and Answers

Aneqth anal^

148 Questions and Answers Vul. 6 7 , Jan.-Veb. 1978









Questions and Answers









( ~ I I I S T I O N : As a noclor o/ Dental Sur- ANSWIA K 2 In most states, it is not illegal

g u y on t h c , stufl of Taiwan (Jnrilersity 110s- foi a dentist to be trained as .in anesthesi-

p t u l nnd Collcyy of M d i c i n e , I a m unclecir ologist For a number of years, the [Jnivcr-

uhoiit the role of (L LIDS in the field of ant’s- sity of Tennessee permitted qu.ilificd dcn-

thesiology. I s it lcgal for a DDS to be tists to enter the anesthesia residencv pro-

tlnincd cis and suhsrqut~ntlyto /unction us gram Standards were hiqh, and onlv those

an trnc~stlirsrologrst! who demonstrated competence uei e pcr init-

tcd to remain in the ptogram l‘hev were

LIDS, D A , exposed to the same tr,itning and curriculum

Taipei, R c pu 0 lic of China as the medical doctois In recent years,

only one IIDS has complctcd the piograni

ANSWER #k1: I3entists were pioneers in the He was an oial surgeon who was interested

field of anesthesia. and have continued to in an instructional position with the College

demonstrate their competence in manage- of Dentistry.

ment, of both general and regional anesthe- There are two basic problrms with the

sia for their patients. Some dentists are pro- training of dentists as anesthesiologists ‘I’he

viding anesthesia for all types of surgery. I t first is their lack of aticquate rnedical back-

is “legal” for dentists to administer anes- ground in areas not covered by the usual

thetics and narcotics, as well as digitalis or anesthesiology training program, ie, infec-

antibiotics. For dentists to provide safe care tious disease, cardiology, gastrocritt.rolofiy,

for their patients they must be able to obtain clc However, it has hcen our cxlwricnce

a history, perform a physical examination, that the motivated dentist, particularly i f he

:ind interpret laboratory studies. They also stays in the proeram lonqcr than the CUS-

should he skilled in resuscitation technics tomary 2 years, xquires a sa

and emergency medical management. How- knowledge of these aspects of medicine

ever, I believe that it is inappropriate for

dentists to perform as specialists in cardi- The 2nd prohlem mole practical, has to

ologv. emergency medical management, or do with the fact that, in many communities,

infectious disease control, just as I believe poorly motivated, inadequately trained den-

it is inappropriate for them to perform as tists pass themselves ol’f as anesthesiologists

specialists in anesthesiology. Dentists should (which implies a medical background) in a

limit their practice to anesthesia for dental community, with consequent possible detri-

patients or, where necessary, to the admin- ment to the level of anesthesia care in that

istration of anesthesia to surgical patients in community and adding to the economic dif-

association with a physician specialist in ficulties of attracting well-trained anesthe-

anesthesiology. siologists to the community. In our area of

the country this has been a problem for both

Douglas W. Eastwood, MD dentists trained in a conventional program

Department of Anesthesiology and the graduates of conventional programs

Case Western Reserve in anesthesiology.

University School of

Medicine A further problem is the fact that there

Cleveland, Ohio is no national accrediting or certifying mech-

Questions ancl Answers 1-19



anism for such individuals, which precludes ured in the plasma and may not reflect in-

any estimate of their qualifications by hos- t racellular responses during the acute e p -

pital staffs, physicians, or patients. We have sode.

h k e n the position that for these reasons we

will no longer accept anyone other than an In summary, it would seem that there is

M D into our training program unless a den- no evidence to restrict the use of magnc5ium

tist is seeking special t,raining, riot to be- sulfate during delivery in a toxemic patient.

come a practicing anesthesiologist. Whrm John F. Ryan, M D

inquiries are made about dentists with anes- Department of Anesthesia

thesia training, we point out that they arc Massachusetts General Hospital

not anesthesiologists in the medical sensc Boston, Massachusetts

and that they have the limitations imposed

by lac!< of undergraduate medical training.



William C. North, MD, PhD

Department of Anesthesiology ANSWER #2: While considerable progress

University of Tennessee has heen made in delineating the patterns,

College of Medicine redi is posing features, and treatment of m;i-

Memphis, Tennessee lignant hyperpyrexia, the exact etiology rc-

mains unknown.1.2 I t has been suggested

that the etiology may be a failure or rcduc-

tion in the capacity of the sarcoplnsmic rc-

ticuluni to accumulate calcium and that the

resulting elevated myoplasrnic calcium ac-

~ r n m w m Please comment on whether or

: tivates phosphorylase kinase and myosin

not it I S safe to use magncwuni suljate in ATl'ase, stimulating glycolysis and produc-

treating toxemia of pregnancy in a worncin ing phosphate and heat. The release of a t e -

uxth a farnily history of malignant hypc.rpy- cholamines, which is also calcium ion de-

rexia. pendent,:' can be envisaged to produce a

vicious cycle in which the metabolic changes

ANSWLR # l : In the framing of the ques-

lead to catecholaminc release and hence f u r -

tion, the pregnant woman is given a positive

ther metabolic char.ges.

