Com ment
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with essential the Noticeand printed on the inside back cover.should Tablesbeand figures should be included only given. if absolutely no more than five references
Catheterisation for nephrectomy? It is with interest that I read the above paper by Davies et al. (Annals, November 1989, vol 71, p368). I was, however, surprised by the cavalier recommendation of the authors to use bladder catheterisation in all cases of postoperative urine retention. Recent investigations carried out in our department have proved that the bladder neck, prostate, prostatic capsule as well as the urethra are rich in a-adrenergic receptors in animals and man. Increased sympathetic activity, in the form of an aadrenergic receptor response to bladder distension developing during surgery, may precipitate an increase in the closure pressure of the urethra, thus causing difficulties in micturition and urine retention (1). Stress due to anaesthesia and surgery may cause central epinephrine secretion by the adrenal medulla and add to the reflexly increased a-receptor stimulation by bladder stimulation. Administration of a-adrenergic blocking agents such as Dibenyline® (phenoxybenzamine) proved to effectively diminish or abolish the difficulties in micturition, or prevent urinary retention in the majority of patients undergoing surgery, quite often in the presence of prostatic obstruction (2). We now recommend the administration of three 10 mg Dibenyline tablets, the first one the evening before surgery, the next one together with the premedication the morning before surgery and the last one about 4 h after the operation, especially in patients undergoing rectal, perianal or vaginal surgery. Catheterisation of the urethra is an invasive procedure, may induce trauma to the urethra as well as ascending urinary infection, sometimes associated with high fever, is, at least, unpleasant to the patient and should be reserved only for cases where catheterisation is absolutely necessary. The availability of effective a-adrenergic blocking agents will relegate the catheter to a minimum of patients with postoperative bladder retention. ALPHOSE PFAU MD FACS Professor and Head of Department of Urology Hebrew University Hadassah Medical Center, Israel
References 1 Caine M, Pfau A, Perlberg S. The use of alpha-adrenergic blockers in benign prostatic obstruction. BrJ Urol 1976;48: 255. 2 Leventhal A, Pfau A. Pharmacologic management of postoperative over-distention of the bladder. Surg Gynecol Obstet 1978;146:347-8.
Parents and paediatric anaesthesia: a prospective survey of parental attitudes to their presence at induction I was interested to read the report of a study on parents and paediatric anaesthesia (Annals, January 1990, vol 72, p41). My survey of 415 parents in two paediatric cardiac units included questions on parents' views about being with their child during induction of anaesthesia (1). An 18-page booklet questionnaire on ward routines, information, and amenities for families, was given out just after the child was transferred from the intensive care unit to the lowdependency ward after cardiac surgery. There were 278 replies
(67%). The questions and answers on leaving the child before surgery were: Before the operation I would prefer to have stayed with my child until: (a) The premed was given 12 (b) My child was taken out of the ward 94 (c) After the journey to theatre 61 78 (d) After the anaesthetic had been given Parents seemed to find this the hardest question to answer, and 33 did not reply, the highest number of non-replies to all the 40 main questions in the completed questionnaires. They added comments such as 'I was allowed to stay until he went out of the ward', as if this were a professional matter which they should not question. However, parents were concerned that some children were awake and afraid, and might have a long wait in the theatre suite. Some parents believed that it is vital 'to get the child to sleep as peacefully as possible, and only someone they know and trust can do that'. The questionnaire reported in the article started by stating professional reservations about parents' presence during induction of anaesthesia, offered mainly negatively worded options which could imply that respondents were criticising the service, was given out and collected in by the anaesthetist who sometimes 'assisted' parents to fill it in, shortly before surgery, when parents are most anxious and least likely to state independent views (2). It is encouraging that anaesthetists at Great Ormond Street are investigating their policy, which differs from many centres that welcome parents into the anaesthetic room, and from centres that are questioning the efficacy of heavy premedication sedation. Yet their questionnaire seems designed to justify the status quo. Sincere enquiry would surely involve repeating the study but with an impartially worded questionnaire, not administered by an anaesthetist, avoiding the immediate perioperative period, and preferably with the option for parents to remain anonymous. PRISCILLA ALDERSON PhD Research Sociologist Community Paediatric Research Unit Westminster Children's Hospital London References I Alderson P. 'What the Parents Think', unpublished report for the Brompton Hospital and the Hospital for Sick Children, Great Ormond Street, 1986. 2 The stages of doubt and trust around surgery are discussed in Alderson P. Choosing for Children: Parents' Proxy Consent to Surgery. Oxford: Oxford University Press, 1990 (in press).
