RED-CELL SUSPENSION TRANSFUSIONS

RED-CELL SUSPENSION TRANSFUSIONS

107 RED-CELL SUSPENSION TRANSFUSIONS M D LEEDS, M R C P LESLIE CENTENARY AND HARDWICK RESEARCH FELLOW, UNIVERSITY OF LEEDS WATSON, RED-CELL susp...

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107

RED-CELL

SUSPENSION

TRANSFUSIONS

M D LEEDS, M R C P LESLIE CENTENARY AND HARDWICK RESEARCH FELLOW, UNIVERSITY OF LEEDS

WATSON,

RED-CELL suspension transfusions have been favourably,reported on by Robertson (1918), Castellanos (1937),

on the same sample of blood, which contained 11-6 g. of Hb. per 100 ml., was 1-8%. Since the coefficient of variation of haemoglobin estimations is less than that of red. cell counting, the former values have been used in drawing conclusions about the effects of transfusion. For the purpose of calculating the colour-index, 14-5 g. of Hb. per 100 ml. has been taken to represent 100% hsemoglobin.

estimations

Before transfusion, major and minor cross-matching of donor’s and recipient’s blood was carried out; in no (1939), MacQuaide and Mollinson (1940), Whitby (1941), instance was incompatibility encountered, but in one case Vaughan (1941), Davidson and Stewart (1941), and cold agglutinins a course of trans Williams and Davie (1941). With the exception of fusions. For the developed during about 1 ml. of suspencross-matching the transfused same who Robertson, suspensions having was removed from the bottle of cell suspension with red-cell concentration as whole blood, the workers quoted sion a sterile Wright’s pipette ; serum and red cells were employed red-cell suspensions containing a greater obtained from the recipient by means of a small puncture concentration of red cells than is found in whole normal in the lobe of the ear, blood for its serum content being blood-concentrated red-cell suspensions. The adminicollected into a Wright’s tube, and red cells being stration of blood plasma has become an established collected into a small quantity of citrate-saline-the To obtain human blood is plasma, procured danger of injuring a valuable vein during collection of the practice. from the blood bank and the plasma is removed, the blood being thus avoided. With the excepremaining ’blood-cells forming a by-product wjaich is recipient’s tion of one transfusion, where cold agglutinins were normally discarded. This by-product may be of high present, the suspensions were administered without therapeutic value, and the investigations herein reported warming ; the transfusions were usually begun within were carried out to determine the usefulness of transan hour of removal of the suspension from the refrigerator. fusions of red-cell suspensions prepared from it. Transfusions were administered with the Medical Research Council (1940) blood-transfusion apparatus, METHODS in all cases by venepuncture without exposing the vein The red-cell suspensions were prepared from stored by dissection. When the red-cell suspension contained blood of group O. Blood was drawn from the donor into a more than 20 g. of Hb. per 100 ml. transfusions could be bottle containing sodium citrate solution, each bottle without difficulty, but the rate of flow became finally containing about 100 ml. of 3% sodium citrate begun after about 30 min., and was apt to stop irregular and The 440 ml. of blood. mixture then was solution, within an hour or so owing to the high viscompletely stored at 4° C., and after about 7 days (the actual period cosity of such suspensions. An attempt was made to varied from 3 to 12 days depending on the local demand force the blood into the vein under pressure by increasing for blood and plasma) the supernatant plasma was the height of the blood container from the normal 4 ft. drawn off. The remaining mass was filtered through a to 12 ft. above the vein ; this resulted in a slight improveand the red cells from several bottles were gas mantle, ment, but was not entirely, satisfactory. A device was designed to place the suspension in the container under a pressure of about 120 mm. Hg ; this was a decided improvement, but stoppages were still too frequent, and there was the ever-present danger of a bottle emptying rapidly, and air under pressure entering the vein. A Riddell’s (1939) pump incorporated in the delivery tube of the administration set was found the most satisfactory method of transfusing concentrated red-cell suspensions (i.e., suspensions containing more than 18 g. of Hb. per 100 ml.). It was found advisable to pump about 20 ml. of suspension fairly rapidly into the vein every half hour or so, allowing the flow to continue by gravity in the interval. Very small veins could be employed if necessary, and the flow could be maintained by slow pumping where the combination of a small vein and a viscous suspension would otherwise have resulted in an inadequate flow.

