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To evaluate the possible cost savings when routine preoperative testing is discontinued in ambulatory cataract surgery patients.A policy was introduced at our hospital to stop routine testing in ambulatory cataract patients. Consecutive patients' medical records were analyzed in a four-month period pre- and a four-month period post-discontinuation of routine laboratory tests. Ambulatory cataract surgery is performed under topical (and sometimes retrobulbar block) anesthesia with iv sedation. Co-morbidities, perioperative events, frequency and cost of tests ordered were compared for the two groups. Average costs per patient pre- and post-discontinuation of routine tests, and total possible cost savings were calculated.One thousand two hundred and thirty-one patients were studied; 636 had routine laboratory tests and 595 had no routine laboratory tests. The ratios of gender, co-morbidities and perioperative events were similar in the two groups. There was a significant reduction in the number of tests ordered after the new policy was introduced, from 5.8 tests per patient to 0.4 tests per patient. The cost of tests per patient was reduced from Can $39.67 to $4.01.In ambulatory cataract surgery, over 90% savings in laboratory costs is possible after elimination of routine tests.

Pentazocine (WIN-20228) is a derivative of the benzmorphan series of drugs It is reported to combine analgesic and narcotic antagonist properties, and is regarded as being free of liability to addiction The effectiveness of pentazocme as an analgesic agent m post-operative patients was established m a randomized blind study in which the drug was compared with equipotent doses of morphine and meperidme In this study there appears to be no difference in the incidence of unwanted side effects produced by the three drugs such side effects were so rare as to make statistical analysis of any differences completely unprofitable

Frederic Mior, Universite de Sherbrooke, Sherbrooke, QC, Canada; Rene Martin, Universite de Sherbrooke; Mariette Lepine, Universite de Sherbrooke; D Greentree, Universite de Sherbrooke; P Lavallee, Centre Hospitalier Universitaire de l'universite de Sherbrooke; MF Raymond, Centre Hospitalier Universitaire de l'universite de Sherbrooke; J Ouellet, Centre Hospitalier Universitaire de l'universite de Sherbrooke;

The influence of arterial O2 and CO2 tensions on electroconvulsive seizure duration was investigated in five mongrel dogs under consistent anaesthetic conditions. Seizure durations were measured in a randomized protocol of nine possible combinations of arterial gas tension spanning increased, normal or decreased levels of PaO2 and PaCO2. Seizure duration was directly related to PaO2 (p less than 0.00001) and inversely related to PaCO2 (p less than 0.0001). A significant synergism was evident at the extremes of PaO2 and PaCO2, with seizure duration being greater than predicted for hyperoxia-hypocapnia and hypoxia-hypercapnia and shorter than predicted for hypoxia-hypocapnia and hyperoxia-hypercapnia. We conclude that arterial gas tensions strongly influence ECT-induced seizure duration and through this may influence the therapeutic efficacy of electroconvulsive therapy.

To assess overall job satisfaction among Canadian anesthesiologists and examine contributing factors.A confidential postal survey of all active members of the Canadian Anesthesiologists Society was conducted in 1998. Demographics, anesthesia practice, overall job satisfaction, anesthetic assistance, and perceived surgeons' and public attitudes towards anesthesiologists were collected.Of 1659 surveys sent, 946 were returned (57% response rate). Seventy-five percent of the respondents were male and 25% female. Staff comprized 91%, residents 9%. The average working week was 59 +/- 11.9 hr. Seventy-five percent of respondents reported overall job satisfaction. Job satisfaction was associated with intellectual stimulation, good quality of care and interaction with patients. Dissatisfaction stemmed from treatment from the provincial government, hospital politics and long hours. Job satisfaction was associated with satisfaction with the level of operating room (OR) assistance, perceived high surgical regard and public image. Residents were more satisfied than staff anesthesiologists. Overall satisfaction was not affected by age, gender, region of practice, type of hospital or clinical work.Job satisfaction among anesthesiologists is significantly associated with intellectual stimulation, quality of care, interaction with the patients, treatment from the provincial government, hospital politics, working hours, OR assistance and perceived attitude of surgeons. Improving these contributing factors may lead to higher job satisfaction.

To describe two patients with brain tumours where general anesthesia was used for cesarean sections under emergency and urgent conditions. CLINICAL FEATURES (CASE #1): The first patient presented at 38 wk gestation with an acute intracranial tumour herniation, requiring emergency craniotomy and simultaneous cesarean section. General anesthesia was induced with thiopental and vecuronium, maintained with enflurane 1% in O2 100%. Maternal P(ET)CO2 was maintained at 25 mmHg. After delivering a healthy infant, she was given syntocinon, mannitol and dexamethasone i.v. anesthesia was maintained with fentanyl, nitrous oxide 50% in O2 and isoflurane 1% during frontal-lobe tumour resection. CLINICAL FEATURES (CASE #2): The second patient presented at 37 wk gestation for urgent cesarean section because of placental insufficiency. She had had a brain tumour resection four years earlier. An increase in intracranial pressure necessitated craniotomy for decompression at 20 wk gestation. She was further treated with dexamethasone, carbamazepine and radiation for control of cerebral oedema at 34 wk. Cesarean section was performed under general anesthesia; rapid-sequence-induction with thiopental and succinylcholine, followed by isoflurane 1% in O2 100%. Syntocinon, fentanyl and atracurium i.v. were administered after delivery of a healthy infant. Although neurosurgeons stood by, their intervention was unnecessary.General anesthesia remains safe and dependable for operative delivery in parturients with intracranial tumour. Tracheal intubation allows maternal hyperventilation thereby controlling raised intracranial pressure. Hemodynamic stability is readily achieved to maintain cerebral perfusion. However, a multidisciplinary-team approach is critical for successful patient management.

