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EDUCATED CHEEK
BRITISH JOURNAL OF ANAESTHESIA
476 Plotz, J , Schreiber, W., and Braun, J. (1981). Multiphasic neuromuscular blockade during and following regional application of succinylcholine in man. Anaesthetist, 30, 534. Schreiber, W., and Plotz, J (1980). Muscular paralysis following I v.regional suxamethonium test. Br. J. Anaesth , 52, 842 Torda, T. A. G., and Klonymus, D. H. (1967). Regional neuromuscular block. Acta Anaesthestol. Scand. (Suppl.), 24, 177. Viby-Mogensen, J., and Hanel, H K. (1978). Prolonged apnoea after luxamethonium. Acta Anaesthestol. Scand., 22, 371.
ADVERSE REACTION TO EXTRADURAL BUPRENORPHINE
F R CHRISTENSEN L. W. ANDERSEN
Fredenksborg, Denmark
REFERENCES
Jasinski, D. R , Pevnick, J. S., and Griffith, J. D. (1978) Human pharmacology and abuse potential of the analgesic buprenorphine. Arch. Gen. Psychtatr , 35, 501. Kay, B. (1978) A double-blind comparison of morphine and buprenorphine in the prevention of pain after operation. Br. J Anaesth., 50,605. (1980). A double-blind comparison between fentanyl and buprenorphine in analgesic-supplemented anaesthesia. Br J. Anaesth., S2,4Si. Leading Article (1978) Postoperative pain Br. Med / . , 2, 517.
EDUCATED CHEEK
Sir,—We are glad that Dr Selwyn Crawford (1981) agrees with our "staircase pattern" expansion of the neonatal lung (Rosen et al , 1981), but question whether his "educated cheek" could generate the pattern as accurately as our apparatus In our research (Rosen, Laurence and Mapleson, 1973; Vaughan et al., 1980) we have shown that the staircase should be one of pressure, not volume, and we have specified an optimal quantification of that pressure staircase If the cheek is used to generate the staircase it will be just as necessary as with the apparatus to judge the time intervals between steps, and extremely difficult to judge the pressure increments accurately (0 25-1 OkPa) since the maximum cheek pressure is about 14kPa If the apparatus is used, chest expansion can still be observed but, since rupture occurs at lest than half normal FRC in some babies, thin is not a very sensiove indicator of progress. The need to watch for the first sign of resuscitation is equally important in both methods, otherwise unnecessarily high pressures will be used, thereby increasing the risk of rupture M ROSEN R S. VAUGHAN W W. MAPLESON
Cardiff REFERENCES
Crawford, J. S. (1981). Resuscitation of the neonate Br. J. Anaesth., 53,1010. Rosen, M., Laurence, K. M , and Mapleson, W. W. (1973) Artificial expansion of the newborn human lung. Br. J Anaesth ,45,535. Vaughan, R. S., Mapleson, W. W , Laurence, K M , and Hillard, E. K. (1981). A new approach to artificial expansion and ventilation of the lung m the severely asphyxiated neonate Br. J. Anaesth , 53, 249. Vaughan, R S., Mapleson, W W., Rosen, M., and Laurence, K. M. (1980) The minimum artificial lung expansion necessary for resuscitation of the newborn lamb. Br. J. Anaesth.,S2, 189
Downloaded from http://bja.oxfordjournals.org/ at Georgetown University on August 24, 2015
Sir,—Many reports have demonstrated the efficacy of extradural morphine, especially in pain associated with cancer. Buprenorphine is a new analgesic with agonist and antagonist effects (Leading Article, 1978; Kay, 1978,1980, McQuay etal., 1980); no respiratory depression nor euphoria have been reported, but nausea and vomiting are described after i v. and i.m. injection (Leading Article, 1978; Jasinski, Pevnick and Griffith, 1978; Kay, 1978, 1980; McQuay etal., 1980). We used buprenorphine extradurally, because two patients developed tolerance to extradural morphine. This phenomenon has been observed by Zenz and colleagues (1981). Two women with terminal cancer were treated with extradural morphine and developed tolerance, so that morphine 12 —15mg twice daily was necessary to obtain complete analgesia Twelve hour after the last extradural morphine injection, buprenorphine 0.3 mg in 0.9% saline 10 ml was injected to the extradural space. Exactly 2 h later both patients developed signs of shock' pale and cold skin, low arterial pressure (90/60 mm Hg) and an average heart rate of 110 beatmin" 1 . The patients remained in this condition for nearly 2 - 3 h, whereafter the symptoms disappeared spontaneously. No treatment (including i.v. naloxone) was successful. The pain was then treated with extradural morphine, but only morphine 6-8 mg twice daily ws necessary to secure complete pain relief. The changed morphine sensitivity and the lack of effect of naloxone were presumably caused by the agonist/antagonist effect of buprenorphine The injection of buprenorphine was given 12 h after the last extradural morphine, so an interaction between buprenorphine and morphine may be excluded. We conclude that extradural buprenorphine should not be used because of the described side-effects, and also because the neurotoxic effect of buprenorphine is for the time being unknown.
