Pentothal sodium in anorectal surgery

PENTOTHAL

SODIUM IN ANORECTAL ANALYSIS RALPH

E.

SURGERY

OF 1,500 CASES CRIGLER,

M.D.

Fort Smith, Arkansas

T

HE author wishes in this article to present his observations as a surgeon of the use of pentotha1 sodium anesthesia given by a trained nurse anesthetist in 2,531 consecutive cases anesthetized for minor anorecta1 operations. Of these cases 1,500 were for operative procedures and 1,03 I for the postoperative removat of rectal packs. PentothaI sodium was first introduced as a new intravenous anesthetic in June, 1934, by Lundy. After the introduction of this drug it was beheved that its field had certain limitations, that it shouId be used onIy in minor operations not requiring over fifteen to twenty minutes and that it was not adaptabIe for use in recta1 surgery. Erroneous concIusions were drawn by severa who read the first few articles pubhshed and, as a resuIt, several fataIities were reported because of the improper administration of pentotha1 sodium. During the past fifteen years, however, much has been Iearned about this new drug and it has been successfuIIy used in a11 branches of surgery and in operations requiring from a few minutes to several hours of anesthesia. One outstanding feature of the literature on pentotha1 during 1943 was the frequent mention of its use in miIitary surgery in both combat and base areas. These reports indicate that pentotha1 sodium has been extensiveIy used in miIitary medicine and that it has been applied, either aIone or in conjunction with other anesthetic agents, for practicaIIy a11types of operative procedures. The frequency of the use of pentotha1 sodium anesthesia has varied in different miIitary organizations and it wouId appear that the agent is reIied upon more often as the operating team approaches or enters the combat area. Some miIitary anesthetists have reported that pentothal sodium was used in g5 per cent of their cases. A number of factors have contributed to this extensive use of pentotha1 in military surgery, nameIy, ready avaiIabiIity, ease of transport, simplified equipment, rapidity of induction and recovery, ease 140

of administration and control, and the Iow incidence of postoperative compIications. It was aIso noted that pentotha1 was particuIarIy we11toIerated by the type of patients requiring war surgery. PentothaI sodium is a derivative of barbituric acid. It differs from nembuta1 by the repIacement of I atom of oxygen by a suIfur atom on the urea side of the molecule. It is the trade name for sodium ethyl (I methyIbutyI), thiobarbituric acid. It is a lemon-coIored powder with a bitter taste and an odor simiIar to acetyIene gas. It dissoIves readily in distiIIed water and when dissoIved shouId form a cIear soIution with a yeIIow tinge. A cloudy soIution should not be utilized. OnIy fresh soIutions prepared within two hours shouId be given as deterioration occurs rapidIy. Pentothal sodium is a respiratory depressant with reIativeIy IittIe untoward action on the heart. In anima1 experimentation an overdose of pentotha1 affects the respiratory center before the cardiovascuIar center. Respiratory faiIure resuIts aIthough cardiac action may continue for fifteen to twenty minutes after the cessation of breathing. For this reason when respiratory faiIure does occur during pentothal anesthesia, artificia1 respiration, using oxygen with very Iight pressure, can be used effectiveIy. This depression is negIigibIe when pentothal is used in therapeutic amounts. If the drug is injected too rapidIy, respirations become shaIIow and cyanosis may occur aIthough the rate and rhythm of the heart are not inff uenced and any pre-existing irreguIarities remain unchanged. The hemogIobin, red bIood count, white bIood count, differentia1 and urinaIysis before, during and after anesthesia with pentotha1 show no noticeabIe change. The same is true for the bIood chemistry, incIuding the bIood sugar, non-protein nitrogen, uric acid, creatinine, coaguIation and bIeeding time. It must be emphasized, however, that pentotha1 sodium is Iike a11 other anesthetics in one respect: it is dangerous and can resuIt in a mortaIity unIess properly administered. For American

