Factors influencing epidural catheter migration

The incidence and amount of migration of epidural catheters was investigated in a prospective randomised study of 153 women who required analgesia in labour. Inward or outward migration occurred in 36% of patients. Inward migration by 1-3 cm occurred in 21 (13.7%) patients and outward migration by 1 cm or more occurred in 34 (22.2%); three (2%) catheters migrated out through the skin. There were significant positive correlations between outward migration and weight, body mass index, and depth of the epidural space. There was no relationship between migration and height, age, intervertebral space used or duration of catheterisation. Problems with epidural block were no more likely in patients in whom migration of 1 cm or more occurred compared with those in whom migration was limited to a maximum of +/- 0.5 cm. However, the pattern of problems was different. All cases of failed epidural block occurred in patients whose epidural catheter migrated outward by 2.5 cm or more. Unilateral blockade was not more likely if migration of 1 cm or more occurred.     

PARANEOPLASTIC PARALYSIS IN A PATIENT WITH MALIGNANT FIBROUS HISTIOCYTOMA

A patient presented with lower limb paralysis and a large malignant fibrous histiocytoma (MFH) on her back. Metastatic disease to the spine was excluded and the diagnosis of paraneoplastic paralysis was made. This may be the first described case of a neuromyopathic paraneoplastic syndrome in malignant fibrous histiocytoma. Tissue culture and electron microscopy assisted in establishing the diagnosis of the tumour. A hitherto unrecognised endocrine factor may account for the hypokalaemia which was a feature in this patient.     

Cardiac Dysrhythmias and Heart Rate Changes at Induction of Anaesthesia: A Comparison of Two Intravenous Anticholinergics

Glycopyrrolate, 0.2 mg, or atropine, 0.6 mg, was administered intravenously together with methohexitone for the induction of anaesthesia in unpremedicated patients. The use of atropine, compared with glycopyrrolate, was associated with a greater rise in heart rate, a greater number of patients whose heart rates doubled, and a higher incidence of dysrhythmias. Glycopyrrolate is recommended for use as an intravenous anticholinergic agent, particularly in patients with cardiovascular impairment.     

BILATERAL BREAST METASTASES FROM A RENAL CARCINOMA

SUMMARY Metastatic involvement of the breast is rare. The commonest cause is spread from a contralateral breast carcinoma. However, metastatic malignant melanoma, lymphoma and lung carcinoma have all been reported sporadically in the literature. Renal carcinoma is well recognised for its protean clinical manifestations ranging from loin pain, haematuria and an abdominal mass to less obvious metastatic effects such as pathological fracture of a long bone or one of a variety of associated paraneoplastic syndromes. We present a case of a renal carcinoma presenting with bilateral breast masses with literature review, and discuss the efficacy of the standard gamut of investigations in a breast mass of non-primary origin.     

Total intravenous anaesthesia for laparoscopy

Two techniques of total intravenous anaesthesia for laparoscopy were compared in 80 patients. Group 1 received alfentanil, propofol and vecuronium, and Group 2 alfentanil, midazolam, ketamine and vecuronium. Haemodynamic stability after induction and the pressor response to tracheal intubation were significantly different. There was no significant difference in recovery times between the two groups and little difference in other postoperative sequelae.     

Method of measuring blood loss

An easy rapid method of calculating blood loss during paediatric surgery using an osmolality dilution technique is described. Known volumes of whole blood packed red blood cells and plasma were measured in the laboratory using this method. A statistical analysis of the results suggest that this technique would be useful for measuring blood loss in the operating theatre.