed. The use of such volumes may exceed the limit of toxicity. Therefore, the plasma concentrations produced by 40 ml of local anesthetic solution were studied in 42 patients for whom brachial plexus block was considered a suitable technique. The latency of onset of sensory analgesia was shortest and with the least variability in the dermatomes C5-C7. The first analgesia was detected by pinprick 5.1 +/- 0.4 (SE) min and complete analgesia in 19 +/- 1 min after bupivacaine hydrochloride and 4.7 +/- 0.5 min and 15 +/- 1 min after bupivacaine carbonate. The more caudad nerves showed a significantly longer latency time than the more cephalad ones. The duration of sensory analgesia varied between 6 and 12 hours, the more caudad nerves showing the shortest duration.(ABSTRACT TRUNCATED AT 250 WORDS)

In 104 patients undergoing anaesthesia of short duration, two different solvents, propylene glycol and cremophor, were compared in a double-blind trial. Diazepam 10 mg in a coded solution was injected into a superficial vein of the hand using a small-gauge needle. The vein was examined after 14 days. The frequency of thrombophlebitis with propylene glycol was 62.2% and with cremophor 3.4% (P less than 0.001). The frequency of pain on injection was also in favour of the new solvent (P less than 0.001). The possibility of anaphylactic reactions accredited to cremophor, however, restricts the use of the new injection.

Alcuronium and pancuronium were compared as muscle relaxants in a randomized and double-blind trial in routine clinical circumstances during combined balanced anesthesia in 40 female patients. The course of endotracheal intubation at 2 min. was statistically significantly better (p less than 0.001) in the pancuronium group than in the alcuronium group. There were no differences between the two groups regarding relaxation, maintenance of anesthesia and postoperative recovery. In the pancuronium group the systolic blood pressure was significantly higher than in the alcuronium group at 2 minutes after induction (p less than 0.01), at 2 minutes after intubation (p less than 0.05) and before incision (p less than 0.05). Also the diastolic blood pressure was significantly higher in the pancuronium group at 2 minutes after induction (p less than 0.001), before incision (p less than 0.01) and at 2 minutes after incision (p less than 0.05) than in the alcuronium group. Thus alcuronium is preferable when hypertensive episodes are to be avoided whereas pancuronium would be more suitable when hypotension can be expected.

The antithrombotic effect of dextran 70 and dextran 40 was studied by a double blind trial in 235 patients with major or medium sized elective procedures. 6% dextran 70 (Macrodex) or 10% dextran 40 (Rhemacrodex) or 5% dextrose in 0.9% saline were given in a double blind manner in 500 ml quantities over 30 minutes starting with the induction of anaesthesia. The diagnosis of deep venous thrombosis was confirmed objectively by the I-125-labelled fibrinogen uptake method. Statistically significant differences in the incidence of deep venous thrombosis between the controls and the dextran groups were not found.

The series comprises 109 healthy females aged 14-49 years (mean age 28 years) hospitalized for legal abortion or diagnostic curettage. The patients were premedicated with morphine-scopolamine 0.4-0.7 ml i.m. (morphine 20 mg/ml, scopolamine 0.6 mg/ml) and atropine 0.01 mg/kg i.v. Ketamine 1.5 mg/kg was administered i.v. and immediately thereafter 2 ml of a coded solution i.v. consisting either of diazepam 10 mg or its solvent only. Supplementary doses of ketamine 0.2-0.4 mg/kg were administered when needed. Diazepam reduced the incidence of unpleasant dreams and experiences to a significant degree (p less than 0.01) according to the postanaesthetic interviews of the patients. Nausea occurred in the diazepam group in 2 per cent and in the placebo group in 17 per cent (p less than 0.01). In respect to the differences in opinion presented in literature the authors consider the time of administration of diazepam at induction to be of decisive importance and find prophylactic prevention of dreams justified as it cannot be predicted which of the patients will have unpleasant or even terrifying dreams. Dreams and/or experiences or their memories must be prevented at the stage at which the effect of ketamine commences. The authors do not, however, recommend ketamine anaesthesia for young adults, even when supplemented with diazepam. On the other hand, the authors consider the positive observations made during the study to be applicable to all other ketamine anaesthesias.

Two preparations of diazepam, Valium Roche mixed Micelles and Diazemuls, were compared as intravenous premedicants in 119 patients undergoing minor gynaecological surgery. There were no differences between the formulations with regard to anxiolytic effects and systemic tolerance. There were no symptoms typical of thrombophlebitis in the Valium Roche Mixed-Micelles group and only one case in the Diazemuls group. Acute local tolerance was similar with both trial drugs and superior to conventional diazepam preparations. Based on the favourable results of the present study it can be concluded that such vehicles should be considered for any injectable preparation with a known tendency to produce venous irritation.

