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AS A PATIENT SEES IT
200
nism, excretion by the kidneys may play a part ; but there
seems
to be
no reason
at
present
to consider any-
other than serum-cholinesterase activity. To produce dramatic delay in recovery, the enzyme level must obviously be very low, and Callaway et awl.4 have shown that there is little chance of encountering such cases in an average sample of the population. Bourne et al. found only 5 among 546 patients in whom the reaction lasted longer than eight minutes, and Evans et al. encountered the first case of prolonged response only after they had employed succinylcholine If patients likely to have a low more than 400 times. serum-cholinesterase level (those with liver-disease, anaemia, malnutrition, and possible polyphosphate poisoning) are excluded from succinylcholine treatment, and if it is realised that neostigmine is contra-indicated after this drug has been given, the use of succinylcholine should be quite safe. It is obvious that no drug producing apnoea should ever be given unless facilities for
thing
artificial respiration are available. Once it is quite clear in the minds of anaesthetists that prolonged response to succinylcholine is due to delay in destruction of the drug by serum cholinesterase, they will stop giving a cholinesterase-inhibitor, such as neostigmine. The obvious treatment, if any, will be to increase rather than lower the enzyme activity ; transfusion of fresh blood or plasma should serve this purpose, and it is noteworthy that even blood stored for several weeks has in its citrated and diluted plasma esterase levels varying from 30 to 50 units. St. Bartholomew’s Hospital, London, E.C.1.
H. LEHMANN.
SIR,-Following recent articles on the use of ultrashort-acting relaxants, an account of a small series in which repeated doses of succinylcholine chloride (’Scoline’) were given may be of interest. On theoretical grounds it seemed that appendicectomy would be the operation of choice for the exhibition of It should be possible to maintain light thisagent. anaesthesia throughout, while providing relaxation when required-that is, until the delivery of the appendix, returning the gut to the abdomen, and closing the peritoneum. Should difficulties be encountered, the relaxation could be prolonged indefinitely by giving repeated doses. Of 30
of appendicectomy in the series, 25 were The 11 " difficult " cases included 3 in which incisions were made ; the longest operation minutes, and the shortest ten ; the age-limits
cases
emergencies. paramedian
lasted fifty 12-58. Premedication was usually morphine gr. Ii and atropine gr. Vioo. The induction was by thiopentone, usually 0-5 g. Maintenance was by nitrous oxide and oxygen from a Boyle’s machine delivered via a Coxeter Mushin apparatus.’Vinesthene ’ was placed in the chloroform bottle, and the lever left just above the minimum position. A flow of 5 litres per minute of nitrous oxide and 1 litre of oxygen was attempted,but usually it was necessary to reduce the proportion of nitrous oxide to avoid hvpoxia. Succinylcholine was given in 5% solution from a 10 ml. syringe strapped to the arm. Assisted or controlled respiration was given when necessary. 5 further patients (i.e., 5 out of 35) were adequately relaxed without succinylcholine. Of 4 cases in which vinesthene
were
not given, only 1 was satisfactory. Recovery was rapid, usually within fifteen minutes. One patient’s recovery was delayed an hour. This patient was a fat chronic bronchitic who had an exacerbation lasting four days. One other chronic bronchitic had a temperature There was no other postoperative of 99F for one day. morbidity, apart from that due to preoperative infection of the pelvis. was
The technique expectations.
has
so
far
fully
confirmed the theoretical
4. Callaway S., Davies, D. R., Rutland, J. P. 5. Dawkins, C. J. M. Anœsthesia, 1950, 5, 81.
Ibid, 1951, ii, 812.
The initial dose is 10 mg., and from the response to this " the size of subsequent doses is judged. In the "difficult" cases, where prolonged relaxation is required, the optimum relaxing dose and its duration is determined, usually by the second or third dose ; and this is then repeated as long as relaxation is required. Each dose is given thirty seconds before the previous dose will wear off. This timing is most important, as the sudden return of abdominal tone may The " simple " case cause the rupture of a friable viscus. usually requires one or two doses before the appendix is delivered, and one for closing. Sometimes it requires one dose only or none. The usual relaxing dose is 5-15 mg., which causes apncea or inadequate, shallow respiration. Commonly adequate spontaneous respiration returns before abdominal tone; sometimes respiration remains adequate throughout. Relaxa. tion starts twenty to thirty seconds after injection, and lasts two to four minutes. During a given operation the same dose always has the same effect, plus or minus a few seconds, thus permitting the accurate timing of repeated doses. No additive effects, and no case of prolonged action, have yet occurred.
