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Premedication and inhalation anesthesia for tonsil and adenoid operations in young children
PREMEDICATION AND INHALATION ANESTHESIA FOR TONSIL AND ADENOID OPERATIONS IN YOUNG CHILDREN* A HUMANE
AND SAFE METHOD
JAMES T. GWATHMEY, M.D. NEW YORK CITY
T
HE method herewith presented is humane because it ehminates that most distressing mentaI state, fear. It has been stated that “to frighten a chiId is a serious matter, which may adverseIy influence its future Iife and irreparabIy injure its whoIe nervous system. Any measure which wiI1 prevent the chiId from being frightened shouId be encouraged.“’ Yet how very common is the practice of struggIing holding a crying, frightened, chiId, administering straight ether, and compeIIing him to undergo something which he instinctiveIy dreads. Such a procedure often leaves an ineffaceabIe memory scar that quite naturaIIy resuIts in an intense hatred for and distrust of doctors, nurses, and hospitaIs. The upset to a highIy neu,rotic chiId may be more than a mere memory scar. I know of one patient who has stuttered ever since undergoing a tons;1 operation performed under ether anesthesia with no preIiminary medication. Another was for sometime under the care of a psychiatrist fw a menta1 condition that foIIowed a tonsi operation without preIiminary medication. Immediate or postoperative death occain tonsi and adenoid sionaIIy occurs operations, but this is much Iess IikeIy to happen with preIiminary medication. Anesthesia for adenoid and ton&I operations is decidedIy the most diffIcuIt in a11 surgery. The usua1 methods of inducing anesthesia in young chiIdren with ether, without preIiminary medication, are unsafe, as the margin between deep surgica1 anesthesia and toxicity is reduced to a minimum. * Read before Section
of OtoIaryngoIogy,
Furthermore, there is a possibiIity of pneumonia or Iung abscess. Straight chIoroform, with or without preIiminary medication, whiIe Iess irritating than ether, is unjustifiabIe because of its possibIe harmfu1 effects upon the heart2 and Iiver?” an unnecessary doubIe hazard. The method to be described is safe because (I) premeditation insures a smooth induction of the anesthesia, (2) the anesthesia is at a11 times under perfect contro1, (3) the fieId of operation is dry and cIear, and (4) postoperative contingencies and compIications are eriminated. The basis for the technique herewith presented rests upon Iaboratory experimentation4v5 and cIinica1 experience. Clinical Experience. The idea1 state or condition of a chiId previous to operation is a deep sIeep. The procedure that we evoIved at the City HospitaI, WeIfare IsIand, New York City, gives just that in the majority of cases. It aboIishes the possibiIity of psychic impuIses and enabIes the operator to start his work with the patient having a dry throat. Mucus and saIiva are not present at any time. The margin of safety and the contro1 of the pIane of anesthesia are so great that the surgeon can proceed with the same care and precision he wouId empIoy as in other operations. Over tweIve hundred cases have demonstrated that a deep sleep for a chiId previous to operation is perfectIy safe and requires no unusua1 precautions, and that there is absoIute contro1 of the pIane of deep anesthesia when reached, whether the operation Iasts three minutes or an
New York Academy 272
of Medicine,
December
19, 1934.
NEW
SERIES
VOL. XxX1,
No.
