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SANDS OF PLANNING
637 comments. I took a locum s.H.M.O. post at a definite announcement had been made, but there was a possibility of a substantive grading; later, when it became apparent that the post would be replaced by a medical assistant grade, I remained hoping vainly (as it turned out) that I could continue broadly on the same basis as before, although now a medical assistant. The new grade is meant to provide a career in the hospital service for those who cannot, or do not, aspire to consultant status ; it specifically denies responsibility for the patient, and so, logically, the remuneration is much lower. Where the S.H.M.O. grade commenced at E2280, the medical assistant commences at E1650-this alone must have been a great source of satisfaction to a Government bent on economy at all costs. For myselfI find the lack of responsibility dreary and the pay prospects unattractive. I have had my pay protected at its former rate as a locum s.H.M.o., but it will take five years before my medical-assistant pay overtakes it, and I shall not receive the maximum pay of E2900 until I am 53. What sort of reward is this for experience and a higher qualification ? Because my mobility has been limited by family obligations, I have had to work within travelling distance of my home, so I cannot easily apply for another post. As an S.H.M.O. I was doing work I liked on a pay scale that was tolerable, and I would have been content to remain in my post until I reached retiring age. This no longer applies. Ulcombe, FREDA REED. near Maidstone, Kent. m
make a few
time when no
SANDS OF PLANNING Sir,-I am sure all can agree that the schemes outlined in Bw leading article last week (p. 578) that might speed up projects are important. In view of the lack of finance it appears that the Ministry has difficulties, perhaps by promising too many eggs in too many baskets. It is a fact that plans already Mised for some hospitals will not come to full fruition in many cases for periods of seven to ten years or even longer. It is impossible to forecast accurately requirements so far ahead, so that at least many departments of our new hospitals will be outdated when they are eventually functioning. Many modern large buildings of the size of hospitals are now completed within about two years. Would it not be wiser to concentrate on fewer projects for short-term completion in tum? It would be better to select those for immediate building out of a hat, rather than wait for a large number of delayed outmoded hospitals in the distant uncertain future. SIDNEY SHAW. Edgware, Middlesex.
HALOTHANE AND AORTIC COARCTATION Sir,-The increased incidence of paradoxical hypertension after correction of aortic coarctation when halothane anaesthesia had been used has been reported by Davis et al.l In their series of 24 patients, 7 developed hypertension. Of these 7 patients, 5 had been given halothane anaesthesia and 2 had received Mtous-oxide/thiopentone anaesthesia. All the remaining 17 patients had received nitrous-oxide/thiopentone anaesthesia. In continuation of that series a review was made of records of all patients who underwent surgical correction of aortic coarctation at this centre over the 71/2-year period 1959-66. Of the total of 41 patients, 20 received halothane anaesthesia, while 21 :eceived balanced anaesthesia (nitrous oxide, supplemented by muscle relaxants, barbiturates, and narcotics). Of the 21 pabents in the balanced-angesthesia group 9 developed hyper:"’1lSlon postoperatively. 14 patients in the halothane group heloped hypertension. Thus, in this series, the incidence of :’hypertension was 70% after halothane anaesthesia and 43% after balanced anaesthesia. The difference between these two values is not statistically significant (x2=2’06, 0.2> P > 0,1). Davis, T. B., Morrow, D. H., Herbert, C. L., Cooper, T. Anesthesiology, 1961, 22, 135.
The cause of paradoxical hypertension after correction of coarctation of the aorta is not known. Srouji and Trusler,2 in their study of 16 patients, found that the incidence of postoperative hypertension was related to the severity of coarctation and the completeness of operative repair. Similarly, the reason for the increased incidence after halothane anaesthesia is unknown. Davis and Morrow1 postulated that the hypertension was " an expression of adaptation of the peripheral vascular bed to increased arterial pressure in a situation of autonomic imbalance following halothane". In laboratory canine preparations they demonstrated greater autonomic imbalance and vascular resistance after relief of aortic occlusion under nitrous-oxide/halothane than under nitrous-oxide/thiopentone anaesthesia. In the light of these tentative reports on halothane and paradoxical hypertension it might be advisable to avoid halothane anaesthesia in aortic-coarctation repair until more definitive studies can be carried out. Department of Anesthesiology, Clinical Center, National Institutes of Health, United States Public Health Service Department of Health, Education, and Welfare,
Bethesda, Maryland, U.S.A.
