POSTOPERATIVE HEADACHE AFTER NITROUS OXIDE-OXYGEN- HALOTHANE ANAESTHESIA

Transcription

1 Brit. J. Anaesth. (969), 4, 972 POSTOPERATVE HEADACHE AFTER NTROUS OXDE-OXYGEN- HALOTHANE ANAESTHESA BY A. F. M. ZOHARY SUMMARY Observations were made in patients of both sexes on the frequency of in the immediate postoperative period following anaesthesia with nitrous oxide, oxygen and halothane. The series was divided into four groups according to premedication. The highest incidence of occurred in the group given atropine only. Significant reductions in the incidence were noted when atropine was combined with promethazine, pethidine, and pethidine with promethazine. The lowest incidence was associated with the use of atropine, pethidine with promedaazine. n a series of 75 patients of both sexes undergoing dental operations, Tyrrell and Feldman (968) reported incidences of of and 44 per cent following halothane anaesthesia. The per cent incidence followed the use of nitrous oxide, oxygen and halothane (-.5 per cent) in a semiclosed circuit with spontaneous respiration. The incidence was 44 per cent when ventilation had been controlled with the aid of tubocurarine, anaesthesia being maintained with nitrous oxide, oxygen and halothane (.5 per cent). was the only premedication given. Since halothane is the main inhalational anaesthetic used in most of the surgical cases in the author's practice an investigation was made of the incidence of and of the influence of premedication. MATERAL AND METHODS OF STUDY The investigation was carried out on adults ( males) ranging in age from 6 to years, who were selected at random from various operating lists (table ). Type of operation General surgical Gynaecological Orthopaedic Ophthalmic E.N.T. TABLE Number Males Females All cases were examined before operation in regard to fitness for surgery and anaesthesia. A careful history was taken concerning the patient's liability to attacks of and to exclude pathological or psychological causes. Patients with a history of recurrent attacks of attributed to pathological causes in the eye, nose and paranasal sinuses, migrainous attacks, different types of facial neuralgias and, in addition, patients widi functional types of, were excluded from this study. Patients were allocated at random to four groups, in each of which a different pre-anaesthetic medication was given by intramuscular injection minutes before anaesthesia (table D- Group V Number and sex (M, F) (72M, 62F) (74M, F) (76M, 58F) TABLE Type of premedication (doses in mg) sulphate 0.6 sulphate promethazine pethidine pethidine promethazine 25 Anaesthetic technique. The basic anaesthetic technique in every case was as follows. A. F. M. ZOHARY, M.D.(ANAES.), State Medical Department, Doha-Qatar, Arabian Gulf.

2 HEADACHE AFTER NTROUS OXDE-OXYGENALOTHANE 973 nduction with thiopentone 2 per cent, 3-5 mg/kg body weight was followed by injection of suxamethonium -00 mg. After inflation of the lungs with 00 per cent oxygen for minute, the larynx and trachea were sprayed with 3 ml of 4 per cent lignocaine solution. The trachea was then intubated using a cuffed tube. Anaesthesia was maintained with nitrous oxide (3./ min) and oxygen ( l./min) using a semiclosed circuit with carbon dioxide absorption. Halothane was added to the circuit in a delivered concentration of -3 per cent from a Fluotec vaporizer. Ventilation was frequently assisted. Muscle relaxants were not given during anaesthesia. The pulse rate and blood pressure were frequently measured. The systolic pressure was maintained above 00 mm Hg by adjustment of the halothane concentration. ntravenous infusions, including blood, were given if needed. At the end of anaesthesia the lungs were inflated with oxygen for 5 minutes to guard against diffusion hypoxia. Patients were returned to the recovery ward and observed by trained anaesthetic nurses until they were fully orientated. Any retching or vomiting occurring during emergence was recorded. Postoperative analgesic drugs were not given unless needed. Patients were seen by the anaesthetist hour after recovery and again 5 hours later. They were then questioned about any complaint during this period, including. nformation