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A RECORD NUMBER OF ANAESTHETICS?
Brit. J. Anaesth. (1970), 42, 736
A RECORD NUMBER OF ANAESTHETICS? A Case Report BY
JANE E. ANWAN SUMMARY
In the year 1968 a young girl was a patient in one of our wards almost continually. In the 3i years that she has been a patient up to the H m of preparing this report fifteen anaesthetists have anaesthetized her by various methods for a variety of procedures. It seems that this young patient may hold the record for the number of anaesthetic administrations. CASE REPORT
History. A young female born in January 1963 was first admitted into University Teaching Hospital, Ibadan, on June 7, 1965. She was then aged 2 i years. She had been ill for 6 days with fever, cough, measles, diarrhoea and vomiting. She had had convulsions for one day and was by the next day comatose; neck rigidity and positive Kernig's sign were demonstrated. A diagnosis of meningitis was made. Treatment included intravenous fluid therapy, humidified oxygen, antimalarials, chlortetracycline and atropine eye ointments, and parenteral antibiotics. She remained comatose for 21 days, after which she made a rapid recovery and was discharged on July 7, 1965. The summary of the diagnosis during this first inpatient management was as follows: (i) mental deficiency due to measles encephalitis (there was a disagreement about this diagnosis later since the girl always behaved in an intelligent manner); (ii) right panophthalmia; (iii) bronchopneumonia; (iv) gastroenteritis; (v) malaria (blood film positive for P. Falciparum). Heaf and Mantoux tests were negative and her haemoglobin was of genotype AA. On October 29, 1965, she was readmitted for enucleation of her right eye but was found to be "hoarse and almost aphonk". Consultation with an ear, nose and throat surgeon was arranged. The mother then gave a history that the child had been hoarse since her first admission in June. It was thought that the child might have a laryngeal papilloma and laryngoscopy under general anaesthesia was arranged. On November 26, 1965, laryngoscopy was performed under general anaesthesia without intubation and the
child was found to have what looked like "a classical laryngeal web of congenital origin". The surgeon had previously seen acquired webs following smallpox but those were never so symmetrical and other scars could be seen in the larynx of those cases. It was just possible that this web may have been formed from an enanthcmous measles lesion. In view of the child's size and the fact that lesion* of this type tend to re-form, it was advised that operation be postponed for a year or two, by which time her greater activity would probably require a larger laryngeal airway. It was suggested that a tracheostomy be done for the purpose of anaesthetizing the patient for the enucleation, since an attempt to intubate the larynx might have been catastrophic. In fact the enucleation was not performed until much later and the operations on her larynx were started much earlier than anticipated. Her first anaesthetic (for laryngoscopy) was on November 26, 1965. On December 22, 1965 (26 days later), a second anaesthetic was given for laryngoscopy and excision of web, uiis being necessary because of respiratory difficulty. Since then she has been continually in the hospital. Her anaesthetic and surgical managements were analyzed for the 3-year period November 26, 1965, to November 20, 1968, during which time she had 94 general anaesthetics. Procedures. By far the commonest procedure was laryngoscopy. Others included granulectomy, laryngeal dilatation, intubation and bronchoscopy (table I; fig. 1). TABLE I
Procedure Laryngoscopy Laryngoscopy „ „ „ Laryngofissure Others JANE
E.
AKWAN,
No. of times alone and granulectomy „ dilatation „ intubation „ bronchoscopy
M J . , CH.B., D.T.MJL,
51 10 14 10 3 5 1 F.F.AJ*X.S.I..
Department of Anaesthesia, University of Ibadan and University College Hospital, Ibadan, Nigeria.
Downloaded from http://bja.oxfordjournals.org/ at UB der TU Muenchen on July 9, 2015
A 6-year-old female patient was first admitted at the age of 2£ years with complicated measles. One of the long-term complications was a laryngeal web for which 94 (since extended to 101) general anaesthetics were required for procedures such as laryngoscopy, granulectomy, laryngeal dilatations. Halothane was used more frequently than other anaesthetic agents.
