Neurolept analgesia

Anesthesiology

Neurolept analgesia An anesthetic

technique

for patients

with

multiple

injuries

Frederick E. Jacksoq Commander (MC) USN,” and Henry J. Sazima, Commander (DC) USN” NAVAL

HOSPITAL,

CAMP

PENDLETON,

CALIF.

S

urgeons responsible for the care of patients following trauma have sought an analgesic agent that may be used safely in patients with multiple severe injuries.s During the current conflict in Vietnam halothane and methoxy Fluothane have been widely used as anesthetic agents, but they may exert undesirable depressant effects upon the myocardium and are occasionally associated with hypotension. Cyclopropane is inflammable and explosive and, therefore, has been little used as an anesthetic agent in Vietnam. Neurolept analgesia (NLA) has recently been used at the Naval Hospital, Camp Pendleton, California, as an anesthetic which has certain advantages over previously administered anesthetics in patients suffering trauma involving the head and face. Neurolept analgesia (NLA) is a state of tranquilization and analgesia with little or no hypnosis. As the name suggests, it is produced by a combination of tranquilizer (sometimes called a neuroleptic) and a potent narcotic. Through its action on subcortical areas, NLA provides selective blockade of pain, while leaving cortical and cardiovascular functions relatively intact. Thus, the neurolept analgesic mixture will enable the patient to undergo most diagnostic proThe opinions or assertions in this paper are those of the authors and are not to be construed as official or reflecting the views of the Navy Department or the naval service at large. Research for this paper was supported by Bureau of Medicine and Surgery, Navy Department, Research Work Unit Grants MROO5.20-02OlA and MR005.19~0058A. Reprint requests should be addressed to Commander Frederick E. Jackson, Department of Neurosurgery, Naval Hospital, Camp Pendleton, Calif. 92055. *Chief, Department of Neurosurgery. **Department of Oral Surgery.

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Neurolept

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cedures and certain types of surgical procedure without discomfort and yet remain responsive and cooperative. Neurolept analgesia has been defined as a condition of the central nervous system characterized by (1) somnolence without loss of consciousness, (2) psychologic detachment from environment, (3) suppression of reflexes, (4) analgesia, and (5) amnesia, which may not always be complete.2 The use of NLA is illustrated in the following report of a patient with multiple cranial and facial injuries and with a complicating Pseudomonas pulmonary infection. Extensive cranial and facial surgery was performed with the help of local anesthesia supplemented by intravenous Innovar. The patient was alert, breathed spontaneously, and maintained stable vital signs and urine output throughout the procedure. CASE REPORT A 34-year-old Marine was admitted to the Naval Hospital at Camp Pendleton, California, in a coma after having driven his car into a bridge abutment at a high rate of speed. Physical examination revealed that the majority of the injuries centered about the head, face, and thorax (Fig. 1). The patient was dyspneic, had Cheyne-Stokes respiration, and had aspirated blood and gastric contents prior to admission. There was a large laceration in the right supraorbital area, as well as soft-tissue swelling of the forehead and entire face. There were right posterior frontal scalp and left posterior parietal scalp lacerations. A mixture of blood and spinal fluid was issuing from both nostrils, and there was spinal fluid otorrhea issuing from the left ear. Thora.& contusions were visible, and coarse rhonchi were present on auscultation of both lung fields. A chest film revealed pulmonary contusion bilaterally, more marked on the right side. Roentgenograms of the skull (Pig. 2) revealed a crescentic bilateral frontal fracture involving the superior portion of the frontal sinuses and a fr,acture of the zygomatic process of the right frontal bone with separation of the superior lateral margin of the right orbit. There were multiple fractures of the nasal bones and fractures through both zygomatic bones. There was a bilateral, comminuted fracture of the maxilla with a free floating maxilla with depression of the middle third of the face. This represented a LeForte Type 3 fracture with resultant craniofacial disjunction. In the emergency room, following administration of a local anesthetic agent., a tracheostomy was performed and the tracheobronchial tree was cleansed. The patient was treated for shock; a nasogastric tube was inserted, and the gastric contents were aspirated. After the vital signs had stabilized, the patient was taken to the main operating room for definitive surgical intervention. Following induction of endotracheal general anesthesia, the multiple scalp lacerations were debrided and sutured. Open reductions of the right supraorbital and zygomatic fractures mere accomplished via a right eyebrow-forehead laceration. The right zygomatic arch was reduced through the same incision after the orbital suture lines were fixed with transosseous wires. The left zygoma was also treated by open reduction at the frontozygomatic suture line, with wire fixation after reduction by the malar hook technique. Suspension wires were passed bilaterally into the mouth from the zygomatic processes of the frontal bone. Arch bars were applied, and bilat,eral transoral open reductions of the body of the mandible were accomplished. The suspension wires were applied to the mandibular appliance with intermaxillary elastic traction to re-establish the dental occlusion and correct facial profile length. Postoperatively, the patient gradually recovered lucidity but developed Pseudomonas pneumonia in the right lower lung field (Pig. 3). Although the left otorrhea stopped spontaneously, profuse spinal fluid rhinorrhea eontinued. Thus, it was essential to repair the spinal fluid leak before the patient developed meningitis. As Pseudomonas was present in the lungs, we wished to avoid the use of an

208

Jackson and Saxinza

Fig. 1. Patient on admission and scalp lacerations overlying mandibular fractures.

Oral Surg. February, 1970

showing multiple

trauma to scalp and face with soft-tissue swelling frontal bone, nasal, zygomatic, maxillary, and

Fig. 8. Roentgenogram on admission showing multiple fractures of frontal bone over frontal sinus., nasal bones, both zygomatic bones and zygomatic processes, and bilateral oblique maxdlary fractures (LeForte Type 3) and bilateral mandibular fractures.

