Annotations
In terms of hypovolemia, I believe t h a t m a n y anesthetists do not put up enough intravenous infusions (to cover paraoperative "normal" water requirements as well as blood), and d o not give enough fluid when the infusion is up. (How m a n y of your patients are thirsty after operation?) In some centers every patient has an intravenous drip put up before anesthesia begins. Somewhere between the two extremes probably is more satisfactory. We must all have seen patients for operation at midday who have had nothing to drink since late the previous evening, and who then on the operating table have to contend with further reduction in blood volume from bleeding and sweating. Surely a cup of tea and biscuit given not less t h a n four hours before premedication does no harm and can only help to stimulate blood flow? Looking further afield, could it be t h a t the published results following treatment for prevention of deep-vein thrombosis following cardiac infarction vary due to varying degrees of hydration? Are cases of venous thrombosis following strokes due to a fear of giving old people too much fluid? Do well controlled long-term unconscious patients in intensive-care units seem to show a relatively low incidence of leg deep-vein thrombosis because the central venous pressure is maintained more near normal? From other anesthetic aspects the prolonged recovery from anesthesia, with its accompanying immobilization and hypoventilation and recognized associated dangers, may produce a tranquil time for the patient, but is often due to an unnecessary "overdose" of anesthesia, or to incorrect timing in the giving of analgesics. In an operation where the patient is paralyzed and asleep, the anesthetist must largely concentrate on the likelihood of awareness and on the prevention of undue pain postoperatively. Of course, we want the patient preoperatively tranquil and postoperatively pain-free, but too much is too much. The likelihood of awareness, I believe, should be gauged on a mental estimation of the preoperative metabolic rate r a t h e r than body-weight per se. I have previously shown 3 t h a t the alteration in arterial Paco ~ following the same premedication (in Jamaica) shows an inverse linear relationship to metabolic rate as expressed as a percentage of normal. Thus a thinner, lighter, nervous individual may require more premedication and/or sleep agent than a fatter, heavier, b u t more tranquil one. This approach is supported by Claridge. 4 My experience further suggests t h a t patients in quiet, rural
"cottage" hospitals often need less narcotic agents t h a n those in busy city hospitals, as judged by sleep time following anesthesia. The routine giving of analgesics during anesthesia should also be carefully examined. When and why to give an agent is part of the unsung science of anesthesia. Is it for keeping the patient asleep by reducing sensory stimulus, to reduce adrenergic activity, or to anticipate an unknown postoperative pain status? Many schools of thought dislike adrenergic activity under anesthesia, but is it not better with a normal heart to permit some, thus allowing a better circulation to counteract a tendency to leg venous stasis and deep-vein thrombosis? Is it not also more "scientifiC" to assess pain as the patient awakes and to "titrate" the analgesic effect by small-dose intravenous analgesic injection? Thus, I believe, t h a t the modern anesthetist must think more broadly in terms of preserving a normal central venous pressure. Coupled with this he must ensure t h a t the preoperative patient is adequately sedated, but not oversedated {remember the accumulative night sedation effect); t h a t during the operation adrenergic activity in the normal patient should not be unduly suppressed; and t h a t postoperatively the patient should be quickly awake {after five minutes in recovery following a relaxant technique) with good muscle tone; and with postoperative pain tending to be treated by titration in the recovery room rather t h a n blindly on the oPerating table. These things, the avoidance of polypharmacy blindly given, and our physiotherapists, should be the greatest factors to concentrate on in the fight against deep-vein thrombosis.
J. Michael Simpson, M.B., B.S., F.F.A., R.C.S. St. Nicolaas Ziekenhuis Waalwijk, The Netherlands REFERENCES
1. Gallus, A. S., Hirsh, J., and Gent, M.: Relevance of preoperative and postoperative blood tests to postoperative leg-vein thrombosis, Lancet 2:805, 1973. 2. Simpson, J. M.: Fibrinolytic activity and postoperative deep-vein thrombosis, Lancet 1:352, 1974. {Letter to Eclitor). 3. Simpson, J. M.: Environmental temperature and reponse to premedicant drugs, Anaesthesia 25:508, 1970. 4. Claridge, G. S.: The relative influence of weight and of "nervous type" on the tolerance of a m y l o b a r b i t o n e sodium, Br. J. Anaes. 43:1121, 1971.
