Correspondence administration (5-10s) did not produce this effect. So consistent is this finding that one of us (W.D.M.) uses it as an additional confirmatory test of the correct placement of the intravenous cannula in the rat. These animals were all healthy and had received no drugs for premedication. We can, therefore, exclude underlying pathology or interaction with pharmacological agents (other than isoflurane). We agree with Davis and Hall that a likely explanation for this phenomenon is a
175
direct action of propofol or its metabolites (or in our study an interaction with isoflurane). North Western Injury Research Centre, Stopford Building Oxford Road, Manchester M I 3 9PT
W.F. DE MELLO E. KIRKMAN
Pilo-erection in anaphylactoid reaction 1 was interested to read the report of Drs Rabey and James (Anaesthesia 1991; 4 6 897) as I had a similar case many years ago. Immediately after the injection of thiopentone 300 mg, THA 15 mg and suxamethonium 30 mg, transient piloerection of both forearms occurred, sufficiently obvious to be noted and remarked upon not only by myself but also by the nursing sister who was assisting me. The subsequent series of events was similar to that reported by Drs Rabey and James and skin testing at a later date showed a response only to suxamethonium. Some years later I had
another patient who had a similar severe anaphylactoid reaction to gallamine, but I d o not remember pilo-erection occurring although I did not specifically look for it. Regarding the question posed ‘might pilo-erection be a useful warning . . .?’ my recollection is that the bronchospasm and profound hypotension occurred almost simultaneously with the ‘gooseflesh’ and in my opinion rather than being a warning it corroborates the diagnosis. Leven, Fqe KY8 5NA
C.K. ADAM
Speed of onset of postoperative analgesia In their excellent paper (.4naesthesia 1991; 4 541-4), Rice et al. report that, after intramuscular administration of ketorolac tromethamine or morphine, ‘in no group did 50% of patients achieve a 50% reduction in pain intensity within the 60 min of the study’. Eight patients from the morphine group (n = 28) and nine patients from the ketorolac group (n = 28) had to be withdrawn from the study ‘because of insufficient analgesia’. This study reflects the typical situation of patients in the early postoperative period: the main reason for this deplorable situation is the fact that, even nowadays, most analgesics are given by intramuscular injection during the early postoperative phase. The conclusion to be drawn from the alarming results reported by Rice et al. is that during the immediate postoperative period, i.e. in the recovery room, analgesics should only be given by the intravenous route and intramuscular injections should be strictly avoided. Only intra-
venous injection ensures rapid onset of analgesia, to which every patient in severe pain has a right. Since sensitivity to pain may show wide interindividual variation, it is important to adapt opioid doses to individual requirements. A prerequisite for demand-adapted opioid titration is that the route of administration ensures rapid onset of action. Only in this way is it possible to judge the efficacy of a single bolus quickly and to decide whether an additional bolus will be required. The intravenous route is facilitated by the fact that, in the immediate postoperative period, all patients still have intravenous lines in situ. Seglitz Medical Center, Free University of Berlin, Hindenburgdamm 30, I000 Berlin 45, Germany
H.W. STRIEBEL
Yet another use for the laryngeal mask
I would like to report yet another use for the laryngeal mask (LM). An 84-year-old woman with a dense right hemiplegia was in end-stage respiratory failure secondary to chronic obstructive pulmonary disease. Neurologically, there was no improvement and she remained unresponsive throughout her stay in the intensive care unit. She was successfully weaned off ventilatory support after 3 weeks of treatment. After careful discussion with her relatives, a policy decision was made not to reventilate her lungs if she deteriorated as she would have had a very poor quality of life. However, a major problem was copious secretions requiring frequent suctioning. It is the practice of the physiotherapists in this hospital
to use an oral airway in these patients in order to facilitate oropharyngeal and tracheal suction, but it was very difficult to get the suction catheter into the right position. A size 3 laryngeal mask was inserted after spraying the back of her throat with four sprays of 10% lignocaine. She tolerated the laryngeal mask without any difficulty. Suction catheters were then passed down the LM into the trachea and secretions removed easily whilst the patient was in the sitting position. She was fed enterally via a nasogastric tube, which was aspirated before physiotherapy to minimise gastric contents. The LM was also used to facilitate oxygen delivery on the occasions when she experienced difficulty. By using a
I76
Correspondence
standard 15 mm connector, humidified 40% oxygen was delivered to the patient via the laryngeal mask and a T-piece breathing system. In this way, we were able to avoid reventilation. A minitracheostomy may have been more effective in helping to clear secretions. However, this is an operative procedure with definite complications. In view of the noninterventionist policy, it was decided that a minitracheostomy was probably too invasive and not justified. Since its advent, the LM has found many different uses, mainly in the management of difficult airways. In a lecture given by its inventor, Dr A.J. Brain, he relates an occasion
