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Paraldehyde: A Basal anesthetic for tonsillectomy in children
PARALDEHYDE: A BASAL ANESTHETIC TONSILLECTOMY IN CHILDREN LOUIS ZISSERMAN, Director
of Anesthesia
M.D.
AND
Division, Jewish HospitaI PHILADELPHIA,
T
importance of preoperative sedation is aImost universaIIy accepted. There is, however, no unanimity as to by recta1 drug or dosage. ParaIdehyde instiIIation has been used for this purpose for many years, aImost a11 of the pubIished Iiterature emanating from abroad. Reports from Great Britain and her coIonies have been most enthusiastic. CIaims have been made that this method of sedation is (a) safe for both chiIdren and aduIts; (b) rapid and certain in action; (c) safe for use in “bad risk” patients, such as decompensated cardiacs, cachectics, and chronic nephritics; (d) offering complete amnesia with a refreshing sIeep.‘-lo In addition, the statement is repeatedIy made that there is no effect upon either circuIatory or respiratory system, aImost a11 of the drug being eIiminated unchanged through the Iungs, the remainder through the kidneys. Impressed with the vaIuable properties ascribed to paraldehyde by rectum, and especiaIIy the favorabIe report of Souraskyl’ on its use as a preliminary to tonsiIIectomy in chiIdren, we have been giving paraIdehyde by rectum routineIS since 1937 as a for tonsiIIectomy to a11 premeditation chiIdren on OtoIaryngoIogicaI Ward Service Number Three at the Jewish HospitaI. The foIIowing technique has been used. The patient is given a simpIe enema the morning of operation. One hour preoperativeIy he receives a retention enema of paraIdehyde. In the first series of 104 consecutive cases, this was used in the proportion of I C.C. for every 5 pounds of body weight. In the second series of I I 7 consecutive cases, the ratio was changed to I :8. In severa unseIected cases this was furHE
HERMAN
C:hiefof Otolaryngological
B.
FOR
COHEN, Service
M.D.
III, Jewish
I hospital
PENNSYLVANIA
ther reduced to I : IO. The Iargest dose ever used was 20 C.C. in a 12 year oId chiId. The paraIdehyde is usuaIIy mixed by simpIe agitation with an equa1 voIume of tap water and given with a soft rubber catheter and syringe at room temperature. Occasionally minera oil is substituted for the water. The enema is easiIy retained b! a11 but the youngest chiIdren who sometimes do not coiiperate. Within fifteen minutes, patients faI1 into a sound sIeep that resembIes norma slumber. AIthough they can be aroused, they are somewhat confused and faI1 off to sIeep again. Preoperative restIessness and excitement are not observed nor are there any other untoward symptoms. A11 the chiIdren in our series took anesthesia we11 (invariabIy open drop ether). After the operation, they continued to sIeep for four or five hours, a sIumber that was peaceful and much Ionger than that usuaIIy seen. If vomiting occurred, they awoke for a short spell and then promptIy returned to sIeep. Drowsiness was observed for about twelve hours. There was no hangover, proctitis, or other unpIeasant sequela. The pharyngea1 reff exes were not interfered with during operation. As a contro1, the records of a number of routine tonsillectomies performed on the same service just prior to 1937 without benefit of any premeditation were reviewed. Postoperative vomiting in the paraldehyde group was diminished both in extent and in the number of patients affected, occurring in 43.3 per cent of patients receiving paraIdehyde in the I : j ratio, 50.4 per cent of those receiving it in the I :8 ratio and 63.3 per cent of the controls.