A RECORD NUMBER OF ANAESTHETICS? She underwent five operations for laryngofissure and eventually enucleation of the right eye was performed. Her first tracheostomv was carried out on Tune 19, 1966.
737 TABLE
111
Up to and including (min) 15 30 45 60 75 90 Over 90 Number of anaesthetics
15 37
7
Number for which time is known Number for which time is not known Total number of general anaesthetics Total exposure time
4
2
1
1
67 27 94 2^35 min 37 hours 15 min 10 min 105 min
Shortest time of exposure Longest time of exposure
4O-i
Downloaded from http://bja.oxfordjournals.org/ at UB der TU Muenchen on July 9, 2015
8 3O|
« 20IOFIG. 1 Patient intubated with Jackson-Rees nasotracheal tube.
—i—
15
45
"T
1—
9O+
75
Duration (min) FIG. 2 Number of anaesthetics plotted against duration of anaesthesia.
Anaesthetic agents. Oxygen was used in all and nitrous oxide in all except one of the anaesthetics. Of other agents halothane was the most commonly used, given either alone or with another agent (table II). TABLE
With halothane
Halothane and another
72
10
I2-,
II
Without halothane
Agents not specified IO-
Oxygen was used on all occasions. Nitrous oxide was used on all except one occasion. Duration of anaesthesia. This was noted on the records of 67 of the 94 anaesthetics (table III; fig. 2). In 37 instances anaesthesia lasted 16-30 minutes. The shortest anaesthetic lasted 10 minutes and the longest 105 minutes. Total time of exposure to anaesthetics was 37 hours 15 minutes, as obtained from the 67 completed records. Frequency of anaesthesia. The period of 3 years was divided into 3-month periods to ascertain the stage during treatment when she had been anaesthetized most frequently. The TT"»T'T"""T frequency of anaesthetic administration occurred during the 3rd and 6th quarters inclusive after which time there was a gradual fall to monthly visits (fig. 3). The intervals between anaesthetics were also examined to show the shortest interval and the longest interval between the anaesthetics in each quarter (table IV). The average length of interval between episodes decreased until the 5th quarter and then increased.
6-
E
42-
8
IO
12
Time in quarter* FIG. 3 Number of general anaesthetics plotted against time in quarters.
BRITISH JOURNAL OF ANAESTHESIA
738 TABLE IV
TABLE VII
Analysis for intervals between general anaesthesia. Quarters Total No. Shortest interval (days) Longest Average
Specimen: Blood Clinical diagnosis: ? Liver dysfunction 9 10 11 12 Date reported: 9.5.68 6 4 6 5 Date sent: 7.5.68 Bilirubin total 0.2 mg/100 ml Phosphatase alkaline 16 K-A units/100 ml turbidity 1 unit 2 1 2 5 1 1 5 7 19 1 12 Thymol Thymol flocculation negative 19 35 21 14 16 28 35 19 37 41 28 S.GO.T. 27 Cabaud units/ml 8 8 8 7 9 13 14 12 26 16 18 S G P T 11 Cholesterol total 148 mg/100 ml " Proteins total 6.3 g/100 ml Albumin 4.1 „ „ DISCUSSION Globulin 2.2 „ ,, sheer number of anaesthetics it Specimen of urine: Bile salts negative 2 3 4 5 6 8 10 12 11 11
i 40 11
TABLE V
Specimen: Urine
Clinical diagnosis:
Liver dysfunction Date sent: 25.1.68 Date reported: 29.1.68 Negative Hay's test Bile salts not detected Bilirubin negative Urobilinogen present in normal quantity Urobilin negative TABLE VI
Specimen: Blood
Clinical diagnosis: ? Liver dysfunction Date sent: 12.2.68 Date reported: 14.2.68 Total serum bilirubin 0.4 mg/100 ml Alkaline phosphatase 18 K-A units S.G.O.T. 43 Cabaud units/ml S.GP.T. 13 Thymol turbidity 3 units Thymol flocculation negative