The doses of succinylcholine suggested are smaller than those previously recommended. This is probably because an attempt has been made in each case to give a dose which provides relaxation without rendering respiration inadequate, while the nitrous oxide and vinesthene anaesthesia will also reduce the dose required. Whether it is possible to retain spontaneous respiration still seems uncertain. - Swedish workers, using a drip, claim that this is possible, while British workers doubt it.6 My own small experience indicates that with the technique described it is possible at least in some cases. It would seem probable that the level of the accompanying anaesthesia, and the degree of respiratory depression that it causes, is the deciding factor. Whatever the place of succinylcholine in more exten. sive operations, I suggest that for appendicectomy it is a very useful agent. The advantages are : a light level of anaesthesia accompanied by profound relaxation when required ; absence of toxic effects; complete control ; and rapid recovery. County Hospital, near Prescot,
Whiston,
Lancashire.
HAROLD T. KAY Anæsthetic Registrar.
AS A PATIENT SEES IT SiB,ŁYour annotation of July 12 tempts me to write of my all too present experience as a patient. The untiring kindness of the nurses is beyond praise; but surely the most terrible thing to bear is the deadly monotony of hospital routine. On many occasions I have tried to break through this, but with no success. I give two examples. Quite early on in my stay in hospital I asked whether the Bible, prayerbook (shortened version), and hymnbook (A and M) which were beside my bed could be moved to the far side of the books (including a Bible) which I had brought in with A very serious-faced probationer replied : "It is a rule me. of the hospital that the Bible, prayerbook, and hymnbook must be next the patient." The second attempt was no more successful. After many weeks in the hospital I said, rather tentatively, to the nurse who was making my bed : " How would you react were -
’
I to ask if, just for a change, I could have my counterpane the other way round ? ""Oh," she replied without a moment’s hesitation, " we should call you a Socialist."
A PATIENT. OSTEOPATHY AND ORTHODOXY SIR,-I have no sympathy for your peripatetic correspondent (July 5) in his chagrin at learning that an osteopath had employed a form of orthodox treatment. If he and some of his colleagues were as quick to appreciate the value of osteopathic treatment, in appropriate cases, 6. Bourne, J. G., Collier, H. O. J., Somers, G. F. Lancet, 1952, i, 1225. Richards, H., Youngman, H. R. Brit. med. J. 1952, i, 1334.
nism, excretion by the kidneys may play a part ; but there
seems
to be
no reason
at
present
to consider any-
other than serum-cholinesterase activity. To produce dramatic delay in recovery, the enzyme level must obviously be very low, and Callaway et awl.4 have shown that there is little chance of encountering such cases in an average sample of the population. Bourne et al. found only 5 among 546 patients in whom the reaction lasted longer than eight minutes, and Evans et al. encountered the first case of prolonged response only after they had employed succinylcholine If patients likely to have a low more than 400 times. serum-cholinesterase level (those with liver-disease, anaemia, malnutrition, and possible polyphosphate poisoning) are excluded from succinylcholine treatment, and if it is realised that neostigmine is contra-indicated after this drug has been given, the use of succinylcholine should be quite safe. It is obvious that no drug producing apnoea should ever be given unless facilities for
thing
artificial respiration are available. Once it is quite clear in the minds of anaesthetists that prolonged response to succinylcholine is due to delay in destruction of the drug by serum cholinesterase, they will stop giving a cholinesterase-inhibitor, such as neostigmine. The obvious treatment, if any, will be to increase rather than lower the enzyme activity ; transfusion of fresh blood or plasma should serve this purpose, and it is noteworthy that even blood stored for several weeks has in its citrated and diluted plasma esterase levels varying from 30 to 50 units. St. Bartholomew’s Hospital, London, E.C.1.