Zisserman,
NEW SERIES VOL. L, No. 3
Cohen-ParaIdehyde
Postoperative resuturing for profuse bIeeding was required in two of the paraldehyde and two of the controI series. In a11 four instances, the additiona suturing was required about five to tweIve hours after the operation. There was nothing to sugTABLE I NUMBER
OF
CASES
BY
AGES
Age
I
Dose
The wide margin of safety present with paraIdehyde is iIIustrated by the foIIowing case report presented here through the courtesy of the attending surgeon.* R. Z., a white maIe child, g years oId, was admitted to the Jewish Hospital with a diagnosis of acute appendicitis. His temperature, p&e and respirations were IOO’F., I IO and 22 respectively. He was to have received 2 drachms of paraldehyde mixed with I ounce of water as a retention enema, but was inadvertentIy given TABLE
-
Paraldehyde Dose
I:Io...... Total ControIs.
gest more bIeeding
or capiIIary oozing in those patients under paraIdehyde narcosis. The nursing staff did not find the administration of the sedation an invoIved procedure. On the contrary, they were most enthusiastic because of the smooth postoperative convaIescence. The higher TABLE NUMBER
OF
CASES
OF
II
POSTOPERATIVE
VOMITING
/
I Total 2
Paraldehyde cases.. ControIs.
3 4
5
6
7 8
9101112
7 8 21 II 14 5 3 5 II 35 28 18,15 3241 33 16 14 16 9 II I
centage
o 8
107 243
47.8 63.3
dosage was considered more effective and more satisfactory. The unpIeasant odor of paraIdehyde was not a factor of any importance in this study in that it was not perceptibIe to anyone postoperatively and was never even noticed by the patient. On questioning, many of the oIder chiIdren acknowIedged compIete amnesia of recent events, some of them asking when the tonsiIIectomy was going to be performed.
III
Average PuIse Rate
i
1:s..
153..
307
American Journal of Surgery
Postoperative
No. of ~ Cases
104 117
I:$.. 1:8..
Before Operation
102.4 100.8
gtFi_ tion
A~~~~Pain
Earache
113.7 108.6
3
1:10..
224 384
Total. ControIs
..... 101.5
-
_!
2 ounces of paraldehyde. Within fifteen minutes, the patient Iapsed into unconsciousness with shalIow breathing, pin-point pupils and some cyanosis. The error in dosage was noted immediateIy and a mixture of oxygen-carbon dioxide administered. One-haIf hour Iater, the patient’s condition heing considered good, operation was performed without additiona anesthesia and a gangrenous appendix removed without drainage. At this time, the pulse reached a high of 160 per minute with a respiratory rate of 44 per minute. The temperature rose to IOI’F. (AI1 temperatures are rectaI.) A continuous intravenous infusion of I0 per cent glucose in norma saIt soIution was begun although there were no aIarming signs. GraduaI return of consciousness began, foIIowed by compIete recovery about twelve hours after the administration of the drug. ConvaIescence thereafter was entirely uneventfu1. UrinaIyses were entirely negative throughout.
Hanson12 described ounces of paraIdehyde
a case in which 4 were given by rec-
* From the surgica1 service of Dr. N. RothschiId.
jO8
An,crkxn
Joum11 or Surgery
Zisserman,
Cohen
turn in a singIe dose to a woman in labor instead of the desired 4 drachms. The patient made a complete recovery and renal activity was at no time affected. the WaIker13 had a simihar experience, dose given being 2 ounces each of paraldehyde and ether. There were no sequelae. The entire subject of paraldehyde poisoning has been reviewed by Katz, Roth and Ryan,‘” who concIuded that paraIdehyde is a relatively safe and effective analgesic agent and that fatal poisoning with it is rare despite frequent overdosage.
-Paraidehyde old
with
une\rentful
reco\'crJ ,
is
rcportctl. HEFEKENCES I.
2.
3. 4. 5. 6. 7.
SUMMARY 8.
Paraldehyde was used as a preoperative sedative for tonsilIectomy in children in 221 cases. Best resuIts were obtained using I C.C. of paraldehyde for every 5 pounds of body weight, mixed with an equa1 volume of tap water as a retention enema. The results were highly gratifying, the method simpIe and safe, the cost insignificant. No untoward reactions were observed. A case of accidental administration of 60 C.C. of paraldehyde by rectum to a 9 year
child,
1)l.cL \‘,1, CR,1,,,,,
9.