units/ml). This blood sample was taken 12 days after an operation. S.g.o.t. was always in the upper range of normal in other reports (e.g., table VII) and unrelated to recent operation but s.g.p.t. was never raised. The patient herself remained remarkably bright and cheerful all through her long stay in hospital (fig. 4). Search of the literature failed to reveal any report of a patient having received anything like the number of anaesthetics given to our patient. One article was found in which 42 episodes of halothane anaesthesia were reported to have been used, probably over a limited period of time (Bolcie-Wikerhauser, 1966). In view of the possible association of halothane with liver necrosis, it was felt to be of interest to report the present case. This child has had numerous anaesthetics and is likely to need more. Halothane has been used repeatedly on her and she has suffered no appreciable ill effect. ADDENDUM Since the preparation of the material of this report the patient has bren anaesthetized on 7 more occasions (between December 18, 1968, and October 8, 1969). Halothane was used for each anaesthetic. Liver function tests were repeated on July 23, 1969 (7 days after an episode of anaesthesia and operation). S.g.o.t. on this occasion was 16 Cabaud units/ml and the s.g.p.t. 8 Cabaud units/ml. Other functions of the liver were also within normal range. The child remained in good general health. The final summary up to Octob:r 8, 1969, therefore is as follows: Total number of general anaesthetics 101 Number for which duration was recorded 69 Total recorded exposure time (min) 2280 Shortest anaesthetic (min) 10 Longest anaesthetic (min) 105 Number of anaesthetics including halothane 89 Number of anaesthetics without halothane 3 Agents unspecified 9
Downloaded from http://bja.oxfordjournals.org/ at UB der TU Muenchen on July 9, 2015
Apart from the is also noteworthy that halothane was used predominantly. Obviously this child does not fall among the unlucky 1 in 100,000 who are "sensitive" to halothane (Rollason, 1964), but it is conceivable that with repetition of anaesthesia on this scale a more toxic agent might have induced some constitutional disorder, in this case perhaps liver dysfunction. For this reason liver function was tested at intervals and, so far, there has been no indication of hepatocellular damage. Serum glutamic pyruvic transaminase (s.g.p.t.) has been shown to be the most sensitive test for hepatocellular damage (Wroblewski and La Due, 1956). It has even been thought that the s.g.p.t. level can be used as a rough quantitative index of liver damage (Zelman and Wang, 1959) and this was never found to be elevated (normal value 525 Cabaud units/ml). Table V shows the results of urine examination. On February 12,1968 (table VI) the s.g.o.t. was 43 units (normal value 5-35
A RECORD NUMBER OF ANAESTHETICS?
739 th: Medical Librarian, and her staff went to great trouble to gather the bibliography that I needed and Professor L. M. Beckham, then of the Department of Anaesthesia, University of Ibadan, with great patience, obtained photographs of the patient, REFERENCES
Bolcic-Wikerhauser. J. (1966). Multiple halothane anaesthesia. Brit. J. Anaesth., 38, 228. Rollason, W. N. (1964). Chloroform, halothane and hepatotoxicity. PTOC. roy. Soc. Med., 57, 307.
