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EPIDURAL ANALGESIA FOR PARTIAL GASTRECTOMY
65
CORRESPONDENCE after, so that in the event of vasomotor collapse or other untoward reactions occurring, either as a reaction to the local analgesic agent or to an inadvertent subarachnoid injection, appropriate action can be immediately undertaken without having to make a futile search for collapsed veins. An ampoule of vasopressor and a syringe should also be at hand. Dr. Buck states that mild toxic effects of lignocaine (drowsiness and muscular twitching) were sometimes seen. May these not be related to the large doses of lignocaine used, viz. 30-50 ml of 1| per cent solution (i.e. 450-750 mg)? JOHN G. FRANCIS
London
M. BUCK
Isleworth REDUCTION OF A DISLOCATED HIP WITHOUT GENERAL ANAESTHESIA
Sir,—Dr. Scott reports the case of a well-built youth who had a full stomach, a potential airway problem and an extremity injury which required prompt treatment and muscle relaxation (Brit. J. Anaesth., (1963), 35, 654). In such a case the contraindications to general anaesthesia are as obvious as the indications for a regional technique. An extradural block to T-10 by the sacral or lumbar route would have provided analgesia and muscle relaxation without affecting respiration, consciousness, airway or reflex protection against vomiting. Dr. Scott omitted to consider the alternative of a regional technique in his discussion. Perhaps it would
DAVID N. GOODSON
Tacoma Sir,—A* case of a patient with mandibular injuries, a full stomach, and a dislocated hip is discussed by Dr. Scott (Brit. J. Anaesth. (1963), 35, 654) but no mention is made of the fact that gallamine in doses insufficient to produce significant respiratory depression can cause serious respiratory obstruction when maxillo-facial injuries are present. The success of the gallamine-pethidine technique used in this case should not be taken as an indication for its use in all cases of this nature, particularly as one reason for its use seems to have been the uncertainty of the anaesthetist of ensuring an unobstructed airway. It would be interesting to know why subarachnoid or extradural block were not considered. If very definite contraindication to these existed, endotracheal intubation facilitated by topical anaesthesia and judicious use of pethidine and triflupromazine, or phentanyl and dehydrobenzperidol, could be attempted. J. W. R. MCINTYRE
Edmonton Sir,—Thank you for the opportunity of commenting on Dr. Goodson's letter. The comment is simple enough—I think he is perfectly correct; regional analgesia would have been far better in this case. The humble truth is that many anaesthetists in this country (myself included) are not thinking enough of regional techniques. This is obviously a fault, and there are probably several reasons for it. I can think of the following: (i) Trainee anaesthetists are not always taught such methods. They are thus not in a good position to carry them out when they reach more senior rank. (ii) Patients in England prefer to be put to sleep. This is the usual method in most hospitals, and there is consequently little "patient-to^patient" recommendation for techniques in which they remain awake during surgery. (iii) The special equipment necessary for the satisfactory performance of these techniques is often non-existent (there was no equipment for extradural block at the small hospital to which the case described was originally admitted), (iv) Non-routine techniques can be enormously time-consuming. This is unpopular with surgeons and theatre staff. The failure rate is higher in inexperienced hands, for example, in caudal and brachial plexus blocks. (v) Surgeons can, and do, refuse to operate under regional analgesia (maybe because of previous unsatisfactory experiences with inadequate incorrectly performed techniques). The above is only an impression and it is obvious from the literature that there are centres in U.K. where these techniques are in routine use and highly successful. But I feel that taking the country as a whole they are more the exceptions than the rule. The point of describing this case is to illustrate a possible technique. The relative safety and success of
Downloaded from http://bja.oxfordjournals.org/ at New York University on May 6, 2015
A copy of the above letter was forwarded to Dr. Buck, who replied as follows: Sir,—In reply to Dr. Francis, it is true that the surgeon requests the conditions described in my article, because with vast experience of performing partial gastrectomies he finds that this method of analgesia provides him with the most advantageous conditions for his particular operating technique. Provided that the method requested by a surgeon is a safe one, acquiescence with this surely has an advantage to the patient; therefore the anaesthetist is fulfilling his responsibility to the patient and his duty to the surgeon. I would point out that as I explained in my article, the operating table is adjusted to be comfortable to the patient and provided that a satisfactory local anaesthetic has been administered, it seems unnecessary to supplement with a general anaesthetic. Concerning the availability of an open vein, I agree that this is a very good point; many of my colleagues do in fact insert the Mitchell needle at the beginning of the procedure. I think this is a matter of individual preference and experience. Drugs and equipment for resuscitation are, of course, at hand and ready for use. In reply to Dr. Walmsley (Brit. J. Anaesth., 35, 825), I feel that the pre-operative phenobarbitone largely counteracts the central nervous stimulant effects of large doses of lignocaine. We have not experienced any profound depressant effects resulting from the combined use of papaveretum. phenobarbitone and lignocaine as described, but, as I pointed out in my article, the doses are modified according to the age and general condition of the patient.
be better for trainee anaesthetists to acquire skill and experience in regional techniques rather than accept the result of Dr. Scott's trial as the answer to a not uncommon clinical situation.
