I routinely go down to 500 ml/min, sometimes lower. Have done for years. No-one has keeled over yet.

The recommendation is certainly responsible for making a lot more money for the manufacturer of sevoflurane.

I think (class 5 evidence here) at least part of the problem with nitrous oxide and PONV is due to distension of the gastric air bubble (and possibly other airspaces in the head?). I only turn it on at the end of fairly long cases where I have been using a high FiO2 (often 1.0), so the patient is fairly well denitrogenated. I think I mentioned this in my post.

Is it also possible that getting rid of a great deal of the smelly may help?

Wow, that's quite a desaturation! Great you had an automated record....

I agree aspiration seems unlikely, especially as recovery was so complete after a relatively short period.

I'm sure some sort of severe shunt must have occured at intubation, but I wonder (and have been for some time) if your choice of induction technique may have contributed.

As we all know maternal oxygen consumption is very high at full term, especially if the mother is in labour and scared witless about an urgent section to "save her baby". We also know her FRC is down, and she's (supposedly) an aspiration risk; that's why a rapid sequence induction (RSI) is the way to go.

The problem is, preoxygenation is often not done long enough when an anxious obstetrician is breathing down our neck, and then a dose of suxamethonium makes every skeletal muscle in our patients body contract - significantly increasing oxygen consumption even further. Many of us were also taught to eschew opioids before the baby is out, so the hypertensive response to intubation probably makes it all worse (your record shows diastolics over 115 after intubation, and systolics off the scale). The net result of this type of RSI is often not very pretty. As an aside, I suspect a lot of failed intubations at caesarean section are more due to haste than anything intrinsically difficult about the paturient's airway.

I now start all GA sections with a modest dose of fentanyl (100-200mcg), then pre-oxygenate for at least three minutes (I use the BP cuff interval as a timer) while the opioid calms the patient down a little. If you are really paranoid about opioids I guess a dose of esmolol would do. I use rocuronium for the intubation. Just like any other GA I do. RSI should stand for "really smooth induction" - haste makes waste :)

The only advantages nitrous oxide has over the smellies are, in my opioin, twofold.

It doesn't smell, so it can be useful at the start to stun a patient who doesn't like needles.

It is still unrivalled for speed of washout at the end of a case (maybe xenon is better?). I do not use it during maintenance, because its well documented adverse effects outweigh (for me) its minimal advantages *during maintenance*. At the end of a long case, I still use it often (with the patient denitrogenated and the sevo turned off) for the last 15-30 minutes and by the last stich the end-tidal sevo is about 0.3%. Turn off the nitrous and the patient is ready to walk by the time the dressings are on.

Sedation means just that. It does not even suggest, let alone guarantee, lack of awareness.

I never promise patients having sedation they will have no recall, but unfotunately the surgeon or nurses have usually got in first. I promise they will be relaxed and comfortable - if they are not, they will let me know somehow and I will give them more stuff.

Like George, if patients insist they do not want to know anything about the procedure, I tell them they are getting a GA.

Defining anaesthesia as loss of airway control is clearly not good enough. Some patients never lose their airway, some do it when clearly quite rousable. I would suggest lack of reponse to a noxious stimulus is more precise, but actually question the usefulness of any such definitions. As was stated earlier, it's all a continuum, and the boundaries are blurred.

A suprascapular nerve block combined with a superficial cervical plexus block can provide equivalent analgesia with *much* less risk. I can no longer justify interscalene blocks for post-operative analgesia.

Polio would be pretty much an absolute contra-indication in my book. Did she recover back to her pre-op level of function eventually?

I prefer to use plain bupivacaine for these. Typically 7-8mg with 20-25mcg fentanyl. Once they roll over and stick their bum in the air the slightly hypobaric local anaesthetic has nowhere to go. No need to wait 20 minutes for it to fix.

Surgeons I work with generally do haemorrhoids in lithotomy, but I do this occasionally for pilonidal sinuses.

Several points could be made.

First, neuraxial anaesthesia should ideally be performed in awake patients, especially if done above L2, as I presume an epidural following a laparotomy would be.

Secondly, if you had two failures, it might have been a good idea to give up. Elderly patients often have very low analgesic requirements after abdominal surgery, which is possibly why so many epidurals look so good ;) They frequently do just fine with paracetamol and a little subcutaneous morphine.

Thirdly, that was a really big dose of bupivacaine if the aim was only analgesia (I'm guessing you used 0.5% which makes for 12.5mg). I would use a fifth of that, so I'm not surprised she wobbled a bit.

I can't comment on the dose of diamorphine, as we do not use it in Australia. Perhaps it was a bit much too?