rectal pentothal in pediatric anesthesia: a comparative clinical study

Acta anaesth. Scandinau. 1960, 4, 51-66.

RECTAL PENTOTHAL I N PEDIATRIC ANESTHESIA

A Comparative Clinical Study

BY FRANCIS BENSON and APOLLON SAARNE

'Avoidance of physical and psychic trauma is a basic principle in pediatric anesthesia. Different methods have been suggested to reduce the unpleasant experiences during inhalation anesthesia induction. Basal anesthesia by rectally administered anesthetic agents is considered a satisfactory method. Basal anesthesia has' been defined as a state of unconsciousness with relative insensibility.

Ether, avertin and paraldehyde were among the agents first used in rectal basal anesthesia. They were far from satisfactory. Their disadvantages included occasional respiratory and circulatory depression, prolonged sleep, instability, large enema volume or complicated drug preparation.

J. T. GWATHMEY (1936)'s introduced evipal sodium in rectal basal anesthesia. M. L. WEINSTEIN (1938)86 tested the same agent but observed many cases complicated with respiratory depression, prolonged sleep and muscle twitchings. He (1939y then tried thiopental sodium (pentothal), which proved to be superior to other agents.

Other clinical studies have established the value of rectal pentothal. The following advantages are emphasized: Rapidity of onset, short duration, low toxicity and ease of administration. Oxygen saturation of blood is not decreased during basal anesthesia with rectal pentothal (B. E. MARBURY (1950)l').

G. SCHOTZ (1942)81 emphasized its advantages in pediatric anesthesia. Separated from their parents, children come in contact with unfamiliar sur- roundings and unknown persons they automatically distrust. These factors make them more vulnerable and increase the psychic trauma caused by anesthesia. Reports on neurosis in connection with anesthesia have been published (E. JACKSON (1942)'3, D. LEVY (1945)1°, J. E. ECKENHOFF (1953)*).

As a rule, a 10% solution of pentothal in tap water or saline has been used. Some investigators have used pentothal suppositories (S. N. ALBERT et al. (1953p and L. ALADJEMOFF et al. (1958)l). Valuable reports on technical and practical problems in basal anesthesia with rectal pentothal have been pub-

From the Department of Anesthesia (Head: G. HAGLUND), Barnsjukhuset, Gijteborg, Sweden. Received March 9, 1960.

52 FRANCIS BENSON AND APOLLON SAARNE

lished (M. L.WEINSTEIN et al. (193926, 19412', 194328) R. W. BURNAP et al. (1948)", J. F. ARTUSIO ( 1950)3).

Opinions differ as to the dosage. WEINSTEIN and BURNAP gave 1 g per 50 lbs. body weight. L. C. MARK et al. (1949)18 and W. MICDAL et al. (1953)lB reported satisfactory results with a dosage of 1 g per 75 lbs. J. S. GRAVENSTEIN (1952)l' used 1 g per 100 lbs. As a rule, the enema has been administered in the ward. The patients should not come in contact with the operating theatre before they are anesthetized. Rectal pentothal can be combined with any inhalation or local anesthetic agent. Most frequently it has been combined with cyclopropane or ether.

Atropine or scopolamine are generally recommended for premedication. Some investigators have combined pentothal with morphine, but this is not to be recommended because of the respiratory depressive effect exerted by morphine in accepted doses. B. B. BRODIE et al. (1950)6 and C. J. RAYBURN et al. (1953y proved that respiratory acidosis prolongs and deepens short-acting barbiturate anesthesia.

Most reports are positive, but critical views are not lacking. C. R. STEPHENS ( 1954)*3 emphasized that the effect on the patient is often unpredictable. Some patients remain awake, and others, who are too sensitive, fall deeply asleep to the extent that respiratory depression is evident. Postoperative sleep may be prolonged for up to eight hours.