L. H. COOPERMAN P. E. G. MANN.
HYDROXYDIONE IN CARDIOPULMONARY BYPASS SIR,-During cardiopulmonary bypass it is important to maintain a high proportion of oxygen in the oxygenator. In addition, at normal body temperatures any technique used must be capable of maintaining unconsciousness. Although nitrous oxide is usually the agent of choice for this purpose in normal cases, it cannot be used in effective concentrations in an oxygenator without dangerously reducing the oxygen tension. Therefore at normal body temperatures it becomes necessary to use either potent volatile or intravenous agents. Halothane is used in many centres,3 but has the disadvantages that it causes cardiovascular depression and that its use may be associated with postoperative jaundice, and has accordingly been abandoned by some workers.4 Pethidine has been used for the purpose by Brown,5 but it too may cause cardiovascular depression, which is especially to be avoided during open heart surgery. A significant advance
seems to have been made by the use of phenoperidene (R.1406, ’Operidene ’, Janssen Pharmaceuticals) which is fairly free from the risk of causing cardiovascular depression. Phenoperidene has been used in conjunction with haloperidol6 and methohexitone,4both of which, however, have been associated with some degree of hypotension. Hydroxydione sodium succinate is a steroid anaesthetic agent which was introduced some years ago, and the early claims of excellent cardiovascular stability have been substantiated in clinical practice.’ Nevertheless it has been largely abandoned because of two big disadvantages-venous thrombosis, and delayed onset of anaesthesia. These disadvantages are largely
eliminated when it is used as an agent to maintain unconsciouswith a pump oxygenator-a certain amount of forethought can allow for the slow onset of anaesthesia, and the problem of venous thrombosis does not apply when the drug is given directly into an oxygenator. We have used hydroxydione in calves undergoing cardiopulmonary bypass, and have been impressed with the absence of cardiac effects, despite very large doses (30 mg. per kg.), which were used to gain some indication of the therapeutic ratio. Our experience of the use of hydroxydione in cardiopulmonary bypass in man is limited to four patients, in all of whom extracorporeal cooling was used. Dosage has ranged
ness
2. 3. 4. 5. 6. 7.
Srouji, M. N., Trusler, G. A. Can. med. Ass. J. 1965, 92, 412. Hutton, A. M., Vale, R. J. Anœsthesia, 1964, 19, 239. Vale, R. J., Hellewell, J. ibid. 1966, 21, 357. Brown, W. M. Personal communication. Prys Roberts, C. The Application of Neuroleptanalgesia in Anaesthetic and Other Practice (edited by N. W. Shepherd); p. 81. Oxford, 1965. Bryce-Smith, R. Br. J. Anœth. 1959, 31, 262.
make a few
time when no
SANDS OF PLANNING Sir,-I am sure all can agree that the schemes outlined in Bw leading article last week (p. 578) that might speed up projects are important. In view of the lack of finance it appears that the Ministry has difficulties, perhaps by promising too many eggs in too many baskets. It is a fact that plans already Mised for some hospitals will not come to full fruition in many cases for periods of seven to ten years or even longer. It is impossible to forecast accurately requirements so far ahead, so that at least many departments of our new hospitals will be outdated when they are eventually functioning. Many modern large buildings of the size of hospitals are now completed within about two years. Would it not be wiser to concentrate on fewer projects for short-term completion in tum? It would be better to select those for immediate building out of a hat, rather than wait for a large number of delayed outmoded hospitals in the distant uncertain future. SIDNEY SHAW. Edgware, Middlesex.
HALOTHANE AND AORTIC COARCTATION Sir,-The increased incidence of paradoxical hypertension after correction of aortic coarctation when halothane anaesthesia had been used has been reported by Davis et al.l In their series of 24 patients, 7 developed hypertension. Of these 7 patients, 5 had been given halothane anaesthesia and 2 had received Mtous-oxide/thiopentone anaesthesia. All the remaining 17 patients had received nitrous-oxide/thiopentone anaesthesia. In continuation of that series a review was made of records of all patients who underwent surgical correction of aortic coarctation at this centre over the 71/2-year period 1959-66. Of the total of 41 patients, 20 received halothane anaesthesia, while 21 :eceived balanced anaesthesia (nitrous oxide, supplemented by muscle relaxants, barbiturates, and narcotics). Of the 21 pabents in the balanced-angesthesia group 9 developed hyper:"’1lSlon postoperatively. 14 patients in the halothane group heloped hypertension. Thus, in this series, the incidence of :’hypertension was 70% after halothane anaesthesia and 43% after balanced anaesthesia. The difference between these two values is not statistically significant (x2=2’06, 0.2> P > 0,1). Davis, T. B., Morrow, D. H., Herbert, C. L., Cooper, T. Anesthesiology, 1961, 22, 135.