Journal

of Surgery

CrigIer-Pentothal this reason it should nc\.cr bc used in the physician’s oilice or in the patient’s home; it is a hospita1 procedure. As stated by several authors it is an ideal anesthetic because the patient has to recover only from the operation and not from the after-effects of the anesthetic such as folIow other general anesthetic agents. It is the consensus of most writers that pentotha1 decreases mortality, especially in the aged patients and those who are poor operative risks. U’e have been somewhat hesitant to use pentothal in chiIdren under ten to tweIve years of age. As a ruIe, in our hands these youngsters do not tolerate a barbiturate intravenously very. we11 because of their susceptibility to respiratory depression and the difficulty of maintaining a patent airway. Moreover, venipuncture is more diflicult because of their fear of the needIe and their small veins. In this series of 1,500 cases there were onIy five patients given pentothal sodium under the age of tweIve years. PREOPERATIVE

MEDICATION

In this series the patients were admitted to the hospita1 the day before surgery. A compIete bIood count, urinalysis, routine history and physica examination were made. Preoperatively, the patients were given a liquid diet for their evening meal, a cleansing enema, sodium amytal, 3 gr. and secona1, I>$ gr. at bedtime the evening preceding surgery. Variations in this routine were used with chiIdren and aged patients. Thirty minutes prior to surgery, dilaudid, gr. l
OF

PENTOTHAL

Different concentrations of pentothal sodium solutions ranging from .5 per cent to 5 per cent have been given and advantages have been claimed for the different concentrations. The consensus Ieans toward a 234 per cent solution as being the idea1 concentration. In this series only a 5 per cent solution was used. The patient is placed in the lateral Sims position and given I cc. of the drug over a period of four to six seconds, after which he was encouraged to talk or count. A second cc. was then given during a perioc1 of five to six seconds. This intermittent type of injection was repeated until the patient ceased to taIk or count. Light anesthesia was usualIy established within thirty to forty

January,

Ig$o

Sodium seconds. At this time the patient’s tongue was pulled forward and an airway was inserted to assure clear passage. Before the anesthetic was started the gas-oxygen machine was made avaiIabIe and metrazo1, picrotoxin, curare and coramine were in reach of the anesthetist. After inserting the airway the administration of pentothal was discontinued for thirty seconds and thereafter I to 2 cc. were injected at intervaIs as indicated. Indications for further injection were noted by slight movement of the extremities, reflex movements due to painful stimuli or an increase in depth of respiration. The best guide to the depth of anesthesia is During light anesthesia the rerespiration. spiratory excursions are full and in deep anesthesia the excursions became shaIlow. At the end of ninety seconds the operative field is prepared, draped and the sensibility of the patient is tested by gentIe digital rectal examination. If there is any reffex spasm, time is alIowed for the administration of another cc. or two of pentotha1. By using a 5 per cent soIution of pentotha1 sodium for anesthesia compIete surgica1 anesthesia is obtained much more quickly than when a 235 per cent soIution is used. In al1 these cases, unIess contraindicated by infection or abscess formation, 5 cc. of an oi1 anesthetic (zyIcaine) were injected in and about the periana1 region before any surgery was started. This oi1 anesthesia is used routineIy not to reinforce the sodium pentothal but because of its proIonged effect, Iasting some ten days to two weeks, which minimizes postoperative pain and discomfort. Oxygen was never used routinely. The gas-oxygen machine was available, however, and was used in less than 2 per cent of these cases when the respirations were shaIIow or a Iaryngospasm or cyanosis occurred. The amount of pentotha1 given varied from . I 3 to 2 Gm. The average duration of anesthesia from the time the anesthetic was started unti1 the patient awoke in the room was fifty-one minutes. The average time consumed for the operation was twenty minutes. As mentioned before this entire series concerns only minor anorecta1 surgery. Many of the individual patients had two or more separate pathologic processes. In spite of a11 that has been written about getting away from rectal packs and using oxyceI or gelfoam we stiI1 use the oId-fashioned recta1 pack of cotton and vaseIine gauze wrapped around a rubber catheter. We beIieve

