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ACUTE REACTIOMS TO PHENOTHIAZINE DERIVATIVES
CORRESPONDENCE
539
AN ADDITIONAL HAZARD OF CAVAL OCCLUSION
J.
SELWYN CRAWFORD
Birmingham A METHOD FOR CATHETERIZING SMALL BLOOD VESSELS WITHOUT OCCLUDING THEIR LUMINA
Sir,—When a small blood vessel is catheterized, the vascular lumen is usually obliterated by at least two ligatures, one above and one below the point at which the catheter enters the vessel. For most purposes this is quite acceptable, but at times it is necessary to maintain blood flow through the catheterized vessel, for example, when the blood flow itself is to be measured by an indicator dilution method. This applies particularly to flow measurements in small experimental animals in which the major blood vessels, such as the pulmonary artery, are relatively narrow and cannot always be catheterized through a branch vessel. This method is based on the use of an external guide, and was devised to simplify the introduction of nylon catheters, with a thermistor at the tip (Branthwaite and Bradley, 1968) into the jugular veins and venae cavae of small experimental animals. Seldinger's technique (Seldinger, 1953) cannot be used because the thermistor sealed into the end prevents the use of an internal guide wire.
FIG. 1. The needle on the end of a plain nylon catheter.
The external guide-needle is shown in figure 1. Its precise dimensions can be varied to suit its application: the one in the figure is made from two 1-cm lengths of stainless steel tubing, outside diameters 0.930 mm and 0.431 mm, silver-soldered together and the joint tapered smoothly. The catheter is fitted into the end of the needle which is then pushed through the exposed vessel wall into the lumen and out again, taking the catheter with it. The needle is removed, the catheter carefully withdrawn until its end re-enters the vessel and then advanced for an appropriate distance and secured with a fine (6/0) atraumatic surgical suture. The method has, so far, been used only to place catheters in the jugular veins of guineapigs and rabbits, but it may be of value in other situations where the vessel lumen must be preserved or where internal guides cannot be used. Nylon catheters have remained in the blood vessel for periods of 3 days without occlusion of the vessel; examination subsequently showed only a small mural thrombus around the point of entry, and clotting on the nylon catheters. With less thrombogenic plastic, this could probably be minimized, thus reducing the chance of permanent occlusion. I am grateful to Mr G. Clements for making the needles, and to Mr J. R. Hunter for the photograph. D.
A.
RUTTER
Porton REFERENCES
Branthwaite, M. A., and Bradley, R. D. (1968). Measurement of cardiac output by thermal dilution in man. J. appl. Physiol, 24, 434. Seldinger, S. I. (1953). Catheter replacement of the needle in percutaneous arteriography. Ada radiol. (StockhX 39, 368. ACUTE REACTIONS TO PHENOTHIAZINE DERIVATIVES
Sir,—Acute reactions to phenothiazine derivatives are not so rare as was first thought. Physicians working in a Regional Tetanus Centre often encounter acute phenothiazine dystonia (Mandal and Sengupta, 1972) following a single dose of perphenazine compound. This presentation as suspected tetanus is apparently a common enough experience. The following incident may be of considerable interest to anaesthetists. Recently, I anaesthetized a patient for a minor operation. Preoperatively, she indicated that she had vomited extensively following previous anaesthetics. In order to minimize postoperative vomiting, prochlorperazine (Stemetil) 12.5 mg was prescribed postopera lively. Following the operation, she received four doses in the next 18 hours to ameliorate her vomiting and then enjoyed lunch and tea. Later that evening the nursing staff contacted me, indicating that the patient was having severe pains in the jaw and throat with evidence of spasmodic contractions involving the mouth; she was also having difficulty in swallowing. They in fact thought trismus was present. Slightly puzzled, I examined the patient and excluded any possibility of tetanus. The nursing staff gave me some reassurance, in that one of their number had seen a similar reaction in a small child receiving large doses of perphenazine (Fentazin). To control what appeared to be fairly severe muscle spasms, diazepam was administered and a hypnotic pentobarbitone sodium given. After a good night's sleep, the patient felt perfectly fit the next morning, but still complained that she felt as if she had received a severe blow on the right side of the jaw. She was discharged later on that day with no further complications. As suggested by Dr Mandal and Dr Sengupta, adequate knowledge of prior immunization, scrupulous enquiry