z
Gwathmey-Premeditation,
hour or more. Laboratory and cIinica1 experience prove that anesthesia comes on more quickIy after the administration of preliminary medication, Iess anesthetic is required, and the margin between compIete anesthesia and respiratory paraIysis is increased. Recovery is aIso more normaI and quiet. Furthermore, with this technique, one anesthetist does the work of two, and the services of an orderIy to hoId the patient are not required. TECHNIQUE
Preliminary Medication. It is desirable to give the chiId a bicarbonate of soda enema upon admission. Thirty or forty minutes before operation, with the patient in bed, nembuta16s7 (pentobarbita1 sodium) dissoIved in one ounce of water is given by mouth. If, for any reason, swaIIowing is d&uIt, the nembuta1 may be given per rectum in 4 C.C. of coId water. If given one hour before operation, the patient is awake when brought to the operating room, thus defeating the purpose for which the nembuta1 is given. The dose varies according to age, size, and condition of the patient. GeneraIIy it is as foIIows: Up to seven years of age, I .5 grams (one capsuIe) ; seven to ten years, 2 grains; ten years and over, 3 grains (two capsuIes). For adoIescents the dose of the barbiturate is preferabIy increased, or a suitabIe amount of morphin derivative may be added. Over go per cent of our patients are asleep within fifteen minutes. With care in Iifting the patient from the bed (which shouId be accomplished by means of sheets or Iifter in preference to hands) to the stretcher, he reaches the operating room asleep. Where time is essential, the operation may be performed whiIe the patient is on the stretcher. A smaI1 piIIow is pIaced under the shouIders and neck. The Anesthesia. There are two methods of continuing the sIeep induced by the prehminary medication into deep surgica1 anesthesia without awakening the child. The jrst and simpIest, and perhaps the
Anesthesia
A merican
Journd d surgery
273
method that wiI1 be most generaIIy used, is to pIace a modified Yankauer mask or a piece of gauze near the face, but not touching it, and to spray a smaI1 amount of ethy1 chIoride on the mask or gauze. As the sense of smeI1 is Iost, the mask may touch the face, whiIe the spray is continued unti1 the rhythmic movement of the diaphragm indicates surgical anesthesia. The ether drop is now commenced. After the patient is in surgica1 anesthesia by the drop method, the usua1 air-ether vapor is used. With preIiminary medication, there is a consequent Iessening of the amount of ether necessary to maintain anesthesia.8 The disadvantage of this method is that it Iacks the eIasticity of the method to be described, and the patient usuaIIy Ieaves the table in deep anesthesia. The second and better method foIIows the same procedure unti1 the patient is brought to the operating room, when the sIeep is converted into anesthesia by giving ethyIene and oxygen with a smaI1 amount of ether, using the vapor mask covered with a moist toweI,g (not a face mask and bag). (If not entireIy asIeep, first use nitrous oxide and oxygen before giving the ethyIene.) In two or three minutes the patient’s automatic respirations indicate surgica1 anesthesia. The ether tube or nasa1 catheter now replaces the vapor mask and the anesthesia is continued. With ethylene, water, and not the usua1 motor suction, must be used. With oxygen and ethyIene, instead of air, as the propeIIing agents, a greater eIasticity and better contro1 resuIt and reduce the amount of ether to a minimum. When the adenoidectomy is started, a11 anesthetics are turned off and the patient is given oxygen and carbon dioxide,‘O so that when he Ieaves the tabIe, the throat reflex is present, thus reducing to a minimum the possibiIity of pneumbnia or Iung abscess. As the operation is concIuded, the patient faIIs back into a quiet sleep which Iasts from thirty minutes to an hour, thereby giving the throat a Ionger rest than when preoperative medication is not used.