Inflammatory lesions of the rectum and loss of control of the anal sphincter are generally considered to be absolute contra-indications. Pentothal is not recommended in cases with cardiac failure, severe anemia, or respiratory insuf- ficiency, whether this is caused by decreased pulmonary ventilation or diffusing capacity or involvement of the free airway implying an increased work of breathing.

It was the purpose of this investigation to study rectal basal anesthesia with pentothal in children using different dosages and different premedication agents. In another investigation (F. BENSON and T. REINAND ( 1960)4), we have studied frequency, causes and different types of psychic side reactions in pediatric anesthesia.

METHODS AND MATERIAL

The investigation was based on observations made in 550 children, each undergoing a single operation of a non-emergency character. The different types of operation common in pediatric surgery are well represented. All patients were in good general condition. Children with anorectal disorders which rendered administration impossible were omitted from the series.

The patients were divided into eight groups and treated as shown in table 1. In the evening before operation all pentothal cases were given a small

cleansing enema of saline. All patients were given promethazine as a mild soporific.

RECTAL PENTOTHAL IN PEDIATRIC ANESTHESIA

TABLE 1.

Age of patients (in months), dosages of pentothal in g per kg and premedication agents in the various group.

53

1 .......... 2. ......... 3. ......... 4 . . . . . . . . . . 5. ......... 6. .......... 7. ......... a. .........

100 100 100 50 50 50 50 50

Atropine Atropine Atropine Scopolamine Atropine Scopolamine Atropine Morphine + acop./atrop.

0.04 0.03 0.02 0.04 0.04 0.03 None None

3-216

12-120 12-120 12-120 12-120 12-120 12-120

7-186

All pentothal cases were premedicated with atrophine or scopolamine. Atropine was used in one of the control groups (7). The dosages were calculated from the body weight according to table 2. In the other control group (8), patients younger than three years (25 patients) were given morphine-atropine and the others morphine-scopolamine. The dosages were calculated according to D. LEIGH and K. BELTON (1948)16. All pre-medications were given in the ward, by the hypodermic route.

TABLE 2. Premedication scheme for atropine and scopolamine.

Weight in k g . . <5 5-10 10-15 15-20 20-25 25-30 30-40 40-50 Dosage in mg.. 0.10 0.15 0.20 0.25 0.30 0.35 0.40 0.50

A 10% solution of pentothal in saline was used. Ordinarily it was prepared for each patient. In groups 1 and 2, the administration was performed in the ward, and in the other groups in the anesthetic room. The children were taken to the anesthetic room directly after premedication, and accompanied by a nurse assistant with whom they had become acquainted. The solution was introduced slowly through a soft catheter, which was inserted two to three centimeters above the anal sphincter. The catheter was cleared with a small amount of air to insure that the whole calculated dose had entered the rectum. A few minutes later the catheter was removed. No special arrangements were made to prevent spontaneous evacuation.

The children in groups 1 and 2 were brought to the anesthetic room after they had gone to sleep in their beds. The interval between the administration


of the pentothal enema and the start of inhalation anesthesia varied in these two groups because of the transport. In the other groups, the interval was not allowed to be below 15 minutes or to exceed 25 minutes.

In all cases inhalation anesthesia started with an open-drop technic. The anesthetic agents used were divinyl ether (vinydan) followed by diethyl ether (ether). The mask was cautiously lowered over the face and at the same time the vinydan concentration was slowly increased. When the patient reached the second plane of the third stage of anesthesia, ether was substituted for vinydan. As soon as an adequate stage of ether anesthesia was attained, the child was brought into the operating theatre. For maintainance of anesthesia an open- drop technic with ether, or a semiclosed or closed system with mask or intra- tracheal tube, with ether-nitrous oxide-oxygen was used. In some cases muscle relaxants were used together with assisted or controlled respiration. All procedures in groups 1 and 2 were handled by the anesthesiologist and in the other groups by specially instructed nurses.