Mivacurium is a new non-depolarizing muscle relaxant consisting of three stereoisomers. The two active isomers (cis-trans andtrans-trans) undergo rapid metabolism by plasma cholinesterase (t1/2 β<2 min). Due to its rapid elimination, the need for reversal of mivacurium-induced neuromuscular block is controversial, and to date there have been no studies evaluating reversal of deep blocks. The object of the current investigation was to establish the lowest effective dose of edrophonium required to reverse deep mivacurium-induced neuromuscular block. One hundred ASA Class I and II patients undergoing outpatient surgery in two teaching institutions were studied in this randomized, placebo-controlled double-blind trial. Under balanced propofol/nitrous oxide/alfentanil anaesthesia, a continuous infusion of mivacurium was adjusted to maintain between 5– 10% of control T1 amplitude. Upon completion of surgery, neuromuscular block was reversed by injecting normal saline (Group PLAC), edrophonium 0.125 mg · kg− 1 (Group EDR- 1), 0.25 mg · kg− 1 (Group EDR- 2), or 0.50 mg · kg− 1 (Group EDR- 3), in addition to a corresponding dose of atropine. 4Spontaneous recovery, from a T1 response of<10% to a TOF ratio ≥0.7, required 13.5 ± 2.6 min (PLAC Group). In comparison, patients in the EDR- 1 group required 9.2 ± 2.6 min (P < 0.01). Higher doses of edrophonium conferred no advantage. Four patients (4%) had not achieved a TOF ratio of ≥ 70%, 20 min after reversal, and required additional edrophonium. Two patients (PLAC group), had dibucaine numbers and cholinesterase levels consistent with an EUEA genotype, whereas the two patients with delayed recovery in the EDR- 1 group had characteristics of a normal genotype. We conclude that a very low dose of edrophonium (0.125 mg · kg− 1) hastens reversal of deep mivacurium-induced neuromuscular block by approximately four minutes, and that edrophonium doses exceeding 0.125 mg · kg− 1 provide no additional benefit. Heterozygous patients with atypical plasma cholinesterase levels, as well as certain individuals with normal dibucaine numbers and plasma cholinesterase activity, are at risk for prolonged neuromuscular block, but the block is easily reversed with edrophonium.

Sevoflurane and propofol are both suitable for neuroanesthesia but have not previously been compared as maintenance agents for long duration (one to five hours) procedures.Using a multicentre international study protocol, 103 patients were randomized to receive either sevoflurane or propofol for maintenance of anesthesia during interventional neuroradiology procedures. After a standardized induction of anesthesia with propofol, 53 patients received sevoflurane 1 to 3% with 60% nitrous oxide (N(2)O) in oxygen (O(2)), and 50 patients received propofol 4 to 10 mg x kg(-1) x hr(-1) with 60% N(2)O in O(2). Maintenance agents were titrated against systemic arterial blood pressure (baseline mean arterial pressure +/- 20%). Recovery times, changes in sedation, pain, nausea and vomiting and psychomotor function during recovery and use of rescue medication were recorded.The group receiving sevoflurane had a more rapid recovery to spontaneous ventilation, extubation, eye opening and orientation compared to the group receiving propofol (3 vs 4 min, P = 0.01; 5 vs 6 min, P = 0.015; 7 vs 10 min, P0.001; 13 vs 17 min, P = 0.028; respectively). Sedation, pain, nausea and vomiting, and psychomotor function scores were similar in the two groups. Use of opioid boluses and vasopressors were similar.The use of sevoflurane for maintenance of anesthesia for prolonged neuroradiological procedures is associated with more rapid early recovery than propofol and is associated with similar side effects. Sevoflurane and propofol can both be recommended for these procedures. The clinical benefit of the more rapid recovery with sevoflurane is unknown.

Introduction We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients. Methods We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined. Results Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies. Conclusion Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.

Modem epidural labour epidural analgesic techniques and medications have resulted in more consistent, predictable and effective analgesia utilizing contemporary techniques which enable anesthesiologists to provide many options to women in labour. Our desire to improve patient care and safety, while increasing the satisfaction and participation of women in their labour and delivery experience, continues to be one of the primary goals and challenges for those providing obstetric analgesia services.