Castellanos and Riera (1937), Beumer and Schwartzer

RESULTS

bulked and stored at 4° C. until required. The time elapsing between removal of the blood from the refrigerator for processing and the return of the red-cell suspension for storage was under 2 hours ; the suspensions were

.

stored for 1-48 hours before transfusion. A bottle of red-cell suspension would contain about 290 ml. of packed red cells, 157 ml. of plasma, and 75 ml. of citrate solution ; this would furnish a suspension containing about 18 g. of haemoglobin per 100 ml. suspension. The longer the period of sedimentation, the more concentrated the red-cell suspension became (fig. 1), but as will be seen the relationship is not very close. Red-cell counts and haemoglobin estimations were performed before and immediately after transfusion in most cases, and at intervals thereafter. Estimations before transfusion were made on oxalated venous blood, while subsequent estimations were made on capillary blood. For the red-cell counts the same hæmocytometer and various BSS diluting pipettes were used ; in all cases at least 900 cells were counted ; the coefficient of variation was 7’3%. Haemoglobin estimations were made with a Newcomer disc, the accuracy of which was checked by oxygen capacity determinations in the Van Slyke manometric apparatus ; the coefficient of variation of haemoglobin estimations, as determined by 8 haemoglobin

In all, 46 transfusions of red-cell suspensions have been administered to 22 adult patients suffering from the following ailments: anaemia after haemorrhage, 13 (cases, 1, 2, 4, 6, 7, 10, 11, 12, 16, 19, 20, 21 and 22) ; chronic anaemia, 5 (cases 8; 13, 14, 15 and 17) ; miscellaneous, 4 (cases 3, 5, 9 and 18). Eighteen of the transfusions were administered to outpatients; transfusions were begun about 9.30 AM, and the patient returned home about 7 PM the same day. The remainder of the transfusions were administered to inpatients. After a red-cell suspension transfusion, the patient usually reported that he felt better all round, that he had more energy, and took greater interest in his surroundings. In general, the patients appeared to derive as much benefit (as judged clinically) from a transfusion of red-cell suspension as from a whole-blood transfusion. Ancrmia after hmmorrhage.-A series of7 patients ansemic as

the result of bleeding into the

gastro-intestinal

tract

(cases

transfused with red-cell suspension, and a satisfactory haemoglobin level was attained immediately after transfusion in all cases. Subsequent changes in haemoglobin are shown in table I. Where a single transfusion was administered (cases 2, 7, 10, 16 and 21), the second column shows the number of days elapsing between transfusion and the final Hb. determination ; the third column shows the difference between the Hb. immediately after transfusion and the final Hb. Where two transfusions were administered (cases 6 and 12), the second column shows the

4, 6, 10, 12, 16, 20 and 21)

were

108 number of days elapsing between the first transfusion and the last Hb. determined before the second transfusion ; the third column shows the difference between the Hb. immediately after the first transfusion, and the last Hb. determination before the second transfusion. The fourth column showsthe TABLE I-CHANGE IN HAEMOGLOBIN AFTER TRANSFUSION OF RED-CELL SUSPENSION IN CASES OF GASTRO-INTESTINAL HÆMORRHAGE

far from the origin (b 5-579). If it is assumed that the final blood-volume is increased by the volume of the transfused red cells only, then the correlation coefficient calculated about the origin is 0.97’71, the slope is 0,21759, and the corres. ponding blood-volume is 4596 ml. The last assumption has been accepted as it gives a higher correlation coefficient, a blood-volume which approximates to that known to obtain in the average adult, and a regression line calculated about the mean which goes nearly through the origin (b =.0,2022), as it should. In fig. 2 the rise in Hb. in the recipient after transfusion has been plotted against the amount of Hb. =

transfused multiplied by a factor allowing for the increase in blood-volume due to the presence of the transfused red cells in the circulation; this factor has been calculated as follows. Letpercentage of packed red cells in normal blood = 45 ; normal Hb.-content of blood 14-5 g. per 100 ml. ; i initial final Hb. in g. per ml. ; A = total Hb. Hb. in g. per ml. ; f in the body before transfusion, in g. ; B amount of Hb. =

