943
CORRESPONDENCE
potent inhalational agent, as long as all other methods for maintaining cerebral perfusion are honoured. J. David Martino MD Louise O. Warner riD Department of Anesthesiology Children's Hospital Columbus, Ohio REFERENCES
1 Suzuki J. Moyamoya Disease. Berlin: Springer-Verlag,
1986: 7-116. 2 Sunder TR, Erwin CW, Dubois PJ. Hyperventilation
3 4 5
6
7
induced abnormalities in the electroencephalogram of children with moyamoya disease. Electroencephalogr Clin Neurophysiol 1980; 49: 414-20. Bingham RM, Wilkinson DJ. Anaesthetic management in moya-moya disease. Anaesthesia 1985; 40:1198-202. Sumikawa K, Nagai H. Moyamoya disease and anesthesia. Anesthesiology 1983; 58: 204-5. Kuro M, Karasawa J, Kuriyama Y, Kikuchi H. Anesthetic management of "moya-moya" disease in children. Proc 10th Jap Conf Surgery of Cerebral Stroke. Tokyo: Neuron Co Ltd., 1981: 207-11. Malley RA, Frost EAM. Moyamoya disease: pathophysiology and anesthetic management. Journal of Neurosurgical Anesthesiology 1989; 1:110-4. Brown SC, Lam AM. Moyamoya disease - a review of clinical experience and anaesthetic management. Can J Anaesth 1987; 34: 71-5.
Propofol infusion in Carcinoid Syndrome To the Editor: Carcinoid tumours are relatively uncommon tumours which arise from enterochromaffin cells. They form and release several vasoactive substances which cause symptoms such as flushing, diarrhoea, hypo- and hypertension, palpitations, bronchospasm and right-sided heart disease. We report the use of propofol in the anaesthethic management of a patient with carcinoid syndrome. The patient was a 69-yr-old, 48.5 kg woman with a four-year history of metastatic carcinoid tumour invading the liver and small intestine. She had been well apart from diarrhoea, controlled with imodium until two months before admission when cramps, diarrhoea and cutaneous flushing became a problem. Octreotide, a long-acting somatostatin analogue, 250 Ixg s.q.t.i.d, controlled the flushing. Several episodes of hypertension were docu-
mented but no hypotension. She was admitted with sub-acute intestinal obstruction which was initially treated conservatively without success. She was scheduled for an exploratory laparotomy. Laboratory studies, ECG and chest x-ray were normal except for hypoalbuminaemia and a urinary 5-hydroxyindolacetic acid (5-HIAA) concentration of 39.8 mg (normal = 9mg)/24 hr. On the morning of surgery the patient received meperidine 25 mg, hydroxyzine HCL 25 mg and glycopyrrolate metho-bromide 0.2 mg im. Octreotide 250 Ixg s.q. was also given. Prior to induction of anaesthesia she recieved diphenhydramine HCL 50 mg iv and ranitidine HC1 50 mg in 50 ml of D5W. Monitoring included a left radial artery catheter and a central venous line in addition to the usual blood pressure, pulse rate, pulse oximetry, capnography and temperature. Anaesthesia was induced with propofol 100 mg iv and vecuronium 5 mg iv was given to facilitate tracheal intubation. Anaesthesia was maintained with N20/O2 60/40%, a propofol infusion at 100-75 i~g. kg -1. min -1 and fentanyl 300 mg in divided doses, during the first hour of surgery. Vital signs remained stable throughout the 89hr of surgery except for a period of hypotension caused by rapid blood loss which responded to blood and fluid replacement. Octreotide 25 I~g iv was given for facial flushing. The surgical procedure was an 80% resection of the small bowel and omental debulking. The patient was awake within six minutes of the end of surgery. The trachea was extubated and she was taken to the postanaesthesia care unit. She was discharged to the floor six hours later. The post-anaesthetic course was uneventful. We chose a continuous intravenous technique with propofol for several reasons. Propofol attenuates the hypertensive response to tracheal intubation. 1 This is beneficial in a patient with carcinoid syndrome who had had episodes of hypertension but not the more common hypotension. The initial dose was titrated in divided doses and was somewhat higher than the recommended 1.5 mg. kg -1 for those over 60 yr. 2 Heart rate also decreased from 110 bpm to 90 bpm. Propofol has been shown not to produce histamine release. 3 The lack of post-anaesthesia emesis is also important in a patient with an active carcinoid tumour where increases in intra-abdominal pressure may precipitate a crisis. Margaret G. Pratila MD Department of Anesthesiology Memorial Sloan-Kettering Cancer Center/Cornell Medical College, New York, N.Y. Vasilios Pratilas MD Department of Anesthesiology Mount Sinai School of Medicine New York, N.Y.