H. LEHMANN.
SIR,-Following recent articles on the use of ultrashort-acting relaxants, an account of a small series in which repeated doses of succinylcholine chloride (’Scoline’) were given may be of interest. On theoretical grounds it seemed that appendicectomy would be the operation of choice for the exhibition of It should be possible to maintain light thisagent. anaesthesia throughout, while providing relaxation when required-that is, until the delivery of the appendix, returning the gut to the abdomen, and closing the peritoneum. Should difficulties be encountered, the relaxation could be prolonged indefinitely by giving repeated doses. Of 30
of appendicectomy in the series, 25 were The 11 " difficult " cases included 3 in which incisions were made ; the longest operation minutes, and the shortest ten ; the age-limits
cases
emergencies. paramedian
lasted fifty 12-58. Premedication was usually morphine gr. Ii and atropine gr. Vioo. The induction was by thiopentone, usually 0-5 g. Maintenance was by nitrous oxide and oxygen from a Boyle’s machine delivered via a Coxeter Mushin apparatus.’Vinesthene ’ was placed in the chloroform bottle, and the lever left just above the minimum position. A flow of 5 litres per minute of nitrous oxide and 1 litre of oxygen was attempted,but usually it was necessary to reduce the proportion of nitrous oxide to avoid hvpoxia. Succinylcholine was given in 5% solution from a 10 ml. syringe strapped to the arm. Assisted or controlled respiration was given when necessary. 5 further patients (i.e., 5 out of 35) were adequately relaxed without succinylcholine. Of 4 cases in which vinesthene
were
not given, only 1 was satisfactory. Recovery was rapid, usually within fifteen minutes. One patient’s recovery was delayed an hour. This patient was a fat chronic bronchitic who had an exacerbation lasting four days. One other chronic bronchitic had a temperature There was no other postoperative of 99F for one day. morbidity, apart from that due to preoperative infection of the pelvis. was
The technique expectations.
has
so
far
fully
confirmed the theoretical
4. Callaway S., Davies, D. R., Rutland, J. P. 5. Dawkins, C. J. M. Anœsthesia, 1950, 5, 81.
Ibid, 1951, ii, 812.
The initial dose is 10 mg., and from the response to this " the size of subsequent doses is judged. In the "difficult" cases, where prolonged relaxation is required, the optimum relaxing dose and its duration is determined, usually by the second or third dose ; and this is then repeated as long as relaxation is required. Each dose is given thirty seconds before the previous dose will wear off. This timing is most important, as the sudden return of abdominal tone may The " simple " case cause the rupture of a friable viscus. usually requires one or two doses before the appendix is delivered, and one for closing. Sometimes it requires one dose only or none. The usual relaxing dose is 5-15 mg., which causes apncea or inadequate, shallow respiration. Commonly adequate spontaneous respiration returns before abdominal tone; sometimes respiration remains adequate throughout. Relaxa. tion starts twenty to thirty seconds after injection, and lasts two to four minutes. During a given operation the same dose always has the same effect, plus or minus a few seconds, thus permitting the accurate timing of repeated doses. No additive effects, and no case of prolonged action, have yet occurred.
The doses of succinylcholine suggested are smaller than those previously recommended. This is probably because an attempt has been made in each case to give a dose which provides relaxation without rendering respiration inadequate, while the nitrous oxide and vinesthene anaesthesia will also reduce the dose required. Whether it is possible to retain spontaneous respiration still seems uncertain. - Swedish workers, using a drip, claim that this is possible, while British workers doubt it.6 My own small experience indicates that with the technique described it is possible at least in some cases. It would seem probable that the level of the accompanying anaesthesia, and the degree of respiratory depression that it causes, is the deciding factor. Whatever the place of succinylcholine in more exten. sive operations, I suggest that for appendicectomy it is a very useful agent. The advantages are : a light level of anaesthesia accompanied by profound relaxation when required ; absence of toxic effects; complete control ; and rapid recovery. County Hospital, near Prescot,
Whiston,
Lancashire.
HAROLD T. KAY Anæsthetic Registrar.
AS A PATIENT SEES IT SiB,ŁYour annotation of July 12 tempts me to write of my all too present experience as a patient. The untiring kindness of the nurses is beyond praise; but surely the most terrible thing to bear is the deadly monotony of hospital routine. On many occasions I have tried to break through this, but with no success. I give two examples. Quite early on in my stay in hospital I asked whether the Bible, prayerbook (shortened version), and hymnbook (A and M) which were beside my bed could be moved to the far side of the books (including a Bible) which I had brought in with A very serious-faced probationer replied : "It is a rule me. of the hospital that the Bible, prayerbook, and hymnbook must be next the patient." The second attempt was no more successful. After many weeks in the hospital I said, rather tentatively, to the nurse who was making my bed : " How would you react were -
’
I to ask if, just for a change, I could have my counterpane the other way round ? ""Oh," she replied without a moment’s hesitation, " we should call you a Socialist."
A PATIENT. OSTEOPATHY AND ORTHODOXY SIR,-I have no sympathy for your peripatetic correspondent (July 5) in his chagrin at learning that an osteopath had employed a form of orthodox treatment. If he and some of his colleagues were as quick to appreciate the value of osteopathic treatment, in appropriate cases, 6. Bourne, J. G., Collier, H. O. J., Somers, G. F. Lancet, 1952, i, 1225. Richards, H., Youngman, H. R. Brit. med. J. 1952, i, 1334.