14
Correspondence
have requested the services of a primary system. This is equivalent to using an accident and emergency department for an intensive care patient. It is not the first such report that we have received. We are deeply concerned that helicopter operators are attempting to set up medical helicopter systems with inadequate input from the medical profession. The resultant schemes, frequently under pressure to fly as much as possible to justify their costs, may attempt to undertake secondary transfers with staff and equipment designed for a totally different purpose, and, as witnessed by Dr Smith,
fall short of the standards we have tried to set for secondary transfers. St Bartholornew’s Hospital, London E C l A 7BE
H.A.L. VYVYAN S . KEE A. BRISTOW
Reference [I] Medical helicopter systems - recommended minimum standards for patient management. Report of a working party. Journal of the Royal Society of Medicine 1991; 84: 2 4 2 4 .
Regional anaesthesia in pemphigus vulgaris Pemphigus comprises a group of mucocutaneous diseases characterized by bullous eruptions of the skin and mucous membranes and is probably of autoimmune aetiology [I]. Pemphigus vulgaris is the most common form of pemphigus. It is characterized by impaired cell adhesion within the epidermis leading to the formation of intraepidermal blisters [I]. Whereas there is extensive literature on the anaesthetic management of epidermolysis bullosa, there are few reports of anaesthesia in pemphigus [2-51. A 46-year-old white female with abnormal uterine bleeding, was admitted for abdominal hysterectomy and bilateral salpingo-oophorectomy. Eight years previously she had been diagnosed as suffering from pemphigus vulgaris. There was no associated internal malignancy. She was receiving prednisone 10 mg and azathioprine 100 mg daily. Physical examination revealed painful bullous formations in the mouth and oropharynx. Except for an iron deficiency anaemia, laboratory tests, chest X ray and electrocardiogram were within normal limits. Immunofluorescence showed IgG and C3 a t the epidermal junction. Hydrocortisone (100 mg intravenously) was given pre-operatively and during surgery. A continuous catheter spinal anaesthesia was the anaesthetic technique selected. A 25-gauge spinal needle was inserted easily at the L2-, interspace and a 32 gauge microspinal catheter passed. The initial injection of 3 ml of plain bupivacaine 0.5% resulted in a T, level of sensory blockade bilaterally. No additional doses were necessary. At the same time, an epidural catheter was inserted a t the L,, interspace. The intra-operative surgical and anaesthetic courses were uneventful. At the end of the operation the spinal catheter was removed. There were no lesions at the site of spinal needle puncture, blood pressure cuff, intravenous cannulation, or oxygen mask application (the face had been pretreated with vaseline gel). There were no lesions a t any of the pressure points that had been in contact with the operating room table. In the recovery room and in the gynaecology ward 10ml of plain
bupivacaine 0.125% and 1 mg of morphine were administrated for pain control. The patient was discharged from the hospital on the 6th postoperative day. The lesions of both pemphigus and pemphigoid resemble those of epidermolysis bullosa, and the anaesthetic management is probably the same, airway management being the primary concern [I]. Continuous thoracic epidural anaesthesia supplemented with intravenous ketamine has been used for cholecystectomy in a patient with buccal pemphigus [2]; a slow intravenous infusion of ketamine and epidural anaesthesia has been used for the removal of a rectal tumour [3]; continuous spinal anaesthesia has been used in undergoing radical vulvectomy [6]. This case illustrates how useful regional anaesthesia can be in providing satisfactory anaesthesia and postoperative pain control. Hospital de la Princessa. Madrid, Spain
F. GILSANZ M.L. MEILAN
R. Ross G. OLIVERA
References [I] SMITHGB, SHRIBMAN AJ. Anaesthesia and severe skin disease. Anaesthesia 1984; 39 443-55. [2] JEYARAMC, TORDA TA. Anesthetic management of cholecystectomy in a patient with buccal pemphigus. Anesthesiology 1974; 40: 600-1. [3] LAVE CJ, THOMAS MA, FONDAK AA. The perioperative management of the patient with pemphigus vulgaris and villous adenoma. Cutis 1984; 34: 180-2. [4] VATASHKY E, ARONSON JB. Pemphigus vulgaris: anaesthesia in the traumatised patient. Anaesthesia 1982; 37: 1195-7. [5] DRENGER B, ZIDENBAUM M, REIFEN E, LEITERSDORF E. Severe upper airway obstruction and difficult intubation in cicatricial pemphigoid. Anaesthesia 1986; 41: 1029-31. KK, CHENL. Anesthetic management of a patient with [6] PRASAD bullous phemphigoid. Anesthesia Analgesia 1989; 69 537-40.
Major incident plans As part of our departmental audit we have recently carried out a survey of junior staff awareness of the local major incident plan (MIP) and of their degree of training in disaster medicine. This survey is particularly pertinent as the Association of Anaesthetists in their most recent report have discussed this issue and made recommendations for training [I]. Our survey included junior anaesthetic, surgical, medical and Accident and Emergency (A & E) staff of SHO level and above (32 in total). Only 69% of junior staff were aware that the Health District did have a MIP, but only 19% had ever seen a copy of the plan, or the section relevant to their specific role within it. No junior staff had
been circulated with any literature relating to the MIP. The superficial high level of awareness of the MIP was related to a conspicuous poster campaign within the A & E department. Only 34% of junior staff had ever received any training period to familiarise them with major incident planning and of these only the A & E officers had received some training in this Health District. Our survey also revealed that 31% of junior staff had been involved in either real or simulated major incident alerts. Of these, half were involved with simulated alerts, but the majority of these were carried out whilst working abroad. Only 6% of staff had been involved in MIP training exercises in this country. Although costly, annual full scale
Correspondence
have requested the services of a primary system. This is equivalent to using an accident and emergency department for an intensive care patient. It is not the first such report that we have received. We are deeply concerned that helicopter operators are attempting to set up medical helicopter systems with inadequate input from the medical profession. The resultant schemes, frequently under pressure to fly as much as possible to justify their costs, may attempt to undertake secondary transfers with staff and equipment designed for a totally different purpose, and, as witnessed by Dr Smith,
fall short of the standards we have tried to set for secondary transfers. St Bartholornew’s Hospital, London E C l A 7BE
H.A.L. VYVYAN S . KEE A. BRISTOW
Reference [I] Medical helicopter systems - recommended minimum standards for patient management. Report of a working party. Journal of the Royal Society of Medicine 1991; 84: 2 4 2 4 .