Downloaded from http://bja.oxfordjournals.org/ at University of Manitoba on June 9, 2015
Sir,—I wish to draw the attention of your readers to a further danger which, I believe, is likely to be associated with failure laterally to tilt a patient during general anaesthesia for operative obstetrics: here it is the mother, and not primarily the infant (see p. 477) who is most at risk. Recently there have been reports^—verbally received or appearing in the course of publications—of patients who have died during, or shortly after, "a difficult intubation". Doubtless we would all agree that death should very rarely occur merely as a result of the anaesthetist's finding it difficult to pass an endotracheal tube. Most of us would admit to having encountered difficulty during attempted intubation not infrequently in the course of our professional lives. The brief period of asphyxia which undoubtedly occurs during such an episode appears rarely to be highly injurious to the patient, except in the case of the desperately ill, and is probably rendered potentially less harmful by appropriately employed preoxygenation. However, a patient in the final trimester of pregnancy who lies supine is likely to have her cardiac output reduced by up to 50 per cent. I would conjecture that under this circumstance a relatively brief period of asphyxia is likely to be of much more ominous import. The combination of reduced cardiac output and asphyxia must surely more rapidly lead to irreversible brain damage or to sudden death than does asphyxia alone. I would therefore urge that this is an additional important reason for employing a lateral tilt in all obstetric patients from, at the latest, the time immediately before induction of anaesthesia.
540
BRITISH JOURNAL OF ANAESTHESIA
regarding the administration of anti-emetic drugs of the phenothiazine group and a diagnostic test employing intravenous benztropine would spare the patient and his relatives from acute anxiety. STEWART LAMONT
Leeds REFERENCE
Mandal, B. K., and Sengupta, P. (1972). Correspondence. Brit. med. J., 1, 441. THE FOETAL AND MATERNAL PHARMACOLOGY OF SOME OF THE DRUGS USED FOR THE RELIEF OF PAIN IN LABOUR
ROBERT G. TWYCROSS
London REFERENCE
Scott, M. E., and Orr, R. (1969). Effects of diamorphine, methadone, morphine and pentazocine in patients with suspected acute myocardial infarction. Lancet, 1, 1065. Sir,—Thank you for allowing me the opportunity of replying to the letter from Dr Twycross. My paper, and the reference to the work by MacDonald et al. (1967), discussed the cardiovascular effects of diamorphine. To describe the work by MacDonald and his colleagues as "uncontrolled" is inaccurate because the authors took half a page to detail the manner in which they controlled the circumstances of their study. However, Dr Twycross appears to believe that the word "controlled" is synonymous with "comparative" and he dismissed the study because no comparator drug was included. This suggests that he also ignores the other studies with morphine (Thomas et al., 1965) pethidine (Rees et al., 1967) and pentazocine (Scott and Adgey, 1971; Jewitt, Maurer and Hubner, 1970), although all the assessments involved similar sensitive and accurate objective measurements. The various authors themselves have felt that the findings from the studies are valid and they have drawn comparisons from the data obtained. While the double-blind method is essential in all investigations involving subjective assessment or the measurement of subjective phenomena, it is only one of the many factors that need to be considered in a clinical investigation, and it cannot by itself "control" the study. The article by Cromie (1963) emphasizes the relevance and impor-
