284
Letters to the Editor
REPLY Dear Editor. e would like to thank the authors for their comments and suggestion. Their contention is well considered and accepted. We would however justify the concentration and volume of anaesthetic mixture used by us because of the following reasons: (a) Both our patients, apart from the dominant limb injuries. had associated injuries elsewhere. Local infiltration was therefore required for their debridement besides the plexus blocks. To limit the total dose to below toxic levels. we did not employ the maximum permissible doses for the block alone. (b) A study done by SChnorr on 131 anaesthsiologists routinely using regional anaesthesia addressed their preferences regarding use of drug mixtures and the reasons thereof. As many as 70% respondents employed local anaesthetic mixtures. The rationale for USe was to combine benefits and avoid individual toxicity by limiting the dosage of the parent compounds to near two thirds of permissible limit Pl. Lr Col Bhot's typical example quoted, apparently for an adult, depicts the use of maximum permissible doses of both bupivacaine and lignocaine employed in combination. Thus. not only are the benefits of reducing individual drug toxicity negated by this approach, the risk is in fact increased.
W
(c) Drug interactions in LA mixtures are unpredictable and do not follow a mathematical linear progression. Higher drug concentration with smaller volume is advocated by some authors for plexus block. which can result in local and systemic toxicity [2]. We rely on using larger volumes in dilution. This not only offsets the need
for very accurate needle placement but also has an added advantage of limiting the dose of individual drug. We have used this method in 80 patients of extremity trauma with successful results 13). (d) Though employed in dilution, it is pertinent to mention thai 5% lignocaine causes irreversible nerve damage in animal studies and is infact employed as a neurolytic agent [41. I would like to put on record my gratefulness and appreciation of Lt Col FB Shot. christened the 'Raja of Regionals ' by his trainees. I have learned regional block techniques from him which have proved to be of immense utility in emergency situations. References I. Schnorr C. Menges T. Hempelmann G. Local anesthet ic mixtures in various regional anaesthesia procedures . Anasth Imensivther Notfall med 1990;25(3):193-7. 2. Halford FJ. A critique of IV anaesthesia in war surgery. Anaesthesiology. 1943:4:67-9.
3. Mehrotra S. Mehrotra M. Regiona l block anaesthesia how effective is it for extremity trauma? MlAFI 2002 ;58(3):205-9. 4. Dook IL. Jeong lY. Kim KS. Neurolytic blockade with 5% Lidocaine.J Anaesthesiology Clin Pharmacol. 15;4:393.
Maj S MEHROTRA·, Maj M MEHROTRA + 'Classified Specialist. (Surgery), (on study leave). Department of Reconstructive Surgery. Post Graduate Institute of Medical Sci ences, Chandigarh, "Graded Specialist (Anaesthesiology), 319, Field Ambulance, Clo 56 APO.
HOSPITAl. BEDS IN THE ARMED FORCES Dear Editor,
radiopaque lop. and absence of facility for head low position.
This is with reference to the leiter to Editor titled "Design Modification of the Back Rest of Hospital Beds in the Armed Forces : A Proposal". The backrest of the ordinance supply bed has serious drawbacks in addition to being rendered immobile following repeated painting. These flaws are being listed below: (a) The design of the backrest obstructs access to head and neck region of the patient. This is a serious flaw in the design, which will be well appreciated by a person who is called upon to intubate a patient in an emergency. Valuable time is lost in removing the backrest before laryngoscopy is possible. After removing the backrest. the medicare provider has to position himself under the horizontal bar (which is difficult to remove) before he can attempt laryngoscopy. (b) The additional limitations of the bed design are heavy weight,
These are worth enumerating here to make all medical officers aware that the basic hospital bed has serious design limitations. A hospital bed should be light , easily transportable, have a radioluscent top. provide easy and ready access to head and airway. and should provide facility to give a head low position. Cost constraints may prevent the organization from changing all the available beds everywhere. However, all efforts should be made to position beds which incorporate design features as mentioned in para 4, especially in areas where patients with acute illnesses are
cared. Wg Cdr HARSH VARDHAN·, Wg Cdr S ANANT T '''Classified Specialist (Anaesthesiology), 7 Air Force Hospital.
Kanpur,
REPLY Dear Editor.
T
his is in reply to the comments received with reference to the Letter to the Editor titled "Design Modification of the BackRest of Hospital Beds in the Armed Forces: A Proposal" from Wg Cdr Harsh Vardhan and Wg Cdr S Anant.
