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Cited by 4 publications
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Summary A c'ase is presented in which a patient dei)eloped an acute unaphylactoid reaction after receiving methohexitone and gallamine for the induction o f anaesthesia. The problem o f eliciting the responsible agent is di.scusscd, with comnients on the method o f rreatment and prewntatiw measures. Key wordsA llergy Anaesthetics, Intrarrenous; methohexitone. Nmromuscular relaxants; gallamine.Sodium methohexitone (Brietal) and gallamine triethiodide (Flaxedil) are both drugs which have been used in anaesthetic practice for many years, and in spite of the vast number of administrations of each drug the number of adverse reactions reported is very small. A case is presented in which a patient developed an anaphylactoid reaction after receiving these drugs. Case historyA fit 43-year-old woman was admitted for laparoscopic sterilisation. She had had two previous operations: a reduction of a fractured radius when she was 8 years old, and an appendicectomy at 18 years of age. Her past medical history included an anxiety state and six normal pregnancies. She was taking no medication before admission, and there was no history of allergies. Her pre-operative haemoglobin was 1 1 g/dl.A prernedication of papaveretum 10 mg and hyoscine 0.3 mg was given 1 hour before induction. and she was calm and relaxed on arrival in the anaesthetic room. Anaesthesia was induced with sodium methohexitone 120 mg and gallamine 120 mg, followed by inflation of the lungs with oxygen, tracheal intubation, and elevation of the legs in Lloyd Davies stirrups. Suddenly she developed erythema and goose pimples on the skin of both legs, her pulse rate rose from 80 to 140 beats/minute, and rapidly became impalpable. The blood pressure was unrecordable using an oscillotonometer, and an electrocardiogram showed complete heart block with a ventricular rate of 54 beats/minute. The patient's lungs were being ventilated by hand with IOO", oxygen through a Bain system. Ventilation became progressively more difficult, and auscultation revealed very little air entry. Peripheral cyanosis then developed.Intravenous infusions were set up in both arms, Adverse reaction to methohexitone and gallamine 41 and 2.5 litres of fluid (0.9% saline 1 litre, plasma 0.4 litre, and Dextran-70 1 litre) were given, together with chlorpheniramine 20 mg, methylprednisolone one gram, and atropine 1.2 mg. Cardiac output was maintained by external cardiac massage for 20 minutes. Ventilation of the lungs improved with this therapy, but there was no alteration in heart rate. Metaraminol4mg was given slowly, but with no effect. This was followed with 10 ml of adrenaline 1 : 10,000 intravenously, again with no effect. An isoprenaline infusion of 4 pg/ml was commenced, the heart rate increased to 140 beats/minute, and a systolic blood pressure of 100 mmHg was achieved. The peripheral circulation slowly returned to normal, and on cessation of the isoprenaline infusion the pulse rate slowed down to 80 beats/minute, and the systolic blood pressure was maintained at 100 mmHg. It was now 45 m...
Summary A c'ase is presented in which a patient dei)eloped an acute unaphylactoid reaction after receiving methohexitone and gallamine for the induction o f anaesthesia. The problem o f eliciting the responsible agent is di.scusscd, with comnients on the method o f rreatment and prewntatiw measures. Key wordsA llergy Anaesthetics, Intrarrenous; methohexitone. Nmromuscular relaxants; gallamine.Sodium methohexitone (Brietal) and gallamine triethiodide (Flaxedil) are both drugs which have been used in anaesthetic practice for many years, and in spite of the vast number of administrations of each drug the number of adverse reactions reported is very small. A case is presented in which a patient developed an anaphylactoid reaction after receiving these drugs. Case historyA fit 43-year-old woman was admitted for laparoscopic sterilisation. She had had two previous operations: a reduction of a fractured radius when she was 8 years old, and an appendicectomy at 18 years of age. Her past medical history included an anxiety state and six normal pregnancies. She was taking no medication before admission, and there was no history of allergies. Her pre-operative haemoglobin was 1 1 g/dl.A prernedication of papaveretum 10 mg and hyoscine 0.3 mg was given 1 hour before induction. and she was calm and relaxed on arrival in the anaesthetic room. Anaesthesia was induced with sodium methohexitone 120 mg and gallamine 120 mg, followed by inflation of the lungs with oxygen, tracheal intubation, and elevation of the legs in Lloyd Davies stirrups. Suddenly she developed erythema and goose pimples on the skin of both legs, her pulse rate rose from 80 to 140 beats/minute, and rapidly became impalpable. The blood pressure was unrecordable using an oscillotonometer, and an electrocardiogram showed complete heart block with a ventricular rate of 54 beats/minute. The patient's lungs were being ventilated by hand with IOO", oxygen through a Bain system. Ventilation became progressively more difficult, and auscultation revealed very little air entry. Peripheral cyanosis then developed.Intravenous infusions were set up in both arms, Adverse reaction to methohexitone and gallamine 41 and 2.5 litres of fluid (0.9% saline 1 litre, plasma 0.4 litre, and Dextran-70 1 litre) were given, together with chlorpheniramine 20 mg, methylprednisolone one gram, and atropine 1.2 mg. Cardiac output was maintained by external cardiac massage for 20 minutes. Ventilation of the lungs improved with this therapy, but there was no alteration in heart rate. Metaraminol4mg was given slowly, but with no effect. This was followed with 10 ml of adrenaline 1 : 10,000 intravenously, again with no effect. An isoprenaline infusion of 4 pg/ml was commenced, the heart rate increased to 140 beats/minute, and a systolic blood pressure of 100 mmHg was achieved. The peripheral circulation slowly returned to normal, and on cessation of the isoprenaline infusion the pulse rate slowed down to 80 beats/minute, and the systolic blood pressure was maintained at 100 mmHg. It was now 45 m...