IO. I I.
BI~AIX, R. Avertin and pualdehyde :IS :I Ixrwl narcotic for children. Lancet, 2: 852, 1~3;. Foe-re, R. R. ParaIdehyde :IS :t prwtncsthctic. &it. .LI. J., 2: 278, ,935. ~Z’HICHAM, J. R. .$l. Paraldehydc :IS :I prc-:twsth+ tic. Hrit. ,\I. J., 2: 320, 1935. FITZWILLIAMS, II. C. L. Paraldch>dc :,s :I ,>I‘v:lnesthetic. hit. .\f. J., 2: 472, ly3j. STEWAKT, .I. D. Rectal pmxldehydr before opcmtion. Brit. XI. J., z: ,138, 1932. STALI.WOKI.HI., J. A. P;lrnldehyde basal mestht&. New Zealund .bl. J., 32: 2oj, 1933. GARRETT, R. B., :r.nd GUTTEKIDGE, E. Anesthesi:t with prcnarcosis t)y morphine and paraldrhyde. &I. J. Austruliu, 2: 46, 1933. ~~AHSTON,A. D. Use of basal narcotics in mesthcsi:b Gq’,s Hosp. Cu., 5 1 70, 193’. ROWBOTHAM, LC. S. P:~rnIdchydc narcosis. 7‘~.. Ophrh. Sot., I/n&d Kingdom, pt. I, 58: 309, 193X. ~IENDEHSOU, J. Pre:lncsthesi:i mrcosis with prxldehyde. Ann. Sup., 103: _tO, 1030. Sot KASKI, 111.Rectal pr:+ldehyde :ls :t prelimin:lr~ to tonsillcctom~in children. Brir. -21. J., 2: Q~S,
12. ‘3. WALKEK, J. Pcrsomd communicatior~. ‘4. KOTZ, J. ROTH, G. B., and RYW, \I’. A. ldiosyncr:wy to pr:~ldehydr. J. A. .I/. A., IIO: 2145, 1038.
of Anesthesia
M.D.
AND
Division, Jewish HospitaI PHILADELPHIA,
T
importance of preoperative sedation is aImost universaIIy accepted. There is, however, no unanimity as to by recta1 drug or dosage. ParaIdehyde instiIIation has been used for this purpose for many years, aImost a11 of the pubIished Iiterature emanating from abroad. Reports from Great Britain and her coIonies have been most enthusiastic. CIaims have been made that this method of sedation is (a) safe for both chiIdren and aduIts; (b) rapid and certain in action; (c) safe for use in “bad risk” patients, such as decompensated cardiacs, cachectics, and chronic nephritics; (d) offering complete amnesia with a refreshing sIeep.‘-lo In addition, the statement is repeatedIy made that there is no effect upon either circuIatory or respiratory system, aImost a11 of the drug being eIiminated unchanged through the Iungs, the remainder through the kidneys. Impressed with the vaIuable properties ascribed to paraldehyde by rectum, and especiaIIy the favorabIe report of Souraskyl’ on its use as a preliminary to tonsiIIectomy in chiIdren, we have been giving paraIdehyde by rectum routineIS since 1937 as a for tonsiIIectomy to a11 premeditation chiIdren on OtoIaryngoIogicaI Ward Service Number Three at the Jewish HospitaI. The foIIowing technique has been used. The patient is given a simpIe enema the morning of operation. One hour preoperativeIy he receives a retention enema of paraIdehyde. In the first series of 104 consecutive cases, this was used in the proportion of I C.C. for every 5 pounds of body weight. In the second series of I I 7 consecutive cases, the ratio was changed to I :8. In severa unseIected cases this was furHE
HERMAN
C:hiefof Otolaryngological
B.
FOR
COHEN, Service
M.D.
