Download THE URGENCY OF EXPEDIENT ECG MONITORING DURING

232
BRITISH JOURNAL OF ANAESTHESIA
There is no doubt that these volumes offer the
finest and most comprehensive surveys of respiratory
physiology which have ever been produced. All the
authors are experts in their fields and their presentation is almost always beyond any but carping criticism.
The marshalling of this vast amount of material must
have been an awesome task and editors and authors
alike deserve the highest praise. It is, however,
inevitably difficult to find particular items amongst
half a million words, and the work would seem to
justify a more elaborate index. The reviewer also
believes that an author index of the type recently
used by Aviado* would be valuable in a work of
this size.
* The Lung Circulation by D . M. Aviado; reviewed
Brit. J. Anaesth. (1965), 37, 857.
It is a little difficult to recommend who should
read or buy the Respiratory Handbook. Were it not
for the high price the answer would be simple:
these volumes should be on every anaesthetist's bookshelf, both for reference and for dipping into on
suitable occasions. Unfortunately, the price will lead
to second thoughts, and many will have to rely on
copies in departmental libraries, none of which can
afford to be without these books. It seems likely that
the Respiratory Handbook will become the point of
departure for intending investigators of respiratory
phenomena. Similarly, aspiring writers on respiratory
topics will be well advised to peruse the Handbook
before commencing their task. It is not too much to
hope that the publication of the Handbook will usher
in an era in which we shall see fewer ill-conceived
and ill-prepared works in the field of respiratory
physiology.
J. F. Nunn
CORRESPONDENCE
THE URGENCY OF EXPEDIENT E.C.G. MONITORING DURING
ANAESTHESIA
Sir,—I believe the publication of figure 1 (upside
down) in my letter (Brit. J. Anaesth. (1965), 37, 886)
justifies a further note. I am presently conducting a
statistical analysis of the incidence1 of muscarinic
(wandering pacemaker with or without e.c.g. quiescence followed by a-v nodal rhythm) and nicotinic
(premature ventricular) effects of suxamethonium in
association with halothane anaesthesia. On three
occasions so far I found the continuation of normal
rhythmic atrial P-waves in association with apparently
fortuitous disappearance of ventricular QRST-waves
which do not depend on heart block as judged from
the preceding and subsequent lengths of the PRintervals. I find no previous reference to this
intriguing arrhythmia which is not clearly muscarinic
or nicotinic. It is illustrated in the bottom trace of
the accompanying figure which was obtained from a
middle-aged man 1 minute after 40 mg suxamethonium as a first dose during stable halothane anaesthesia in the absence of an endotracheal tube. The
patient received no premedication and the induction
was with halothane and oxygen only.
The utility of e.c.g. monitoring can be further
emphasized by reference to the top tracings in the
accompanying figure. It was obtained from a 63-yearold man with ischaemic heart disease who received
halothane and nitrous oxide anaesthesia induced by
thiopentone and preceded by pethidine and atropine
medication. The trachea was intubated with the aid
of suxamethonium. He had a fractured femur requiring open surgical fixation. When the tracings to the
left of the upper half of the figure were obtained
from the V4 chest position, 3 pints of blood were
transfused prior to significant further blood loss
associated with the surgical procedure. Although the
satisfactory blood pressure rose only slightly, it can
be seen from the further traces in the upper half of
the figure that this augmentation of the blood volume
completely corrected the ischaemic and injury currents in his e.c.g. We would not have known about
this easily remediable heart morbidity were the e.c.g.
not employed.
J. W. MOSTERT
Buffalo, USA.
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