At the end of anesthesia, the patient returned directly to the ward. All observations were recorded on special charts. The time was noted from

the enema to the patient’s falling asleep, disappearance of eyelid reflex, start of inhalation anaesthesia, end of anesthesia, and to awakening and complete recovery from anesthesia. We considered the patient to be awake when he reacted to normal sounds, and completely recovered when he could give adequate answers, and no longer needed careful postoperative supervision. Reac- tions at the start of induction and deviations during anesthesia were noted. During recovery we recorded emesis and psychic behaviour. The day after operation most patients were questioned about their memories in connection with anesthesia, and how they would feel about repeating the experience.

RESULTS

The basal anesthesia obtained was classified as follows :- Good.-The patient was asleep and did not respond to stimuli other than

pain; nor did he respond to the start of inhalation anesthesia. Fair.-The patient was asleep but did respond to stimuli other than

pain. Patients who were lethargic or relaxed and unafraid were also included in this group. Smooth induction.

Failure.-Sedation inadequate; afraid. When inhalation anesthesia started, the patient was overactive and excited.

The different types of basal anesthesia obtained in the series are presented in figure 1. For comparison, groups 7 and 8 are included as they have had no basal anesthesia. There is no significant difference between the two latter groups. A comparison between the other groups discloses that the results obtained in groups 4, 5 and 6 are significantly better (P<O.Ol) than in group 1, which in turn has a better result than groups 2 and 3 (P<O.Ol).


&-

55

5

6R

Fig. 1 .-Basal anesthesia result in the different groups.

In order to analyse the different groups they have been divided into sub- groups according to age and sex. In table 3, these sub-groups have been com- pared as to the incidence of failures, fair and good basal anesthesias. There seems to be a difference between boys and girls. In group 3, there were 15 failures among the boys and only one among the girls. The number of cases is, however, too small for statistical analyses. There was no proved difference between boys and girls when the whole series was analyzed (P>0.05). The results appeared to be better among children younger than 5 years. This was especially true of group 3, in which statistical analysis revealed significantly better results in the younger ages (P<O.Ol), and in which patients between 5 and 7 years had the highest frequency of failures (P<O.Ol).

The day after operation, children old enough to give adequate answers were asked about their recollections of anesthesia, and whether they were afraid of another anesthesia of the same type. The results obtained in groups 1,2, 3, 7 and 8 are presented in table 4. In this table, groups 7 and 8 are taken together because of similar results.

The intervals between the different stages of anesthesia and postanesthetic recovery have been recorded. The data obtained are presented in tables 5 and 6. In table 5, the moment of pentothal administration has been used as starting point and the moments of disappeared response to normal sound, disappearance


TABLE 3.

Distribution of basal anesthesia result. The series is divided according to age and sex.

Gr. 1 Basal anesthesia- I 3 yean I 3-5 yean I %7 years I 7 years I Girls 1 Boys

Good.. ...... 16 15 7 37 36 39 Fair. ........ 5 0 4 15 8 16 Failure. ..... 1 0 0 0 1 0

Good ........ 15 10 8 21 11 43 Fair. ........ 9 5 4 25 11 32 Failure. ..... 0 0 2 1 0 3

Good ........ 22 25 ' 13 11 24 47 Fair ......... 1 3 3 6 5 8 Failure. ..... 3 4 8 1 1 15

...... 21 39 88 ......... 3 4 16 Fair 6 8 4

2 [

3 [

6 Y Failure.. .... 1 0 2 0 1 2

Good.. 39 41 ?5

of eyelid reflex and start of inhalation anesthesia have been registered. Dis- appearance of response to pain was also recorded; it was noted to correspond with the disappearance of the eyelid reflex. The intervals between enema and start of induction are much longer and have a wider range of variation in groups 1 and 2, because no limit was set on this interval beforehand.

TABLE 4.

Memory of anesthesia within the groups related to the result of basal anesthesia.

