Burton S. Epstein

The Antiemetic Effect of Droperidol Following Outpatient Strabismus Surgery in Children

The Antiemetic Effect of Droperidol Following Outpatient Strabismus Surgery in Children Michael Abramowitz;Tae Oh;Burton Epstein;Urs Ruttimann;David Friendly; Anesthesiology

Subacute Upper Respiratory Infection in Small Children

Although it is widely accepted as good practice to avoid elective administration of general anesthesia to a patient who has an acute upper respiratory infection (URI), there is a paucity of information regarding the nature of the morbidity that may result if anesthesia were administered. Furthermore, the optimal period of recovery from the URI that should be allowed prior to considering the patient a candidate for an elective surgical procedure has not been defined. The following are two case reports which are representative of 11 patients who developed unexplained intra-anesthetic pulmonary dysfunction. The common factor in all but one patient was a history of an upper respiratory infection during the previous month.

Effect of lidocaine with epinephrine versus lidocaine (plain) on induced labor.

HE USE of local analgesic solutions conT taining epinephrine continues to be a controversial issue in continuous lumbar epidural analgesia for obstetrics.1-3 In an excellent recent study* of caudal epidural analgesia, 1 percent lidocaine with 1 :200,000 epinephrine was compared with 1 percent mepivacaine. Compared with administration of mepivacaine alone, the duration of first-stage labor was significantly prolonged by the addition of epinephrine to lidocaine, and twice as many parturients required oxytocic augmentation of labor. Hence, it was concluded that epinephrine was the important variable. technics that there can be a measurable decrease in the form of labor while the cervix continues to dilate and efface.5

The American Society of Anesthesiologist's efforts in developing guidelines for sedation and analgesia for nonanesthesiologists: The 40th Rovenstine lecture

I am honored to have been selected to deliver the 40th Annual Emery A. Rovenstine Memorial Lecture. At previous Rovenstine lectures, I learned about his pioneering efforts as the Director of the Anesthesia Service at Bellevue Hospital (New York City, New York) where he served from 1935 to 1960; his Presidency of the American Society of Anesthesiologists (ASA), 1943–1944; and as the recipient of the ASA’s Distinguished Service Award in 1957. In the past year, however, two outstanding articles have been written that present material I was unaware of. Lucien Morris, M.D. (Professor Emeritus, Medical College of Ohio, Toledo, Ohio) authored the fascinating article “Ralph M. Waters’ Legacy: The Establishment of Academic Anesthesia Centers by the ‘Aqualumni’.” The ’aqualumni,’ is defined as Waters’ own trainees. The article was written to commemorate the 75th Anniversary of Waters accepting an academic appointment to the medical faculty of the University of Wisconsin (Madison, Wisconsin). I found particularly interesting the section describing Professor Waters’ concern that when Dr. Rovenstine, one of his aqualumni, went to Bellevue Hospital, New York University (NYU, New York City, New York), he might not have sufficient staff to establish a new academic training center for anesthesia. As a result, Waters split his Wisconsin group, sending both staff and residents to New York City to ensure the success of Dr. Rovenstine at NYU. Waters had enough confidence in Dr. Rovenstine to predict that he would succeed. He would not disappoint Dr. Waters. David Waisel, M.D. (Department of Anesthesia, Children’s Hospital, Boston, Massachusetts) provided a comprehensive review of “The Role of World War II and The European Theater of Operations in the Development of Anesthesiology as a Physician Specialty in the USA.” In 1942, Waters and Rovenstine and others teamed up to train “90-day wonders” in 12-week courses “to prepare medical officers to take charge of the anesthesia sections of the various types of hospitals of the U.S. Army.” Courses were given at several institutions, including Bellevue, and were developed by the Subcommittee on Anesthesia of the National Research Council. The latter was chaired by Dr. Waters. Dr. Rovenstine was the Secretary. Many future anesthesiologists were attracted to the specialty as a result of their initial exposure to the field in World War II and the influence of role models such as Dr. Rovenstine. Although I did not know Dr. Rovenstine personally, I was trained by another aqualumnus of Dr. Waters, Robert D. Dripps, M.D. (Professor and Chair, Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania). Dr. Dripps was interested in attracting medical students into the field of Anesthesiology. One of his efforts led to the establishment of the ASA Preceptorship Program and the Committee on which I first served the ASA. In the 36 yr in which I have been involved in the activities of the ASA, 20 yr have been spent on developing guidelines for sedation for nonanesthesiologists. It has been the most challenging, frustrating, and contentious issue I have had to address. Even though ASA’s efforts have been exemplary, the results have been misunderstood by not only the groups we have attempted to educate but also by our own members. I have decided to set the record straight by discussing the history of “ASA’s Efforts in Developing Guidelines for Sedation and Analgesia for Nonanesthesiologists.” Some of the comments that follow are my own thoughts and interpretations; however, most of the statements are documented in the literature or are part of my own collection of documents. The latter will be donated to the Wood Library Museum (Park Ridge, Illinois) together with the script of this lecture. The formal process of ASA’s evidence-based guideline development for members did not begin until 1990, and for nonanesthesiologists, in 1993. Other specialty groups began setting guidelines earlier and their efforts must be acknowledged before proceeding with ASA’s efforts. It is not intended to provide a comprehensive or complete review of these accomplishments but rather to attempt Professor Emeritus in Pediatrics and Anesthesiology. Received from the Department of Pediatrics and Anesthesiology, The George Washington University Medical Center, Washington, District of Columbia.