944
C A N A D I A N J O U R N A L OF A N A E S T H E S I A
REFERENCES
1 Harris CE, Murray AM, Anderson JM, Grounds RM, Morgan M. Effects of thiopentone, etomidate and
propofol on the hemodynamic response to tracheal intubation. Anaesthesia 1988; 43: 32-6. 2 Dundee JW, Robinson FP, McCollum JSC, Patterson CC. Sensitivity to propofol in the elderly. Anaesthesia
1986; 41: 482-5. 3 Doenicke A, Lorenz W, Stanworth D, Duha T, Geln JB. Effects of propofol on histamine release, immuno-
globulin levels and activation of complement in healthy volunteers. Postgrad Med J 1985; 61: 15-20.
An unusual reaction to
precurarization To the Editor: We recently witnessed an unusual reaction to "precurarization". An ASA I, 40-yr-old Caucasian female presented for varicose vein surgery. Her medical history included tonsillectomy, migraine headaches and allergies to penicillin and tape. No premedication was ordered. Midazolam 1 mg was administered iv on arrival outside the operating room. In the operating room, standard monitors and an automatic BP cuff were placed. Her BP was 110/72 mmHg and HR 118" min -l. Oxygen was applied by mask and d-tubocurarine 3 mg was administered iv. At this time the patient complained of "tingling and pins and needles" on the scalp and raised her hands to hold her head. Erythematous wheals were evident on the arm proximal to the iv site. Vital signs were unchanged and the patient was reassured. Within seconds she became very distressed, grabbed her head and complained of pain like "pins and needles" in her head. Her entire skin became bright red and warm. The BP was 128/83 mmHg and HR 115 .min -1. The patient was severely distressed and remained conscious with no obvious neurological deficits. Because of the patient's discomfort but haemodynamic stability, she was anaesthetized with thiopentone and tracheal intubation was facilitated with succinylcholine. Anaesthesia was maintained with N20:O2 (70:30) and isoflurane. Blood pressure, heart rate and oxygen saturation remained stable throughout the period of the reaction and anaesthesia. Within five minutes of induction, the cutaneous vasodilatation had resolved completely. There was no evidence of bronchospasm, oedema or urticaria. Surgery proceeded uneventfully and recovery from anaesthesia was normal. In the recovery room she was pain free, had no neurological deficit, headache or rash, but complained of being cold.
Unfortunately the patient was not followed up with allergy testing, as recommended by Watkins. ~ We can offer no completely satisfactory explanation for this reaction but suggest that the history of migraine may have played a role. Acute cerebral vasodilatation due to histamine release may possibly be a basis for certain migraine headaches and this might suggest a mechanism for the reaction observed following iv d-tubocurarine. 2,3 In our patient, there were signs of histamine release such as cutaneous erythema but no hypotension. No similar case could be found in the literature. Mark Friedlander MBCHa FRCPC John Brebner Mo PnD FRCPC Department of Anaesthesia The Toronto Hospital and University of Toronto, Toronto REFERENCES
1 Watkins J. Investigation of allergic and hypersensitivi-
ty reactions to anaesthetic agents. Br J Anaesth 1987; 59: 104-11. 2 Vesely R, Hoffinan WE, Gil KSL, Albrecht RF, Miletich DJ. The cerebrovascular effects of curare and hista-
mine in the rat. Anesthesiology 1987; 66: 519-23. 3 Saxena PR. Agonists and antagonists of vascular receptors. In: M. Critchley et al. (Eds.). Advances in
Neurology, Vol 33, New York: Raven Press, 1982.