I agree with me flaws brought out in the above mentioned comments. However, I would like to offer the following comments/suggestions : (a) The comments reinforce the fact that there is a need to study the usability/functional role of the hospital beds in its entirety and not from tile viewpoint of a medical officer at the periphery or the
speci alist at bigger hospitals. (b) Most of the hospital beds and their design specifications can be divided into those used in acute care/intensive care and chronic care settings. It is obvious that the requirements of acute care would be different from a chronic care patient. This would also explain the requirement of radiolucent chest X-ray top with cassette holder in beds , being used in intensive care settings. It may be wonhwhile to point that the radio-lucent lop is offered as an optional accessory by the manufacturers and does not come as an integral pan of all intensive care beds. (c) With the above in mind, there may not be a single design MJAFI. VOL 58. NO. .~. 2002
Letters to the Editor
REPLY Dear Editor. e would like to thank the authors for their comments and suggestion. Their contention is well considered and accepted. We would however justify the concentration and volume of anaesthetic mixture used by us because of the following reasons: (a) Both our patients, apart from the dominant limb injuries. had associated injuries elsewhere. Local infiltration was therefore required for their debridement besides the plexus blocks. To limit the total dose to below toxic levels. we did not employ the maximum permissible doses for the block alone. (b) A study done by SChnorr on 131 anaesthsiologists routinely using regional anaesthesia addressed their preferences regarding use of drug mixtures and the reasons thereof. As many as 70% respondents employed local anaesthetic mixtures. The rationale for USe was to combine benefits and avoid individual toxicity by limiting the dosage of the parent compounds to near two thirds of permissible limit Pl. Lr Col Bhot's typical example quoted, apparently for an adult, depicts the use of maximum permissible doses of both bupivacaine and lignocaine employed in combination. Thus. not only are the benefits of reducing individual drug toxicity negated by this approach, the risk is in fact increased.
W
(c) Drug interactions in LA mixtures are unpredictable and do not follow a mathematical linear progression. Higher drug concentration with smaller volume is advocated by some authors for plexus block. which can result in local and systemic toxicity [2]. We rely on using larger volumes in dilution. This not only offsets the need
for very accurate needle placement but also has an added advantage of limiting the dose of individual drug. We have used this method in 80 patients of extremity trauma with successful results 13). (d) Though employed in dilution, it is pertinent to mention thai 5% lignocaine causes irreversible nerve damage in animal studies and is infact employed as a neurolytic agent [41. I would like to put on record my gratefulness and appreciation of Lt Col FB Shot. christened the 'Raja of Regionals ' by his trainees. I have learned regional block techniques from him which have proved to be of immense utility in emergency situations. References I. Schnorr C. Menges T. Hempelmann G. Local anesthet ic mixtures in various regional anaesthesia procedures . Anasth Imensivther Notfall med 1990;25(3):193-7. 2. Halford FJ. A critique of IV anaesthesia in war surgery. Anaesthesiology. 1943:4:67-9.
3. Mehrotra S. Mehrotra M. Regiona l block anaesthesia how effective is it for extremity trauma? MlAFI 2002 ;58(3):205-9. 4. Dook IL. Jeong lY. Kim KS. Neurolytic blockade with 5% Lidocaine.J Anaesthesiology Clin Pharmacol. 15;4:393.
Maj S MEHROTRA·, Maj M MEHROTRA + 'Classified Specialist. (Surgery), (on study leave). Department of Reconstructive Surgery. Post Graduate Institute of Medical Sci ences, Chandigarh, "Graded Specialist (Anaesthesiology), 319, Field Ambulance, Clo 56 APO.
HOSPITAl. BEDS IN THE ARMED FORCES Dear Editor,
radiopaque lop. and absence of facility for head low position.
This is with reference to the leiter to Editor titled "Design Modification of the Back Rest of Hospital Beds in the Armed Forces : A Proposal". The backrest of the ordinance supply bed has serious drawbacks in addition to being rendered immobile following repeated painting. These flaws are being listed below: (a) The design of the backrest obstructs access to head and neck region of the patient. This is a serious flaw in the design, which will be well appreciated by a person who is called upon to intubate a patient in an emergency. Valuable time is lost in removing the backrest before laryngoscopy is possible. After removing the backrest. the medicare provider has to position himself under the horizontal bar (which is difficult to remove) before he can attempt laryngoscopy. (b) The additional limitations of the bed design are heavy weight,
These are worth enumerating here to make all medical officers aware that the basic hospital bed has serious design limitations. A hospital bed should be light , easily transportable, have a radioluscent top. provide easy and ready access to head and airway. and should provide facility to give a head low position. Cost constraints may prevent the organization from changing all the available beds everywhere. However, all efforts should be made to position beds which incorporate design features as mentioned in para 4, especially in areas where patients with acute illnesses are
cared. Wg Cdr HARSH VARDHAN·, Wg Cdr S ANANT T '''Classified Specialist (Anaesthesiology), 7 Air Force Hospital.
Kanpur,
REPLY Dear Editor.
T
his is in reply to the comments received with reference to the Letter to the Editor titled "Design Modification of the BackRest of Hospital Beds in the Armed Forces: A Proposal" from Wg Cdr Harsh Vardhan and Wg Cdr S Anant.
I agree with me flaws brought out in the above mentioned comments. However, I would like to offer the following comments/suggestions : (a) The comments reinforce the fact that there is a need to study the usability/functional role of the hospital beds in its entirety and not from tile viewpoint of a medical officer at the periphery or the
speci alist at bigger hospitals. (b) Most of the hospital beds and their design specifications can be divided into those used in acute care/intensive care and chronic care settings. It is obvious that the requirements of acute care would be different from a chronic care patient. This would also explain the requirement of radiolucent chest X-ray top with cassette holder in beds , being used in intensive care settings. It may be wonhwhile to point that the radio-lucent lop is offered as an optional accessory by the manufacturers and does not come as an integral pan of all intensive care beds. (c) With the above in mind, there may not be a single design MJAFI. VOL 58. NO. .~. 2002
