TWO WEEKS IN AUGUST, SOUTHMEAD 1958

 

In August 1958 the anaesthetists at Southmead Hospital , Bristol, decided to keep a central record of the anaesthetics given in their two main theatres. Initially this was to be for a two-month trial period, but in the event it continued for 9 years. The normal anaesthetic chart continued to be placed in the patient’s notes. The central record did not include any anaesthetics given in the obstetric or casualty departments. It began on 6th August 1958.

During the first 2 weeks (i.e. 6/8/58 – 19/8/58 inclusive) 5 anaesthetists worked with 18 surgeons and made 172 entries:

Patients: female 94, male 67, not stated 2. Age 6 – 82 yrs (but often not recorded)

Type of operation (n=172):

  • General surgery..........72..........(42%)

  • Gynaecology..............43..........(25%)

  • Urology.....................40..........(23%)

  • ENT.........................13...........(8%)

  • Orthopaedic................4...........(2%)

    • Elective cases......................126......(73%)

    • Emergency cases...................46......(27%)

Type of anaesthesia (n=172)

  • GA alone........................152..........(88%)

  • GA + spinal/epidural..........11..........(6%)

  • Spinal, no GA.....................3..........(2%)

  • Spinal + GA.......................5 .........(3%)

  • Epidural, no GA .................3..........(2%)

  • Epidural + GA....................6..........(3%)

  • Local infiltration.................2..........(1%)

  • Brachial plexus block..........1..........(0.6%)

Induction of GA (n=163)

  • Thiopentone...................121.........(74%)

  • Hexobarbitone..................28.........(17%).......(preceded by lytic cocktail 1)

  • Ethyl chloride...................10.........(6%)

  • N2O.................................4..................(+Trilene 1, +Ether 1, +Neothyl 1)

Depolarising relaxants at induction (presumably prior to intubation) - 60 patients (37%)

  • Suxamethonium..............48

  • Suxethonium..................12

    • In 3 cases, further doses of suxamethonium were give intraoperatively.

Maintenance of general anaesthesia (n=163)

  • Nitrous oxide.......................150.........(92%)

    • + Trilene.............53.........(33%)

    • + Neothyl.............8..........(5%)

    • + Ether................5..........(3%)

    • + Halothane..........1.........(0.6%)

    • + Cyclopropane....5..........(3%)

    • + Pethidine.........84..........(49%)

  • Cyclopropane/O2.............4..........(2%............Cyclopropane, total....9 (6%)

  • Ether/O2........................7..........(4%)

  • Ether, open...................1..........(0.6%)..........Ether, total .............13 (8%)

A non-depolarising muscle relaxant was used in 116 cases (71% of GAs), but in 58 of these only a subapnoeic dose of gallamine was given - see Elective GA below. One patient was given gallamine before intubation.

When used in full apnoeic dose (n=58)

  • d-tubocurarine...................27..........(47%)

  • gallamine...........................31..........(53)

Hexamethonium was used to lower blood pressure in six cases (pelvic floor repair 2, gastrectomy 1, mastectomy 1, cholecystectomy 1, thyroidectomy 1)

 _______________________________

Discussion

Elective GA cases (n = 107)

The commonest anaesthetic technique (53%) was based on

  • IV induction, with thiopentone (63%) or hexobarbitone (23%)

  • A "softening" (subapnoeic) dose of gallamine (40 mg where stated)

  • Nitrous oxide +/- Trilene (67%) or Neothyl (12%) +/- Pethidine (46%)

using a "Magill attachment" (Mapleson A) and face mask

This technique of limited NMJ block preserving spontaneous respiration may seem somewhat bizarre to-day, but in practice it worked well, particularly after a heavy premed. By itself the small dose of gallamine did not cause significant rise in the pCO2(Tobin et al. Brit. J Anaesth. 1970; 42, 633.), but it did take the fight out of the patient.

In short cases the patients were rarely aware of any residual paralysis because of the heavy premedication and the slow elimination of Trilene. Also (in contrast to curare) gallamine is not potentiated by acidosis, even if other factors cause hypoventilation.

 

Gastrectomy (n=5)

Patient No. 1 The first entry in the book; a 58-yr old man who underwent elective partial gastrectomy. The anaesthetic is recorded as follows:

Epidural Xylo: 48 cc 1.2%, Evipan 10% Scoline Xyl spray, N2O + O2 Endo:

i/v 1/5 N/S Lt. Wrist. BP 96/60 end. Normal BP 120/80. Uneventful

The anaesthetist (WMM) says that

  • The patient would have been given IM Omnopon gr 1/3 and Scopolamine gr 1/150 (ie papaveretum 20mg and hyoscine 0.4 mg) before coming to theatre.

  • Lignocaine 1.2% was chosen to give a good sensory block without too much motor block. Adrenaline was added to the lignocaine to give a final concentration of 1/200,000.

  • The epidural was performed using an 18 gauge Harris needle before the induction of light general anaesthesia.

  • Once the intubating dose of suxamethonium had worn off, spontaneous respiration was maintained throughout the operation.

    (See also Maidlow WM. I did it my way - confessions of an epiduralist. Anaesthesia Points West 17 No.2; pp 63-68. There is link to this paper on my homepage)

Patient No.3 Another partial gastrectomy. A similar anaesthetic to Patient no.1, but this time two further doses of suxamethonium (40mg, 60mg) were given to avoid bucking at critical moments during the operation, and also a hexobarbitone drip was used together with small doses of iv Pethidine to a total of 50mg.

Patient No.41. An emergency gastrectomy for severe haematemesis; GA with a Scoline drip.

Evipan 0.15 Scoline to 725. GOT

Patient No. 118 Similar to No.1, i.e. epidural + GA with spontaneous respiration, but a reduced dose of lignocaine (40cc).

Patient No. 146. Another emergency operation for haematemesis; Scoline drip; Pethidine rather than Trilene this time.

Back to Anaesthesia in the Sixties (if applicable)

Prostatectomy (n=4)

Patient No.24

TURP. The only GA (n=163) patient to receive halothane. The record reads:

Evipan 10% .5 +.2 Scoline 70 Xyl. Spray N2O + O2 4:4 Fluothane

Endo. Peth. 30. Very obese BP 200/130 Cyanosed.

Patient No. 70 another TURP and Patients No. 35 (RPP) and No.119 (prostatectomy) all had spinal anaesthetics. The patient for TURP was sedated with Nembutal, and the other 2 had light covering GA.

 

Tonsillectomy in children

Most commonly open ethyl chloride-ether on Schimmelbusch mask, followed by insufflation of ether in O2 or N2O-O2 down the side tube attached to the tongue plate of the Boyle-Davis gag. An endotracheal tube was not used.

 

Suxethonium

Suxethonium came as dry powder in an ampoule. It was said to cause less potassium release than suxamethonuim, and it was useful where there was not a fridge available, as in the anaesthetic equipment box that went out with the Obstetric Flying Squad.

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