Regional anaesthesia in pemphigus vulgaris Pemphigus comprises a group of mucocutaneous diseases characterized by bullous eruptions of the skin and mucous membranes and is probably of autoimmune aetiology [I]. Pemphigus vulgaris is the most common form of pemphigus. It is characterized by impaired cell adhesion within the epidermis leading to the formation of intraepidermal blisters [I]. Whereas there is extensive literature on the anaesthetic management of epidermolysis bullosa, there are few reports of anaesthesia in pemphigus [2-51. A 46-year-old white female with abnormal uterine bleeding, was admitted for abdominal hysterectomy and bilateral salpingo-oophorectomy. Eight years previously she had been diagnosed as suffering from pemphigus vulgaris. There was no associated internal malignancy. She was receiving prednisone 10 mg and azathioprine 100 mg daily. Physical examination revealed painful bullous formations in the mouth and oropharynx. Except for an iron deficiency anaemia, laboratory tests, chest X ray and electrocardiogram were within normal limits. Immunofluorescence showed IgG and C3 a t the epidermal junction. Hydrocortisone (100 mg intravenously) was given pre-operatively and during surgery. A continuous catheter spinal anaesthesia was the anaesthetic technique selected. A 25-gauge spinal needle was inserted easily at the L2-, interspace and a 32 gauge microspinal catheter passed. The initial injection of 3 ml of plain bupivacaine 0.5% resulted in a T, level of sensory blockade bilaterally. No additional doses were necessary. At the same time, an epidural catheter was inserted a t the L,, interspace. The intra-operative surgical and anaesthetic courses were uneventful. At the end of the operation the spinal catheter was removed. There were no lesions at the site of spinal needle puncture, blood pressure cuff, intravenous cannulation, or oxygen mask application (the face had been pretreated with vaseline gel). There were no lesions a t any of the pressure points that had been in contact with the operating room table. In the recovery room and in the gynaecology ward 10ml of plain
bupivacaine 0.125% and 1 mg of morphine were administrated for pain control. The patient was discharged from the hospital on the 6th postoperative day. The lesions of both pemphigus and pemphigoid resemble those of epidermolysis bullosa, and the anaesthetic management is probably the same, airway management being the primary concern [I]. Continuous thoracic epidural anaesthesia supplemented with intravenous ketamine has been used for cholecystectomy in a patient with buccal pemphigus [2]; a slow intravenous infusion of ketamine and epidural anaesthesia has been used for the removal of a rectal tumour [3]; continuous spinal anaesthesia has been used in undergoing radical vulvectomy [6]. This case illustrates how useful regional anaesthesia can be in providing satisfactory anaesthesia and postoperative pain control. Hospital de la Princessa. Madrid, Spain
F. GILSANZ M.L. MEILAN
R. Ross G. OLIVERA
References [I] SMITHGB, SHRIBMAN AJ. Anaesthesia and severe skin disease. Anaesthesia 1984; 39 443-55. [2] JEYARAMC, TORDA TA. Anesthetic management of cholecystectomy in a patient with buccal pemphigus. Anesthesiology 1974; 40: 600-1. [3] LAVE CJ, THOMAS MA, FONDAK AA. The perioperative management of the patient with pemphigus vulgaris and villous adenoma. Cutis 1984; 34: 180-2. [4] VATASHKY E, ARONSON JB. Pemphigus vulgaris: anaesthesia in the traumatised patient. Anaesthesia 1982; 37: 1195-7. [5] DRENGER B, ZIDENBAUM M, REIFEN E, LEITERSDORF E. Severe upper airway obstruction and difficult intubation in cicatricial pemphigoid. Anaesthesia 1986; 41: 1029-31. KK, CHENL. Anesthetic management of a patient with [6] PRASAD bullous phemphigoid. Anesthesia Analgesia 1989; 69 537-40.
Major incident plans As part of our departmental audit we have recently carried out a survey of junior staff awareness of the local major incident plan (MIP) and of their degree of training in disaster medicine. This survey is particularly pertinent as the Association of Anaesthetists in their most recent report have discussed this issue and made recommendations for training [I]. Our survey included junior anaesthetic, surgical, medical and Accident and Emergency (A & E) staff of SHO level and above (32 in total). Only 69% of junior staff were aware that the Health District did have a MIP, but only 19% had ever seen a copy of the plan, or the section relevant to their specific role within it. No junior staff had
been circulated with any literature relating to the MIP. The superficial high level of awareness of the MIP was related to a conspicuous poster campaign within the A & E department. Only 34% of junior staff had ever received any training period to familiarise them with major incident planning and of these only the A & E officers had received some training in this Health District. Our survey also revealed that 31% of junior staff had been involved in either real or simulated major incident alerts. Of these, half were involved with simulated alerts, but the majority of these were carried out whilst working abroad. Only 6% of staff had been involved in MIP training exercises in this country. Although costly, annual full scale