==

=

=

number of days elapsing between the second transfusion and the final Hb. determination ; the last column shows the difference between the Hb. immediately after the second transfusion ’ and the final Hb. Chronic anœmias.—A group of 5 patients (cases, 8, 13, 14, 15 and 17) had been under treatment as outpatients for 4, 4, 6, 11 and 5 years respectively. All suffered from chronic hypochromic ansemia (case 15 had a liver-factor deficiency in addition), and all had received more than average amounts of iron, liver by injection, and vitamins ; special attention This treatment had not produced a was also paid to the diet. satisfactory haematological response. Repeated red-cell suspension transfusions (see table II) have resulted, in 4 out of 5 cases, in a significant and sustained rise in the colour-index, increased hæmoglobinisation of the red cell as judged from an inspection of stained blood films, and a rise in Hb. which persisted for longer than was to be expected in view of the supposed life-span of the red cell in the circulation of the recipient. All the patients could be regarded as chronic invalids unable to work on account of their illness ; 4 have benefited to such an extent that they can now do a day’s work without undue exhaustion . the remaining patient (case 14) showed transient improvement lasting some 6 months, and has now asked for further transfusions.

TABLE II-RESULTS IN

46

RED-CELL TRANSFUSIONS

.

*

RISE IN HÆMOGLOBIN AFTER TRANSFUSION

It is misleading to say that a bottle of blood will raise the Hb. in the recipient by so much per cent. The rise in Hb. after transfusion depends on many factors, among which are the blood-volume of the patient, the degree of anaemia, the blood-volume when the final Hb. is determined (this depends to some extent on the time allowed to elapse between the end of the transfusion and the Hb. determination), and the composition of the transfusion fluid. Thus the rise in Hb. concentration for each litre of transfused blood of constant composition will be greater in an infant than in an adult, and greater when the Hb. before transfusion is low than when it is high. Furthermore, when a blood-citrate mixture is transfused the blood-volume is temporarily increased and the normal blood-volume is eventually restored by shift of salt solution and plasma from blood to tissue spaces. If the final Hb. is estimated immediately after transfusion (when the blood-volume is greater than normal), the rise in Hb. will appear lower than it is when equilibrium has been achieved. From an analysis of the data contained in table IIA, it is apparent that there is a close correlation between the amount of Hb. transfused, and the rise in Hb. in the recipient. An assumption was made that all the Hb. transfused is present in the circulation at the end of the transfusion, but a similar assumption in regard to the added volume of fluid may not be justified, as it is known that many fluids, when given intravenously, leave the circulation in a very short time. Assuming that the final blood-volume is increased by the volume of the red cells transfused, plus the plasma transfused, the correlation coefficient between the rise in Hb. and the amount of Hb. transfused, when the regression line is forced * The first figure indicates the number of the case, the second the number of the transfusion ; thus 1/3 the third transfusion through the origin (this is justifiable, for if no Hb. is transgiven to case 1. the of be no rise in the there will is fused, Hb.), 0-9645 ; slope Complete records. Final Hb. estimated immediately after regression line is 0-28570, and-this slope corresponds to a A. transfusion. blood-volume of 3500 ml., which is unlikely. When theB Final Hb. estimated several hours after transfusion. regression line is calculated about the mean, the line passes 0 Incomplete records. =

=

=

=

-

109 added during transfusion, in g. : V = initial blood-volume of the patient; v = additional blood-volume (i.e., due to the added red cells). Thenf = A + B/V + v Since A = iV



-

Therefore fv + fV = iV + B fV—iV=B—fv

V(f-i)=B-fv f - i 1/V (B - fv)

;

the rise in Hb. Since 100 ml. of blood- contains 14-5 g. Hb, 45 ml. of packed red cells contains 14-5 g. Hb. (14.5/45 × v) ml. Therefore B B (45/14.5) ml. v volume of added red cells f - i 1/V (B - f x B x 45/14-5) =

;

=

.

=

=

=

=

= ,

, .

1/V (B) (1 —f 45/14-5)

If the rise in Hb. is plotted on the y axis, and the Hb. added multiplied by 1 — f 45/14-5 is plotted on the x axis, then the slope will be 1/V, and the initial blood-volume at which this relationship holds is V ml. It has been noted that the Hb. after transfusion depends partly on the quantity of red cells transfused and the increase in blood-volume resulting from transfusion. After an exceedingly rapid transfusion of large volume and low red-cell concentration, a decided increase in blood-volume, and hence a low Hb. immediately after transfusion, might be anticipated. To determine the effect of these and other variables, the effect of rate of transfusion, reciprocal of rate of transfusion, volume transfused, age of the red cells before transfusion, and the concentration of the red-cell suspen-