was obtained about the site and character of if present. The statistical significance of the differences in frequency of among different groups was evaluated by the chi-square test using absolute numbers. RESULTS The incidence of in the four groups is shown in table. Group. Of patients receiving atropine only, 44 (32.8 per cent) developed in the first 6 hours after operation. Group. Of patients receiving atropine with promethazine, 2 (5.6 per cent) developed in the first 6 hours after operation. Group. Of patients receiving atropine with pethidine, 5 (. per cent) developed in the first 6 hours after operation. Group Of patients receiving atropine with pethidine and promethazine, 2 (8.9 per cent) developed in the first 6 hours after operation. The statistical significance of differences in the incidence of in the various groups is shown in table Premedication with a combination of atropine, pethidine and promethazine (Group V) caused a highly significant decrease in the incidence of postoperative compared to premedication with atropine alone (Group ). Premedication with atropine if combined with pethidine alone (Group ) or with promethazine alone (Group ) also was associated with a significant reduction in the incidence of postoperative Group and premedication + promethazine +pethidine V +pethidine + promethazine TABLE ncidence of postanaesthetic in the four groups of cases. No. Male Female Age (years ±SD) Duratn. (min ±SD) No 44 (24F, 20M) 2 (4F, 7M) 5 (0F, 5M) 2 (8F, 4M) 92 % with SE of the percentage ±3. ±

3 974 BRTSH JOURNAL OF ANAESTHESA Groups compared TABLE V Statistical comparison of results. V V V P value =0.006 <0.00 <0.000 >0.8<0.9 >0.9<0.95 >0.05<0 LU co s 3 0 a o c op CNJ CO CO compared to premedication with atropine alone (Group ). Comparing the incidence in Group (atropine with promethazine) and Group (atropine with pethidine), the difference was not statistically significant, nor did the combination of pethidine with promethazine and atropine (Group V) lead to a significantly lower incidence than that following atropine and promethazine (Group ). Similarly, the addition of promethazine to atropine and pethidine (Group V) did not lead to a significantly lower incidence than that which followed atropine with pethidine (Group H). The highest incidence of postoperative following halothane anaesthesia occurred in Group who received atropine alone (fig. ). Frequency of as related to sex (table V). Of males 36 (2 per cent) developed, and of females 56 (8 per cent) developed. n the atropine group 24 of females developed, compared with only 20 of males. n the atropine with promethazine group, 4 (22 per cent) of 62 females developed compared with 7 (9 per cent) of 72 males. TABLE V ncidence of in males and females in four premedication groups. Group V Females % Males o' O) C 0) o 0 A 0 V GROUPS FG. Histogram showing the incidence of in the various groups. The SE of the percentage is superimposed. Failure of the SE limits to overlap indicates a significant difference. n the atropine with pethidine group, 0 (7 per cent) of females developed, compared with 5 (7 per cent) of 74 males. n the atropine, pethidine, promethazine group, 8 (7 per cent) of 58 females developed, compared with 4 (5 per cent) of 76 males. Severity of. The was described as a continuous or throbbing dull ache, deeply seated inside the head, more to the front than the back of the head and shooting into the eyes which felt heavy and were painful to open. The was accompanied by giddiness in 75 per cent of the cases. Vomiting with or without nausea occurred in per cent of the cases (vomiting once as they emerged from anaesthesia). The subsided slowly as time passed, was modified or cured if an analgesic was given, and had completely disappeared after 6 hours (second visit to the patient) when only a sense of non-painful heaviness was described. n the group premedicated with atropine only, the severity of as indicated by the relative numbers who complained spontaneously was higher as compared to the other three groups. ob