U N RECORD D A N S LE NOMBRE D'ANESTHESIES? DESCRIPTION D*UN CAS SOMMAIRE
Un enfant feminin, &g6 de 6 ans, avait tti hospitalise pour la premiere fois a l'Sge de 2$ ans pour une rougeole compliquee. Une des complications e'tait la formation d'une membrane laryngeale; il a fallu 94 (maintenant deja 101) anesthesies gtoc'rales pour des interventions, telles que laryngoscopie, granulectomie, dilatation du larynx. L'halothane a e t i utilis6 plus fr6quemment que d'autres anesthesiques. HOCHSTZAHL VON ANAESTHESIEN? EIN FALLBERICHT ZUSAMMENFASSUNG
4 Patient was generally happy and settled in hospital— though camera-shy 1 FIG.
ACKNOWLEDGEMENTS
I thank Professor F. D . Martinson of the Ear, Nose and Throat Department for allowing me to study this case and for all help rendered. Mrs M. Amosu,
Ein 6 Jahre alter, weiblicher Patient wurde zuerst im Alter von 2\ Jahren wegen komplizierter Masem aufgenommen. Eine der Langzeitkomplikationen war ein Larynxmembran, fiir die 94 (in der Zwischenzeit 101) Vollnarkosen notwendig wurden, wobei Mafinahmen wie Laryngoskopie, Granulektomie und Larynxdilatationen notwendig wurden. Halothan wurde am haufigsten von alien benutzten Anaestheticis angewendeL
NORFOLK AND NORWICH INSTITUTE FOR MEDICAL EDUCATION A SYMPOSIUM ON PAEDIATRIC ANAESTHESIA AND INTENSIVE CARE
will be held at Norwich on Saturday, October 24, 1970. Speakers: Dr T. B. Boulton, Dr J. N. Lunn, Dr D. Gairdner, Dr G. H. Bush and Dr W. J. Glover. Details from the Secretary, Norfolk and Norwich Institute for Medical Education, Norfolk and Norwich Hospital, Norwich NOR 53A.
Downloaded from http://bja.oxfordjournals.org/ at UB der TU Muenchen on July 9, 2015
Wroblewski, F., and La Due, J. S. (1956). Serum glutamic pyruvic transaminase (SGP-T) in hepatic disease: a preliminary report Ann. intern. Med., 45, 801. Zelman, S., and Wang, C. C (1959). Transaminases in serum and liver correlated with liver cell necrosis in needle aspiration biopsies. Amer. J. med Sci., 237, 323.
A RECORD NUMBER OF ANAESTHETICS? A Case Report BY
JANE E. ANWAN SUMMARY
In the year 1968 a young girl was a patient in one of our wards almost continually. In the 3i years that she has been a patient up to the H m of preparing this report fifteen anaesthetists have anaesthetized her by various methods for a variety of procedures. It seems that this young patient may hold the record for the number of anaesthetic administrations. CASE REPORT
History. A young female born in January 1963 was first admitted into University Teaching Hospital, Ibadan, on June 7, 1965. She was then aged 2 i years. She had been ill for 6 days with fever, cough, measles, diarrhoea and vomiting. She had had convulsions for one day and was by the next day comatose; neck rigidity and positive Kernig's sign were demonstrated. A diagnosis of meningitis was made. Treatment included intravenous fluid therapy, humidified oxygen, antimalarials, chlortetracycline and atropine eye ointments, and parenteral antibiotics. She remained comatose for 21 days, after which she made a rapid recovery and was discharged on July 7, 1965. The summary of the diagnosis during this first inpatient management was as follows: (i) mental deficiency due to measles encephalitis (there was a disagreement about this diagnosis later since the girl always behaved in an intelligent manner); (ii) right panophthalmia; (iii) bronchopneumonia; (iv) gastroenteritis; (v) malaria (blood film positive for P. Falciparum). Heaf and Mantoux tests were negative and her haemoglobin was of genotype AA. On October 29, 1965, she was readmitted for enucleation of her right eye but was found to be "hoarse and almost aphonk". Consultation with an ear, nose and throat surgeon was arranged. The mother then gave a history that the child had been hoarse since her first admission in June. It was thought that the child might have a laryngeal papilloma and laryngoscopy under general anaesthesia was arranged. On November 26, 1965, laryngoscopy was performed under general anaesthesia without intubation and the