Of smoking and the respiratory tract
The publicity and propaganda t h a t smoking produces carcinoma of the lungs and heart disease have diverted the attention of all people from the more important fact that, even though these claims are true, the incidences of these illnesses are relatively minor when it is realized t h a t all (100 per cent) of the people who smoke have chronic diseases of their entire
American Heart Journal
respiratory tract. All smokers have chronic pharyngitis, chronic paranasal sinusitis, chronic laryngitis, chronic tracheitis, chronic bronchitis and bronchiectasis, and many are destined to have serious emphysema. Furthermore, acute respiratory tract infections are prone to develop upon these chronic diseases. Any physician who remembers or reviews the
401
Annotations
histology of the mucous membranes and epithelial lining realizes the extreme delicacy of these tissues. Irritation by tobacco smoke predisposes to necrosis or at least to some injury to those tissues. This damage, in turn, results in infection, inflammatory reactions, purulent discharges, postnasal drip, cough, etc.-all symptoms and signs of respiratory tract disease. The many sorts of medical therapy employed to control the infections and injury further tend to damage the tissues and may even result in serious drug reaction. If the patient would only stop smoking, the results, though slow, would be rewarding. But, most important of all, people should n o t even begin to smoke.
402
Cancer and heart disease are important, b u t their incidence among smokers is minor compared to the fact t h a t all smokers {millions of people) have chronic diseases of their entire respiratory tract. Furthermore, the dentures and teeth of most smokers are dirty and stained and their breath is unpleasant!
G. E. Burch, M.D. Tulane University School of Medicine and Charity Hospital New Orleans, La.
March, 1976, Vol. 91, No. 3
In terms of hypovolemia, I believe t h a t m a n y anesthetists do not put up enough intravenous infusions (to cover paraoperative "normal" water requirements as well as blood), and d o not give enough fluid when the infusion is up. (How m a n y of your patients are thirsty after operation?) In some centers every patient has an intravenous drip put up before anesthesia begins. Somewhere between the two extremes probably is more satisfactory. We must all have seen patients for operation at midday who have had nothing to drink since late the previous evening, and who then on the operating table have to contend with further reduction in blood volume from bleeding and sweating. Surely a cup of tea and biscuit given not less t h a n four hours before premedication does no harm and can only help to stimulate blood flow? Looking further afield, could it be t h a t the published results following treatment for prevention of deep-vein thrombosis following cardiac infarction vary due to varying degrees of hydration? Are cases of venous thrombosis following strokes due to a fear of giving old people too much fluid? Do well controlled long-term unconscious patients in intensive-care units seem to show a relatively low incidence of leg deep-vein thrombosis because the central venous pressure is maintained more near normal? From other anesthetic aspects the prolonged recovery from anesthesia, with its accompanying immobilization and hypoventilation and recognized associated dangers, may produce a tranquil time for the patient, but is often due to an unnecessary "overdose" of anesthesia, or to incorrect timing in the giving of analgesics. In an operation where the patient is paralyzed and asleep, the anesthetist must largely concentrate on the likelihood of awareness and on the prevention of undue pain postoperatively. Of course, we want the patient preoperatively tranquil and postoperatively pain-free, but too much is too much. The likelihood of awareness, I believe, should be gauged on a mental estimation of the preoperative metabolic rate r a t h e r than body-weight per se. I have previously shown 3 t h a t the alteration in arterial Paco ~ following the same premedication (in Jamaica) shows an inverse linear relationship to metabolic rate as expressed as a percentage of normal. Thus a thinner, lighter, nervous individual may require more premedication and/or sleep agent than a fatter, heavier, b u t more tranquil one. This approach is supported by Claridge. 4 My experience further suggests t h a t patients in quiet, rural
