Scientific Abstracts Human renal function following methoxy- The antagonism of morphine anesthesia by flurane anesthesia naloxone R.B. Merkle, F.D. McDonald, J. Waldman, J.D. Hasbrouck G.D. Maynwrd, J. Petiti, P.J. Fleming, and Anesth Analg (Cleveland) 50(6):954 Nov.- W.J. Murray Dec., 1971 JAMA 218(6):841 Nov. 8, 1971 The use of morphine as an anesthetic has some advantages with hypoxic, acidotic, Methoxyflurane and halothane, both hypotensive patients undergoing intracar- fluorinated hydrocarbons, have become diac surgery, in that it produces little car- popular anesthetics, but the effect of meth- diovascular depression and may- actually oxyflurane on renal function has recently augment ventricular action in the failing been the object of much concern. The 1960 heart. A major disadvantage is that somno- report of Artusio et al., introducing meth- lence and respiratory depression due to the oxyflurane with its results in 100 patients, dosage required for anesthesia may last 8 did not cover renal effects, though Artusio to 16 hours. Levallorphan and nalorphine, and other workers later described patients the most commonly used antagonists to with elevated urinary output and BUN morphine, frequently produce CNS excita- following exposure to this agent. tion and other undesirable side effects in In this study, 49 patients requiring 50 the doses required to counteract morphine retinal detachment repairs were selected anesthesia. Naloxone, the N-allyl deriva- alternately to receive methoxyflurane or tive of oxymorphone, is virtually free of halothane. This surgical procedure was such side effects. Its efficacy in antagoniz- chosen to exclude effects of hypotension, ing morphine anesthesia was tested in 25 blood loss, and trauma to the kidneys. The patients undergoing surgery for valvular two groups of patients were well matched heart disease. A 19-lead EEG record was in age, weight, and duration of anesthesia. obtained in addition to the usual monitors The group receiving methoxyflurane ex- before and after the administration of nar- hibited increased serum creatinine and cotic and during its reversal with naloxone. lowered urine osmolality on each post-op- Each patient's degree of narcosis was as- erative day, while the halothane patients sessed by examination and questioning, did not. A greater decline in urine osmolal- and objectively by respiratory and EEG ity for older patients, reported by other measurements. Repeated 5 mcg/kg doses workers, was noted in the methoxyflurane of naloxone were given at intervals; a total group but not in the halothane group. The dose of 10 mcg/kg was effective in re- data indicate that renal function changes versing respiratory depression in all pa- are identifiable in a group of patients re- tients. The mean duration of action was ceiving methoxyflurane, but the relation of about three hours, so the narcotic effect these changes to the progressive renal in- tended to outlast the naloxone; patients sufficiency that has been reported for spe- breathing spontaneously were observed cific patients is unclear. Additional surgical carefully and given additional doses as nec- stress, prolonged hypotension, or dehydra- essary. Naloxone has a wide margin of safe- tion may cause the abnormalities described ty and no narcotic effects; its potential may here to progress to the more severe syn- also make morphine anesthesia more at- drome. tractive for other types of surgery. SEPTEMBER-OCTOBER, 1972 129 Apparent anaphylactic reaction to propanidid man phenomena of sensitization. A case is H.L. Thornton reported of primary necrosis of the liver, Anaesthesia 26(4) :490 Oct. 1971 associated with extensive renal oxalosis, fol- Propanidid, an ultra-short-acting intra- lowing a single exposure to methoxyflurane. venous anesthetic, has been used in thou- A 67-year-old patient undergoing surgery sands of patients over the past six to seven for bladder carcinoma with methoxyflurane years without evidence of serious reaction; anesthesia had an uneventful recovery for however, a 34-year-old female undergoing the first two postoperative days, but on the orthopedic manipulation of the sacro-iliac third day became stuporous and developed received propanidid twice with about two fever, jaundice, and seizures. Steroids were weeks intervening, and on the second ex- begun on the sixth day, but the patient posure displayed an anaphylactic reaction. died on the seventh. Autopsy revealed ex- The first administration was uneventful. tensive liver necrosis with evidence of Following recovery from the second expo- biliary stasis; the kidneys showed hydropic sure, the patient began to retch, suffered a degeneration of the tubular epithelium and transient fall in blood pressure, and then amino acid crystals in the tubules, re- complained of dyspnea and chest pain. The flecting the damage to the liver parenchy- blood pressure recovered when the pa- ma. tient's head was lowered; oxygen was ad- The time of onset and the fact that this ministered, and the dyspnea subsided. The was the patient's first exposure to this type patient then complained of severe abdom- of