Number of Number of casca Number of cases Cr. I Basal anesthesia patients with memory of afraid of 1 1 anesthesia 1 aneathesia

Good.. .......... 62 0 0 Fair.. ........... 18 7 2 Failure. ......... 0 0 0

Good ............. 40 0 0 Fair. ............ 36 12 3 Failure. ......... 3 3 3

Good.: .......... 50 0 0 Fair.. ........... 12 3 1 Failure.. ........ 15 10 8

7 f Fair ........ J .... 42 40 14

2 [

3 [

8 1 Failure.. ........ 34 34 28


response to sound stimuli

57

Disappearance of Start of inhalation eyelid reflex an a the ria

TABLE 5.

The intervals of basal anesthesia. The moment of pentothal adminis- tratiofi has been used as the starting point; time in minutes.

Response to sound rtimuli i Duration of

anathaia Group Adequate anawen

1 ......... 14.5% 8.5 16.8k 7.5 36.3& 11.8 2 ......... 14.7k12.1 17.0+ 1 1 .O 36.5 & 14.0 3 ......... 9.6k 3.5 13.4k 3.9 19.6k 3.6 4-54 ..... 9.2k 3.4 13.0k 4.0 19.2* 3.8

Table 6 gives data concerning duration of anesthesia and the interval between the end of anesthesia and the moments of response to sound stimuli and the patient giving adequate answers. The duration of the immediate recovery period varies widely. These variations have been submitted to statistical analysis, which proved that recovery periods are similar in groups 1, 3 and 8. There was no difference between groups 2 and 7, nor between groups 5 and 6. The shortest recovery time was recorded in groups 2 and 7 (P<O.Ol). Next in order come groups 1, 3 and 8 with a significantly shorter recovery period (P<O.Ol) than groups 5 and 6, which in turn had a shorter recovery period than group 4 (P<O.Ol).

1 ......... 2 ......... 3. ........ 4. ........ 5. ........ 6. ........ 7. ........ 8 .........

42.3k 12.3 45.0k28.4 47.2*26.7 36.6k 16.2 43.0k 18.5 38.0k 17.2 36.0% 15.8 32.0k 10.1

55.0 k32.6 38.3 k20.5 61.9k25.6

116.4k56.8 93.0%37.4 92.0k43.0 43.0k22.1 57.0k26.2

83.7&40 56.3k25.1 74.8 k31.6

151.2 k63.4 115.5k41.5 112.0k48.4 58.0f29.8 75.0&29.6

There are some difference between the groups according to duration of anesthesia, but these variations are too small to affect the result.

The interval between induction of inhalation anesthesia and the moment the patient reaches the second plane of the third stage of ether anesthesia was noted. In the pentothal groups, the time varied between 12 and 15 minutes. In the control groups, similar results were recorded. These observations are,


of course, subjective, but it is our impression that pentothal does not shorten the time of induction.

As to the frequency of evacuations, all defecations are included irrespective of volume. Most occurred during the first minutes following the pentothal administration. Less than 1 per cent occurred after the patient had been trans- ferred to the operating theater. Table 7 presents the incidence of evacuations in the various groups. The frequency differs in the various groups. There is a significantly higher percentage of defecations in groups 1, 4 and 5, which received a dose of 0.04 g per kg, than in groups 2, 6 and 3, which were given a dose of 0.03 and 0.02 g per kg, respectively (P<O.Ol).

TABA 7.

Incidence of spontaneous defecation in the various groups.

Group

1 1 2 1 3 1 4 / 5 / 6 1 7 / 8 Number of patients with

defecation.. ......... 16 6 7 6 6 3 0 0 Percentage. ........... 16 6 7 12 12 6 0 0

In the table 8, the pentothal cases are divided into sub-groups according to the basal anesthesia obtained. I t reveals an increasing frequency of fair or failure anesthesia when the patients evacuate (P<O.Ol).

TABLE 8.