,

Fig.3

however, to examine the record of a case of aplastic anaemia (case 9). For two months the red-cell count and haemoglobin had remained constant, and it appeared that the patient’s blood-forming tissue could produce

sufficient red cells to maintain a blood-count of about 1,000,000 red cells per c.mm., and 4 g. of Hb. per 100 ml. A series of red-cell suspension transfusions were administered (table II). It was found (fig. 3) that after the transfusions in February and March the red-cell count and Hb. content fell gradually to the pre-transfusion level in approximately forty days. This period seems to represent the maximum life of the transfused cell, the red cells being stored for six to ten days before transfusion. The transfusions in April were of suspensions twelve or thirteen days old, and the red cells appeared to survive about fourteen days only. It should be noted that no glucose was added to the anticoagulant mixture. Further investigations could not be carried out because the patient was discharged home at her own request. REACTIONS

types of reaction were encountered that do not occur with transfusions of whole or citrated’blood. The reactions are arranged according to Riddell’s (1939) classification. No

Cases

Grade

Fig.2

1. Rise of temperature to 100° F. with

no

other objective changes...... Grade II. Similar or greater rise of temperature; cold shivery feeling without actual rigor.. Grade III. With a definite rigor........ No reaction

sion on the rise of Hb. has been examined by calculating the correlation coefficients of deviations from the regression line about the origin. None of these variables has a significant effect on the rise of Hb (table ill).

............

8 17 2 19

TABLE III

Half-hourly temperature charts were kept during and for some hours after transfusion. From Dec. 7, 1940, to Feb. 26, 1941, 19 transfusions were administered, 5 of which were associated with reactions. From March 5, 1941, to Sept. 11, 1941,,20 transfusions were administered, 18 of which were associated with reactions. The average period of storage of the blood before transfusion was about the same in the two periods, and it seems likely that some factor other than the period of storage was responsible for the reactions. Since this factor may mask any real influence of the period of storage on the reaction incidence no conclusions can be drawn from the data on this point. It has been noted already that a reaction had no significant effect on the rise of Hb.

A "t"" test has been performed on the rise in Hb. after transfusion, between transfusions by a reaction, and between reaction-free transfusions, and no significant difference between the rises has been found (t = 1-52, DF 29, P lies between 0-2 and 0-1).

accompanied

=

LIFE OF THE TRANSFUSED RED CELL IN THE RECIPIENT’S CIRCULATION

No effort

was

made to determine the life of the red-cell

suspension in the circulation of the recipient, but there is to believe that a red cell transfused as a susa shorter life than one transfused in the more usual citrated blood mixture. It is of interest,

no reason ’

pension should have

DISCUSSION

-

_

Uses of red-cell suspension.—When a patient is anaemic as a result of external blood loss, the bone-marrow is normally quite able to restore the lost cells, and bloodtransfusion is required to keep the patient alive during the period of red-cell regeneration or to improve the clinical condition. In the present series of 7 cases of