anesthetic eliminates acquired hypersen- inal and pelvic pain but recovered enough sitivity as the explanation of the reaction; to return home after about four hours; she infective processes and other hepatotoxic reported facial edema and erythema of the drugs are ruled out for similar reasons. trunk lasting several hours more. The chain Fewer than ten cases of primary hepato- of symptoms strongly suggest a drug- toxicity due to methoxyflurane have been induced anaphylaxis, especially in view of reported previously. In this case and a few the identical but uneventful previous ad- others, liver damage preceded renal failure. ministration. A search of English literature The true incidence of hepatorenal damage revealed five other cases of reactions to caused by methoxyflurane remains to be propanidid, one fatal, all of which were established. marked by hypotension and erthymatous skin reactions. Though such dangerous re- Thiopental anaphylaxis: A case and a sponses to propanidid are rare, their pos- method sibility argues that this agent should not for diagnosis be used except in the presence of all neces- G.S. Fox, R.D. Wilkinson, and F.I. Rabow sary facilities for resuscitation. Anesthesiology 35(6) :655 Dec., 1971 Seven cases of anaphylactic shock due to thiopental have been reported to date, in- dicating that such reactions are extremely Hepatorenal failure with renal oxalosis after rare; they may sometimes go undiagnosed. methoxyflurane anesthesia A case is reported of thiopental anaphylaxis J.W. Mostert, U. Kim, and M.W. Woodruff confirmed by the basophil degranulation New York J. Med 71(22):2676 Nov. 15, test. 1971 A 40-year-old woman, admitted for cor- The renal toxicity of methoxyflurane has rection of bilateral hallux valgus, had a his- received more attention than its tendency tory of a rash following penicillin, and to damage the liver. With repeated expo- coryza from perfumed cosmetics, but had sure to halothane, a related anesthetic, liver no seasonal allergies; she had received necrosis is usually explained on the basis thiopental in 1957, 1958, and 1967 without of acquired sensitivity, and patients similar- untoward reaction. In the present instance, ly sensitive to methoxyflurane have been anesthesia was induced with sodium thio- reported. Like other fluorocarbons, how- pental, and recovery was uneventful. The ever, these compounds can cause liver patient returned 14 days later for below- damage without the characteristic Shwartz- knee casts. Anesthesia was induced with 130 ANESTHESIA PROGRESS thiopental again, and salivation and cyano- The time course of EDVST response to sis were noted after a few minutes; blood diazepam differed significantly, however, pressure and brachial and radial pulse were from the reaction to lidocaine. Lidocaine absent. Lanatoside and phenylephrine precipitated a more rapid rise followed were given, then epinephrine and hydo- by a gradual decline, while diazepam cortisone when skin reddening and facial reached a gradual plateau. edema appeared. The patient responded, The EDVST reaction to 2 mg/kg of and was discharged in good condition after lidocaine was significantly greater after 0.5 four days. mg/kg than after 1.0 mg/kg of diazepam. Diagnosis was difficult, since the patient And the EDVST reaction to 2 mg/kg lido- had tolerated thiopental in the past. Apart caine was greater than to 1 mg/kg. from the three historical exposures, the last Because diazepam has little harmful ef- had been two weeks previously, and a two- fect hemodynamically, has an inherent anti- week incubation period is optimal for ex- arrhythmic action, and increases the anti- pression of a primary sensitivity to drugs. arrhythmic effect of lidocaine, it suggests Not only the multiplicity but the timing of that this is a useful drug in daily anesthesia. previous exposures can be important in such sensitivity. Confirmation of thiopental hypersensitivity has been difficult, but the indirect basophil degranulation test partial- What's Wrong with Our Operating Rooms? ly duplicates anaphylaxis in vitro. Applied Harold Laufman to blood samples from this patient the test Amer I Surg 122(9) :332-43 Sept. 1971. revealed marked degranulation with thiop- Surgical suites constructed over more ental, slight with penicillin G and secobar- than 20 years ago, which have not been bital, and no response to other drugs tested. renovated, are easy to discern. They often consist of poor space usage, a disorderly or badly designed traffic pattern, ineffec- tive materials-handling system, and unsatis- The Effect of Diazepam on the Antiarrhythmic factory electrical wiring system or a poorly Response to Lidocaine. designed ventilation system. Newly built Ronald W. Dunbar, Robert B. Boettner, surgical rooms often contain worse offenses John V. Haley, Vivian E. Hall, and Dean which are harder to determine, due to the H. Morrow. bright new atmosphere and the abundance Anesthes and Analges 50(4): 685-92 July- of awesome equipment. There may even be Aug, 1971. more instruments and equipment (thus Thirty-two open-chest dogs, weighing more money expended) than necessary.