Ncurolept analgesia 209

Volume 29 Number 2

1Yig. 3. Area inter ,vention.

of

Pseudomonas

Fig. 4. Complete postoperative

pneumonia

resolution

in right

lower

of Pseudomonas

lung

field

prior

to surgical

pneumonia.

inhalation anesthetic. After consultation with the anesthesiologist, Innovar combined with a local anesthetic was selected. A bilateral frontal osteoplastic craniotomy was performed with the Hall Neurairtome. The dural lacerations were sutured, and the entire anterior cranial fossa was covered with fascia lata taken from the thigh. The patient was completely conscious during the entire operation and was able to answer questions lucidly and coherently. He felt no pain during the procedure and had partial amnesia for the operation postoperatively. Analgesia extended well into the recovery period. The Pseudomonas pneumonia cleared rapidly after treatmerrt with intravenous Coly-Mycin and IPPB, and external curaisse assisted respirations (Pig. 4). The facial suspension wires were removed 6 weeks postoperatively. Eight weeks postoperatively, the patient had no physical or nourologic deficit other than bilateral anosmia as a result of the division of the olfactory tracts, which was necessary to effect complete covering and repair

210

Oral Surg. February, 1970

Jackson and Sazima

Fig. 5. Patient well-healed multiple

2 months after facial lacerations

injury. Note well-healed and surgical scars.

bicorond

craniotomy

of the dural defects in the anterior cranial fossa at the time of surgical There has been no recurrence of the cerebrospinal fluid rhinorrhea.

intervention

scar and

(Fig.

5).

DISCUSSION The neuroleptic state is characterized by (1) disconnection-mental withdrawal from the immediate situation, (2) hypomobility with disinclination to move, (3) homeostatic stabilization by blockage of alpha-adrenergic receptors, and (4) a potent antiemetic effect. In this particular case it was the ability to obtain complete analgesia without recourse to inhalation anesthetic that prompted our use of Innovar. The proprietary Innovar is a mixture of droperidol, 2.5 mg. per milliliter, combined with fentanyl, 0.05 mg. per milliliter, a ratio of 50 :l. Fentany149 6 is a narcotic that is 100 times as potent as morphine and 500 times as potent as meperidine (Demerol) . The addition of the droperidol, which is a tranquilizer similar in its effects to chlorpromazine, adds, in addition to a tranquilizing effect, a powerful antiemetic, antifibrillatory, blockade assures and alpha-adrenergic blocking action. This alpha-adrenergic unusual vascular stability. Its dilating effect on the peripheral vascular bed provides optimal capillary perfusion in patients suffering from sudden hemorrhage or shock. Hence, Innovar may well find increasing usefulness in the management of severely wounded patients, including war-wounded patients with shock. Two further advantages of neurolept analgesia are that nausea and vomiting during induction and in the postoperative period are virtually absent and that analgesia extends well into the postoperative period. In a study of 156

Jeurolept

analgesia

211

patients in whom Innovar anesthesia was used, Martin and associates5 found that only three patients had nausea or emesis during the postoperative period. Respirations were controlled in all cases. Three of their 156 patients had postoperative respiratory depression and six had hypotension or vascular collapse. Two moribund patients died 10 and 36 hours postoperatively. Innovar has a further field of usefulness in patients with severe facial fractures and bleeding, where it is not possible to apply a mask and therefore dangerous to use muscle relaxants during intubation. Spoerel’ was able to carry out intubation safely without haste by utilizing Innovar analgesia. No analgesic or anesthetic agent is perfect, and Innovar does not give good muscular re1axation.l If muscular relaxation is required, a suitable muscle relaxant must be added. In addition, hypoventilation may occur shortly after the administration of Innovar, with concomitant decrease in pulmonary compliance. This may be counteracted by the administration of succinylcholine. SUMMARY It is neurophysiologically possible to block pain perceptions without completely abolishing wakefulness and without the necessity of resorting to a general inhalation anesthetic. It is this combination of properties that makes Innovar a particularly useful anesthetic agent in the management of certain severely traumatized patients with cranial, brain, and facial injuries and pulmonary complications. We have also found Innovar to be a useful analgesic agent for carotid angiography. , REFERENCES 1. 2.

3. 4. 5. 6. 7.

Bechtoldt, A. A., and Murray, W. J.: Innovar Induced Respiratory Depression, Anesth. Analg. 47: 395-398, 1968. Berenvi. I. J.. Sakara. I.. and Snow. J. C!.: Innovar Nitrous Oxide Anesthesia in otolaiyigology; Laryngdscope 76: 772, 1966. Corssen, G. : Neurolept Analgesia and Anesthesia : Its Usefulness in Poor-Risk Surgical Cases, Southern Med. J. 59: 801809, 1966. Jannsen, P. A. J., Niemegeers, C. J. E., and Deny, J. G. H.: The Inhibitory Effect of Fentanyl and Other Morphine-Like Analgesics on the Warm Water Induced Tail Wit,hdrawal Reflex in Rats, Arzneimittelforschung 13: 562, 1963. Martin, 5. J., Murphy, J. D., Colliton, R. J., and Zeffiro, R. 0.: Clinical Studies with l$‘,“,“,“n’, $nesthesiology 28: 458463, 1967. . Origin and Rationale of Neurolept-Analgesia, Anesthesiology 24: 267-268, 1963. ’ .* Some Problems Spoerel, W. E.: Anaesthesia for the Patient With Multiple Injuries: Concerning Anaesthetic Management Illustrated by a Case Report, Canad. Anaesth. Sot. J. 14: 49-58, 1967.