Relation between incidence of spontaneous defecation and result of basal anesthesia.

Basal anesthesia -

Good 1 Fair I Failure

Number of cases. ............ 326 101 23 Number of cases with defecation 26 12 6 Percentage .................. 8 12 26

Table 9 gives the frequency of laryngeal stridor and laryngospasm in connection with induction of inhalation anesthesia. Groups 4, 5 and 6 are combined because of similar results. Because of the irritating agents in use (vinydan and ether) we have been cautious to increase the vapor concentration gradu- ally. The observation reveals a significantly higher frequency of laryngeal stri-


TABLE 9. Incidence of laryngeal stridor and laryngospasm.

59

I Croup

Percentage of laryngeal stridor.. . . . . . . . . . . . . . . 14 16 8 9 18 6

Percentage of laryngospasm 8 12 3 5 14 4

33

25

22

14

10 8

5

I r 1. 2. 3 4.5.6.

Fig. 2.-Relation between incidence of laryngeal stridor and laryngospasrn and basal anesthesia result.

dor and laryngospasm in groups 1, 2 and 7 (P<O.Ol). No difference is noted between the other groups. In figure 2, the distribution of laryngeal stridor and laryngospasm within the groups is presented. The groups have been divided according to the basal anesthesia obtained. There is a significantly higher incidence among patients with failure or fair result (P<O.Ol). The high indi- cence of laryngeal stridor and laryngospasm in groups 1 and 2 cannot be explained entirely by the results of basal anesthesia obtained in these groups. In figure 3, the time elapsing between pentothal administration and start of induction is stated for cases with laryngeal stridor and laryngospasm. It reveals that these side reactions did not occur when inhalation started 20 to 30 minutes after the enema.


+ Group 1. Group 2.

.+ 0. + + 0 ++ 0 ..... 0.. 0. .+ +.+ +.+ 0. :+ +:+ 0:. :+ +! minutes

0 5 10 15 20 25 30 35 40 45 50

Fig. 3.-Interval between enema and induction for patients with laryngospasm or laryngea stridor in groups 1 and 2.

Table 10 gives the incidence of disturbing salivation during induction and inhalation anesthesia. The figures disclose obvious differences between the effect of the various premedication agents. The combinations of morphine- scopolamine and pentothal-scopolamine had a better antisialogogue effect than morphine-atropine and pentothal-atropine, which in turn had a better effect than atropine alone (P<O.Ol).

TABLE 10.

Antisialogogue effect of preanesthetic medication.

Croup Disturbing salivation I Premedication agent

Morphine-scopolamine .............. 8 5 % Pentoth.-scopolamine 4+6 12 %

Morphine-atropine 8 37 % Atropine 7 79 %

............... Pentoth.-atropine.. ................. 1+2+3+5 27%

................. ..........................

Table 11 presents the frequency of postoperative vomiting and restlessness. Between groups 1, 2, 4, 5 and 6 there is no difference, but they have a significantly lower incidence of vomiting (P<O.Ol) than group 3 (pentothal dosage 0.02 g per kg) and the two control groups 7 and 8. Restlessness during recovery

TABLE 11.

Incidence of vomiting and restlessness during recovery period.

Group I Percentage ofvomiting.. 20 20 43 12 24 12 38 40 Percentage of restlessness 8 9 11 8 12 10 24 10

RECTAL PENTOTHAL IN PEDIATRIC ANESTHESIA 61

period occurred in about 10 per cent with the exception of group 7, premedicated with atropine alone, in which the figure is significantly higher, 24 per cent (P<O.Ol).

No cases with clinical signs of respiratory depression were observed. No deaths occurred during the actual treatment period.