CrigIer-Pentothal

142

there is less diffIcuIty in estabIishing adequate postoperative diIatation. In the past the removaI of these packs has caused the patient considerable pain, distress and spasm of the sphincter muscle which lasted for a number of hours. Since December, 1946, we have been

Sodium about from then on and either goes home that afternoon or the foIIowing morning. At the time this paper was written the packs were removed on the second postoperative day. Since March I, 1949, we have been using a sheet of oxyce1 gauze wrapped around the TABLE III PATIENTSU’ITHPHYSICALIMPAIRMENTS

No.

of

Cases

(:ryptitis.. Fist&-in-ano. Internal hemorrhoids External hemorrhoids.. ProIapsed hemorrhoids Fissure-in-ano. Recta1 abscess. lom ‘d a I cyst............................... P’I PoIyps..................................... Anal stricture. Pruritis ani.. PapJlitis.

1,341 211

925 141

56

201

“;; 22 25

‘15 120

TABLE AGE

o- 10 I v-20 20-30 30-40 40-V

II

IKCIDENCE

:

!

5040

60-70 70-80

80-90

84 170 176 104

3 ‘7

‘32 278 266

128

57

52

IO

‘4

0

I

609

891

,-----

Total

No.

Impairments Red blood count under 4,ooo,ooo. I lcmogfobin under 80 per cent. Alhuminuria.. Active tuberculosis. Blood pressure with systoIic pressure over 200.

of

CZXS 482

414 245 I3 ’0

Vaseline gauze. This forms a jelly-like dark substance. The pack all but comes out of its own accord the foIlowing morning at the end of twenty-four hours. This, of course, has nom eIiminated the pentotha1 anesthesia for the removal of packs. As shown by Table II the ages of these patients ranged from seven years to eighty-six years of age; 609 \vere maIes and 891 were femaIes. AIthough several authors insist there are no contraindications to the use of pentothal sodium if properIy administered, we have made note of a number of cases that couId be considered to have had physica impairments. The only compIications we have encountered, and none of them serious, were: TABLE

11

COMPLICATIONS

unduly proIonged:* I?,4 tozhr _..................... 88 zto3hr .._.................. 43 3to4 hr .._......_... 8 Laryngospasm. 22 Venous thrombosis. u) * The duration of anesthesia includes from the time the anesthetic was started in the operating room until the patient awoke in the room. Anesthesia

I removing these recta1 packs in the patient’s room under pentotha1 anesthesia. The patient is in a Iateral Sims position and 3 to 6 cc. of a 5 per cent soIution of pentotha1 sodium are given the patient intravenously. The pack is removed and continuous hot, wet, saIine packs are appIied to the rectum. Often these patients wiI1 wake up and start counting where they Ieft off. Sometimes the nurse has troubIe convincing them that they have been asIeep and that the pack has been removed. Since this procedure was started, 1,03 I patients have been treated without a single compIication. None of these patients has sIept over ten minutes and usuaIIy he is awake in three to five minutes. As a ruIe, the foIlowing morning the patient receives a saIine enema after which he is pIaced in a hot sitz bath. He is up and

We have found during the past tweIve to fourteen months that the undue proIongation of anesthesia can be prevented by the administration of I to 3 cc. of metrazo1 given intravenously when the patient Ieaves the operating room. The amount given is determined by the depth of anesthesia. With reference to thrombosis of the vein used in the cubita fossa none of these was serious; each one cleared up within ten to twenty-one days. Some surgeons may consider the incidence of postoperative complications as unusuaIIy American

.Journal

(4 Surger,y

Crigler-Pentothal high. All the complications reported, however, were very mild. An attempt was made to keep an accurate record of the slightest possible complication in order that pentotha1 sodium might he correctly evaluated from the standpoint of safety for anorectal operations. It is our belief that the complications which have occurred have been of sufficient mildness to justify our continuation of the use of this agent and are no worse or more numerous than those which WC have seen following the use of other spinal or local anesthetic agents. In our experience \ve have been satisfied with the use of pentothal sodium and hope to be abfe to continue it. CONCLUSIONS

Pentothal sodium has been demonstrated to be a safe anesthetic, if properly administered, in anorectal surgery, the use of pentothal sodium involves a minimum loss of time in the operating room for the production of surgical anesthesia and it is pIeasing to the patient as well as the surgeon inasmuch as postoperative nausea and vomiting are practically eliminated. REFERENCES I. ADAMS, R. C. Pentothal

sodium intravenous anesthesia in peace and war. J. A. M. A., 126: 282,

‘944. 2. BATTAGLIA, D. and WINNE,

3.