2 74
American Journal of Surgery
Gwathmey-Premeditation,
If Iigatures have been used and cIots formed, this rest is important in preventing postoperative hemorrhage. As the operative fieId is free from mucous and saIiva and as a smaIIer amount of ether is used, aIthough the pIane of anesthesia is just as deep, there is Iess irritation postoperativeIy, Iess possibiIity of infection, and nausea and vomiting are The combination and usuaIIy absent. sequences outIined are safer than any one anesthetic, i.e., ether, nitrous oxide, or ethyIene aIone. This statement is the resuIt of an anaIysis of over 488,000 anesthesias recorded in the United States.ll The anesthesia induced by the technique advocated is as near idea1 as is possibIe with an inhaIation anesthetic, as evidenced by the patient’s puIse, quiet, deep respiration, pink color, and smaI1 pupi1. The anesthetists at the City HospitaI have had no diffIcuIty in mastering the methods outIined. SUMMARY
A method of premeditation and anesthesia of young chiIdren for tonsi and adenoid operations is presented. The foIIowing are its advantages: (I) eIimination of
Anesthesia
,FEBRUAHY, 1936
preoperative fear, (2) easier induction and maintenance of anesthesia (3) earIier return of the throat reffex, and (4) absence of postoperative nausea and vomiting. REFERENCES I. SINGTON, H. Premeditation by paraIdehyde in children. Proc. Roy. Sot. Med., 22: 1197-1198, 1929. Disc., 1199-1200. 2. SOLLMAN, TORALD. A ManuaI of PharmacoIogy. 3rd Edition, p. 712. 3. BEVAN, A. D., and FAVILL, H. B. Acid intoxication, and late poisonous effects of anesthetics. J. A. M. A., 45: 691-696; 754-759, 1905. A. GWATHMEY. J. T. Genera1 Anesthesia. Nelson’s New Loo~?-Leaf .%?‘gery. I: 503-532 G, 1932. Work by Hooper and Gwathmey reported on P. 515. 5. GWATHE~LY,J. T. Same. Work by Wallace reported On p. 5 13. 6. GWATHMEY, J. T. The Barbiturates a safe preIiminarv medication for suraicaI onerations. J. A. ti. A., 103: 1536-1537, I9;4. A 7. HALSEY, J. T. The Effects of barbiturates and morphin in ether anesthesia. Anestb. em A&g., 13: 204-205. 1934. 8. BARLOW, 0. W., FIFE, G. L., and HODGINS, A. C. Arch. Surg., 29-527, 1934. 9. GWATHMEY, J. T. The open method of nitrous oxide-oxygen anesthesia. Am. J. Surg., 34: Anesthe& SuppI., 104-106, Oct., 1920. IO. HENDERSON, Y., HAGGARD, H. W., and COBURN, R. C. The theraoeutic use of carbon dioxide after anesthesia and operation. J. A. M. A., 74: 783-786, 1920. I I. GWATHMEY, J. T. Anesthesia, 1st Edition p. 857. I
AND SAFE METHOD
JAMES T. GWATHMEY, M.D. NEW YORK CITY
T
HE method herewith presented is humane because it ehminates that most distressing mentaI state, fear. It has been stated that “to frighten a chiId is a serious matter, which may adverseIy influence its future Iife and irreparabIy injure its whoIe nervous system. Any measure which wiI1 prevent the chiId from being frightened shouId be encouraged.“’ Yet how very common is the practice of struggIing holding a crying, frightened, chiId, administering straight ether, and compeIIing him to undergo something which he instinctiveIy dreads. Such a procedure often leaves an ineffaceabIe memory scar that quite naturaIIy resuIts in an intense hatred for and distrust of doctors, nurses, and hospitaIs. The upset to a highIy neu,rotic chiId may be more than a mere memory scar. I know of one patient who has stuttered ever since undergoing a tons;1 operation performed under ether anesthesia with no preIiminary medication. Another was for sometime under the care of a psychiatrist fw a menta1 condition that foIIowed a tonsi operation without preIiminary medication. Immediate or postoperative death occain tonsi and adenoid sionaIIy occurs operations, but this is much Iess IikeIy to happen with preIiminary medication. Anesthesia for adenoid and ton&I operations is decidedIy the most diffIcuIt in a11 surgery. The usua1 methods of inducing anesthesia in young chiIdren with ether, without preIiminary medication, are unsafe, as the margin between deep surgica1 anesthesia and toxicity is reduced to a minimum. * Read before Section
of OtoIaryngoIogy,
Furthermore, there is a possibiIity of pneumonia or Iung abscess. Straight chIoroform, with or without preIiminary medication, whiIe Iess irritating than ether, is unjustifiabIe because of its possibIe harmfu1 effects upon the heart2 and Iiver?” an unnecessary doubIe hazard. The method to be described is safe because (I) premeditation insures a smooth induction of the anesthesia, (2) the anesthesia is at a11 times under perfect contro1, (3) the fieId of operation is dry and cIear, and (4) postoperative contingencies and compIications are eriminated. The basis for the technique herewith presented rests upon Iaboratory experimentation4v5 and cIinica1 experience. Clinical Experience. The idea1 state or condition of a chiId previous to operation is a deep sIeep. The procedure that we evoIved at the City HospitaI, WeIfare IsIand, New York City, gives just that in the majority of cases. It aboIishes the possibiIity of psychic impuIses and enabIes the operator to start his work with the patient having a dry throat. Mucus and saIiva are not present at any time. The margin of safety and the contro1 of the pIane of anesthesia are so great that the surgeon can proceed with the same care and precision he wouId empIoy as in other operations. Over tweIve hundred cases have demonstrated that a deep sleep for a chiId previous to operation is perfectIy safe and requires no unusua1 precautions, and that there is absoIute contro1 of the pIane of deep anesthesia when reached, whether the operation Iasts three minutes or an
New York Academy 272
of Medicine,
December
19, 1934.