The TURP syndrome To the Editor: We read with interest Dr. Jensens's article on TURP syndrome. 1 Her guidelines regarding "prevention of TURP syndrome" contain some disputed areas. (1) She advocated restricting the duration of resection to one hour although Melchoir et al., after an analysis of 2223 consecutive TURP operations, concluded that absorption is time-related only in resections which exceeded 150 min. 2 (2) With regard to limiting the hydrostatic pressure of the irrigating fluid to 70 cm of water, we wish to point out that there are two pressures in action in the operating field: the dynamic pressure of the jet and the static pressure exerted by the contents of the urinary bladder and the weight of the tissues resting on the bladder (intestines, abdominal wall etc.). Most of the driving head of pressure is lost as a result of friction and lateral losses against the tubing and the valve of the resectoscope and what is left is the final dynamic pressure in the jet. Hultrn, using an engineering model of the human bladder,
CORRESPONDENCE
potent inhalational agent, as long as all other methods for maintaining cerebral perfusion are honoured. J. David Martino MD Louise O. Warner riD Department of Anesthesiology Children's Hospital Columbus, Ohio REFERENCES
1 Suzuki J. Moyamoya Disease. Berlin: Springer-Verlag,
1986: 7-116. 2 Sunder TR, Erwin CW, Dubois PJ. Hyperventilation
3 4 5
6
7
induced abnormalities in the electroencephalogram of children with moyamoya disease. Electroencephalogr Clin Neurophysiol 1980; 49: 414-20. Bingham RM, Wilkinson DJ. Anaesthetic management in moya-moya disease. Anaesthesia 1985; 40:1198-202. Sumikawa K, Nagai H. Moyamoya disease and anesthesia. Anesthesiology 1983; 58: 204-5. Kuro M, Karasawa J, Kuriyama Y, Kikuchi H. Anesthetic management of "moya-moya" disease in children. Proc 10th Jap Conf Surgery of Cerebral Stroke. Tokyo: Neuron Co Ltd., 1981: 207-11. Malley RA, Frost EAM. Moyamoya disease: pathophysiology and anesthetic management. Journal of Neurosurgical Anesthesiology 1989; 1:110-4. Brown SC, Lam AM. Moyamoya disease - a review of clinical experience and anaesthetic management. Can J Anaesth 1987; 34: 71-5.
Propofol infusion in Carcinoid Syndrome To the Editor: Carcinoid tumours are relatively uncommon tumours which arise from enterochromaffin cells. They form and release several vasoactive substances which cause symptoms such as flushing, diarrhoea, hypo- and hypertension, palpitations, bronchospasm and right-sided heart disease. We report the use of propofol in the anaesthethic management of a patient with carcinoid syndrome. The patient was a 69-yr-old, 48.5 kg woman with a four-year history of metastatic carcinoid tumour invading the liver and small intestine. She had been well apart from diarrhoea, controlled with imodium until two months before admission when cramps, diarrhoea and cutaneous flushing became a problem. Octreotide, a long-acting somatostatin analogue, 250 Ixg s.q.t.i.d, controlled the flushing. Several episodes of hypertension were docu-
mented but no hypotension. She was admitted with sub-acute intestinal obstruction which was initially treated conservatively without success. She was scheduled for an exploratory laparotomy. Laboratory studies, ECG and chest x-ray were normal except for hypoalbuminaemia and a urinary 5-hydroxyindolacetic acid (5-HIAA) concentration of 39.8 mg (normal = 9mg)/24 hr. On the morning of surgery the patient received meperidine 25 mg, hydroxyzine HCL 25 mg and glycopyrrolate metho-bromide 0.2 mg im. Octreotide 250 Ixg s.q. was also given. Prior to induction of anaesthesia she recieved diphenhydramine HCL 50 mg iv and ranitidine HC1 50 mg in 50 ml of D5W. Monitoring included a left radial artery catheter and a central venous line in addition to the usual blood pressure, pulse rate, pulse oximetry, capnography and temperature. Anaesthesia was induced with propofol 100 mg iv and vecuronium 5 mg iv was given to facilitate tracheal intubation. Anaesthesia was maintained with N20/O2 60/40%, a propofol infusion at 100-75 i~g. kg -1. min -1 and fentanyl 300 mg in divided doses, during the first hour of surgery. Vital signs remained stable throughout the 89hr of surgery except for a period of hypotension caused by rapid blood loss which responded to blood and fluid replacement. Octreotide 25 I~g iv was given for facial flushing. The surgical procedure was an 80% resection of the small bowel and omental debulking. The patient was awake within six minutes of the end of surgery. The trachea was extubated and she was taken to the postanaesthesia care unit. She was discharged to the floor six hours later. The post-anaesthetic course was uneventful. We chose a continuous intravenous technique with propofol for several reasons. Propofol attenuates the hypertensive response to tracheal intubation. 1 This is beneficial in a patient with carcinoid syndrome who had had episodes of hypertension but not the more common hypotension. The initial dose was titrated in divided doses and was somewhat higher than the recommended 1.5 mg. kg -1 for those over 60 yr. 2 Heart rate also decreased from 110 bpm to 90 bpm. Propofol has been shown not to produce histamine release. 3 The lack of post-anaesthesia emesis is also important in a patient with an active carcinoid tumour where increases in intra-abdominal pressure may precipitate a crisis. Margaret G. Pratila MD Department of Anesthesiology Memorial Sloan-Kettering Cancer Center/Cornell Medical College, New York, N.Y. Vasilios Pratilas MD Department of Anesthesiology Mount Sinai School of Medicine New York, N.Y.
