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Case Report Section
* In future issues of the Newsmonthly,
this section will be devoted to the presenta-
tion of case reports submitted by readers
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.
...... ....... ............
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).