NEW
SERIES
VOL. XxX1,
No.
z
Gwathmey-Premeditation,
hour or more. Laboratory and cIinica1 experience prove that anesthesia comes on more quickIy after the administration of preliminary medication, Iess anesthetic is required, and the margin between compIete anesthesia and respiratory paraIysis is increased. Recovery is aIso more normaI and quiet. Furthermore, with this technique, one anesthetist does the work of two, and the services of an orderIy to hoId the patient are not required. TECHNIQUE
Preliminary Medication. It is desirable to give the chiId a bicarbonate of soda enema upon admission. Thirty or forty minutes before operation, with the patient in bed, nembuta16s7 (pentobarbita1 sodium) dissoIved in one ounce of water is given by mouth. If, for any reason, swaIIowing is d&uIt, the nembuta1 may be given per rectum in 4 C.C. of coId water. If given one hour before operation, the patient is awake when brought to the operating room, thus defeating the purpose for which the nembuta1 is given. The dose varies according to age, size, and condition of the patient. GeneraIIy it is as foIIows: Up to seven years of age, I .5 grams (one capsuIe) ; seven to ten years, 2 grains; ten years and over, 3 grains (two capsuIes). For adoIescents the dose of the barbiturate is preferabIy increased, or a suitabIe amount of morphin derivative may be added. Over go per cent of our patients are asleep within fifteen minutes. With care in Iifting the patient from the bed (which shouId be accomplished by means of sheets or Iifter in preference to hands) to the stretcher, he reaches the operating room asleep. Where time is essential, the operation may be performed whiIe the patient is on the stretcher. A smaI1 piIIow is pIaced under the shouIders and neck. The Anesthesia. There are two methods of continuing the sIeep induced by the prehminary medication into deep surgica1 anesthesia without awakening the child. The jrst and simpIest, and perhaps the
Anesthesia
A merican
Journd d surgery
273
method that wiI1 be most generaIIy used, is to pIace a modified Yankauer mask or a piece of gauze near the face, but not touching it, and to spray a smaI1 amount of ethy1 chIoride on the mask or gauze. As the sense of smeI1 is Iost, the mask may touch the face, whiIe the spray is continued unti1 the rhythmic movement of the diaphragm indicates surgical anesthesia. The ether drop is now commenced. After the patient is in surgica1 anesthesia by the drop method, the usua1 air-ether vapor is used. With preIiminary medication, there is a consequent Iessening of the amount of ether necessary to maintain anesthesia.8 The disadvantage of this method is that it Iacks the eIasticity of the method to be described, and the patient usuaIIy Ieaves the table in deep anesthesia. The second and better method foIIows the same procedure unti1 the patient is brought to the operating room, when the sIeep is converted into anesthesia by giving ethyIene and oxygen with a smaI1 amount of ether, using the vapor mask covered with a moist toweI,g (not a face mask and bag). (If not entireIy asIeep, first use nitrous oxide and oxygen before giving the ethyIene.) In two or three minutes the patient’s automatic respirations indicate surgica1 anesthesia. The ether tube or nasa1 catheter now replaces the vapor mask and the anesthesia is continued. With ethylene, water, and not the usua1 motor suction, must be used. With oxygen and ethyIene, instead of air, as the propeIIing agents, a greater eIasticity and better contro1 resuIt and reduce the amount of ether to a minimum. When the adenoidectomy is started, a11 anesthetics are turned off and the patient is given oxygen and carbon dioxide,‘O so that when he Ieaves the tabIe, the throat reflex is present, thus reducing to a minimum the possibiIity of pneumbnia or Iung abscess. As the operation is concIuded, the patient faIIs back into a quiet sleep which Iasts from thirty minutes to an hour, thereby giving the throat a Ionger rest than when preoperative medication is not used.