Changes in heart rate and rhythm after intramuscular succinylcholine with or without atropine in anesthetized children.

The effects of intramuscular injections of Succinylcholine with or without atropine on heart rate and rhythm were studied in 50 unpremedicated children 6–18 months of age. All had anesthesia induced with N2O-O2 and halothane 2% by face mask. Sixty seconds later, one of four study drugs or drug combinations was injected into the deltoid muscle of patients in groups 1–4. Following injection, halothane concentration was reduced to 1%, and ventilation was controlled. Patients given atropine only (0.02 mg/kg), succinylcholine only (4 mg/kg), or a combination of both (4 mg/kg Succinylcholine plus 0.02 mg/kg atropine) showed transient increases in heart rate to 106 ± 7.5%, 113 ± 11.8%, and 109 ± 20.1% (mean ± so) of control, followed by a decrease to 78 ± 6.7%, 79 ± 9.4%, and 80 ± 10.5%, respectively, in 2–3 min after injection. Patients given a combination of Succinylcholine (4 mg/kg) plus a higher dose of atropine (0.03 mg/kg) also had a transient increase in heart rate to 107 ± 7.5%, followed by a decrease to 82 ± 11.8% 2 min after injection. However, this group differed from the other three groups in presenting a second, prolonged increase in heart rate to 115 ± 9.0% of preinjection levels. Patients in group 5 (controls) received no injections. Their heart rate decreased to 76 ± 10.78% of preinduction level within 90 sec of induction, and remained unchanged thereafter. We conclude that Succinylcholine (4 mg/kg) can be used intramuscularly with or without atropine (0.02 mg/kg) in lightly anesthetized young children without producing severe bradycardia. If an increase in heart rate is desired, a higher dose of atropine (0.03 mg/kg) is recommended.

COMPARISON OF OROTRACHEAL INTUBATION WITH TRACHEOSTOMY FOR ANESTHESIA IN PATIENTS WITH FACE AND NECK BURNS

Before 1961, S.R.U. patients with fresh burns of the face and neck were usually tracheostomized for intubation before anesthesia. Study of the records of these patients revealed frequent complications; hence it was decided to employ orotracheal intubation rather than recommend tracheostomy unless there was edema of the oropharynx or larynx. This procedure was followed during the 13 months covered by this report.