The cause of paradoxical hypertension after correction of coarctation of the aorta is not known. Srouji and Trusler,2 in their study of 16 patients, found that the incidence of postoperative hypertension was related to the severity of coarctation and the completeness of operative repair. Similarly, the reason for the increased incidence after halothane anaesthesia is unknown. Davis and Morrow1 postulated that the hypertension was " an expression of adaptation of the peripheral vascular bed to increased arterial pressure in a situation of autonomic imbalance following halothane". In laboratory canine preparations they demonstrated greater autonomic imbalance and vascular resistance after relief of aortic occlusion under nitrous-oxide/halothane than under nitrous-oxide/thiopentone anaesthesia. In the light of these tentative reports on halothane and paradoxical hypertension it might be advisable to avoid halothane anaesthesia in aortic-coarctation repair until more definitive studies can be carried out. Department of Anesthesiology, Clinical Center, National Institutes of Health, United States Public Health Service Department of Health, Education, and Welfare,
Bethesda, Maryland, U.S.A.
L. H. COOPERMAN P. E. G. MANN.
HYDROXYDIONE IN CARDIOPULMONARY BYPASS SIR,-During cardiopulmonary bypass it is important to maintain a high proportion of oxygen in the oxygenator. In addition, at normal body temperatures any technique used must be capable of maintaining unconsciousness. Although nitrous oxide is usually the agent of choice for this purpose in normal cases, it cannot be used in effective concentrations in an oxygenator without dangerously reducing the oxygen tension. Therefore at normal body temperatures it becomes necessary to use either potent volatile or intravenous agents. Halothane is used in many centres,3 but has the disadvantages that it causes cardiovascular depression and that its use may be associated with postoperative jaundice, and has accordingly been abandoned by some workers.4 Pethidine has been used for the purpose by Brown,5 but it too may cause cardiovascular depression, which is especially to be avoided during open heart surgery. A significant advance
seems to have been made by the use of phenoperidene (R.1406, ’Operidene ’, Janssen Pharmaceuticals) which is fairly free from the risk of causing cardiovascular depression. Phenoperidene has been used in conjunction with haloperidol6 and methohexitone,4both of which, however, have been associated with some degree of hypotension. Hydroxydione sodium succinate is a steroid anaesthetic agent which was introduced some years ago, and the early claims of excellent cardiovascular stability have been substantiated in clinical practice.’ Nevertheless it has been largely abandoned because of two big disadvantages-venous thrombosis, and delayed onset of anaesthesia. These disadvantages are largely
eliminated when it is used as an agent to maintain unconsciouswith a pump oxygenator-a certain amount of forethought can allow for the slow onset of anaesthesia, and the problem of venous thrombosis does not apply when the drug is given directly into an oxygenator. We have used hydroxydione in calves undergoing cardiopulmonary bypass, and have been impressed with the absence of cardiac effects, despite very large doses (30 mg. per kg.), which were used to gain some indication of the therapeutic ratio. Our experience of the use of hydroxydione in cardiopulmonary bypass in man is limited to four patients, in all of whom extracorporeal cooling was used. Dosage has ranged
ness
2. 3. 4. 5. 6. 7.
Srouji, M. N., Trusler, G. A. Can. med. Ass. J. 1965, 92, 412. Hutton, A. M., Vale, R. J. Anœsthesia, 1964, 19, 239. Vale, R. J., Hellewell, J. ibid. 1966, 21, 357. Brown, W. M. Personal communication. Prys Roberts, C. The Application of Neuroleptanalgesia in Anaesthetic and Other Practice (edited by N. W. Shepherd); p. 81. Oxford, 1965. Bryce-Smith, R. Br. J. Anœth. 1959, 31, 262.