child was found to have what looked like "a classical laryngeal web of congenital origin". The surgeon had previously seen acquired webs following smallpox but those were never so symmetrical and other scars could be seen in the larynx of those cases. It was just possible that this web may have been formed from an enanthcmous measles lesion. In view of the child's size and the fact that lesion* of this type tend to re-form, it was advised that operation be postponed for a year or two, by which time her greater activity would probably require a larger laryngeal airway. It was suggested that a tracheostomy be done for the purpose of anaesthetizing the patient for the enucleation, since an attempt to intubate the larynx might have been catastrophic. In fact the enucleation was not performed until much later and the operations on her larynx were started much earlier than anticipated. Her first anaesthetic (for laryngoscopy) was on November 26, 1965. On December 22, 1965 (26 days later), a second anaesthetic was given for laryngoscopy and excision of web, uiis being necessary because of respiratory difficulty. Since then she has been continually in the hospital. Her anaesthetic and surgical managements were analyzed for the 3-year period November 26, 1965, to November 20, 1968, during which time she had 94 general anaesthetics. Procedures. By far the commonest procedure was laryngoscopy. Others included granulectomy, laryngeal dilatation, intubation and bronchoscopy (table I; fig. 1). TABLE I
Procedure Laryngoscopy Laryngoscopy „ „ „ Laryngofissure Others JANE
E.
AKWAN,
No. of times alone and granulectomy „ dilatation „ intubation „ bronchoscopy
M J . , CH.B., D.T.MJL,
51 10 14 10 3 5 1 F.F.AJ*X.S.I..
Department of Anaesthesia, University of Ibadan and University College Hospital, Ibadan, Nigeria.
Downloaded from http://bja.oxfordjournals.org/ at UB der TU Muenchen on July 9, 2015
A 6-year-old female patient was first admitted at the age of 2£ years with complicated measles. One of the long-term complications was a laryngeal web for which 94 (since extended to 101) general anaesthetics were required for procedures such as laryngoscopy, granulectomy, laryngeal dilatations. Halothane was used more frequently than other anaesthetic agents.
A RECORD NUMBER OF ANAESTHETICS? She underwent five operations for laryngofissure and eventually enucleation of the right eye was performed. Her first tracheostomv was carried out on Tune 19, 1966.
737 TABLE
111
Up to and including (min) 15 30 45 60 75 90 Over 90 Number of anaesthetics
15 37
7
Number for which time is known Number for which time is not known Total number of general anaesthetics Total exposure time
4
2
1
1
67 27 94 2^35 min 37 hours 15 min 10 min 105 min
Shortest time of exposure Longest time of exposure
4O-i
Downloaded from http://bja.oxfordjournals.org/ at UB der TU Muenchen on July 9, 2015
8 3O|
« 20IOFIG. 1 Patient intubated with Jackson-Rees nasotracheal tube.
—i—
15
45
"T
1—
9O+
75
Duration (min) FIG. 2 Number of anaesthetics plotted against duration of anaesthesia.
Anaesthetic agents. Oxygen was used in all and nitrous oxide in all except one of the anaesthetics. Of other agents halothane was the most commonly used, given either alone or with another agent (table II). TABLE
With halothane
Halothane and another
72
10
I2-,
II
Without halothane
Agents not specified IO-
Oxygen was used on all occasions. Nitrous oxide was used on all except one occasion. Duration of anaesthesia. This was noted on the records of 67 of the 94 anaesthetics (table III; fig. 2). In 37 instances anaesthesia lasted 16-30 minutes. The shortest anaesthetic lasted 10 minutes and the longest 105 minutes. Total time of exposure to anaesthetics was 37 hours 15 minutes, as obtained from the 67 completed records. Frequency of anaesthesia. The period of 3 years was divided into 3-month periods to ascertain the stage during treatment when she had been anaesthetized most frequently. The TT"»T'T"""T frequency of anaesthetic administration occurred during the 3rd and 6th quarters inclusive after which time there was a gradual fall to monthly visits (fig. 3). The intervals between anaesthetics were also examined to show the shortest interval and the longest interval between the anaesthetics in each quarter (table IV). The average length of interval between episodes decreased until the 5th quarter and then increased.
