- Email: [email protected]
HUNTINGTON’S CHOREA
CORRESPONDENCE
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manifold outlet to prevent such a loss of oxygen. Bishop, Levick and Hodgson (1967) reported two accidents caused by this "fundamental fault in the design of the Boyle machine"; Katz (1968) and Liew and Ganendran (1973) reported similar accidents. In 1975, a report by Gupta and Varshneya, of a death attributable to the escape of oxygen through the washer intended to seal the top of a downstream flowmeter in a Boyletype machine, drew further comment (Muliyil, 1976; RcndellBaker, 1976; Varshney, 1976) through correspondence. There are two ways to eliminate this hazard. The simplest, mechanically, in the Boyle-type machine is to relocate the oxygen flowmeter to the right-hand side of the manifold. This could be performed in the hospital by the manufacturer's serviceman, thus requiring that the apparatus be out of service for a minimum time. This solution will require a re-education programme for anaesthetists similar to that mounted when the colours of gas cylinders were changed in the 1950's. The other more difficult and expensive solution would be to fit an internal conduit in the top of the flowmcter manifold to conduct the oxygen directly to the outlet of the manifold as described by Katz (1969). This would require the return of the flowmeter manifold to the manufacturer to be rebuilt or the purchase of a new flowmeter manifold incorporating the oxygen conduit. With present hospital budget problems the first solution— "oxygen on the right"—has both financial and mechanical arguments in its favour as a safety measure. After all, Henry Ford managed to persuade our fathers to change from a hand throttle on the steering wheel on his Model T to a foot-accelerator on the right with his Model A . . . would it really be so difficult to change to "oxygen to the right?" LESLIE RENDELL-BAKER
California, U.S.A. REFERENCES
Bishop, C , Levick, C. H., and Hodgson, C. (1967). A design fault in the Boyle apparatus. Br. J. Anaesth., 39, 908. Eger, E. I. n, Hylton, R. R., Irwin, R. H. et al. (1963). Anesthetic flowmeter sequence—a cause for hypoxia. Anesthesiology, 24, 396. Gupta, B. L., and Varshneya, A. K. (1975). Anesthetic accident caused by unusual leakage of Rotameter. Br.J. Anaesth., 47, 805. Katz, D. (1968). Recurring cyanosis of intermittent mechanical origin in anesthetized patient. Anesth. Analg. [Cleve.), 47, 233. (1969). Increasing the safety of anesthesia machines. I: Further modification of the Drager machine: II: Considerations for standardization of certain basic components. Anesth. Analg. (Cleve.), 48, 242. Uew, P. C , and Ganendran, A. (1973). Oxygen failure: a potential danger with air-flowmeters in anaesthetic machine with remote controlled needle valves. Br. J. Anaesth., 45, 1165. Muliyil, J. A. (1976). Anaesthetic accident caused by unusual leakage of Rotameter. Br. J. Anaesth., 48, 499. Powell, J. (1981). Leak from an oxygen flowmeter. Br. J. Anaesth., 53, 671. Rendell-Baker, L. (1976). Anaesthetic accident caused by unusual leakage or Rotameter. Br. J. Anaesth., 48, 500. Varshney, J. P. (1076). Anaesthetic accident caused by unusual leakage of Rotameter. Br. J. Anaesth., 48, 500.