Propofol, in emulsion formulation, was compared with methohexitone for short duration anaesthesia with the main emphasis on acute and long-term venous tolerance. Flunitrazepam and fentanyl were given to all the patients. Fifty-two female patients undergoing short gynaecological procedures were randomly allocated to two groups to receive propofol or methohexitone as the intravenous anaesthetic agent. The dose of propofol was 2.0 mg/kg at induction with an average total dose of 2.58 mg/kg and the dose of methohexitone was 1.5 mg/kg and 2.20 mg/kg, respectively. Propofol or methohexitone were given through a 1.0 mm Teflon indwelling cannula in a superficial vein of one hand. All other drugs were given through a similar cannula in the other hand. There were no significant differences in acute or late tolerance between the propofol and methohexitone or control (all other drugs) groups. Because there was no thrombophlebitis following either drug the venous tolerance of both drugs can be regarded as good. Moreover this type of short anaesthesia was characterized with fast recovery and high patient acceptance.

This is a review article of the debated massive use of balance electrolyte solutions in the replacement of blood loss. We cannot directly apply the results and conclusions of American reviews on this subject as there are significant differences between USA and Finland in the use and availability of alternative fluids. Electrolyte solutions pass freely across the capillary membrane and are distributed in the extracellular compartment and as such poorly restore and maintain blood volume. In order to be effective they have to be infused in volumes trice the blood loss. Efficient protective mechanisms in the pulmonary capillary membranes prevent the appearance of pulmonary interstitial edema even when crystalloids are used in massive amounts. There is however significant water retention and edema in the periphery which results in impaired tissue oxygenation. The optimum anion composition of balanced electrolyte solutions is unsettled. In blood loss replacement electrolyte solutions without dextrose are preferred. The minimal amounts of potassium in balanced electrolyte solutions is of no practical value. Even though crystalloid solutions can be tolerated in massive amounts, marked blood loss is replaced more physiologically and effectively using natural or artificial colloids in iso-oncotic concentrations together with red cell concentrates and fresh blood.

The effects of flunitrazepam and Althesin as anaesthetic induction agents were studied in a double-blind trial in 97 patients undergoing abdominal or gynaecological surgery. There was no difference between the two preparations in respect of the quality of induction. A marked difference in the quality of maintenance of anaesthesia were seen, in favour of flunitrazepam. Recovery was more rapid from Althesin anaesthesia. A low incidence of nausea was observed in both groups.

Venous sequelae were studied in 93 female patients undergoing minor gynaecological procedures. They were premedicated with diazepam i. v. dissolved in a fat emulsion (Diazemuls) injected to a superficial vein of the right hand. The patients observed the site of injection for 14 days and recorded their findings. Twenty-eight per cent reported mild tenderness and 7.5% mild or moderate swelling of short duration. Signs of thrombophlebitis were found in 2.2%. Thrombophlebitis after injection can be prevented effectively and safely using fat emulsion as a solvent for diazepam.

Flunitrazepam is a benzodiazepine derivative whose hypnotic effect predominates over the sedative, anxiolytic, muscle-relaxing and anticonvulsant effects characteristic of benzodiazepines. Thus, it is used as a night-time hypnotic and in anaesthesiology: due to the pronounced hypnotic effect it is not appropriate as a daytime sedative. As a hypnotic for insomnia its effect is usually characterised by a very fast onset of action and quiet sleep without interruptions. On the morning after a hypnotic dose some residual psychomotor impairment does occur, which is comparable to that with usual doses of nitrazepam or flurazepam, but clinically apparent 'hangover' occurs infrequently. There is no pronounced cumulative effect with chronic use. In anaesthesiology it has proven to be useful as a hypnotic on the night before operation, as an oral, intramuscular or intravenous premedication, in induction and as a supplement to other anaesthetics. Its sedative and amnesic properties can also be beneficial in intensive care patients. Much of the usefulness of flunitrazepam in anaesthesia relates to its synergistic effect with other anaesthetics, to its effective amnesic action and its acceptable effects on circulation and respiration. Possible drawbacks include a somewhat unusual course of induction (when used for this purpose) and an often prolonged recovery. Although the safe dosage range is wide with flunitrazepam, its effective application both as a hypnotic for insomnia and in anaesthesiology is dependent upon use of the optimal dosage, and adequate knowledge of its pharmacokinetic properties.