II. COMPARATIVE EFFECTS OF PRILOCAINE AND LIDOCAINE DURING PERIDURAL ANESTHESIA FOR OBSTETRICS

METHOD A double-blind study was performed using coded solutions of (1) 1.5 per cent lidocaine, ( 2 ) 1.5 per cent lidocaine with 1: 200,000 epinephrine, (3) 1.5 per cent prilocaine, and (4) 2 per cent prilocaine. Special data collection sheets were completed for each study, noting especially the amount of solution injected, anesthetic level in 20 minutes, general impression of the adequacy of the anesthesia for labor and delivery, and signs of cardiovascular and central nervous system toxicity. for concentration of the local anesthetic by a modified methyl orange technic.2 The error in the measurement is 50.5 mcg. per ml. Students t-test and chi-square methods were used for statistical analyses.

Blood Concentration of Prilocaine and Lidocaine With Epinephrine During Continuous Epidural Anesthesia for Obstetrics

IGNIFICANT accumulation of an anesthetic S in the blood can follow intermittent injections of a local anesthetic agent through an epidural catheter.1 Indeed, this rise in blood anesthetic level has been reported to be associated with toxicity in certain patienh2-4 Since such an accumulation might occur during continuous epidural anesthesia for obstetrics and might result in toxicity to the mother andfor fetus, it was decided to compare the vascular absorption of two local anesthetic agents after repeated injections in such patients.

Where we were, where we are, where we are going.

WHERE WE WERE The Early Days From 1958 to 1961 and 1963 to 1964, I was a resident in anesthesiology and a member of the faculty at the Hospital of the University of Pennsylvania (HUP). The chairman of the department and McNeil Professor was Robert D. Dripps. None of his trainees or faculty was allowed to use the phrase, “in my experience,” when participating in a conference. The bywords were, “show me the data!” This philosophy has greatly influenced my approach to learning, teaching, and research. In the 1950s, general inhaled anesthesia using gasoxygen-ether was usually used. Breathe it in through the lungs and exhale it by the same route was the preferred anesthetic technique. At the HUP, there was no ambulatory surgery, prolonged recovery was common, and nausea and vomiting were frequent complications. In 1959, however, Egbert et al. compared the recovery from IV administration of methohexital (later known as Brevital) with that from thiopental. Healthy, “normal,” volunteers’ recovery reactions were studied using an American Automobile Association driving simulator. The authors of the study noted that methohexital had a shorter duration of effect than thiopental and “would be an advantage for anesthesia in outpatients.” Later, a remarkable philosophical change occurred at HUP. Dr. Dripps agreed to conduct a trial of Innovar, an IV drug consisting of droperidol and fentanyl in a ratio of 50:1 (2.5 mg/mL; 50 g/mL). The McNeil Pharmaceutical Company wanted to field test the practical application of the combination of the hypnotic, sedative, and antiemetic properties of droperidol and the analgesic effects of fentanyl (so called “neuroleptanalgesia”). This study was done on inpatients to the virtual exclusion of gasoxygen-ether. My early exposure to this drug and its components led to my later research. I became a member of the faculty at the George Washington University Medical Center (GWUMC) in 1964. In 1966, at GWUMC, Levy and Coakley had opened an “In and Out Surgery” unit. I was not part of that development process. At the time, I was initiating a lumbar epidural service in obstetrics. In 1972, because of my previous association with HUP, my familiarity with Innovar, and Dr. Dripps’ association with McNeil Laboratories, I was approached by their medical director with a proposal for a research study. The company wanted to test the use of fentanyl as an adjunct in the overall anesthetic management of outpatient surgery. This had not been previously attempted in that setting. Levy and Coakley agreed that I would relocate from obstetrics to the outpatient unit, and in 1973 I undertook a study to evaluate Sublimaze (fentanyl) in short surgical procedures.