DISCUSSION

The basal anesthesia obtained corresponds fairly well with earlier reports (R. W. BURNAP et al. ( 1948)6, M. L. WEINSTEIN et al. ( 1943)88, W. MIGDAL et al. ( 1953)18 and L. ALADJEMOPP (1958)'), but comparisons are difficult because of differences in the classifications. The excellent results in groups 4, 5 and 6 are probably due to the fact that all procedures in connection with anesthesia were performed in the anesthetic room. In our opinion, the child is not afraid of the transport when it is accompanied by a penon who has gained its confidence. Moreover; it is an advantage that persons with knowledge of the method handle it throughout. The investigation also proved that specially instructed nursb can manage rectal pentothal singlehanded. The dosage levels 0.04 and 0.03 g per kg gave satisfactory results, whereas the group with a dosage of 0.02 g per kg had a high frequency of failures.

The two control groups present interesting data. Children premedicated with morphine-scopolamine or morphine-atropine have the same high incidence of panic reactions in connection with induction of inhalation anesthesia as those premedicated with atropine only. Moreover, the groups have the same frequency of psychic side reactions (F. BENSON and T. REINAND ( 1960)4).

The fact that with basal anesthesia children younger than five years have better results must be considered an important advantage. It is generally accepted that these children are more apt to show psychic side reactions in connection with anesthesia.

Questioning on the day after operation gave some important data. The superiority of rectal basal anesthesia is obvious. It is of interest to note that 50% of the children with fair results had no recollections of anesthesia procedures. Moreover, the majority of memories are not unpleasant. In the pentothal groups with satisfactory results only 3% were afraid of a hypothetical second anesthesia of the same kind. The figure for our control groups is 55%. The result corresponds fairly well to that reported by J. F. ARTUSIO et al. ( 1950)3.

The interval between the different stages of basal and inhalation anesthesia and of postanesthetic recovery has attracted much attention. The initial phase has been considered time-consuming. Many investigators emphasize that the recovery period is too long. In our series, the interval between enema and disappearance of eyelid reflex was significantly shorter when the patient was managed in the anesthetic room. This must be due to inavoidable disturbances in the ward and during transport.


Three factors influence the length of the recovery period. I. Dosage of pentothal. 11. Premedication agent used. 111. The person managing anesthesia. It is evident that a dosage of 0.04 g per kg produces a longer recovery period than a dosage of 0.03 g per kg. The latter dosage combined with atropine gives the same values as the control group premedicated with atropine alone. I t is surprising that a dosage of 0.02 g per kg gives such a long recovery time. The explanation must be that nurses hesitate to bring the patient into a light anesthetic level toward the end of operation. Unlike scopolamine, atropine used as a prernedication agent does not prolong the recovery period. This must be due to the fact that atropine produces stimulation of the medulla and higher cerebral centers, while scopolamine has a sedative and tranquilizing effect (L. S. GOODMAN and A. GILMAN ( 1955) l?) .

Our electro-encephalographic studies in six cases showed that the absorp- tion rate of pentothal from the rectum is very rapid, and that a cautious han- dling of the patient and a quiet environment are necessary to obtain a good result. The EEG changes observed correspond, to those described in detail by D. K. KIERSY et al. (1951)14.

Occurrence of spontaneous defecation in connection with rectal basal anesthesia is a disadvantage which has been emphasized in earlier reports. In our groups, we recorded this in from 6 to 16 per cent. This occurrence was directly correlated to the volume of enema. It might possibly be avoided by increasing the concentration of the pentothal solution and thus reducing the enema volume.

The explanation of high frequency of laryngeal stridor and laryngospasm in the first two groups must be that inhalation anesthesia started either too early or too late. When induction starts between 20 to 30 minutes after pentothal administration, laryngeal stridor or laryngospasm does not occur. In the other groups this knowledge was used with a significantly better result. In our control groups, the incidence was also high among patients premedicated with morphine, evidently because of the reflex-inhibiting effect of opiates.

