542

Correspondence

pharmacological abreaction in the hope that an insight might be gained into the origin of his disorder. The technique was planned on a ‘one-off outpatient basis and in view of the good recovery associated with propofol a decision was made to use this. Small incremental doses of propofol were slowly given to the patient to a total of approximately 125mg, the dose titrated against his degree of sedation so that he was kept drowsy, but still just able to nod his head in response to the questions and prompting of two therapists skilled in adolescent and family psychiatry. After a period of time the patient began slowly to include answers by whisper and eventually came to describe recent significant past events, underlying hostilities, loyalties and violence both within his immediate family as well as with relatives within the extended ethnic family group. It is possible that his ‘condition’ had been used by him, either consciously or subconsciously as a diversion in order to manipulate his family into focusing their attentions and concerns onto him, thus in the process alleviating pre-existing family tensions. Since then, with skilled follow-up and much counselling, he has improved so that he is now talking and walking again. The use of propofol in psychiatry needs further evaluation, but unfortunately suitable opportunities are limited. However, if used in conjunction with psychotherapy, there are a number of observations and precautions to be made. ( I ) As yet, abreaction is not a licensed indication for the

use of propofol. (2) Abreaction is a technique likely to be carried out under the subdued lighting and relaxed ambience of the psychiatry couch. However, the usual anaesthetic precautions on administration of a powerful intravenous agent should still apply, i.e. administration of the drug by an experienced anaesthetist to a starved patient, an indwelling canula, resuscitation facilities to hand and minimally obtrusive monitoring such as a pulse oximeter. (3) Psychiatric recommendations include the recognition that clear consent needs to be obtained from all participants. Much work may have to be done to establish that the patient her or himself has made the choice. It is not a form of therapy that should be entered into lightly before other avenues have been explored beforehand. There is the great need to ensure that the therapist has enough control over the situation to deal with a possible suicide risk that might be uncovered, and also that there is adequate skilled follow-up to ensure that the experience is made use of in further consultations. University College Hospital. London WCI E 6 A U

S.M. ROBERTSON A. CWKLIN

Reference [I] ROBINSONDA. Abreaction on recovery from propofol anaesthesia. Anuesfhesiu 1989;44: 364.

Airway maintenance for short ophthalmological procedures in children The modified Guedel airway described by Sethi etal. (Anaesthesia 1991; 46: 1084) is in essence a Phillips airway with a Charles cap. This device was used in this hospital from 1968 to 1990 for ophthalmological procedures in children. We would suggest that, in current practice, neither device is now suitable for this purpose except for the shortest anaesthetics (up to 10min). It is difficult to ensure correct positioning of the device and thus a clear airway for the duration of the procedure; the anaesthetist must frequently support the jaw and dilution of anaesthetic vapours requires high fresh gas flows which may increase pollution. These problems may be overcome by the use of the laryngeal mask airway (LMA). We initially gained experience in the use of the LMA in small children for radiotherapy [ 11 and have since found the technique well

suited to ophthalmological procedures. The correctly positioned LMA provides a secure airway, leaving the anaesthetist’s hands free. Satisfactory conditions can be obtained with oxygen, nitrous oxide and a volatile agent without the need for promethazine or pethidine and the children recover quickly. We now use this technique for the majority of children having ophthalmological procedures. St. Bartholomew’s Hospital,

West Smithjield, London ECI A 7BE

M.H. NATHANSON C. FERGUSON D.G. NANCEKIEVILL

Reference [l]GREBENIK CR, FERGUSONC, WHITEA. The laryngeal mask airway in pediatric radiotherapy. Anesfhesiology 1990; 7 2 474-7.

Pain relief after day case laparoscopy We were interested to read the article by Edwards et al. concerning pain relief after day-case laparoscopy (Anaesthesia 1991; 46: 1077-80) since we have recently audited the figures for 1991 of our own Day Case Unit. Like the authors, we have found diclofenac to be unsatisfactory for analgesia after laparoscopic sterilisation, and intramuscular opioid analgesia is often required. However, we were surprised to read that pain necessitated overnight admission in seven out of 40 patients undergoing this procedure (17.5%) and we reject the suggestion that laparoscopic sterilisation is unsuitable for day-case surgery. In our unit, 275 laparoscopies were performed in 1991, of which 123 were for sterilisation. Of these, there were four admissions, two of which were for surgical reasons, leaving just two admissions for pain (1.6%). We believe this is a very acceptable figure. However, we

now think we have solved the problem of pain relief after laparoscopic sterilisation by performing a bilateral mesosalpinx block as described by Smith et a1 [l]. This has proved remarkably effective and no patient has required intramuscular analgesia to date. A zero admission rate for pain would therefore seem to be an attainable goal for 1992. Day Surgery Unit, Southlandr Hospital, Shoreham-by-Sea

L. MARKANDAY N.G. LAVIES

Reference [I] SMITHBE, MACPIERSON GH, DE JONGE M, GRIFFITHS JM. Rectus sheath and mesosalpinx block for laparoscopic sterilation. Anaesfhesiu 1991;46: 875-7.