CORRESPONDENCE after, so that in the event of vasomotor collapse or other untoward reactions occurring, either as a reaction to the local analgesic agent or to an inadvertent subarachnoid injection, appropriate action can be immediately undertaken without having to make a futile search for collapsed veins. An ampoule of vasopressor and a syringe should also be at hand. Dr. Buck states that mild toxic effects of lignocaine (drowsiness and muscular twitching) were sometimes seen. May these not be related to the large doses of lignocaine used, viz. 30-50 ml of 1| per cent solution (i.e. 450-750 mg)? JOHN G. FRANCIS
London
M. BUCK
Isleworth REDUCTION OF A DISLOCATED HIP WITHOUT GENERAL ANAESTHESIA
Sir,—Dr. Scott reports the case of a well-built youth who had a full stomach, a potential airway problem and an extremity injury which required prompt treatment and muscle relaxation (Brit. J. Anaesth., (1963), 35, 654). In such a case the contraindications to general anaesthesia are as obvious as the indications for a regional technique. An extradural block to T-10 by the sacral or lumbar route would have provided analgesia and muscle relaxation without affecting respiration, consciousness, airway or reflex protection against vomiting. Dr. Scott omitted to consider the alternative of a regional technique in his discussion. Perhaps it would
DAVID N. GOODSON
Tacoma Sir,—A* case of a patient with mandibular injuries, a full stomach, and a dislocated hip is discussed by Dr. Scott (Brit. J. Anaesth. (1963), 35, 654) but no mention is made of the fact that gallamine in doses insufficient to produce significant respiratory depression can cause serious respiratory obstruction when maxillo-facial injuries are present. The success of the gallamine-pethidine technique used in this case should not be taken as an indication for its use in all cases of this nature, particularly as one reason for its use seems to have been the uncertainty of the anaesthetist of ensuring an unobstructed airway. It would be interesting to know why subarachnoid or extradural block were not considered. If very definite contraindication to these existed, endotracheal intubation facilitated by topical anaesthesia and judicious use of pethidine and triflupromazine, or phentanyl and dehydrobenzperidol, could be attempted. J. W. R. MCINTYRE
Edmonton Sir,—Thank you for the opportunity of commenting on Dr. Goodson's letter. The comment is simple enough—I think he is perfectly correct; regional analgesia would have been far better in this case. The humble truth is that many anaesthetists in this country (myself included) are not thinking enough of regional techniques. This is obviously a fault, and there are probably several reasons for it. I can think of the following: (i) Trainee anaesthetists are not always taught such methods. They are thus not in a good position to carry them out when they reach more senior rank. (ii) Patients in England prefer to be put to sleep. This is the usual method in most hospitals, and there is consequently little "patient-to^patient" recommendation for techniques in which they remain awake during surgery. (iii) The special equipment necessary for the satisfactory performance of these techniques is often non-existent (there was no equipment for extradural block at the small hospital to which the case described was originally admitted), (iv) Non-routine techniques can be enormously time-consuming. This is unpopular with surgeons and theatre staff. The failure rate is higher in inexperienced hands, for example, in caudal and brachial plexus blocks. (v) Surgeons can, and do, refuse to operate under regional analgesia (maybe because of previous unsatisfactory experiences with inadequate incorrectly performed techniques). The above is only an impression and it is obvious from the literature that there are centres in U.K. where these techniques are in routine use and highly successful. But I feel that taking the country as a whole they are more the exceptions than the rule. The point of describing this case is to illustrate a possible technique. The relative safety and success of
Downloaded from http://bja.oxfordjournals.org/ at New York University on May 6, 2015
A copy of the above letter was forwarded to Dr. Buck, who replied as follows: Sir,—In reply to Dr. Francis, it is true that the surgeon requests the conditions described in my article, because with vast experience of performing partial gastrectomies he finds that this method of analgesia provides him with the most advantageous conditions for his particular operating technique. Provided that the method requested by a surgeon is a safe one, acquiescence with this surely has an advantage to the patient; therefore the anaesthetist is fulfilling his responsibility to the patient and his duty to the surgeon. I would point out that as I explained in my article, the operating table is adjusted to be comfortable to the patient and provided that a satisfactory local anaesthetic has been administered, it seems unnecessary to supplement with a general anaesthetic. Concerning the availability of an open vein, I agree that this is a very good point; many of my colleagues do in fact insert the Mitchell needle at the beginning of the procedure. I think this is a matter of individual preference and experience. Drugs and equipment for resuscitation are, of course, at hand and ready for use. In reply to Dr. Walmsley (Brit. J. Anaesth., 35, 825), I feel that the pre-operative phenobarbitone largely counteracts the central nervous stimulant effects of large doses of lignocaine. We have not experienced any profound depressant effects resulting from the combined use of papaveretum. phenobarbitone and lignocaine as described, but, as I pointed out in my article, the doses are modified according to the age and general condition of the patient.
be better for trainee anaesthetists to acquire skill and experience in regional techniques rather than accept the result of Dr. Scott's trial as the answer to a not uncommon clinical situation.