R. A. P. BURT
Surbiton-upon-Thames REFERENCES
Cromie, B. W. (1963). The feet of clay of the double-blind trial. Lancet, 2, 994. Jewitt, D. E., Maurer, B. J., and Hubner, P. J. B. (1970). Increased pulmonary arterial pressure after pentazocine in myocardial infarction. Brit. med. J., 1, 795. Loan, W. B., Morrison, J. D., Dundee, J. W., Clarke, R. S. J., Hamilton, R. C , and Brown, S. S. (1969). Studies of drugs given before anaesthesia. XVII: The natural and semi-synthetic opiates. Brit. J. Anaesth., 41, 57. MacDonald, H. R., Rees, H. A., Muir, A. L., Lawrie, D. M., Burton, J. L., and Donald, K. W. (1967). Circulatory effects of heroin in patients with myocardial infarction. Lancet, 1, 1070. Rees, H. A., Muir, A. L., MacDonald, H. R., Lawrie, D. M., Burton, J. L., and Donald, K. W. (1967). Circulatory effects of pethidine in patients with acute myocardial infarction. Lancet, 2, 863. Scott, M. E., and Adgey, A. A. J. (1971). Circulatory effects of intravenous pentazocine in patients with acute myocardial infarction. Curr. Ther. Res., 13, 81. Thomas, M., Malmcrona, R., Fillmore, S., and Shillingford, J. (1965). Haemodynamic effects of morphine in patients with acute myocardial infarction. Brit. Heart J., 27, 863. ADRENALINE INFILTRATION DURING HALOTHANE ANAESTHESIA
Sir,—In the correspondence section of the February 1972 number of the British Journal of Anaesthesia (p. 234), Dr John G. Brock-Utne comes to the conclusion that the infiltration of a small dose of adrenaline during halothane anaesthesia carries little risk. Though this may be true, Dr Brock-Utne's experiments are by no means conclusive as no electrocardiographic tracings were recorded. Several authors point out that all kind of arrhythmias can occur that cannot be detected by pulse and auscultation alone but need electrocardiographic monitoring and recording to be discovered. A. F. WEHLBURG
Apeldoorn, Holland
REFERENCES
Haldeman, G., and Schaer, H. (1972). Haemodynamic effects of transient atrioventricular dissociation in general anaesthesia. Brit. J. Anaesth., 44, 159. Katz, R. L., and Bigger, J, Th. (1970). Cardiac arrhythmias during anesthesia and operation. Anesthesiology, 33, 199. Wallbank, W. A. (1970). Cardiac effects of halothane and adrenaline in hare lip and cleft palate surgery. Brit. J. Anaesth., 42, 548.
Printed in Great Britain by John Sherratt & Son Ltd, Park Road. Altrincham, Cheshire, W A 1 4 5QQ
Downloaded from http://bja.oxfordjournals.org/ at University of Manitoba on June 9, 2015
Sir,—I was interested to read in the article by R. A. P. Burt (.Bin. J. Anaesth., 43, 824, Sept. 1971) that diamorphine "has less effect on the cardiovascular system (MacDonald, 1967)" than morphine. I would like to point out that the study referred to by Dr Burt was not a controlled trial. Indeed all the patients in that study received diamorphine: none morphine. More recently a double-blind trial comparing diamorphine, morphine, methadone and pentazocine in patients with suspected acute myocardial infarction has been published (Scott and Orr, 1969). These authors found no significant difference between diamorphine and morphine apart from the well-known fact that the action of diamorphine occurs earlier than that of morphine. As many people feel that diamorphine ought not to be used in medical practice it is regrettable that an unsubstantiated statement alleging the superiority of diamorphine over morphine should appear in your columns.
tance, as well as the applications and limitations, of the double-blind technique. The comment that the findings by MacDonald et al. are "unsubstantiated" is also incorrect, as the authors denned the limits of accuracy of their measurements. Even if Dr Twycross was, in fact, asking for corroboration of these findings, he will find this in this journal (Loan et al., 1969) and this from a double-blind comparative study at that. Finally, I wonder whether the last comment by Dr Twycross that "many people feel that diamorphine ought not to be used in medical practice" is based on the findings of a double-blind comparative study, as I notice he offers no substantiation or corroboration for his statement.