4 HEADACHE AFTER NTROUS OXDE-OXYGENALOTHANE 975 Of 44 cases with 20 cases (4 females and 6 males) in the atropine-premedicated group complained spontaneously. n the promethazine, pethidine, and pethidine-promethazine groups the severity of s was judged to be less than in the atropine-premedicated cases. Of 2, 5 and 2 patients with respectively, was the main spontaneous complaint in 5, 3 and 3 cases respectively. However, the spontaneous complaint of by the patient, although considered here as an index of severity was no more than a rough clinical guide to such subjective symptom. Frequency as related to the duration of anaesthesia. The quantity of halothane given to each patient depended upon the depth of anaesthesia required and the length of time for which it was needed. Since the same depth of anaesthesia in different patients required different doses of the anaesthetics due to variation in body weight, sensitivity, metabolic state, etc., it is clear that the dose given was not a fixed one but that which was necessary for the required purpose. Accordingly the duration of anaesthesia does not reflect a known relation to the quantity of anaesthetic used. n this investigation, the higher concentration of halothane was administered at the beginning to stabilize anaesthesia at the appropriate level, after which it was gradually reduced to the minimum concentration necessary (range -3 per cent). The duration of anaesthesia at the level appropriate to the purpose appears to have influenced the frequency of postoperative. n general the longer the duration the higher was the incidence of (table V). ncidence Duration (min) >90 TABLE V of as related to duration anaesthesia. No. of patients No. with of % DSCUSSON may result from stimulation of, pressure on, or traction on, any of the pain-sensitive structures of the head. These include all tissues covering the cranium, the 5th, 9th and 0th cranial nerves, as well as the upper three cervical nerves; the large intracranial venous sinuses, the large arteries at the base of the brain, the large dural arteries and the dura mater at the base of the skull. Dilatation or contraction of the walls of the sensitive vascular channels stimulate nerveendings, causing. Changes in the calibre and permeability of the cranial vessels may be responsible in part for the which follows general anaesthesia in patients without other organic or psychological disease. Pain may be referred to the head from disease in the eye, middle ear, nasal sinuses, teeth, pharynx, tongue and also from intrathoracic and intra-abdominal viscera. also is frequently a result of psychogenic troubles (Brain, 962). Possible causes of. following halothane anaesthesia has been attributed to several factors, namely: reduction in the cerebral oxygen uptake; changes in the cerebral haemodynamics; and increased cerebrospinal fluid tension (Tyrrell and Feldman, 968). Halothane, like other anaesthetics, reduces the cerebral oxygen uptake due to depression of the cerebral oxidative metabolism. The degree of such depression is directly related to the depth of anaesthesia (McHenry et al., 965; McDowall, 966, 967; Christensen, Hoedt-Rasmussen and Larsen, 967). Halothane increases cerebral blood flow, due to cerebral vasodilatation. This increase is directly related to the concentration inhaled, provided a pronounced hypotension is not reached (Wollman et al., 964; McHenry et al., 965; McDowall, 966, 967). The reactivity of the cerebral vessels to carbon dioxide (chemical control) and to variations in blood pressure (autoregulation) is preserved during halothane anaesthesia (Christensen, Hoedt- Rasmussen and Larsen, 967). As a result, the combination of halothane anaesthesia with moderate hypotension and hypercapnia may cause maximal degree of vasodilatation in both