III, Jewish
I hospital
PENNSYLVANIA
ther reduced to I : IO. The Iargest dose ever used was 20 C.C. in a 12 year oId chiId. The paraIdehyde is usuaIIy mixed by simpIe agitation with an equa1 voIume of tap water and given with a soft rubber catheter and syringe at room temperature. Occasionally minera oil is substituted for the water. The enema is easiIy retained b! a11 but the youngest chiIdren who sometimes do not coiiperate. Within fifteen minutes, patients faI1 into a sound sIeep that resembIes norma slumber. AIthough they can be aroused, they are somewhat confused and faI1 off to sIeep again. Preoperative restIessness and excitement are not observed nor are there any other untoward symptoms. A11 the chiIdren in our series took anesthesia we11 (invariabIy open drop ether). After the operation, they continued to sIeep for four or five hours, a sIumber that was peaceful and much Ionger than that usuaIIy seen. If vomiting occurred, they awoke for a short spell and then promptIy returned to sIeep. Drowsiness was observed for about twelve hours. There was no hangover, proctitis, or other unpIeasant sequela. The pharyngea1 reff exes were not interfered with during operation. As a contro1, the records of a number of routine tonsillectomies performed on the same service just prior to 1937 without benefit of any premeditation were reviewed. Postoperative vomiting in the paraldehyde group was diminished both in extent and in the number of patients affected, occurring in 43.3 per cent of patients receiving paraIdehyde in the I : j ratio, 50.4 per cent of those receiving it in the I :8 ratio and 63.3 per cent of the controls.
Zisserman,
NEW SERIES VOL. L, No. 3
Cohen-ParaIdehyde
Postoperative resuturing for profuse bIeeding was required in two of the paraldehyde and two of the controI series. In a11 four instances, the additiona suturing was required about five to tweIve hours after the operation. There was nothing to sugTABLE I NUMBER
OF
CASES
BY
AGES
Age
I
Dose
The wide margin of safety present with paraIdehyde is iIIustrated by the foIIowing case report presented here through the courtesy of the attending surgeon.* R. Z., a white maIe child, g years oId, was admitted to the Jewish Hospital with a diagnosis of acute appendicitis. His temperature, p&e and respirations were IOO’F., I IO and 22 respectively. He was to have received 2 drachms of paraldehyde mixed with I ounce of water as a retention enema, but was inadvertentIy given TABLE
-
Paraldehyde Dose
I:Io...... Total ControIs.
gest more bIeeding
or capiIIary oozing in those patients under paraIdehyde narcosis. The nursing staff did not find the administration of the sedation an invoIved procedure. On the contrary, they were most enthusiastic because of the smooth postoperative convaIescence. The higher TABLE NUMBER
OF
CASES
OF
II
POSTOPERATIVE
VOMITING
/
I Total 2
Paraldehyde cases.. ControIs.
3 4
5
6
7 8
9101112
7 8 21 II 14 5 3 5 II 35 28 18,15 3241 33 16 14 16 9 II I
centage
o 8
107 243
47.8 63.3
dosage was considered more effective and more satisfactory. The unpIeasant odor of paraIdehyde was not a factor of any importance in this study in that it was not perceptibIe to anyone postoperatively and was never even noticed by the patient. On questioning, many of the oIder chiIdren acknowIedged compIete amnesia of recent events, some of them asking when the tonsiIIectomy was going to be performed.
III
Average PuIse Rate
i
1:s..
153..
307
American Journal of Surgery
Postoperative
No. of ~ Cases
104 117
I:$.. 1:8..
Before Operation
102.4 100.8
gtFi_ tion
A~~~~Pain
Earache
113.7 108.6
3
1:10..
224 384
Total. ControIs
..... 101.5
-
_!