110

uncomplicated anaemia due to blood loss, a satisfactory Hb. level was attained in all. In these patients, none of whom showed evidence of continued blood loss immediately before or after transfusion, it seemed that blood regeneration proceeded as rapidly as the transfused cells were removed from the circulation, and that when a satisfactory Hb. level had been attained the functional activity ’of the erythropoietic tissue was sufficient to maintain that level. Since a satisfactory Hb. level can be attained by the transfusion of red-cell suspensions, and since the post-transfusion level remains more or less constant while red-cell regeneration is occurring, it is suggested that the transfusion of whole blood could well be replaced by red-cell suspension transfusions in these The red-cell suspension is a by-product of the cases. plasma preparation process, and thus makes no call on blood-donors, whose blood can be reserved for those cases requiring fresh blood, or for conversion into plasma. Since most transfusions administered in a general hospital are called for on account of external blood loss, the use of red-cell suspensions for these cases would result in a substantial economy in whole blood-an important consideration at a time when large calls are liable to be made on the blood-donors’ services. The indiscriminate transfusion of group 0 blood may not be without risk, especially when the isoagglutinin titre of the donor’s plasma is high. Thisrisk may be accentuated when large volume transfusions are administered to extremely anaemic patients of other than group O. The use of group 0 red-cell suspensions results in a lower volume of plasma being transfused ; the risk of reactions due to the isoagglutinin is reduced accordingly if the red-cell suspension is employed and hence fewer heterogeneous agglutinins transfused. When large volume transfusions are contemplated (e.g., where it is desired to increase the Hb. of the patient by say 8 g. per’100 ml.) about 3400 ml. of stored blood, which contains about 11-8 g. of Hb. per 100 ml. will be required, whereas 1820 ml. of red-cell suspension containing 22-0 g. of Hb. per 100 ml. will produce the same rise in Hb. The use of the smaller volume transfusion is desirable, as the alteration in the recipient’s blood-volume is kept relatively low. The property of the red-cell suspension of producing a maximum rise in Hb. with a minimum transfusion volume is of advantage where there is a special danger of circulatory failure due to overloading-for example, in chronic anaemias with low Hb. levels, or where it is desired to administer transfusions ’to outpatients. Outpatient transfusions present several new problems. Patients likely to benefit from this form of treatment are usually suffering from chronic anaemias requiring a series of transfusions; it is desirable therefore to make a special effort to cause the patient the minimum of discomfort and to avoid untoward events during or after transfusion. Special care should be taken to prevent the contamination of the suspension with pyrogens, for should a reaction occur it is unlikely that the temperature will have returned to normal by the time the patient is ready to be taken home. In all transfusions administered for chronic anaemia, there is a danger of overloading the circulation ; this danger is increased if the ansemia is complicated by a waning cardiac reserve due to the anaemia or any other When a transfusion is given to an inpatient, cause. provided there are no symptoms of overloading during the transfusion, and provided- no pyrogen reaction develops which might, through the extra load on the circulatory system, precipitate circulatory failure after the transfusion is ended, it is unlikely that the circulation will fail later on, since the patient is kept under supervision at complete rest in bed. When outpatients are transfused circumstances are different : it is always possible for the patient’s circulation to be on the verge of failure, warning signs and symptoms being absent ; and provided there was no posttransfusion reaction, there would be no ill effect as long as the patient remained at complete rest. Any exertion, however, might precipifailure, and this is most likely to happen when the patient has arrived home, out of sight of the doctor (who tate

will have warned him to avoid any form of exertion until the next day) and out of reach of immediate medical help. Realising,the danger of incipient overloading, the operator can plan his transfusion so as to leave a reason-

able margin of safety, and it is in this form of transfusion that the red-cell suspension finds a valuable application, since it provides a means of raising the Hb. with a transfusion volume about half that required when citrated but otherwise unmodified blood is used. Dosage.-No simple relationship holds between the concentration of the red-cell suspension and the expected rise of Hb. in the recipient, but where the aim of the transfusion is to increase the oxygen-carrying power of the blood the benefit derived from transfusion, in any one case, is directly related to the red-cell content of the fluid transfused. Concentrated red-cell suspensions are the medium of choice because they contain more red cells per unit volume than whole or citrated blood. If the pretransfusion Hb., the body-weight of the recipient, and the desired rise of Hb. are known, the transfusion volume can be accurately prescribed :Initial Hb. : 5 g. per 100 ml. Body-weight : 55 kg. Desired Hb. after transfusion : 15 g./100 ml. Hb. concentration of red-cell suspension : 20 g. /100 ml: 5 litres. Then, blood-volume is approximately 55/11 Total Hb. in body before transfusion is =

250 g. 5000 X 5/100 body after transfusion is 750 g. 5000 x 15/100 Therefore the amount of Hb. to be added is 750 - 250 500 g. 500 g. Hb. is contained in 2500 ml. of the suspension. This method of calculating dosage is especially valuable where children are concerned. That the final Hb. as =

Total Hb. in

=

=

estimated immediately after transfusion is a little lower than the figure anticipated need cause no concern. The patient has the desired additional red cells circulating in his blood-stream, and the aim of the transfusion has been fulfilled. As the temporarily increased blood-volume returns to normal, the Hb. per 100 ml. will rise

accordingly.

Recommendations.—Concentrated red-cell suspensions of choice where the aim is to restore oxygen-carrying power of the blood. Fresh blood should be used in preparing the suspensions, which should be administered after the shortest possible period of storage. Where the transfusion is used to replace blood lost by haemorrhage, stored blood is satisfactory, especially if glucose is- added at the time of collection of the blood from the donor. Group 0 blood should be used for making the suspensions, especially when such red cells are available as a by-product of blood plasma separation. Suspensions should not be warmed before administration. A Riddell’s pump should be incorporated in the administration apparatus when concentrated suspensions are transfused. The transfusion volume should be calculated in terms -of Hb. Patients suffering from refractory anaemia should be given the benefit of repeated red-cell suspension transfusions, in the outpatient department if beds are not available. The maximum volume transfused to an are the transfusions a reduced