when he has had a laryngeal mask inserted in himself awake and found no difficulty in tolerating its presence. It was this which prompted our usage of the laryngeal mask. It was remarkable how well it was tolerated by our patient. Perhaps the laryngeal mask has a role in intensive care to aid oropharyngeal and tracheal suction without the need to resort to a minitracheostomy. Barnsley District General Hospital, Barnsley , South Yorkshire S7.5 2EP
W. LIM
175
direct action of propofol or its metabolites (or in our study an interaction with isoflurane). North Western Injury Research Centre, Stopford Building Oxford Road, Manchester M I 3 9PT
W.F. DE MELLO E. KIRKMAN
Pilo-erection in anaphylactoid reaction 1 was interested to read the report of Drs Rabey and James (Anaesthesia 1991; 4 6 897) as I had a similar case many years ago. Immediately after the injection of thiopentone 300 mg, THA 15 mg and suxamethonium 30 mg, transient piloerection of both forearms occurred, sufficiently obvious to be noted and remarked upon not only by myself but also by the nursing sister who was assisting me. The subsequent series of events was similar to that reported by Drs Rabey and James and skin testing at a later date showed a response only to suxamethonium. Some years later I had
another patient who had a similar severe anaphylactoid reaction to gallamine, but I d o not remember pilo-erection occurring although I did not specifically look for it. Regarding the question posed ‘might pilo-erection be a useful warning . . .?’ my recollection is that the bronchospasm and profound hypotension occurred almost simultaneously with the ‘gooseflesh’ and in my opinion rather than being a warning it corroborates the diagnosis. Leven, Fqe KY8 5NA
C.K. ADAM
Speed of onset of postoperative analgesia In their excellent paper (.4naesthesia 1991; 4 541-4), Rice et al. report that, after intramuscular administration of ketorolac tromethamine or morphine, ‘in no group did 50% of patients achieve a 50% reduction in pain intensity within the 60 min of the study’. Eight patients from the morphine group (n = 28) and nine patients from the ketorolac group (n = 28) had to be withdrawn from the study ‘because of insufficient analgesia’. This study reflects the typical situation of patients in the early postoperative period: the main reason for this deplorable situation is the fact that, even nowadays, most analgesics are given by intramuscular injection during the early postoperative phase. The conclusion to be drawn from the alarming results reported by Rice et al. is that during the immediate postoperative period, i.e. in the recovery room, analgesics should only be given by the intravenous route and intramuscular injections should be strictly avoided. Only intra-
venous injection ensures rapid onset of analgesia, to which every patient in severe pain has a right. Since sensitivity to pain may show wide interindividual variation, it is important to adapt opioid doses to individual requirements. A prerequisite for demand-adapted opioid titration is that the route of administration ensures rapid onset of action. Only in this way is it possible to judge the efficacy of a single bolus quickly and to decide whether an additional bolus will be required. The intravenous route is facilitated by the fact that, in the immediate postoperative period, all patients still have intravenous lines in situ. Seglitz Medical Center, Free University of Berlin, Hindenburgdamm 30, I000 Berlin 45, Germany
H.W. STRIEBEL
Yet another use for the laryngeal mask
I would like to report yet another use for the laryngeal mask (LM). An 84-year-old woman with a dense right hemiplegia was in end-stage respiratory failure secondary to chronic obstructive pulmonary disease. Neurologically, there was no improvement and she remained unresponsive throughout her stay in the intensive care unit. She was successfully weaned off ventilatory support after 3 weeks of treatment. After careful discussion with her relatives, a policy decision was made not to reventilate her lungs if she deteriorated as she would have had a very poor quality of life. However, a major problem was copious secretions requiring frequent suctioning. It is the practice of the physiotherapists in this hospital
to use an oral airway in these patients in order to facilitate oropharyngeal and tracheal suction, but it was very difficult to get the suction catheter into the right position. A size 3 laryngeal mask was inserted after spraying the back of her throat with four sprays of 10% lignocaine. She tolerated the laryngeal mask without any difficulty. Suction catheters were then passed down the LM into the trachea and secretions removed easily whilst the patient was in the sitting position. She was fed enterally via a nasogastric tube, which was aspirated before physiotherapy to minimise gastric contents. The LM was also used to facilitate oxygen delivery on the occasions when she experienced difficulty. By using a
I76
Correspondence
standard 15 mm connector, humidified 40% oxygen was delivered to the patient via the laryngeal mask and a T-piece breathing system. In this way, we were able to avoid reventilation. A minitracheostomy may have been more effective in helping to clear secretions. However, this is an operative procedure with definite complications. In view of the noninterventionist policy, it was decided that a minitracheostomy was probably too invasive and not justified. Since its advent, the LM has found many different uses, mainly in the management of difficult airways. In a lecture given by its inventor, Dr A.J. Brain, he relates an occasion
when he has had a laryngeal mask inserted in himself awake and found no difficulty in tolerating its presence. It was this which prompted our usage of the laryngeal mask. It was remarkable how well it was tolerated by our patient. Perhaps the laryngeal mask has a role in intensive care to aid oropharyngeal and tracheal suction without the need to resort to a minitracheostomy. Barnsley District General Hospital, Barnsley , South Yorkshire S7.5 2EP
W. LIM