Total intravenous anaesthesia with low dose ketamine and Althesin Assessment of a technique for minor surgery in difficult situations
In 38 patients subjected to minor surgery, totally intravenous anaesthesia with low dose ketamine and Althesin produced adequate operating conditions in 9P4 of patients with minimal cardiorespiratory disturbance. Problems arose from muscular hypertonus. spontaneous movement and occasionally salivation. Initial recovery was quicker and the incidence of side-effects lower, than those reported when ketamine was used as the sole agent. The technique could be useful in dificult situations ar an alternative to inhalation anaesthesia or other intrauenous techniques. Key words Anaesthesia, intravenous; ketamine, AlthesinAt extremes of altitude and depth inhalation anaesthesia may be inappropriate, while in difficult situations and certain parts of the world medical gases may be unavailable because of expense or non-portability.'*2 In such circumstances, a balanced totally intravenous, anaesthetic technique may be suitable for certain surgical procedure^.^ Ketamine has established a useful place in paediatric anaesthesia but can have disadvantages when used as the sole anaesthetic agent in adult^.^ In particular, muscle hypertonicity, spontaneous movement, unpleasant dreams and psychotomimetic effects can occur in up to 40% of patient^,^.^ although all of these can be reduced by premedication and careful technique.' Ketamine causes apnoea in less than 1% of patients4 and the respiratory depressant effect of Althesin is less than that recorded with either thiopentone or methohexitone.8 Furthermore ketamine has antidysrthythmic properties and has been used in poor risk orthopaedic patients with apparent advantage.' The cardiac effects of both ketamine and Althesin have been reported.10.'' Althesin, despite reports of allergic reactions of varying severityI2-l6 is widely used, both as an induction agent and as sole agent for non-painful investigative Because the duration of action of Althesin is short, it is easy to control and its rapid metabolism lessens the risk of accumu1ation.'~~20The severity of adverse drug responses is generally proportional to total dose.21. 22 It therefore seems possible that a balanced technique, using ketamine in low dose for its analgesic proper tie^;^ combined with Althesin for its sedative properties, might allow a reduction in the dose requirement of each, thereby reducing their individual undesirable effects and might be a useful alternative to either conventional inhalational anaesthesia or to other available intravenous techniques?'26 The object of the present study was to form a preliminary clinical assessment of the anaesthetic efficacy of this technique. Patients and methodsPatients, the majority Arabs, from the daily case load of a busy hospital were included in the assessment if they required surgery of a suitable nature and had no history of allergy or contraindication to ketamine or Althesin. Hospital inpatients were premedicated with lorazepam 1-3 mg depending on age and weight, administered orally 2-3 hours before surgery,' but those who presented as day cases or emergencies were...
SI',Jere histamine mediated reactions to intrw(}clloltS drltgs ltsed ill anaesthesia may occur as a result of anaphylactic and anaphylactoid reactions. The incidence is rare, but appears to be increasing, The difficulties in diagnosing sltch reactions and in determining the dm{!. responsible and ho1.£' these difficulties hm.'c led to confllsionin the literatllre are discussed. Six cases of SC1 ' cre histamine mediated reactions are presented and detailed analyses of the drugs in these and other reported reactions is made sho1.£'ing l ' aried clinical patterns It'itll different dmgs. The prel'clltioJ1, treatment, and fol101c-up of SC1 ' ere histamine mediated reactions are considered.
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