family history for malignant hyperthermia

Assuming that she is a susceptible individ- Magnesium sulfate is still widely wed in

ual, there is no evidence presently to show the management of toxemia of pregn:incy,4

that the use of magnesium sulfate would be although the mechanism by which the mag-

detrimental and cause a trigqering of the nesium ion controls the convulsions is not

syndrome during delivery. Since the tox- completely understood. I t is known that

emia obviously can be life threatening, it is there is an action on the neuromuscular

reasonable to treat a patient for this with junction reducing the number of acetylcho-

magnesium sulfate. In experimental pigs line quanta released by the nerve action 110-

and in man, neither calcium nor magnesium tc-ntial.5 In humans susceptible to malig-

injections have been reported as triggering nant hyperpyrexia, the serum magnesium

the syndrome. Also, in the literature there level is in the low-normal range a t rest,"

has not yet been reported a full-blown case while during a hyperpyrexial episode the

of malignant hyperthermia during anesthe- serum magnesium, calcium, and potassium

sia for delivery. There has been a report of are all raised, as one might expect from the

a susceptible individual who developed a muscle ltsion. Many of thc actions of cal-

rise in creatine phosphokinase ( CPK ) dur- cium are antagonized by magnesium, nota-

ing spinal anesthesia for delivery. This pa- hly the effect on myosin ATPase and catc-

tient already had a markedly elevated pre- cholamine release. In pigs, magnesium has

anesthetic CPK level, and her CPK re- been used successfully in the treatment of

mained elevated. She did not demonstrate an established hyperpyrexial episode,. an

any of the clinical symptoms of malignant experiment which might justify the use o f

hyperpyrexia. During the acute syndrome, magnesium as a prophylactic agent against

magnesium and phosphate levels generally a pyrexial episode in man. Magnesium has

have been reported as elevated, whereas also been shown to potentiate the inhibitory

calcium determinations initially are elevated effect of procaine HCI on calcium transport.y

and later decrease sharply. I t should be This might be an advantage in using pro-

remembered that these are total levels nicas- caine, which, with dantrolene, is the niajor

Anrsth Anala

150 Questions and Answers Vu1. 5 7 . Jan-P‘eb. 1 9 7 8



active therapy against established malignant REFERENCES

hyperpyrexia. 1. H r i l l H A : Mod Met1 Can 31:511-517, 1976

Finally, it is clear that not all members 2. Icyaii J I ? : ASA Refresher Course. San Fran-

of a family demonstrating the trait are cisco, California, Ortobcr 1976, pp 1-6

equally susceptible to the condition. The 3 . Douglas WW, Itubin RI’: .J I’hysiol l(i7:288,

caffeine contracture test of a muscle biopsy l%i3

would indicate an unusually sensitive indi-

4. I’ritc.hard J A : Surg Cvnecol Obstet 100: 131-

vidual.!’ I n this type of patient, adequate 140, I Y S ~

resuscitative measures should always be

available against an unexpected reaction to 5. Aldrete .JA, ct al: Can Anaeslh Sor ,T 17:477-

481, 1970

any drug.”’

6. Uritt BA, et al: Can Anaesth Soc~J 20:431-

The use of magnesium sulfate to treat 467, 1973

toxemia of pregnancy is not contraindicated

in this type of patient. Indeed, it may find

a place in the prevention or treatment of

8 Coutinho EM J Gen I’hvsiol 49 845-84(;,

hyperpyrexial episodes. 19(iG

R. Stuart Bramwell, MD 9. Ellis E’IZ, Harriman DGE’: 1(r d Anweslh 46:

Department of Anesthesiology 638, 1973

Grady Memorial Hospital 10. Clarke FR, Ellis TMC: Anaesthesia 29:452,

Atlanta, Georgia 1974









The progress of labor a n d eventual outcomc were studied in 698 paticnts receiving

epidural analgesia wit,h bupivacaine 0.125 Iwrcent with epinephrine 1:200.000. Epidural

analgesia was started when the cervix was dilated 4 to cm and only after demonstration

of progressive dilatation o f the cervix. T h e epidural labor curves were characterized by

acceleration in the rate o f cervical dilatation and correlated well with the previously

publishc,d curves for “normal” labor. The dilutc concentration of local anesthctic used

is Iiostulated as one factor promoting maintcnancr of a normal rate ol progress in labor.

( P h i l l i p s J L , Hochhcrg C J , Pctrcihis J K , c’t al: Epidural analgrsia and its c f f r c t s on

t h o “normal” progrrss of labor. A m J 0hstc.t ( ; ~ ‘ n c w d 129:316-323, 1977)