944
C A N A D I A N J O U R N A L OF A N A E S T H E S I A
REFERENCES
1 Harris CE, Murray AM, Anderson JM, Grounds RM, Morgan M. Effects of thiopentone, etomidate and
propofol on the hemodynamic response to tracheal intubation. Anaesthesia 1988; 43: 32-6. 2 Dundee JW, Robinson FP, McCollum JSC, Patterson CC. Sensitivity to propofol in the elderly. Anaesthesia
1986; 41: 482-5. 3 Doenicke A, Lorenz W, Stanworth D, Duha T, Geln JB. Effects of propofol on histamine release, immuno-
globulin levels and activation of complement in healthy volunteers. Postgrad Med J 1985; 61: 15-20.
An unusual reaction to
precurarization To the Editor: We recently witnessed an unusual reaction to "precurarization". An ASA I, 40-yr-old Caucasian female presented for varicose vein surgery. Her medical history included tonsillectomy, migraine headaches and allergies to penicillin and tape. No premedication was ordered. Midazolam 1 mg was administered iv on arrival outside the operating room. In the operating room, standard monitors and an automatic BP cuff were placed. Her BP was 110/72 mmHg and HR 118" min -l. Oxygen was applied by mask and d-tubocurarine 3 mg was administered iv. At this time the patient complained of "tingling and pins and needles" on the scalp and raised her hands to hold her head. Erythematous wheals were evident on the arm proximal to the iv site. Vital signs were unchanged and the patient was reassured. Within seconds she became very distressed, grabbed her head and complained of pain like "pins and needles" in her head. Her entire skin became bright red and warm. The BP was 128/83 mmHg and HR 115 .min -1. The patient was severely distressed and remained conscious with no obvious neurological deficits. Because of the patient's discomfort but haemodynamic stability, she was anaesthetized with thiopentone and tracheal intubation was facilitated with succinylcholine. Anaesthesia was maintained with N20:O2 (70:30) and isoflurane. Blood pressure, heart rate and oxygen saturation remained stable throughout the period of the reaction and anaesthesia. Within five minutes of induction, the cutaneous vasodilatation had resolved completely. There was no evidence of bronchospasm, oedema or urticaria. Surgery proceeded uneventfully and recovery from anaesthesia was normal. In the recovery room she was pain free, had no neurological deficit, headache or rash, but complained of being cold.
Unfortunately the patient was not followed up with allergy testing, as recommended by Watkins. ~ We can offer no completely satisfactory explanation for this reaction but suggest that the history of migraine may have played a role. Acute cerebral vasodilatation due to histamine release may possibly be a basis for certain migraine headaches and this might suggest a mechanism for the reaction observed following iv d-tubocurarine. 2,3 In our patient, there were signs of histamine release such as cutaneous erythema but no hypotension. No similar case could be found in the literature. Mark Friedlander MBCHa FRCPC John Brebner Mo PnD FRCPC Department of Anaesthesia The Toronto Hospital and University of Toronto, Toronto REFERENCES
1 Watkins J. Investigation of allergic and hypersensitivi-
ty reactions to anaesthetic agents. Br J Anaesth 1987; 59: 104-11. 2 Vesely R, Hoffinan WE, Gil KSL, Albrecht RF, Miletich DJ. The cerebrovascular effects of curare and hista-
mine in the rat. Anesthesiology 1987; 66: 519-23. 3 Saxena PR. Agonists and antagonists of vascular receptors. In: M. Critchley et al. (Eds.). Advances in
Neurology, Vol 33, New York: Raven Press, 1982.
The TURP syndrome To the Editor: We read with interest Dr. Jensens's article on TURP syndrome. 1 Her guidelines regarding "prevention of TURP syndrome" contain some disputed areas. (1) She advocated restricting the duration of resection to one hour although Melchoir et al., after an analysis of 2223 consecutive TURP operations, concluded that absorption is time-related only in resections which exceeded 150 min. 2 (2) With regard to limiting the hydrostatic pressure of the irrigating fluid to 70 cm of water, we wish to point out that there are two pressures in action in the operating field: the dynamic pressure of the jet and the static pressure exerted by the contents of the urinary bladder and the weight of the tissues resting on the bladder (intestines, abdominal wall etc.). Most of the driving head of pressure is lost as a result of friction and lateral losses against the tubing and the valve of the resectoscope and what is left is the final dynamic pressure in the jet. Hultrn, using an engineering model of the human bladder,