,

outpatient

should not exceed 1000 ml.

occasion.

on

any one ’

SUMMARY

A series of 46 transfusions of red-cell suspensions have been administered to 23 patients ; 18 of the transfusions were administered to outpatients, who returned home a few hours after transfusion. The suspensions, which were prepared from a byproduct available through the steady demand for blood plasma, contained about 18 g. of haemoglobin per 100 ml. Transfusions were administered with the MRC bloodtransfusion apparatus ; a Riddell’s pump was useful in maintaining a satisfactory flow when the Hb. concentration exceeded 18 g. per 100 ml. Red-cell suspension, transfusions were found to be a satisfactory substitute for whole-blood transfusions when the aim is to increase the oxygen-carrying capacity of the patient’s blood. These transfusions are especially valuable when it is desired to obtain the maximum rise in Hb. with the minimum transfusion volume (e.g., in outpatient transfusions, or where there is a waning cardiac reserve, or where the pretransfusion Hb. is very low). When large volume group 0 transfusions are

111 administered to patients of other than group 0, the use of the suspension reduces the risk of a reaction due to the transfusion of large quantities of iso-agglutinin. A group of 5 outpatients, who suffered from refractory chronic hypochromic ansemia, received a small series of transfusions, and 4 of these patients derived great benefit which has persisted, so far, for 8-9 months. The rise in .Hb. following transfusion of red-cell suspensions is considered, and a relationship is shown to exist between the amount of Hb. transfused, and therise in Hb. in the recipient. The rate of transfusion, the reciprocal of the rate of transfusion, the volume transfused, the reciprocal of the volume transfused, the age of the red cells, the concentration of the suspension, and the presence or absence of a transfusion reaction have been shown to exert no influence on the rise in Hb. in the recipient. As the Hb.-raising power of any transfusion medium cannot be expressed accurately (or even helpfully) in terms of " so much % rise in Hb. per pint transfused," a simple method of calculating the transfusion volume is suggested ; this method is especially valuable in transfusing the young. The utilisation of red-cell suspensions, which are prepared from a discarded by-product, reduces the calls made on the blood-donor panel. I wish to thank the honorary staff of the Leeds General Infirmary and the Leeds Public Dispensary and Hospital for giving me access to cases under their care, Dr. W. S. Stanbury for the supply of the red-cell suspensions, and Mr. R. C. Palmer for assistance with the statistical analysis. .

recovers consciousness quickly, the cystoscopy may still be continued satisfactorily, since he remains sufficiently stuporous for about ten minutes longer ; during this period he can respond to instructions and appears to be quite comfortable. The withdrawal of the cystoscope may cause a momentary twinge of pain, but the patient rarely remembers this afterwards. The only

patient

complaint on recovering consciousness is, as a rule, a pressing desire to micturate. Delirium and excitement are absent. Unless the injection is made rapidly, the patient will be incompletely anaesthetised, and without supplementary anaesthesia cystoscopy will be difficult ; moreover, complete return to consciousness will be delayed. There is on an average three minutes complete anaesthesia during which the bladder neck and trigone may be examined comfortably. After this time any but gentle movements*of the cystoscope will tend to wake the patient and result in some reaction on his part, but he is easily controlled by a few encouraging words. At the beginning of anaesthesia there was in nearly every case cessation of breathing for varying periods up to half a minute. None of the patients became cyanosed, no anxiety was ever felt, and there was never any need for restorative measures. Ureteric catheterisation was carried out on 11 patients satisfactorily. In all these 0-3 g. was followed by 0-2 g. The patients remained deeply unconscious for an average of three minutes, the average time of operation being ten minutes. The completely anaesthetised period was almost the same as when only 0-3 g. was used; the postanaesthetic stupor was deeper and enabled the catheterisation to be carried out without any trouble. In all cases the patient recovered sufficiently to cooperate fully with the radiographer in the X-ray room adjoining the theatre by the time he was taken there. The ages of patients ranged from 19 to 44 years and there appeared to be no appreciable difference in reaction to the anaesthetic on this score. All patients were able to get off the table with assistance and to walk to their wheeled chairs, although at this time their behaviour and gait were drunken in character ; this was 10-15 minutes after the first injection. Full recovery was invariable within an hour, although at the end of this time some patients still complained of slight muzziness ; they were, however, considered to be fully capable of going home. Except for one patient who complained of violent nausea, there were no unpleasant

