Anesthesiology and otolaryngology

948

QUARTERLY

REVIEW

OF LITERATURE

ANESTHESIOLOGY Local Sequelae of Endotracheal Anesthesia. W. Arnold and Francis M. Grem. Anesthesiology 9: 490, 1948.

Donnelly,

Arnold

A. Grossman,

The types of trauma incident to endotracheal anesthesia are discussed, and the findings on postanesthetic indirect (mirror) laryngoscopic examinations in 100 cases are described. Even with residents recently introduced to the endotracheal technique, the local damage following intubation was, in all cases, moderate in degree and caused only minimal subjective complaint or functional change. No permanent damage was encountered. It is not unreasonable to assume that in the hands of the skilled anesthesiologist, the incidence of trauma resulting from intubation will be minimal and that the occurrence of even slight injuries (noted in this series) will ho loss frequent. The advantages of endotracheal anesthesia which have not been discussed in this paper far outweigh any minor undesirable effects discovered in this study. T. J. C.

Anesthesiology

and Otolaryngology.

Samuel Rochberg.

Arch.

Otolaryng.

49: 33, January,

1949. ‘LTheoretically, the patient should be admitted the day before operation so that he may become acclimated to the atmosphere of the hospital and properly prepared for surgical treatment. However, the critical shortage of beds has forced many institutions to admit patients for minor surgical operations on the morning on which these operative procedures are to be performed. Breakfast should be withheld, and it is imperative that the persons responsible for the patient be instructed to keep food away from him. Too many mothers, feeling sorry for their children, give them a ‘little’ breakfast. Vomiting and aspirating the vomitus during the induction of anesthesia or postoperatively in the reactive period form the background of many a surgical tragedy. “From sixty to ninety minutes prior to surgical treatment the patient should be given either an opiate or a barbituric acid derviative in appropriate dosage and either atropine or A morphine salt, a codeine salt, ‘ pantopon’ (a mixture of hydrochlorides of scopolamine. opium alkaloids), dihydromorphinone hydrochloride and meperidine hydrochloride (‘ demerol who show an idiosyncrasy to morphine will hydrochloride’) are frequently used. Patients hydrochloride frequently tolerate one of the synthetic products, ‘pantopon, ’ dihydromorphinone such as pentobarbital sodium The short-acting barbiturates, or meperidine hydrochloride. of their action, are preferable to the longerand ‘seconal sodium,’ because of the rapidity Morphine and allied drugs will relieve pain, but moderate doses of the acting barbiturates. Proper premeditation, in addition to relieving the patient’s pain or barbiturates will not. apprehension or both, will reduce the amount of anesthetic required. “Scopolamine and atropine diminish or abolish salivary secretion. Mucus can interfere which not only makes the induction and mainwith the airway by initiating laryngospasm, tenance of anesthesia difficult but interferes with the proper oxygenation of the patient. Furthermore, various degrees of atelectasis can be produced by the aspiration of mucus. (‘Atropine and scopolamine directly stimulate metabolism and therefore counteract the depression of the respiratory center produced by the sedative drugs. In addition, they depress the activity of the vagus nerve, thereby helping to protect against cardiac irregulariScopolamine will also produce euphoria or amnesia and that is adties and laryngospasm. vantageous in the proper preparation of the patient. “It requires one to one and a half hours for the drugs used as premedicants to exert When given intramuscularly, they their maximum effect when administered subcutaneously. Only five minutes is necessary for the become effective within fifteen to twenty minutes. desired effect when t,he intravenous route is used. This avenue is helpful when the premedicaWith intravenous administration, tion has been erroneously omitted or has lost its effect. can be given rectally in both chilhowever, smaller doses should be used. The barbiturates dren and adults.

ABSTRACTS

OF CURRENT.

