Summary A controlled investigation was conducted to compare the effectiveness of morphine and nalbuphine in theOther side effects were uncommon. Nalbuphine may ofSer advantages compared with morphine in regard to safety and convenience of use for the treatment of post-tonsillectomy pain in children. Key wordsAnalgesics, narcotic; morphine, nalbuphine. Pain; postoperative.It is axiomatic that adequate analgesia should be provided after any painful operation. In the case of tonsillectomy it is desirable to ensure smooth awakening since increased vascular congestion of head and neck associated with crying and straining might precipitate bleeding.' Children are usually afraid of injections and the use of intramuscular opioid premedication is therefore avoided by many anaesthetists. Furthermore, intra-operative use of morphine or any other opioid could produce respiratory depression when used in spontaneously breathing children in combination with a volatile anaesthetic drug such as halothane or enflurane.Nalbuphine is a partial agonist opioid with a proven maximum respiratory depressant effect in man.2 Its analgesic potency appears to be similar to that of morphine in the 8-10 mg dose range.3 However, in common with other partial agonists, it has a relatively flat log dose response relation and, therefore, the choice of dose is less critical than would be the case with morphine. Hence, larger doses of nalbuphine will produce less effect than the equivalent dose of morphine. The side effects of nalbuphine also appear to be limited, with a lower incidence and severity than those likely to occur after other partial agonist opioids such as pentaz~cine.~
A IS-yew-old female suffered urticaria and severe bronchospasm sufjcient to cause hypoxic cardiac arrest after intravenous indiicrion of anaesthesia. Etnmidaie was strongly implicated in the reaction. The management and mechanism of the reaction are described and discussed, fogether wilh consideration ojfiture anaesthesia in the patient. Key wordsAnursthetics, intravenous; etomidate. Conrplications; bronchospasm, urticaria.Each year 10 000 patients in the UK may have a clinically significant anaphylactoid reaction to anaesthetic drugs.' Allergic and atopic individuals often appear particularly at and some drugs are more commonly involved than ~t h e r s .~ The combination of etomidate, fentanyl and vecuronium has been found to be predominantly free from histamine r e l e a~e .~ It is, therefore, an appropriate combination for anaesthesia in atopic asthmatic patients, hut must be seen as a low risk, rather than a 'no risk' drug combination. We report a severe reaction in an asthmatic patient, following these drugs. Case historyA 13-year-old female who weighed 33 kg, required a pleurectomy. She had had pneumonia in infancy followed throughout childhood by repeated cough and wheeze. Bronchograms at age 10 years showed cystic change in the left lung, and she had a ventilationiperfusion deficit in this area. She had had three pneumothoraces in the last year. Her usual medication was prednisolone, theophylline, longterm co-trimoxazole and salbutamol by inhalation. She had had one uneventful exposure to thiopentone, suxamerhonium, nitrous oxide and halothane and had n o known allergies.She arrived in the operating theatre crying after premedication with lorazepam 1 mg and inhaled salbutamol. A needle was sited in her hand and etomidate 10 mg, fentanyl 0.2 mg and vecuronium 4 mg were given. Ventilation was attempted with the aid of several types of airway and mask, a tracheal tube and a bronchoscopc with Sanders injector, but proved impossible. The view down the bronchoscope showed both main bronchi clamped shut. The chcst was exposed and wheals were seen. An intravenous infusion of crystalloid was established and hydrocortisone 100 mg and chlorpheniramine 10 mg were given intravenously. Ventilation of the lungs remained impossible and bradycardia was followed by cardiac arrest. The pulse returned after adrenaline, 0.2 mg given intravenously, and ventilation was possible. A size 6.0 mm tracheal tube was passed and she became pink with an arterial blood pressure of 120/80 mmHg.The patient was now paralysed, but had received no volatile agents since induction. Etomidate 10 mg was therefore given to maintain sleep and within 2 minutes her lungs were impossible to ventilate, with cyanosis and bradycardia ensuing. Adrenaline 0.1 mg administered intravenously brought rapid relief: enfurane was added to the oxygen to achieve anaesthesia. The operation was abandoned. Muscle relaxation had worn off and after much deliberation, vecuronium 2 mg was given with no ill effect. Admission to the Intensive Care Unit was arranged and ini...
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