2 74
American Journal of Surgery
Gwathmey-Premeditation,
If Iigatures have been used and cIots formed, this rest is important in preventing postoperative hemorrhage. As the operative fieId is free from mucous and saIiva and as a smaIIer amount of ether is used, aIthough the pIane of anesthesia is just as deep, there is Iess irritation postoperativeIy, Iess possibiIity of infection, and nausea and vomiting are The combination and usuaIIy absent. sequences outIined are safer than any one anesthetic, i.e., ether, nitrous oxide, or ethyIene aIone. This statement is the resuIt of an anaIysis of over 488,000 anesthesias recorded in the United States.ll The anesthesia induced by the technique advocated is as near idea1 as is possibIe with an inhaIation anesthetic, as evidenced by the patient’s puIse, quiet, deep respiration, pink color, and smaI1 pupi1. The anesthetists at the City HospitaI have had no diffIcuIty in mastering the methods outIined. SUMMARY
A method of premeditation and anesthesia of young chiIdren for tonsi and adenoid operations is presented. The foIIowing are its advantages: (I) eIimination of
Anesthesia
,FEBRUAHY, 1936
preoperative fear, (2) easier induction and maintenance of anesthesia (3) earIier return of the throat reffex, and (4) absence of postoperative nausea and vomiting. REFERENCES I. SINGTON, H. Premeditation by paraIdehyde in children. Proc. Roy. Sot. Med., 22: 1197-1198, 1929. Disc., 1199-1200. 2. SOLLMAN, TORALD. A ManuaI of PharmacoIogy. 3rd Edition, p. 712. 3. BEVAN, A. D., and FAVILL, H. B. Acid intoxication, and late poisonous effects of anesthetics. J. A. M. A., 45: 691-696; 754-759, 1905. A. GWATHMEY. J. T. Genera1 Anesthesia. Nelson’s New Loo~?-Leaf .%?‘gery. I: 503-532 G, 1932. Work by Hooper and Gwathmey reported on P. 515. 5. GWATHE~LY,J. T. Same. Work by Wallace reported On p. 5 13. 6. GWATHMEY, J. T. The Barbiturates a safe preIiminarv medication for suraicaI onerations. J. A. ti. A., 103: 1536-1537, I9;4. A 7. HALSEY, J. T. The Effects of barbiturates and morphin in ether anesthesia. Anestb. em A&g., 13: 204-205. 1934. 8. BARLOW, 0. W., FIFE, G. L., and HODGINS, A. C. Arch. Surg., 29-527, 1934. 9. GWATHMEY, J. T. The open method of nitrous oxide-oxygen anesthesia. Am. J. Surg., 34: Anesthe& SuppI., 104-106, Oct., 1920. IO. HENDERSON, Y., HAGGARD, H. W., and COBURN, R. C. The theraoeutic use of carbon dioxide after anesthesia and operation. J. A. M. A., 74: 783-786, 1920. I I. GWATHMEY, J. T. Anesthesia, 1st Edition p. 857. I