REFERENCES

Beumer, H. and Schwartzer, K. (1939) Klin. Wschr. 18, 1604. Castellanos, A. (1937) Arch. Med. Infant. 6, 319. — and Riera, R. (1937) Bol. Soc. cubana, Pediat. 9, 234. Davidson, S. and Stewart, C. P. (1941) Brit. med. J. i, 644. MacQuaide, D. H. G. and Mollinson, P. L. (1940) Ibid, ii, 555. Med. Res. Coun., Lond. (1940) War Memorandum No. 1. Riddell, V. H. (1939) Blood Transfusion, London. Robertson, O. H. (1918) Brit. Med. J. i, 691. Vaughan, J. M. (1941) Lancet, i, 178. Whitby, L. E. H. (1941) Proc. R. Soc. Med. 34, 257. Williams, G. E. O. and Davie, T. B. (1941) Brit. med. J. ii, 641.

PENTOTHAL SODIUM ANÆSTHESIA FOR CYSTOSCOPY

a.ft.nr fPFf’=!

-

GltLlJt:::::.1.- CJtJLC’0.

I. N. BLUSGER F R C S SURGEON EMS, AND TEMPORARY SURGEON TO THE CONNAUGHT HOSPITAL

J. H. DIXON

In 3 cases the recovery of consciousness brought with it evacuation of the bladder alongside the cystoscope ;; this was probably due to the fact that the bladder had been overfilled. When this happened it was found satisfactory to stop the examination for a short period until the patient was sufficiently awake to follow instructions. Cystoscopy, using the above technique, was carried out in a further 5 patients whose ages ranged from 59 to 77 ;the number of cases in this group is so small that we do not feel disposed to express any opinion except to record that results were uniformly satisfactory.

MB CAMB., D A ANÆSTHETIST, EMS

THE purpose of this artiole is to suggest

a method by cystoscopy may be carried out with comfort both patient and the operator. The use of intravenous anaesthesia for cystoscopy is well known, but as used up to date it has been inconvenient for outpatient purposes on account of the long recovery period. Although only 55 cystoscopies have so far been performed, using the

which to the

method of ansesthesia described here, success of the method in all cases seems to warrant publication at this stage. The investigation was primarily conducted with a view to finding a method of anaesthesia suitable for

SUMMARY

outpatient cystoscopy.

.

Method.-In 6 c.cm. of distilled water 0-5 g. of ’Penthothal Sodium’ (Abbott) is dissolved. The patient and instruments are prepared so that the cystoscope can be passed as soon as anaesthesia, is obtained, and 4 e.cm. of the solution (0-3 g. of pentothal) is injected intravenously as rapidly as possible through a no. 14 SWG needle. Needle and syringe are left in situ and the patient is asked to count ; when consciousness is lost a few seconds are allowed to elapse before the cystoscope is passed. The average time taken to lose consciousness was 18 sec. from the beginning of the injection. If the patient was not completely unconscious by this time we administered the remaining 2 c.cm. of the solution, but this was rarely necessary for simple cystoscopy. Where retrograde catheterisation of the ureters was to be carried out 0-3 g. was given, the cystoscope was passed and a further 0-2 g. was injected two minutes later, as rapidly as before. Rapid injection is essential to ensure complete loss of consciousness with the small dose of anaesthetic used, and also to bring about rapid recovery. Though the



.

Pentothal sodium anaesthesia has been found successful in 55 consecutive cystoscopic investigations. A dose of 0-3-0-5 g. seems to be completely safe. It is essential to inject the anaesthetic rapidly if adequate anaesthesia is to be attained. FoR SURGEONS’ SoNs.-Under the will of Mrs. Emily Wilson Barkworth grants can be made to the sons of fellows and members of the Royal College of Surgeons of England who need financial assistance to meet the cost of their education at Winchester College.. The number of candidates so far does not suggest that this limited application will lead to sufficient use being made of the income of the trust.- The trustees are therefore considering whether they should apply for permission to make selections from a wider field, but before consenting to any enlargement of the field the council of the college wish to be certain that applications from fellows and members are not likely to be sufficient to ensure full use of the trust. Theytherefore ask if fellows and members who are anxious to take advantage of the bequest will communicate with Sir Alfred Webb-Johnson, PROS, at their earliest convenience.