HUNTCNGTON'J CHOREA
Sir,—Further to the article by Farina and Rauscher (1977), we report the successful anaesthetic management of two patients with Huntington's chorea. Two brothers presented with chronic left lower lobe consolidation and pleural effusion. Left pleura] decorrication was the Surgical treatment indicated. The elder (aged 25 yr) had frank manifestations of Huntington's chorea (dysarthria, dementia, atoxia, and choreifonn movements), while the younger (aged 19 yr) had early signs of the disease (ataxia, and occasional choreifonn movements). The patients received papaveretum and hyoscine before operation. Anaesthesia was induced with thiopentone. Suxamethonium facilitated bronchoscopy and tracheal intubation with a Robertshaw double-lumen tube. Further muscle relaxation was provided by pancuronium and analgesia by fentanyl and nitrous oxide. Both operations were uneventful. Neuromuscular blockade was antagonized with neostigmine and atropine. Davies (1966) suggested that patients with Huntington's chorea might be unduly sensitive to barbiturates. This problem did not arise with our patients. Gualandi and Bonfanti (1968) postulated that prolonged apnoea, as a result of abnormal plasma cholinesterase activity, may follow the use of depolarizing muscle relaxants. We measured plasma cholinesterasec concentrations before operation in both patients: Plasma cholinesterase: 0.73 and 0.61 iu ml"' (riormal values 0.6-1.4 iu ml" 1 Dibucaine numbers: 79 and 83 Fluoride numbers: 69 and 57 Probable genotype for both patients: E, U E, U We agree with the suggestion of Farina and Rauscher that the anaesthetic requirements of patients with Huntington's chorea can be provided by a nitrous oxide-narcotic combination, and successful management of myoneural blockade by pancuronium. M. G. BROWNE R. CROSS
Cardiff
REFERENCES
Davies, D. D. (1966). Abnormal response to anaesthesia in a case of Huntington's chorea. Br. J. Anaesth., 38, 490. Farina, J., and Rauscher, L. A. (1977). Anaesthesia and Huntington's chorea. A report of two cases. Br. J. Anaesth., 49, 1167. Gualandi, W., and Bonfanti, G. (1968). A case of prolonged apnoea in Huhtington's chorea. Ada Anaesthesiol. (Padova), 19, (Suppl. 6), 235.
ADVERSE REACTIONS TO I.V. ANAESTHETICS
In response to enquiries regarding the number of patients studied by Drs Beamish and Brown (Br.J. Anaesth., 53,55), we are pleased to publish the following letter from Dr Brown: The number of administrations of each induction agent— from which we calculated frequencies of reactions—was the total number of administrations of the anaesthetic including those in which other drugs, including relaxants, were used.
Downloaded from http://bja.oxfordjournals.org/ at New York University on July 1, 2015
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manifold outlet to prevent such a loss of oxygen. Bishop, Levick and Hodgson (1967) reported two accidents caused by this "fundamental fault in the design of the Boyle machine"; Katz (1968) and Liew and Ganendran (1973) reported similar accidents. In 1975, a report by Gupta and Varshneya, of a death attributable to the escape of oxygen through the washer intended to seal the top of a downstream flowmeter in a Boyletype machine, drew further comment (Muliyil, 1976; RcndellBaker, 1976; Varshney, 1976) through correspondence. There are two ways to eliminate this hazard. The simplest, mechanically, in the Boyle-type machine is to relocate the oxygen flowmeter to the right-hand side of the manifold. This could be performed in the hospital by the manufacturer's serviceman, thus requiring that the apparatus be out of service for a minimum time. This solution will require a re-education programme for anaesthetists similar to that mounted when the colours of gas cylinders were changed in the 1950's. The other more difficult and expensive solution would be to fit an internal conduit in the top of the flowmcter manifold to conduct the oxygen directly to the outlet of the manifold as described by Katz (1969). This would require the return of the flowmeter manifold to the manufacturer to be rebuilt or the purchase of a new flowmeter manifold incorporating the oxygen conduit. With present hospital budget problems the first solution— "oxygen on the right"—has both financial and mechanical arguments in its favour as a safety measure. After all, Henry Ford managed to persuade our fathers to change from a hand throttle on the steering wheel on his Model T to a foot-accelerator on the right with his Model A . . . would it really be so difficult to change to "oxygen to the right?" LESLIE RENDELL-BAKER