539
AN ADDITIONAL HAZARD OF CAVAL OCCLUSION
J.
SELWYN CRAWFORD
Birmingham A METHOD FOR CATHETERIZING SMALL BLOOD VESSELS WITHOUT OCCLUDING THEIR LUMINA
Sir,—When a small blood vessel is catheterized, the vascular lumen is usually obliterated by at least two ligatures, one above and one below the point at which the catheter enters the vessel. For most purposes this is quite acceptable, but at times it is necessary to maintain blood flow through the catheterized vessel, for example, when the blood flow itself is to be measured by an indicator dilution method. This applies particularly to flow measurements in small experimental animals in which the major blood vessels, such as the pulmonary artery, are relatively narrow and cannot always be catheterized through a branch vessel. This method is based on the use of an external guide, and was devised to simplify the introduction of nylon catheters, with a thermistor at the tip (Branthwaite and Bradley, 1968) into the jugular veins and venae cavae of small experimental animals. Seldinger's technique (Seldinger, 1953) cannot be used because the thermistor sealed into the end prevents the use of an internal guide wire.
FIG. 1. The needle on the end of a plain nylon catheter.
The external guide-needle is shown in figure 1. Its precise dimensions can be varied to suit its application: the one in the figure is made from two 1-cm lengths of stainless steel tubing, outside diameters 0.930 mm and 0.431 mm, silver-soldered together and the joint tapered smoothly. The catheter is fitted into the end of the needle which is then pushed through the exposed vessel wall into the lumen and out again, taking the catheter with it. The needle is removed, the catheter carefully withdrawn until its end re-enters the vessel and then advanced for an appropriate distance and secured with a fine (6/0) atraumatic surgical suture. The method has, so far, been used only to place catheters in the jugular veins of guineapigs and rabbits, but it may be of value in other situations where the vessel lumen must be preserved or where internal guides cannot be used. Nylon catheters have remained in the blood vessel for periods of 3 days without occlusion of the vessel; examination subsequently showed only a small mural thrombus around the point of entry, and clotting on the nylon catheters. With less thrombogenic plastic, this could probably be minimized, thus reducing the chance of permanent occlusion. I am grateful to Mr G. Clements for making the needles, and to Mr J. R. Hunter for the photograph. D.
A.
RUTTER
Porton REFERENCES
Branthwaite, M. A., and Bradley, R. D. (1968). Measurement of cardiac output by thermal dilution in man. J. appl. Physiol, 24, 434. Seldinger, S. I. (1953). Catheter replacement of the needle in percutaneous arteriography. Ada radiol. (StockhX 39, 368. ACUTE REACTIONS TO PHENOTHIAZINE DERIVATIVES
Sir,—Acute reactions to phenothiazine derivatives are not so rare as was first thought. Physicians working in a Regional Tetanus Centre often encounter acute phenothiazine dystonia (Mandal and Sengupta, 1972) following a single dose of perphenazine compound. This presentation as suspected tetanus is apparently a common enough experience. The following incident may be of considerable interest to anaesthetists. Recently, I anaesthetized a patient for a minor operation. Preoperatively, she indicated that she had vomited extensively following previous anaesthetics. In order to minimize postoperative vomiting, prochlorperazine (Stemetil) 12.5 mg was prescribed postopera lively. Following the operation, she received four doses in the next 18 hours to ameliorate her vomiting and then enjoyed lunch and tea. Later that evening the nursing staff contacted me, indicating that the patient was having severe pains in the jaw and throat with evidence of spasmodic contractions involving the mouth; she was also having difficulty in swallowing. They in fact thought trismus was present. Slightly puzzled, I examined the patient and excluded any possibility of tetanus. The nursing staff gave me some reassurance, in that one of their number had seen a similar reaction in a small child receiving large doses of perphenazine (Fentazin). To control what appeared to be fairly severe muscle spasms, diazepam was administered and a hypnotic pentobarbitone sodium given. After a good night's sleep, the patient felt perfectly fit the next morning, but still complained that she felt as if she had received a severe blow on the right side of the jaw. She was discharged later on that day with no further complications. As suggested by Dr Mandal and Dr Sengupta, adequate knowledge of prior immunization, scrupulous enquiry
