Letters to the Editor Epidural Blood Patch Does Cause a Decrease in Heart Rate To the Editor: We read with interest the letter by Ramsay and Roberts that suggested an epidural blood patch (EBP) may increase and maintain cerebrospinal fluid pressure because blood administered in the epidural space coagulates (1). We report another physiologic change noted when an EBP is performed in healthy parturients. After obtaining institutional review board approval and patient informed consent, we examined the effect of an EBP in 10 healthy ASA I or I1 parturients who requested EBP for postdural puncture headache. Noninvasive electroencephalography, electromyography, electrocardiography, and pulse oximetry were monitored continually before, during, and 30 min after EBP administration. Each patient’s arterial blood pressure was monitored every 5 min during the time interval mentioned. Each patient had an EBP done while in a sitting position with a 17-gauge Tuohy epidural needle placed in the epidural space at L2-3 or L M through which 15 mL of autologous blood was administered in a sterile fashion. Each parturient exhibited a statistically significant (Student’s t-test, P < 0.05, with each patient serving as their own control) decrease in heart rate from a mean baseline of 88.6 (k7.31) beats/min to 51.3 (k7.60) beats/min within 122.6 (k16.9) s from the time of the EBP. Bradycardia was observed for a duration of 12.4 (21.1) s. The velocity of epidural blood administration was 0.5 mL/s. Because of these findings, we have initiated a further multiinstitutional study investigating changes in hemodynamic variables using noninvasive hemodynamic monitoring during EBP. Furthermore, we are initiating a laboratory investigation utilizing invasive hemodynamic monitoring to study hemodynamic variables during EBP. As a result of our preliminary findings we recommend that an EBP be administered with intravenous access and electrocardiographic monitoring. William E. Ackerman 111, MD Mushtaque Juneja, MD, FFARCS Peter J. Andrews, MD, FFARCS Victoria Cases-Cristobal, MD Angel M. Gomez, MD Department of Anesthesiology Norton Hospital and University of Louisville College of Medicine Louisville, KY 40291

Reference 1. Ramsay M, Roberts C. Epidural injection does cause an increase in CSF pressure. Anesth Analg 1991;73668. ~

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01992 by the International Anesthesia Research Society

Insidious Illness and Performance To the Editor: Much has been written about factors that may affect the anesthesiologist’s performance. Last year Weinger and Englund published an extensive article in the journal Anesthesiology with nearly 300 references (1). Variables ranging from ambient temperature to fatigue and interpersonal relations were discussed. I would like to share an experience that highlights the need to be aware of yet another factor affecting performance: insidious disease. Recently, one of our residents appeared tired, pale, and lacking energy. This individual was known for his dedication and hard work. When I asked him “Are you sick?” He replied: ”No, I am just a little tired and I was on call last night.“ And when I asked: “Why are you so pale?’ The answer was: ”I have not been in the sun for a while.” Others, concerned, also inquired obtaining similar answers. We must have collectively rationalized: After all, he has been working hard and simply looks pale. Substance abuse was considered. Several days later, while in the operating room holding area, the resident became dizzy, clammy, and diaphoretic. His pulse was weak and fast. We positioned him supine on a stretcher and someone spun a hematocrit. To everyone’s astonishment it was only 15%! It was repeated and confirmed. He was transferred to the Emergency Room, admitted to the hospital, and required several units of blood. The diagnosis was iron deficiency anemia due to chronic bleeding from hemorrhoids. Although many factors can influence the anesthesiologist’s performance, we, as physicians, must also consider insidious disease as yet another possibility, even in young healthy residents. Rafael Ortega, MD Department of Anesthesiology Boston University School of Medicine 88 East Newton Street Boston, M A 02118-2393

Reference 1. Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating roam environment. Anesthesiology 1990;73:995-1021.

Training in Antibiotic Administration To the Editor: Anesthesiologists are often responsible for administering antibiotics in the perioperative period, mainly as prophylaxis against surgical wound infections. Unlike their train-

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