McQuay, H. J , Bullingham, R. E S., Paterson, G. M. C , and Moore, R. A. (1980). Glinical effects of buprenorphine during and after operation Br J. Anaesth , 52,1013 Zenz, M., Schappler-Scheele, B., Neuhaus, R., Piepenbrock, S., and Hilfnch, J. (1981) Long-term peridural morphine analgesia in cancer pain. Lancet, 1,91
476 Plotz, J , Schreiber, W., and Braun, J. (1981). Multiphasic neuromuscular blockade during and following regional application of succinylcholine in man. Anaesthetist, 30, 534. Schreiber, W., and Plotz, J (1980). Muscular paralysis following I v.regional suxamethonium test. Br. J. Anaesth , 52, 842 Torda, T. A. G., and Klonymus, D. H. (1967). Regional neuromuscular block. Acta Anaesthestol. Scand. (Suppl.), 24, 177. Viby-Mogensen, J., and Hanel, H K. (1978). Prolonged apnoea after luxamethonium. Acta Anaesthestol. Scand., 22, 371.
ADVERSE REACTION TO EXTRADURAL BUPRENORPHINE
F R CHRISTENSEN L. W. ANDERSEN
Fredenksborg, Denmark
REFERENCES
Jasinski, D. R , Pevnick, J. S., and Griffith, J. D. (1978) Human pharmacology and abuse potential of the analgesic buprenorphine. Arch. Gen. Psychtatr , 35, 501. Kay, B. (1978) A double-blind comparison of morphine and buprenorphine in the prevention of pain after operation. Br. J Anaesth., 50,605. (1980). A double-blind comparison between fentanyl and buprenorphine in analgesic-supplemented anaesthesia. Br J. Anaesth., S2,4Si. Leading Article (1978) Postoperative pain Br. Med / . , 2, 517.
EDUCATED CHEEK
Sir,—We are glad that Dr Selwyn Crawford (1981) agrees with our "staircase pattern" expansion of the neonatal lung (Rosen et al , 1981), but question whether his "educated cheek" could generate the pattern as accurately as our apparatus In our research (Rosen, Laurence and Mapleson, 1973; Vaughan et al., 1980) we have shown that the staircase should be one of pressure, not volume, and we have specified an optimal quantification of that pressure staircase If the cheek is used to generate the staircase it will be just as necessary as with the apparatus to judge the time intervals between steps, and extremely difficult to judge the pressure increments accurately (0 25-1 OkPa) since the maximum cheek pressure is about 14kPa If the apparatus is used, chest expansion can still be observed but, since rupture occurs at lest than half normal FRC in some babies, thin is not a very sensiove indicator of progress. The need to watch for the first sign of resuscitation is equally important in both methods, otherwise unnecessarily high pressures will be used, thereby increasing the risk of rupture M ROSEN R S. VAUGHAN W W. MAPLESON
Cardiff REFERENCES
Crawford, J. S. (1981). Resuscitation of the neonate Br. J. Anaesth., 53,1010. Rosen, M., Laurence, K. M , and Mapleson, W. W. (1973) Artificial expansion of the newborn human lung. Br. J Anaesth ,45,535. Vaughan, R. S., Mapleson, W. W , Laurence, K M , and Hillard, E. K. (1981). A new approach to artificial expansion and ventilation of the lung m the severely asphyxiated neonate Br. J. Anaesth , 53, 249. Vaughan, R S., Mapleson, W W., Rosen, M., and Laurence, K. M. (1980) The minimum artificial lung expansion necessary for resuscitation of the newborn lamb. Br. J. Anaesth.,S2, 189
Downloaded from http://bja.oxfordjournals.org/ at Georgetown University on August 24, 2015
Sir,—Many reports have demonstrated the efficacy of extradural morphine, especially in pain associated with cancer. Buprenorphine is a new analgesic with agonist and antagonist effects (Leading Article, 1978; Kay, 1978,1980, McQuay etal., 1980); no respiratory depression nor euphoria have been reported, but nausea and vomiting are described after i v. and i.m. injection (Leading Article, 1978; Jasinski, Pevnick and Griffith, 1978; Kay, 1978, 1980; McQuay etal., 1980). We used buprenorphine extradurally, because two patients developed tolerance to extradural morphine. This phenomenon has been observed by Zenz and colleagues (1981). Two women with terminal cancer were treated with extradural morphine and developed tolerance, so that morphine 12 —15mg twice daily was necessary to obtain complete analgesia Twelve hour after the last extradural morphine injection, buprenorphine 0.3 mg in 0.9% saline 10 ml was injected to the extradural space. Exactly 2 h later both patients developed signs of shock' pale and cold skin, low arterial pressure (90/60 mm Hg) and an average heart rate of 110 beatmin" 1 . The patients remained in this condition for nearly 2 - 3 h, whereafter the symptoms disappeared spontaneously. No treatment (including i.v. naloxone) was successful. The pain was then treated with extradural morphine, but only morphine 6-8 mg twice daily ws necessary to secure complete pain relief. The changed morphine sensitivity and the lack of effect of naloxone were presumably caused by the agonist/antagonist effect of buprenorphine The injection of buprenorphine was given 12 h after the last extradural morphine, so an interaction between buprenorphine and morphine may be excluded. We conclude that extradural buprenorphine should not be used because of the described side-effects, and also because the neurotoxic effect of buprenorphine is for the time being unknown.
McQuay, H. J , Bullingham, R. E S., Paterson, G. M. C , and Moore, R. A. (1980). Glinical effects of buprenorphine during and after operation Br J. Anaesth , 52,1013 Zenz, M., Schappler-Scheele, B., Neuhaus, R., Piepenbrock, S., and Hilfnch, J. (1981) Long-term peridural morphine analgesia in cancer pain. Lancet, 1,91