California, U.S.A. REFERENCES
Bishop, C , Levick, C. H., and Hodgson, C. (1967). A design fault in the Boyle apparatus. Br. J. Anaesth., 39, 908. Eger, E. I. n, Hylton, R. R., Irwin, R. H. et al. (1963). Anesthetic flowmeter sequence—a cause for hypoxia. Anesthesiology, 24, 396. Gupta, B. L., and Varshneya, A. K. (1975). Anesthetic accident caused by unusual leakage of Rotameter. Br.J. Anaesth., 47, 805. Katz, D. (1968). Recurring cyanosis of intermittent mechanical origin in anesthetized patient. Anesth. Analg. [Cleve.), 47, 233. (1969). Increasing the safety of anesthesia machines. I: Further modification of the Drager machine: II: Considerations for standardization of certain basic components. Anesth. Analg. (Cleve.), 48, 242. Uew, P. C , and Ganendran, A. (1973). Oxygen failure: a potential danger with air-flowmeters in anaesthetic machine with remote controlled needle valves. Br. J. Anaesth., 45, 1165. Muliyil, J. A. (1976). Anaesthetic accident caused by unusual leakage of Rotameter. Br. J. Anaesth., 48, 499. Powell, J. (1981). Leak from an oxygen flowmeter. Br. J. Anaesth., 53, 671. Rendell-Baker, L. (1976). Anaesthetic accident caused by unusual leakage or Rotameter. Br. J. Anaesth., 48, 500. Varshney, J. P. (1076). Anaesthetic accident caused by unusual leakage of Rotameter. Br. J. Anaesth., 48, 500.
HUNTCNGTON'J CHOREA
Sir,—Further to the article by Farina and Rauscher (1977), we report the successful anaesthetic management of two patients with Huntington's chorea. Two brothers presented with chronic left lower lobe consolidation and pleural effusion. Left pleura] decorrication was the Surgical treatment indicated. The elder (aged 25 yr) had frank manifestations of Huntington's chorea (dysarthria, dementia, atoxia, and choreifonn movements), while the younger (aged 19 yr) had early signs of the disease (ataxia, and occasional choreifonn movements). The patients received papaveretum and hyoscine before operation. Anaesthesia was induced with thiopentone. Suxamethonium facilitated bronchoscopy and tracheal intubation with a Robertshaw double-lumen tube. Further muscle relaxation was provided by pancuronium and analgesia by fentanyl and nitrous oxide. Both operations were uneventful. Neuromuscular blockade was antagonized with neostigmine and atropine. Davies (1966) suggested that patients with Huntington's chorea might be unduly sensitive to barbiturates. This problem did not arise with our patients. Gualandi and Bonfanti (1968) postulated that prolonged apnoea, as a result of abnormal plasma cholinesterase activity, may follow the use of depolarizing muscle relaxants. We measured plasma cholinesterasec concentrations before operation in both patients: Plasma cholinesterase: 0.73 and 0.61 iu ml"' (riormal values 0.6-1.4 iu ml" 1 Dibucaine numbers: 79 and 83 Fluoride numbers: 69 and 57 Probable genotype for both patients: E, U E, U We agree with the suggestion of Farina and Rauscher that the anaesthetic requirements of patients with Huntington's chorea can be provided by a nitrous oxide-narcotic combination, and successful management of myoneural blockade by pancuronium. M. G. BROWNE R. CROSS
Cardiff
REFERENCES
Davies, D. D. (1966). Abnormal response to anaesthesia in a case of Huntington's chorea. Br. J. Anaesth., 38, 490. Farina, J., and Rauscher, L. A. (1977). Anaesthesia and Huntington's chorea. A report of two cases. Br. J. Anaesth., 49, 1167. Gualandi, W., and Bonfanti, G. (1968). A case of prolonged apnoea in Huhtington's chorea. Ada Anaesthesiol. (Padova), 19, (Suppl. 6), 235.
ADVERSE REACTIONS TO I.V. ANAESTHETICS
In response to enquiries regarding the number of patients studied by Drs Beamish and Brown (Br.J. Anaesth., 53,55), we are pleased to publish the following letter from Dr Brown: The number of administrations of each induction agent— from which we calculated frequencies of reactions—was the total number of administrations of the anaesthetic including those in which other drugs, including relaxants, were used.
Downloaded from http://bja.oxfordjournals.org/ at New York University on July 1, 2015
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1367