Our investigation shows that pentothal has a contributory antisialogogue effect of the same order as morphine. I t also shows that scopolamine is superior to atropine as a drying agent and thus confirms the findings in earlier reports. (G. M.WYANT (1957)29, S. GALLOON (1956)9, C. R. STEPHEN (1956)24 and C. L. BURSTEIN (1953)'). No cases of atropine flush or scopolamine excitement were observed. Scopolamine prolongs the recovery time, and it would therefore be desirable to reduce the dosage. The drying effect will still be satisfactory, but the vagolytic action will be inadequate (R. M. SMITH ( 1950p2).

Positive reports on the antiemetic effect of rectal pentothal are on record (J. F. ARTUSIO ( 1950)3 and L. ALADJEMOFF (1958)'). Our investigation confirms this effect as to the dosages of 0.03 and 0.04 g per kg. On the other hand, a dosage of 0.02 g per kg has no proved antiemetic effect.

The incidence of restlessness during the recovery period seems to be the same when either pentothal or morphine are used in pre-anesthetic preparation.


The necessity of sedation pre-operatively to avoid or reduce the incidence of restlessnes during the recovery period is revealed by the fact that children premedicated with atropine only have a significantly higher frequency of postanesthetic restlessness.

In addition to this investigation, we have closely followed another group of about 500 cases in which rectal pentothal was used. A few of these cases are of particular interest in this connection.

Two boys, four and five years old, were in a good general condition before operation. Routine laboratory findings revealed a normal status. The acid-base balance was not controlled. A few years earlier ureteroenteroanastomosis according Coffey was performed because of extrophic bladder. Pre-anesthetic preparation included atropine and rectal pentothal (0.04 g per kg). In both cases, minor plastic surgery on the abdominal wall was carried out. Inhalation anesthesia was uneventful, and postoperatively the patients returned to the ward. They soon showed signs of slight respiratory and circulatory depression with shallow breathing and moderately reduced blood pressure. It was not necessary to institute 'any active treatment but careful supervision was called for. They both had a prolonged sleep and responded to sound stimuli 8 and 9 hours after the end of operations, respectively. Careful laboratory analyses revealed that they had moderate metabolic acidosis with standard bicarbonate in capillary blood between 14 and 15 m M. Disturbances of this kind are common in connection with Coffey's operation.

A boy of 4 years had an uneventful appendectomy. Rectal pentothal and inhalation anesthesia were used. Postoperative recovery was prolonged, and the child did respond to sound stimuli 7 hours later. It was found that, by a mistake, morphine-scopolamine had been used instead of scopolamine as the premedication agent.

These three are the only cases with extremely prolonged postoperative recovery periods, and the first two are the only cases with signs of respiratory depression among 1050 rectal pentothal cases observed.

We therefore conclude that not only respiratory but also metabolic acidosis and changes in electrolyte and water balance must be carefully evaluated in connection with rectal pentothal. In cases with slight or moderate disturbances of the acid-base-water-electrolyte balance which has not been corrected before operation we now use a reduced dosage of 0.02 g pentothal per kg. The same dosage is used in cases with cardiac decompensation or severe anepia. Severe involvement of the airway implying an increased work of breathing is considered to be an absolute contra-indication.

We have thus used rectal pentothal routinely in emergency cases, in cardiac catheterization and in heart and lung surgery with satisfactory result.

S U M MARY

Rectal pentothal was used in 450 children in a good general condition, different dosages of pentothal and different premedication agents being em- ployed. Either instructed nurses or anesthesiologists have handled all proce-


dures. Two control groups each of 50 patients were used. All patients were closely observed. The following conclusions were made :-

Satisfactory results are obtained with a pentothal dosage of 0.04 g per kg; 0.03 g per kg gives good results when the premedication agent is scopolamine. When atropine is used, basal anesthesia is obtained in 53 per cent and a state of basal hypnosis in 44 per cent. The dosage of 0.02 g per kg is inadequate.