949

LITERATURE

“Many surgeons and anesthesiologists prefer one drug or combination of drugs to others and have used them with great, success. However, one must always remember that the dosage In choosing the dosage, the pavaries with the patient, the operation and the anesthesia. pregtient ‘s age, size and occupation must be borne in mind; fever, pain, hyperthyroidism, nancy, alcoholism (both chronic and social), emotional excitement-all call for increased dosage; cachectic and debiliating diseases, anemia, hemorrhage, shock, cardiorenal disease and hypothyroidism all necessitate smaller doses. When the patient is to be operated on under local anesthesia, a barbiturate should be given in addition to an opiate, not only for its hppnotic effect but also for its counteraction of any possible reaction evoked by the local anesthetic agent. If the procedure is a long one, and the premeditation is wearing off, one can make the patient more comfortable by further administ,ration of the opiate or the barbiturate or both. TABLE I. MORPIIINE AND SCOPOLAMINE OR ATROPINE

AGE

WEIGHT J>B. i-10

MORl'HliYE SULFATE, GRAIN. MG. l/480 (0.13 mg.)

SCOI'OLUWINE HYDROBROMIUE, GRBIN. MG.

2-3 mo. 3-4 mo. 4-7 mo.

IO-12

l/360

(0.18 mg.)

l/600 l/600

(0.10 mg.) (0.10 mg.)

12-14 14-16

l/240

(0.27

I/600

(0.10

16-19 19-24

(0.45 m&j CO.54 mn.‘l lo.60 rn2.j

l/600

7-11 mo. 11-18 mo. 18 mo.-2 yr, 2-3 yr. 3-5 yr. 6-8 yr. 8-10 yr. lo-12 yr. 12-14 yr. Adult

l/144 l/120

li600

(0.10 mg. j 10.10 rnp.1 (0.10 mi.j

(0.90 ma) (1.0 m2.j 11.35 mn.1 il.80 m”g.j

l/450

(0.14

Up to 2 mo.

24-27 27-30 30-40 40-55 js.&y 65-80 X0-90 Over 90

I)108 l/72 l/60 l/48 I)36

me.)

l/24 (2.70 nip.) l/18 (3.60 mz.j l/12 (5.40 mg.) 1/8-l/4 (8.10-16 me.)

l/600

mg.)

mg.)

i/450 (0.14 @.j l/4.50 10.14 rng.) lj300 to.22 n1E.j l/300 (0.22 mg.) l/200 (0.30 rni.j l/150 (0.43 mg.) l/l%l/100 (0.43-0.65 me.)

AZTKOPINE

SULFbTE, GRAIN. MC. l/400 (0116 mg.) l/400 (0.16mg.j l/400 (0.16 ma.)

l/400 l/400 l/400 l/300

(0.16 (0.16 (0.16 (0.22

mg.) mg.) mg.) mg.)

l/300 l/300 l/200 l/200

(0.22 "lg.) (0.22 my.) (0.30 "lg.) (0.30 mg.)

l/1 00 (0.65 mg.) l/75 (0.86 mg.) l/75 (0.86 mg.)

“Table I, prepared by Leigh and Belton,” of Montreal, Cana,da, and based on a great deal of experience, may be helpful. “Many anesthetic agents and various technics of administration have been used in the field of otolaryngology. Except for rare cases, anesthesiologists do not feel that any one specific drug or technic is indicated for a certain surgical procedure. The case is a better risk when surgeon and anesthesiologist are using familiar methods, provided those methods are physiologically sound. “The action of the local anesthetic agents can be prolonged by the addition of such vasoconstrictors as epinephrine hydrochloride or ‘ cobefrin ’ (3, 4-dihydroxy-norephedrine). When the blood vessels at the site of injection become constricted, the absorption of the anesthetic agent is delayed; thus its effectiveness is increased, and the body is allowed more is present. time in which to detoxify the drug. This is important in cases in which sensitivity Cocaine will itself produce vasoconstriction, thereby delaying its own absorption. “The inherent danger of the use of the agents producing local anesthesia lies in inThe manifestation of such sensitivity is commonly dividual susceptibility or sensitivity. It may be mild and long in appearing or swift known as a cocaine or a procaine reaction. and tragic. Headache, vertigo, restlessness, tremors and convulsions may be seen, with death resulting from respiratory failure. “In many instances the operative procedure or the desires of the patient or of the First, the anesthesiologist and the surgeon must surgeon may warrant general anesthesia. I can vividly recall a case in which I ask themselves, ‘Should this patient be put to sleep8’ was involved during my training: uterine