Downloaded from http://bja.oxfordjournals.org/ at University of Manitoba on June 9, 2015
Sir,—I wish to draw the attention of your readers to a further danger which, I believe, is likely to be associated with failure laterally to tilt a patient during general anaesthesia for operative obstetrics: here it is the mother, and not primarily the infant (see p. 477) who is most at risk. Recently there have been reports^—verbally received or appearing in the course of publications—of patients who have died during, or shortly after, "a difficult intubation". Doubtless we would all agree that death should very rarely occur merely as a result of the anaesthetist's finding it difficult to pass an endotracheal tube. Most of us would admit to having encountered difficulty during attempted intubation not infrequently in the course of our professional lives. The brief period of asphyxia which undoubtedly occurs during such an episode appears rarely to be highly injurious to the patient, except in the case of the desperately ill, and is probably rendered potentially less harmful by appropriately employed preoxygenation. However, a patient in the final trimester of pregnancy who lies supine is likely to have her cardiac output reduced by up to 50 per cent. I would conjecture that under this circumstance a relatively brief period of asphyxia is likely to be of much more ominous import. The combination of reduced cardiac output and asphyxia must surely more rapidly lead to irreversible brain damage or to sudden death than does asphyxia alone. I would therefore urge that this is an additional important reason for employing a lateral tilt in all obstetric patients from, at the latest, the time immediately before induction of anaesthesia.
540
BRITISH JOURNAL OF ANAESTHESIA
regarding the administration of anti-emetic drugs of the phenothiazine group and a diagnostic test employing intravenous benztropine would spare the patient and his relatives from acute anxiety. STEWART LAMONT
Leeds REFERENCE
Mandal, B. K., and Sengupta, P. (1972). Correspondence. Brit. med. J., 1, 441. THE FOETAL AND MATERNAL PHARMACOLOGY OF SOME OF THE DRUGS USED FOR THE RELIEF OF PAIN IN LABOUR
ROBERT G. TWYCROSS
London REFERENCE
Scott, M. E., and Orr, R. (1969). Effects of diamorphine, methadone, morphine and pentazocine in patients with suspected acute myocardial infarction. Lancet, 1, 1065. Sir,—Thank you for allowing me the opportunity of replying to the letter from Dr Twycross. My paper, and the reference to the work by MacDonald et al. (1967), discussed the cardiovascular effects of diamorphine. To describe the work by MacDonald and his colleagues as "uncontrolled" is inaccurate because the authors took half a page to detail the manner in which they controlled the circumstances of their study. However, Dr Twycross appears to believe that the word "controlled" is synonymous with "comparative" and he dismissed the study because no comparator drug was included. This suggests that he also ignores the other studies with morphine (Thomas et al., 1965) pethidine (Rees et al., 1967) and pentazocine (Scott and Adgey, 1971; Jewitt, Maurer and Hubner, 1970), although all the assessments involved similar sensitive and accurate objective measurements. The various authors themselves have felt that the findings from the studies are valid and they have drawn comparisons from the data obtained. While the double-blind method is essential in all investigations involving subjective assessment or the measurement of subjective phenomena, it is only one of the many factors that need to be considered in a clinical investigation, and it cannot by itself "control" the study. The article by Cromie (1963) emphasizes the relevance and impor-