The perimedian incision I read this paper (Annals, January 1990, vol 72, p64) with great interest. What to do with the umbilicus is a real problem in making long midline incisions. Surgeons get over it by skirting around the umbilicus or even cutting straight through it in the midline. I even saw one of my chiefs excising it deliberately as he made the incision. When asked why he was removing the
Contributors to this section are asked to make their comments brief and to the point. Letters should comply with essential the Noticeand printed on the inside back cover.should Tablesbeand figures should be included only given. if absolutely no more than five references
Catheterisation for nephrectomy? It is with interest that I read the above paper by Davies et al. (Annals, November 1989, vol 71, p368). I was, however, surprised by the cavalier recommendation of the authors to use bladder catheterisation in all cases of postoperative urine retention. Recent investigations carried out in our department have proved that the bladder neck, prostate, prostatic capsule as well as the urethra are rich in a-adrenergic receptors in animals and man. Increased sympathetic activity, in the form of an aadrenergic receptor response to bladder distension developing during surgery, may precipitate an increase in the closure pressure of the urethra, thus causing difficulties in micturition and urine retention (1). Stress due to anaesthesia and surgery may cause central epinephrine secretion by the adrenal medulla and add to the reflexly increased a-receptor stimulation by bladder stimulation. Administration of a-adrenergic blocking agents such as Dibenyline® (phenoxybenzamine) proved to effectively diminish or abolish the difficulties in micturition, or prevent urinary retention in the majority of patients undergoing surgery, quite often in the presence of prostatic obstruction (2). We now recommend the administration of three 10 mg Dibenyline tablets, the first one the evening before surgery, the next one together with the premedication the morning before surgery and the last one about 4 h after the operation, especially in patients undergoing rectal, perianal or vaginal surgery. Catheterisation of the urethra is an invasive procedure, may induce trauma to the urethra as well as ascending urinary infection, sometimes associated with high fever, is, at least, unpleasant to the patient and should be reserved only for cases where catheterisation is absolutely necessary. The availability of effective a-adrenergic blocking agents will relegate the catheter to a minimum of patients with postoperative bladder retention. ALPHOSE PFAU MD FACS Professor and Head of Department of Urology Hebrew University Hadassah Medical Center, Israel
References 1 Caine M, Pfau A, Perlberg S. The use of alpha-adrenergic blockers in benign prostatic obstruction. BrJ Urol 1976;48: 255. 2 Leventhal A, Pfau A. Pharmacologic management of postoperative over-distention of the bladder. Surg Gynecol Obstet 1978;146:347-8.
Parents and paediatric anaesthesia: a prospective survey of parental attitudes to their presence at induction I was interested to read the report of a study on parents and paediatric anaesthesia (Annals, January 1990, vol 72, p41). My survey of 415 parents in two paediatric cardiac units included questions on parents' views about being with their child during induction of anaesthesia (1). An 18-page booklet questionnaire on ward routines, information, and amenities for families, was given out just after the child was transferred from the intensive care unit to the lowdependency ward after cardiac surgery. There were 278 replies
(67%). The questions and answers on leaving the child before surgery were: Before the operation I would prefer to have stayed with my child until: (a) The premed was given 12 (b) My child was taken out of the ward 94 (c) After the journey to theatre 61 78 (d) After the anaesthetic had been given Parents seemed to find this the hardest question to answer, and 33 did not reply, the highest number of non-replies to all the 40 main questions in the completed questionnaires. They added comments such as 'I was allowed to stay until he went out of the ward', as if this were a professional matter which they should not question. However, parents were concerned that some children were awake and afraid, and might have a long wait in the theatre suite. Some parents believed that it is vital 'to get the child to sleep as peacefully as possible, and only someone they know and trust can do that'. The questionnaire reported in the article started by stating professional reservations about parents' presence during induction of anaesthesia, offered mainly negatively worded options which could imply that respondents were criticising the service, was given out and collected in by the anaesthetist who sometimes 'assisted' parents to fill it in, shortly before surgery, when parents are most anxious and least likely to state independent views (2). It is encouraging that anaesthetists at Great Ormond Street are investigating their policy, which differs from many centres that welcome parents into the anaesthetic room, and from centres that are questioning the efficacy of heavy premedication sedation. Yet their questionnaire seems designed to justify the status quo. Sincere enquiry would surely involve repeating the study but with an impartially worded questionnaire, not administered by an anaesthetist, avoiding the immediate perioperative period, and preferably with the option for parents to remain anonymous. PRISCILLA ALDERSON PhD Research Sociologist Community Paediatric Research Unit Westminster Children's Hospital London References I Alderson P. 'What the Parents Think', unpublished report for the Brompton Hospital and the Hospital for Sick Children, Great Ormond Street, 1986. 2 The stages of doubt and trust around surgery are discussed in Alderson P. Choosing for Children: Parents' Proxy Consent to Surgery. Oxford: Oxford University Press, 1990 (in press).
The perimedian incision I read this paper (Annals, January 1990, vol 72, p64) with great interest. What to do with the umbilicus is a real problem in making long midline incisions. Surgeons get over it by skirting around the umbilicus or even cutting straight through it in the midline. I even saw one of my chiefs excising it deliberately as he made the incision. When asked why he was removing the