It is best to manage all procedures in a quiet anesthetic room. Rapidity of onset has been revealed. Exact timing is important. The method is safe for good-risk patients in the hands of instructed nurses. The length of the postoperative recovery period depends on the pentothal dosage, premedication agent used and the person managing anesthesia. Rectal pentothal has an anti- sialogue, antiemetic and amnestic effect.

Three cases from another series are briefly mentioned because they give important information concerning prolonged postoperative sleep and respiratory depression in connection with rectal pentothal.

:

ZUSAMMENFASSUNG

Pentothal wurde bei 450 Kindern in gutem Allgemeinzustand als rectaler Einlauf gegeben, wobei man sich verschiedener Dosierungen des Mittels und verschiedener Pramedikationen bediente. Die Prozeduren wurden entweder von eingeschulten Schwestern oder von Anaesthesisten durchgefuhrt. Zwei Gruppen von je 50 Patienten dienten als Kontrollgruppen. Alle Patienten wurden ge- nauestens beobachtet und dabei konnten folgende Schliisse gezogen werden :

Zufriedenstellende Resultate wurden mit einer Dosis von 0,04 g Pentothal pro kg erzielt; 0,03 g pro kg ergab nur dann gute Resultate, wenn Scopolamin zur Vorbereitung gegeben worden war. Wurde hingegen Atropin verwendet, dann konnte eine Basisanaesthesie nur in 53% und eine Art Basishypnose in 440/, der Falle erreicht werden. Pentothal in einer Dosierung von 0,02 g/kg war nicht ausreichend.

Die Prozeduren sollten vorzugsweise in einem ruhigen Vorbereitungsraum durchgefuhrt werden. Die Geschwindigkeit des Narkoseeintrittes wurde unter- sucht. Exakte Zeitmessung ist wichtig. Die Methode ist fur Patienten in gutem Zustand auch in den Handen von eingeschulten Schwestern sicher. Die Dauer der postoperativen Erholungsperiode hangt ab von der Pentothaldosis, dem Pramedikationsmittel und der Person, die die Anaesthesie durchgefuhrt hat. Rectales Pentothal hat einen speichelhemmenden, antiemetischen und amne- stischen Effekt.

Drei Falle aus einer anderen Serie wurden kurz erwahnt, weil sie wichtige Informationen uber prolongierten postoperativen Schlaf und Atemdampfung in Verbindung mit rectalem Pentothal abgaben.


REFERENCES

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2. ALBERT, S. N., H. N. ECCLKSTON, J. S. BOLINO and C. A. ALBERT: Basal hypnosis by the rectal administration of a multidose thiobarbiturate suppository. Current Researches in Anesth. d Analg. 1956, 35, 330.

3. ARTUSIO, J. F., and M. TROUSDELL: A comparative study of rectal pentothal and morphine for basal anesthesia upon children for tonsillectomi. Anesthesiology. 1950, 11,443.

4. BENSON, F., and T. REINAND: Psychic side reactions in pediatric anesthesia. In preparation.

5. BRODIE, B. B., L. C. MARK, E. M. PAPPER, P. A. LIEF, E. BERNSTEIN and E. A. ROVEN- STINE: The fate of thiopental in man and a method for its estimation in biological material. 3. Pharmacol. d Exper. T k a p . 1950, 98, 85.

6. BURNAP, R. W., E. A. GAIN and E. H. WATTS: Basal anesthesia in children using sodium pentothal by rectum. Anesthesiology. 1948, 9, 524.

7. BURSTEIN, C. L. : Pediatric preanesthetic medication in children. Anesthesiology. 1953, 14,567.

8. ECKENHOPF, J. E.: Relationship of anesthesia to postoperative personality changes in children. Am. 3. Dis. Child. 1953, 86, 587.

9. GALLOON, S.: A comparison of the antisialogogue action of atropine and hyoscyamine. Brit. 3. Anaesth. 1956, 28, 113.

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rectal pentothal in pediatric anesthesia: a comparative clinical study

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