"cottage" hospitals often need less narcotic agents t h a n those in busy city hospitals, as judged by sleep time following anesthesia. The routine giving of analgesics during anesthesia should also be carefully examined. When and why to give an agent is part of the unsung science of anesthesia. Is it for keeping the patient asleep by reducing sensory stimulus, to reduce adrenergic activity, or to anticipate an unknown postoperative pain status? Many schools of thought dislike adrenergic activity under anesthesia, but is it not better with a normal heart to permit some, thus allowing a better circulation to counteract a tendency to leg venous stasis and deep-vein thrombosis? Is it not also more "scientifiC" to assess pain as the patient awakes and to "titrate" the analgesic effect by small-dose intravenous analgesic injection? Thus, I believe, t h a t the modern anesthetist must think more broadly in terms of preserving a normal central venous pressure. Coupled with this he must ensure t h a t the preoperative patient is adequately sedated, but not oversedated {remember the accumulative night sedation effect); t h a t during the operation adrenergic activity in the normal patient should not be unduly suppressed; and t h a t postoperatively the patient should be quickly awake {after five minutes in recovery following a relaxant technique) with good muscle tone; and with postoperative pain tending to be treated by titration in the recovery room rather t h a n blindly on the oPerating table. These things, the avoidance of polypharmacy blindly given, and our physiotherapists, should be the greatest factors to concentrate on in the fight against deep-vein thrombosis.
J. Michael Simpson, M.B., B.S., F.F.A., R.C.S. St. Nicolaas Ziekenhuis Waalwijk, The Netherlands REFERENCES
1. Gallus, A. S., Hirsh, J., and Gent, M.: Relevance of preoperative and postoperative blood tests to postoperative leg-vein thrombosis, Lancet 2:805, 1973. 2. Simpson, J. M.: Fibrinolytic activity and postoperative deep-vein thrombosis, Lancet 1:352, 1974. {Letter to Eclitor). 3. Simpson, J. M.: Environmental temperature and reponse to premedicant drugs, Anaesthesia 25:508, 1970. 4. Claridge, G. S.: The relative influence of weight and of "nervous type" on the tolerance of a m y l o b a r b i t o n e sodium, Br. J. Anaes. 43:1121, 1971.
Of smoking and the respiratory tract
The publicity and propaganda t h a t smoking produces carcinoma of the lungs and heart disease have diverted the attention of all people from the more important fact that, even though these claims are true, the incidences of these illnesses are relatively minor when it is realized t h a t all (100 per cent) of the people who smoke have chronic diseases of their entire
American Heart Journal
respiratory tract. All smokers have chronic pharyngitis, chronic paranasal sinusitis, chronic laryngitis, chronic tracheitis, chronic bronchitis and bronchiectasis, and many are destined to have serious emphysema. Furthermore, acute respiratory tract infections are prone to develop upon these chronic diseases. Any physician who remembers or reviews the
401
Annotations
histology of the mucous membranes and epithelial lining realizes the extreme delicacy of these tissues. Irritation by tobacco smoke predisposes to necrosis or at least to some injury to those tissues. This damage, in turn, results in infection, inflammatory reactions, purulent discharges, postnasal drip, cough, etc.-all symptoms and signs of respiratory tract disease. The many sorts of medical therapy employed to control the infections and injury further tend to damage the tissues and may even result in serious drug reaction. If the patient would only stop smoking, the results, though slow, would be rewarding. But, most important of all, people should n o t even begin to smoke.
402
Cancer and heart disease are important, b u t their incidence among smokers is minor compared to the fact t h a t all smokers {millions of people) have chronic diseases of their entire respiratory tract. Furthermore, the dentures and teeth of most smokers are dirty and stained and their breath is unpleasant!
G. E. Burch, M.D. Tulane University School of Medicine and Charity Hospital New Orleans, La.
March, 1976, Vol. 91, No. 3