6-
E
42-
8
IO
12
Time in quarter* FIG. 3 Number of general anaesthetics plotted against time in quarters.
BRITISH JOURNAL OF ANAESTHESIA
738 TABLE IV
TABLE VII
Analysis for intervals between general anaesthesia. Quarters Total No. Shortest interval (days) Longest Average
Specimen: Blood Clinical diagnosis: ? Liver dysfunction 9 10 11 12 Date reported: 9.5.68 6 4 6 5 Date sent: 7.5.68 Bilirubin total 0.2 mg/100 ml Phosphatase alkaline 16 K-A units/100 ml turbidity 1 unit 2 1 2 5 1 1 5 7 19 1 12 Thymol Thymol flocculation negative 19 35 21 14 16 28 35 19 37 41 28 S.GO.T. 27 Cabaud units/ml 8 8 8 7 9 13 14 12 26 16 18 S G P T 11 Cholesterol total 148 mg/100 ml " Proteins total 6.3 g/100 ml Albumin 4.1 „ „ DISCUSSION Globulin 2.2 „ ,, sheer number of anaesthetics it Specimen of urine: Bile salts negative 2 3 4 5 6 8 10 12 11 11
i 40 11
TABLE V
Specimen: Urine
Clinical diagnosis:
Liver dysfunction Date sent: 25.1.68 Date reported: 29.1.68 Negative Hay's test Bile salts not detected Bilirubin negative Urobilinogen present in normal quantity Urobilin negative TABLE VI
Specimen: Blood
Clinical diagnosis: ? Liver dysfunction Date sent: 12.2.68 Date reported: 14.2.68 Total serum bilirubin 0.4 mg/100 ml Alkaline phosphatase 18 K-A units S.G.O.T. 43 Cabaud units/ml S.GP.T. 13 Thymol turbidity 3 units Thymol flocculation negative
units/ml). This blood sample was taken 12 days after an operation. S.g.o.t. was always in the upper range of normal in other reports (e.g., table VII) and unrelated to recent operation but s.g.p.t. was never raised. The patient herself remained remarkably bright and cheerful all through her long stay in hospital (fig. 4). Search of the literature failed to reveal any report of a patient having received anything like the number of anaesthetics given to our patient. One article was found in which 42 episodes of halothane anaesthesia were reported to have been used, probably over a limited period of time (Bolcie-Wikerhauser, 1966). In view of the possible association of halothane with liver necrosis, it was felt to be of interest to report the present case. This child has had numerous anaesthetics and is likely to need more. Halothane has been used repeatedly on her and she has suffered no appreciable ill effect. ADDENDUM Since the preparation of the material of this report the patient has bren anaesthetized on 7 more occasions (between December 18, 1968, and October 8, 1969). Halothane was used for each anaesthetic. Liver function tests were repeated on July 23, 1969 (7 days after an episode of anaesthesia and operation). S.g.o.t. on this occasion was 16 Cabaud units/ml and the s.g.p.t. 8 Cabaud units/ml. Other functions of the liver were also within normal range. The child remained in good general health. The final summary up to Octob:r 8, 1969, therefore is as follows: Total number of general anaesthetics 101 Number for which duration was recorded 69 Total recorded exposure time (min) 2280 Shortest anaesthetic (min) 10 Longest anaesthetic (min) 105 Number of anaesthetics including halothane 89 Number of anaesthetics without halothane 3 Agents unspecified 9
Downloaded from http://bja.oxfordjournals.org/ at UB der TU Muenchen on July 9, 2015
Apart from the is also noteworthy that halothane was used predominantly. Obviously this child does not fall among the unlucky 1 in 100,000 who are "sensitive" to halothane (Rollason, 1964), but it is conceivable that with repetition of anaesthesia on this scale a more toxic agent might have induced some constitutional disorder, in this case perhaps liver dysfunction. For this reason liver function was tested at intervals and, so far, there has been no indication of hepatocellular damage. Serum glutamic pyruvic transaminase (s.g.p.t.) has been shown to be the most sensitive test for hepatocellular damage (Wroblewski and La Due, 1956). It has even been thought that the s.g.p.t. level can be used as a rough quantitative index of liver damage (Zelman and Wang, 1959) and this was never found to be elevated (normal value 525 Cabaud units/ml). Table V shows the results of urine examination. On February 12,1968 (table VI) the s.g.o.t. was 43 units (normal value 5-35
A RECORD NUMBER OF ANAESTHETICS?