“An obese lady in her early thirties was to undergo a pelvic laparotomy for Nothing in her history foretold any difficulties relative to anesfibroids.

*Leigh. M. D.. and Belton, ology 7: 611-615, 1946.

M. K.:

Prcmedication

in Infants

and Children,

Anesthesi-

thesis. Several minutes after the induction I heard gurgling and bubbling noises coming from her mouth. The face mask was removed, and there was fresh blood pouring from her nose and mouth. Suction was begun immediately, the patient being placed in the Trendelenburg position, and the operation was canceled, .I soon realized that a nosebleed was the problem; it was controlled by packing, and the patient was returned to her room. She later confessed that she frequently had nosebleeds but had forgotten to mention this minor fact to the house staff. The operation was done forty-eight hours later, with this patient under spinal anesthesia. “I

should like to recall another

case :

“A colleague of mine was called one afternoon to administer a ‘little pentothal sodium’ to a patient who was to undergo incision and drainage of the site of Ludwig’s angina (cellulitis of the floor of the mouth). The anesthesiologist requested that a preliminary tracheotomy be done. The request was refused. A few cubic centimeters of i pentothal sodium’ was aclministeretl, and suddenly the patient stopped breathing. All efforts at resuscitation failecl. : ’ T. J. C.

Anoxia in Anaesthesia With Nitrous Oxide and Oxygen.

David Grinstein.

Rev. Cdontol.

25: 708, 1947. The author shows according to the experiments of the physiologists that human life is compatible with percentages of 10 to 12 per cent of O2 given in anesthesias with nitrous oxide and oxygen. His experience acquired through more than 10,000 anesthesias with nitrogenorrs protoxide and oxygen without any deaths or postanesthetic sequelae is proof of the harmlessness of this anesthetic agent. An essential condition is to watch the respirations of the patient and to employ premedication (barbiturates) or to utilize synergists in resistant patients in order to avoid administrations with very redzlced percentages of Oz.

Danger in Prolonged Anaesthesia.

Open Forum.

Modern

Dent. 16: 21, April,

1949.

Case Report of Dr. Milton Rothstein “Miss M. M., age thirteen, a normal young lady came into the office complaining revealed a caries exof a toothache in the lower right mandibular area. X-ray examination I decided to remove the tooth and injected 2 C.C. of posure in the lower right first molar. 2 per cent procaine in the standard manner for mandibular block anesthesia, The tooth was removed uneventfully. Three hours later the young lady returned t,o the office with a frantic I was figuratively floored when the mother explained that the daughter had bitten mother. a huge area of tissue off the inner lip including the vermilion border. I would estimate the It seems that the young size of the area to be two and one-half centimeters in diameter. lady is a habitual lip biter and in the presence of complete anesthesia to the lip she created I referred her immediately to a physician for an injection of tetanus this self mutilation. antitoxin and a routine of antiseptic care of the open area until healing would result through granulation. “I am sure that my fellow practitioners shall be happy to accept this incident merely as another caution to be considered in the daily management of practice of dentistry.”

Editor’s

Comment (In Part)

at times really too strong, incidents of the “With the advent of strong anesthetics, When anesthesia lasts for more than one type described by Dr. Rothstein are not uncommon. hour after a mandibular injection, the patient must be warned not to eat, or bite the lips, For the same reason, it is advisable to avoid, if until all normal sensation has returned.