Post Thiopental Tremors

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                         Case Report Section
                                        * In future issues of the Newsmonthly,
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                                        of the Newsmonthly. Any case which in-
                                        volves any phase of anesthesiology prac-
                                        tice in dentistry should be sent to the
                                        editorial office. This section is edited by
                                        Harry A. Sultz, D.D.S. Dr. Sultz, who
                                        practices in Buffalo, New York, is a
                                        former resident and teaching fellow in
                                        anesthesia at the University of Pittsburgh
                                        School of Dentistry and Medical Center
                                        Hospitals, Pittsburgh, Pennsylvania.
                                             All case reports should be      accom-
                                        panied by the name of the author. Names
                                        will be withheld from publication on
      HARRY /&. SULTZ,    D.D.S.        1        L.

          Case Report editor

                Post Thiopental Tremors
               Sidney Silver, D.D.S., M.S.
 * A 21-year-old female was ad-             cedure. Her blood pressure and
 mitted to the hospital for oral sur-       pulse remained normal throughout
 gery. She appeared in good general          the surgery.
condition and had a normal labor-              Upon recovery she began to
 atory urine analysis and blood             shake and shiver. Her extremities
count. She was exceptionally ap-            became stipled and goose-pimpled
prehensive but reacted well to pre-         in appearance. She was returned to
medication with 2 grains of pheno-          her room when in control of her
barbital and 1/150 grain of atro-           reflexes. Her nurse was ordered
pine. For the surgical procedure            to cover her with blankets and to
she was induced with .5 per cent            call if the shivering continued for
thiopental sodium followed by               more than ten minutes. When re-
nitrous oxide and oxygen. In all,           called to the patient's bedside, her
she received 500 mg. of thio-               shaking and shivering had become
pental sodium in the half-hour pro-         severe. An intravenous injection of
 Demerol® was begun and, within portant part in stimulating heat
 45 seconds, when 25 mg. had production by liberating glycogen
 been administered, all extraneous from liver and muscles, adrenal
 movements ceased and the shiver- suppression may be a contributory
 ing stopped.                            factor in thiopental shivering. Thio-
                                         pental also causes increased peri-
                                         pheral dilatation, facilitating heat
    It is difficult to explain this gen- loss through the skin. Hence, during
 eralized tremor which occasionally open or semi-closed technics, large
 follows anesthesia with intravenous ventilatorv heat losses can occur.'-
 barbiturates. Many causative agents Thus, the importance of shivering
have been suggested such as pyrogen must not be overlooked.
 reaction, carbon dioxide excess,           Beattie:3 has indicated that oxygen
 hypoxia, or depression of the tem- demand due to muscular activity
 perature regulating center by direct may be increased 200 to 400 per
 action of the drug. A review of the cent. It is obvious that patients may
 literature discloses that, with the thus be placed in great danger.
 exception of one article, no care- Smith, Bachman, and Bougas' warn
 ful study has been undertaken to of the dangers of postanesthetic
determine its origin or significance. tremors in addition to the increased
 In Smith, Bachman and Bougas' side effects from premedicants and
 study1, a series of 259 children were tranquilizers, and possible hypo-
anesthetized with thiopental so- tension, as well as possible problems
dium. They reached the conclu- from present-day hospital air-con-
sions that:                              ditioning.
    1. Such tremors represent true
thermal shivering.                                     Conclusion
    2. No significant depression of 1. The causative agent of post-
the temperature regulating mech-             thiopental tremors seems to be
anism was found.                            an increased sensitivity to cold,
   3. The underlying factor is not          not greater heat loss.
greater heat loss but increased 2. Regardless of treatment, the
sensitivity to cold with this agent.        tremors will disappear by them-
   Clinically, thiopental depresses         selves as the drug is detoxified
adrenal activity. This is shown by          and the patient recovers.
lowered pulse rate and blood pres- 3. Demerol®)administered slowly in-
sure, and constricted pupils.               travenously is the drug of choice
   Since the adrenals play an im-           to counteract the tremors.
                                  References                Coimmient: This type of reaction is not
                                                         uncoitmmon with any of the barbiturates
1. Smith R. M., Bachman, L., and(                        used intravenously. Many theories have
   Bougas, T.- Shivering Following
   Thiopental Sodium and Other Anes-                     been advanced as to its cause, some of
   thetic Agents. Anesthesiology 16:655                  which are mnentioned in this case report.
   (Sept. 1955)                                             One explanation, not mentioned, re-
2. Clark, R. E., Orkin, L. R., and                       calls that thiopental does not raise the
   Rovenstine, E. A.- Body Tempera-                      pain threshold and that any imtpulses
   ture Studies in Anesthetized Man:
   Effect of Environmental Tempera-                      reaching the depressed cerebral cortex
   ture, Humidity, and Anesthesia Sys-                   may be miisinterpreted and produce these
    tent, J.A.M.A. (154:311) Jan 23,                     generalized mtuscle twitchings. To bear
   1954.                                                 out this theory, it is generally agreed that
3. Beattie, J. - Functional Aspects of                   premedication or administration of drugs
   the Hypothalamius, Henderson Trust
   Lectures, Edinburgh, Oliver and                       tha(t elevate the pain threshold reduces
   Boyd, 1938.                                           the incidence of this reaction.      H. . S.

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                               Component Society Representatives Receive Charters
                                 at A.D.S.A. Miami Meeting, November 3, 1957

Left to riglht: James Jones (Alabamia); Richard Lowell (New York); Louis
Schwartz (Pennsylvania); Morgan Allison (Ohio); Freeman Slaughter (Northl
Carolina); J. D. Whisenand (Iowa); Joseph Osterlohl (California); WAilliam
Kinney (Utah); Sylvan Shane (Maryland); Aaron Moss (New Jersey) Emmett
                Jurgens (Illinois); Leonard Fox (Massachlusetts).

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