739 th: Medical Librarian, and her staff went to great trouble to gather the bibliography that I needed and Professor L. M. Beckham, then of the Department of Anaesthesia, University of Ibadan, with great patience, obtained photographs of the patient, REFERENCES
Bolcic-Wikerhauser. J. (1966). Multiple halothane anaesthesia. Brit. J. Anaesth., 38, 228. Rollason, W. N. (1964). Chloroform, halothane and hepatotoxicity. PTOC. roy. Soc. Med., 57, 307.
U N RECORD D A N S LE NOMBRE D'ANESTHESIES? DESCRIPTION D*UN CAS SOMMAIRE
Un enfant feminin, &g6 de 6 ans, avait tti hospitalise pour la premiere fois a l'Sge de 2$ ans pour une rougeole compliquee. Une des complications e'tait la formation d'une membrane laryngeale; il a fallu 94 (maintenant deja 101) anesthesies gtoc'rales pour des interventions, telles que laryngoscopie, granulectomie, dilatation du larynx. L'halothane a e t i utilis6 plus fr6quemment que d'autres anesthesiques. HOCHSTZAHL VON ANAESTHESIEN? EIN FALLBERICHT ZUSAMMENFASSUNG
4 Patient was generally happy and settled in hospital— though camera-shy 1 FIG.
ACKNOWLEDGEMENTS
I thank Professor F. D . Martinson of the Ear, Nose and Throat Department for allowing me to study this case and for all help rendered. Mrs M. Amosu,
Ein 6 Jahre alter, weiblicher Patient wurde zuerst im Alter von 2\ Jahren wegen komplizierter Masem aufgenommen. Eine der Langzeitkomplikationen war ein Larynxmembran, fiir die 94 (in der Zwischenzeit 101) Vollnarkosen notwendig wurden, wobei Mafinahmen wie Laryngoskopie, Granulektomie und Larynxdilatationen notwendig wurden. Halothan wurde am haufigsten von alien benutzten Anaestheticis angewendeL
NORFOLK AND NORWICH INSTITUTE FOR MEDICAL EDUCATION A SYMPOSIUM ON PAEDIATRIC ANAESTHESIA AND INTENSIVE CARE
will be held at Norwich on Saturday, October 24, 1970. Speakers: Dr T. B. Boulton, Dr J. N. Lunn, Dr D. Gairdner, Dr G. H. Bush and Dr W. J. Glover. Details from the Secretary, Norfolk and Norwich Institute for Medical Education, Norfolk and Norwich Hospital, Norwich NOR 53A.
Downloaded from http://bja.oxfordjournals.org/ at UB der TU Muenchen on July 9, 2015
Wroblewski, F., and La Due, J. S. (1956). Serum glutamic pyruvic transaminase (SGP-T) in hepatic disease: a preliminary report Ann. intern. Med., 45, 801. Zelman, S., and Wang, C. C (1959). Transaminases in serum and liver correlated with liver cell necrosis in needle aspiration biopsies. Amer. J. med Sci., 237, 323.