4. 5. 6.

B. A. PentothaI sodium anesthesia in major surgery. New York State J. Med., 44: 1120-1 123, 1944. CARRAWAY, C. N. and CARRAWAY, B. $1. Administration of pentotha1 sodium oxygen anesthesia. J. M. A. Alabama, 12: 325, 1943. INWARDS, S. and HAND, L. V. Intravenous anesthesia. S. C/in. Nortb America, 22: 925932, 1942. FISHER, K. Pentothal anesthesia as used in a smal1 hospita1. Kentucky M. J., 39: 145, 1941. IIESS, E. and MERSKI, A. T. Some observations in

Januwy,

r9p

Sodium

143

7. LONG, C. H. and OCHSNER, A. Intravenous pentothn1 sodium anesthesia. Surgery, I I : 474, 1942. 8. LUNDY, J. S. Intravenous and regional anesthesia. Ann. Surg., I IO: 878-885, 1939. 9. LUNDY, J. S. et al. Annual report for 1942 of section on anesthesia. f’roc. .StafP Meel., Mqo Clin., 18: 129, 1943. 10. PORTER, A. R. Intravenous anesthesia. Memphis M. J., 15: 3, ,940. I I. ROSE, A. T. Sodium pentotha1. Anestbe.sio/ngJ., 4: 534. 1943. I 2. SCIIEIFL~Y, C. H. Pentothat sodium. Anesthesiology, 7: 263, 1946. 13. SEARLES, P. W. and LENAHAM, R. M. Intravenous anesthesia. New York State J. Med., 48: 1699, 1948. 14. TUCKER, A. C. Intravenous anesthesia with pentothal sodium in genera1 surgery. Northwest Med., 38: 246, 1939. 15. CARRAWAY, C. N. and CARRAWAY, B. nl. Pcntothal-oxygen anesthesia. J. M. A. Alabamu, I 2: 325, 1943. i6. SEIXO, J. A. The medical department of :I battleship in action. ff. S. NW. ,W. S&l., 41: 1213, 1943. 17. ROSE, A. T. Sodium pentothal; actual experience in the combat zone. Anestbesiolog,y, 4: 534, 1943. 18. CARR, C. R. and LAMATHE, D. E. Sodium pentothal anesthesia in intra-ora surgery at sea. U. S. NW. M. Bull., 4 I : 1374, 1943. 19. MOORHEAD, J. D. Trends in war surgery; anesthesia. S. Clin. North America, 23: 313, 1943. 20. PICKRELL, K. L. and RICHARDS, R. K. Pentothalmetrazol antagonism. Ann. Surg., 121:495, 1945. 21. GOULD, R. B. Intravenous Anesthesia in War Surgery. Anestb. @ A&g., 25: II5, 1946. 22. MCALLISTER, F. F. The effect of pentotha1 sodium on mean arterial blood pressure in the presence of high spinal cord paraIysis. Ann. Surg., 124: 328, ;946. 2~. _, KOHN. R. and LEDERER. L. PentothaI studies with special reference to the electrocardiogram. J. Lab. 6~ Ciin. Med., 23: 717-728, 1938. 24. CARRAWAY, B. hl. Penthal sodium with nasa1 oxygen. Anestb. ey An&., 18: 259-269, 1939. 25. TOVELL, R. M. and GAROFALO, M. An evaIuation of intravenous anesthesia. New York State J. Med., 39: 21, 1939.