R. A. P. BURT
Surbiton-upon-Thames REFERENCES
Cromie, B. W. (1963). The feet of clay of the double-blind trial. Lancet, 2, 994. Jewitt, D. E., Maurer, B. J., and Hubner, P. J. B. (1970). Increased pulmonary arterial pressure after pentazocine in myocardial infarction. Brit. med. J., 1, 795. Loan, W. B., Morrison, J. D., Dundee, J. W., Clarke, R. S. J., Hamilton, R. C , and Brown, S. S. (1969). Studies of drugs given before anaesthesia. XVII: The natural and semi-synthetic opiates. Brit. J. Anaesth., 41, 57. MacDonald, H. R., Rees, H. A., Muir, A. L., Lawrie, D. M., Burton, J. L., and Donald, K. W. (1967). Circulatory effects of heroin in patients with myocardial infarction. Lancet, 1, 1070. Rees, H. A., Muir, A. L., MacDonald, H. R., Lawrie, D. M., Burton, J. L., and Donald, K. W. (1967). Circulatory effects of pethidine in patients with acute myocardial infarction. Lancet, 2, 863. Scott, M. E., and Adgey, A. A. J. (1971). Circulatory effects of intravenous pentazocine in patients with acute myocardial infarction. Curr. Ther. Res., 13, 81. Thomas, M., Malmcrona, R., Fillmore, S., and Shillingford, J. (1965). Haemodynamic effects of morphine in patients with acute myocardial infarction. Brit. Heart J., 27, 863. ADRENALINE INFILTRATION DURING HALOTHANE ANAESTHESIA
Sir,—In the correspondence section of the February 1972 number of the British Journal of Anaesthesia (p. 234), Dr John G. Brock-Utne comes to the conclusion that the infiltration of a small dose of adrenaline during halothane anaesthesia carries little risk. Though this may be true, Dr Brock-Utne's experiments are by no means conclusive as no electrocardiographic tracings were recorded. Several authors point out that all kind of arrhythmias can occur that cannot be detected by pulse and auscultation alone but need electrocardiographic monitoring and recording to be discovered. A. F. WEHLBURG
Apeldoorn, Holland
REFERENCES
Haldeman, G., and Schaer, H. (1972). Haemodynamic effects of transient atrioventricular dissociation in general anaesthesia. Brit. J. Anaesth., 44, 159. Katz, R. L., and Bigger, J, Th. (1970). Cardiac arrhythmias during anesthesia and operation. Anesthesiology, 33, 199. Wallbank, W. A. (1970). Cardiac effects of halothane and adrenaline in hare lip and cleft palate surgery. Brit. J. Anaesth., 42, 548.
Printed in Great Britain by John Sherratt & Son Ltd, Park Road. Altrincham, Cheshire, W A 1 4 5QQ
Downloaded from http://bja.oxfordjournals.org/ at University of Manitoba on June 9, 2015
Sir,—I was interested to read in the article by R. A. P. Burt (.Bin. J. Anaesth., 43, 824, Sept. 1971) that diamorphine "has less effect on the cardiovascular system (MacDonald, 1967)" than morphine. I would like to point out that the study referred to by Dr Burt was not a controlled trial. Indeed all the patients in that study received diamorphine: none morphine. More recently a double-blind trial comparing diamorphine, morphine, methadone and pentazocine in patients with suspected acute myocardial infarction has been published (Scott and Orr, 1969). These authors found no significant difference between diamorphine and morphine apart from the well-known fact that the action of diamorphine occurs earlier than that of morphine. As many people feel that diamorphine ought not to be used in medical practice it is regrettable that an unsubstantiated statement alleging the superiority of diamorphine over morphine should appear in your columns.
tance, as well as the applications and limitations, of the double-blind technique. The comment that the findings by MacDonald et al. are "unsubstantiated" is also incorrect, as the authors denned the limits of accuracy of their measurements. Even if Dr Twycross was, in fact, asking for corroboration of these findings, he will find this in this journal (Loan et al., 1969) and this from a double-blind comparative study at that. Finally, I wonder whether the last comment by Dr Twycross that "many people feel that diamorphine ought not to be used in medical practice" is based on the findings of a double-blind comparative study, as I notice he offers no substantiation or corroboration for his statement.