5 976 BRTSH JOURNAL OF ANAESTHESA healthy and arteriosclerotic blood vessels (Christensen, Hoedt-Rasmussen and Larsen, 967). A rise in c.s.f. pressure follows the cerebral vasodilatation produced by halothane. This rise can be minimized by hyperventilation and reduction of arterial carbon dioxide tension below 35 mm Hg (McDowall, Barker and Jennett, 966). t is possible that the interaction of all these factors may be responsible for the occurrence of postoperative halothane. Halothane, being a potent inhalational anaesthetic with a poor analgesic effect (Johnstone, 956) is usually given as an adjuvant to nitrous oxide-oxygen anaesthesia. The rapid recovery of consciousness deprives the patient of a period of analgesia (sleep) before adequate readjustment of the possible factors contributing to the occurrence of. Thus, was most severe on waking, then slowly improved as halothane was eliminated and its effects wore off (Tyrrell and Feldman, 968). n order to minimize the occurrence of what may be called "halothane ", drugs given in premedication seemed to be of value. Apart from atropine which was given mainly to guard against the tendency of halothane to produce bradycardia, sedative or analgesic drugs were of importance. n the present series, the use of pethidine and promethazine, alone or togedier, proved to be of clinical value. The impression was gained that these drugs reduced the concentration of halothane necessary to stabilize anaesthesia at the appropriate level. t is also possible that they may modify or mask the in the immediate postoperative period through their sedative, analgesic effect. Postoperative sedation and analgesia were evident in the cases of the present series. The patients, although conscious and responding to questions, lapsed into a natural sleep for 2-3 hours after operation. Also the was less severe in these groups of cases than in the atropine-premedicated group. REFERENCES Brain, Sir R. (962). Diseases of the Nervous System, 5th ed., pp London: O.U.P. Christensen, M. S., Hoedt-Rasmussen, K., and Lassen, N. A. (967). Cerebral vasodilatation by halothane anaesthesia in man and its potentiation by hypotension and hypercapnia. Brit. J. Anaesth., 39, 927. Johnstone, M. (956). The human cardiovascular response to Fluothane anaesthesia. Brit. J. Anaesth., 28, 932. McDowall, D. G. (966). Cerebral haemodynamics and metabolism during general anaesthesia. Acta anaesth. scand., Suppl. XXV, proc. ll, 307. (967). Effect of clinical concentration of halothane on the blood flow and oxygen uptake of cerebral cortex. Brit. J. Anaesth., 39, 68. Barker, J., and Jennett, W. B. (966). Cerebrospinal fluid pressure measurement during anaesthesia. Anaesthesia, 2, 89. McHenry, L. C. jr., Slocum, H. C, Bivens, H. E., Mayes, H. A., and Hayes, G. J. (965). Hyperventilation in awake and anesthetised man: effects on cerebral blood flow and metabolism. Arch. Neurol. (Chic.), 2, 270. Tyrrell, M. F., and Feldman, S. A. (968). following halothane anaesthesia. Brit. J. Anaesth.,, 99. Wollman, H., Alexander, S. C, Cohen, P. J., Chase, P. E., Melman, E., and Behar, M. G. (964). Cerebral circulation of man during halothane anesthesia. Anesthesiology, 25, 80. CEPHALEES POSTOPERATORES APRES ANESTHESE PAR LE MELANGE PROTOXYDE D'AZOTE-OXYGENESALOTHAN SOMMARE Chez cinq-cent-trente-six patients des deux sexes la frequence des cephalees postoperatoires a 6t tudiee apres anesthesie par le protoxyde d'azote, l'oxygene et l'halothan. Le materiel a ete divise en quatre groupes suivant la premedication recue. La plus forte frequence des cephalees a ete observee dans le groupe qui avait recu seulement de l'atropine. Une frequence significativement plus faible a ete observee si l'atropine avait ete combinee avec la promethazine, la pethidine, et promethazine et pe'thidine. La plus faible frequence a ete observee avec une premedication avec atropine, pethidine et promediazine. POSTOPERATVE KOPFSCHMERZEN NACH ENER NARKOSE MT LACHGAS, SAUER- STOFF UND HALOTHAN ZUSAMMENFASSUNG An funfhundertsechsunddreibig Patienten beiderlei Geschlechts wurden Untersuchungen iiber die unmittelbar nach der unter Lachgas-Sauerstoffalothan- Narkose durchgefiihrten Operation beobachteten Kopfschmerzhaufigkeit angestellt. Das Patientenkollektiv wurde der verabfolgten Pramedikation entsprechend in vier Gruppen eingeteilt. Die hochste nzidenz der Kopfschmerzen wurde in der Gruppe festgestellt, die nur Atropin als Pramedikation erhalten hatte. Eine erhebliche Reduzierung in der nzidenz wurde beobachtet, wenn Atropin in Kombination mit Promethazin, Pethidin und Pethidin mit Promethazin verabreicht wurde. Die niedrigste nzidenz wurde durch die Pramedikation von Atropin zusammen mit Pethidin und Promethazin erreicht.