2 ounces of paraldehyde. Within fifteen minutes, the patient Iapsed into unconsciousness with shalIow breathing, pin-point pupils and some cyanosis. The error in dosage was noted immediateIy and a mixture of oxygen-carbon dioxide administered. One-haIf hour Iater, the patient’s condition heing considered good, operation was performed without additiona anesthesia and a gangrenous appendix removed without drainage. At this time, the pulse reached a high of 160 per minute with a respiratory rate of 44 per minute. The temperature rose to IOI’F. (AI1 temperatures are rectaI.) A continuous intravenous infusion of I0 per cent glucose in norma saIt soIution was begun although there were no aIarming signs. GraduaI return of consciousness began, foIIowed by compIete recovery about twelve hours after the administration of the drug. ConvaIescence thereafter was entirely uneventfu1. UrinaIyses were entirely negative throughout.
Hanson12 described ounces of paraIdehyde
a case in which 4 were given by rec-
* From the surgica1 service of Dr. N. RothschiId.
jO8
An,crkxn
Joum11 or Surgery
Zisserman,
Cohen
turn in a singIe dose to a woman in labor instead of the desired 4 drachms. The patient made a complete recovery and renal activity was at no time affected. the WaIker13 had a simihar experience, dose given being 2 ounces each of paraldehyde and ether. There were no sequelae. The entire subject of paraldehyde poisoning has been reviewed by Katz, Roth and Ryan,‘” who concIuded that paraIdehyde is a relatively safe and effective analgesic agent and that fatal poisoning with it is rare despite frequent overdosage.
-Paraidehyde old
with
une\rentful
reco\'crJ ,
is
rcportctl. HEFEKENCES I.
2.
3. 4. 5. 6. 7.
SUMMARY 8.
Paraldehyde was used as a preoperative sedative for tonsilIectomy in children in 221 cases. Best resuIts were obtained using I C.C. of paraldehyde for every 5 pounds of body weight, mixed with an equa1 volume of tap water as a retention enema. The results were highly gratifying, the method simpIe and safe, the cost insignificant. No untoward reactions were observed. A case of accidental administration of 60 C.C. of paraldehyde by rectum to a 9 year
child,
1)l.cL \‘,1, CR,1,,,,,
9.
IO. I I.
BI~AIX, R. Avertin and pualdehyde :IS :I Ixrwl narcotic for children. Lancet, 2: 852, 1~3;. Foe-re, R. R. ParaIdehyde :IS :t prwtncsthctic. &it. .LI. J., 2: 278, ,935. ~Z’HICHAM, J. R. .$l. Paraldehydc :IS :I prc-:twsth+ tic. Hrit. ,\I. J., 2: 320, 1935. FITZWILLIAMS, II. C. L. Paraldch>dc :,s :I ,>I‘v:lnesthetic. hit. .\f. J., 2: 472, ly3j. STEWAKT, .I. D. Rectal pmxldehydr before opcmtion. Brit. XI. J., z: ,138, 1932. STALI.WOKI.HI., J. A. P;lrnldehyde basal mestht&. New Zealund .bl. J., 32: 2oj, 1933. GARRETT, R. B., :r.nd GUTTEKIDGE, E. Anesthesi:t with prcnarcosis t)y morphine and paraldrhyde. &I. J. Austruliu, 2: 46, 1933. ~~AHSTON,A. D. Use of basal narcotics in mesthcsi:b Gq’,s Hosp. Cu., 5 1 70, 193’. ROWBOTHAM, LC. S. P:~rnIdchydc narcosis. 7‘~.. Ophrh. Sot., I/n&d Kingdom, pt. I, 58: 309, 193X. ~IENDEHSOU, J. Pre:lncsthesi:i mrcosis with prxldehyde. Ann. Sup., 103: _tO, 1030. Sot KASKI, 111.Rectal pr:+ldehyde :ls :t prelimin:lr~ to tonsillcctom~in children. Brir. -21. J., 2: Q~S,
12. ‘3. WALKEK, J. Pcrsomd communicatior~. ‘4. KOTZ, J. ROTH, G. B., and RYW, \I’. A. ldiosyncr:wy to pr:~ldehydr. J. A. .I/. A., IIO: 2145, 1038.