380
GUILLAIN, BARRE .... AND STROHL? SIR,-Like you (July 29, p. 243) I used to wonder, when studying the early work on Guillain-Barré syndrome, why the name of Strohl was dropped from the eponym. I asked a French physician for enlightenment, but he only shrugged his shoulders and said "Strohl was from Alsace". Perhaps the "historical callousness" suggested was not the only explanation. On the other hand the exclusion of Landry’s name is surely logical. Guillain, Barre, and Strohl defined their syndrome partly on the cerebrospinal-fluid findings, using an investigation, lumbar puncture, not available to Landry, and adding an objective, if imperfect, diagnostic criterion. Moreover Landry’s syndrome was at that time regarded as usually fatal, while Guillain held that his cases always recovered. Not until the Brussels symposium of 1938,1 22 years after the original publication, did he admit the possibility of death in these somewhat grudging terms "On a pu cependant voir exceptionellement des cas de mort dans la varicelle; ceux-ci ne sont pas suffisante pour modifier le prognostic classique de la maladie. 11 me parait etre le meme pour notre syndrome." It is hard to say now what Landry’s cases really were, and clarity rather than callousness suggests the omission of his ’
PARADOXICAL CHANGES IN SERUM-POTASSIUM DURING CARDIOPULMONARY BYPASS IN ASSOCIATION WITH NON-CARDIOSELECTIVE BETA BLOCKADE
SIR,-We have observed a spontaneous rise in serum-potassium of 2.6 mmol/1 during cardiopulmonary bypass in a patient who had been on propranolol for angina pectoris before coronary-artery surgery. After coronary-artery grafts had been completed an attempt was made to discontinue bypass, but myocardial function was inadequate. At this time the serumpotassium was 7 mmol/1. After the administration of 15 g dextrose, 6 !.U. insulin, and 1 mmol calcium chloride and with 10 min of additional bypass the myocardium functioned well with inotropic support (isoprenaline 1.0 p.g/min). 10 min after discontinuation of the bypass the serum-potassium was 6.2 mmol/1, and it fell over the next 2 h to below the prebypass level of 4.4 mmol. After this incident the records of 45 con-
name.
Manor
House, Wolferton, King’s Lynn, Norfolk PE31 6HA
C. P. PETCH
ZINC CONTENT OF AMINOACID SOLUTIONS
SIR,-Dr Van Caillie and colleagues (July 22, p. 200) have drawn attention to the requirement of patients for zinc supplements even during short periods of parenteral nutrition, especially patients with a gastrointestinal fistula. They showed that the mean zinc content of one brand of aminoacid solution (’Vamin’ series) was 9.9 (range 1.5-15.6) mol/1. Assuming that about 1 1 of this solution is given daily, this represents only about a quarter of the normal daily requirement. Though it is possible to add zinc supplements to a regimen on an ad-hoc basis for those patients whose plasma-zinc becomes low, we recommend commercially prepared zinc-containing solutions for three reasons: it is disadvantageous for a patient to wait for clinical or laboratory evidence of deficiency; adding to nutrient solutions on the ward raises the risk of sepsis ; and it is possible for ad-hoc prescribing to lead to lethal overdose.2 rational to give a standard daily zinc supplement and we use a dextrose solution containing trace metals developed in collaboration with Travenol Laboratories Ltd. ’Electrolyte Solution A’ contains 20% weight/volume dextrose, zinc (40 mol), calcium (7-5 mmol), and magnesium (9-0 mmol) per 500 ml bottle. We gave this solution to 76 surgical patients who needed parenteral nutrition and found zinc supplements necessary in only one instance. The same idea has been applied to the provision of available phosphate. Although some aminoacid solutions contain adequate amounts of this radical, ’Electrolyte Solution B’ is available : this contains dextrose (20% weight/volume), phosphate (30 mmol), and potassium (30 mmol) per 500 ml bottle. This approach may be appropriate for other trace elements such as copper and selenium. However, the case for the addition of these trace metals during short-term or medium-term parenteral nutrition is as yet less strong. It
seems more
Surgical Unit, St. Mary’s Hospital Medical School, London W2
1. 2.
Guillain, G.J. belge Neurol. Psychiat. 1938, 38, 322. Brock, A., Reid, H., Glazer, G. Br. med. J. 1977,i, 1390.
B. W. ELLIS L. P. FIELDING H. A. F. DUDLEY
Change in serum-potassium (rnrnoL4) before potassium patients on cardiopulmonary bypass.
in
Mean+2 S.E.M.
secutive patients were examined to determine the influence of preoperative treatment on serum-potassium during standard cardiopulmonary bypass. 16 patients had been treated with j3 blockers (12 propranolol, 4 oxprenolol) until the evening before operation (group 1); 18 had been treated with digitalis and diuretics until 48 h before surgery (group 2); and group 3 contained 11 patients who were not receiving drugs before operation. Anaesthesia, fluid therapy, priming of the heart-lung machine, and cardioplegic arrest were managed according to a strict protocol, including inhalational induction of anaesthesia, avoidance of respiratory alkalosis, and profound myocardial hypothermia using a recirculating technique. There were no significant differences in fluid or electrolyte administration to the patients in the three groups. None of the patients received stored blood before or during cardiopulmonary bypass, and there were no significant differences in the serum-potassium level before bypass or in the blood gas and acid-base determininations before and during bypass. The last serum-potassium measurement before potassium supplements were given was compared with the prebypass level (see figure). The serum-potassium fell in patients treated before operation with digitalis and diuretics (mean fall 0.51 mmol/1) and in patients not receiving any drugs (mean fall 0.21 mmol/1), confirming other reports of serum-potassium
381
changes during cardiopulmonary bypass.’ However, the serum-potassium rose in patients on -blocking drugs by 0-92 mmol/1. The difference between group 1 and groups 2 and 3 is significant (p
GUILLAIN, BARRE .... AND STROHL? SIR,-Like you (July 29, p. 243) I used to wonder, when studying the early work on Guillain-Barré syndrome, why the name of Strohl was dropped from the eponym. I asked a French physician for enlightenment, but he only shrugged his shoulders and said "Strohl was from Alsace". Perhaps the "historical callousness" suggested was not the only explanation. On the other hand the exclusion of Landry’s name is surely logical. Guillain, Barre, and Strohl defined their syndrome partly on the cerebrospinal-fluid findings, using an investigation, lumbar puncture, not available to Landry, and adding an objective, if imperfect, diagnostic criterion. Moreover Landry’s syndrome was at that time regarded as usually fatal, while Guillain held that his cases always recovered. Not until the Brussels symposium of 1938,1 22 years after the original publication, did he admit the possibility of death in these somewhat grudging terms "On a pu cependant voir exceptionellement des cas de mort dans la varicelle; ceux-ci ne sont pas suffisante pour modifier le prognostic classique de la maladie. 11 me parait etre le meme pour notre syndrome." It is hard to say now what Landry’s cases really were, and clarity rather than callousness suggests the omission of his ’
PARADOXICAL CHANGES IN SERUM-POTASSIUM DURING CARDIOPULMONARY BYPASS IN ASSOCIATION WITH NON-CARDIOSELECTIVE BETA BLOCKADE
SIR,-We have observed a spontaneous rise in serum-potassium of 2.6 mmol/1 during cardiopulmonary bypass in a patient who had been on propranolol for angina pectoris before coronary-artery surgery. After coronary-artery grafts had been completed an attempt was made to discontinue bypass, but myocardial function was inadequate. At this time the serumpotassium was 7 mmol/1. After the administration of 15 g dextrose, 6 !.U. insulin, and 1 mmol calcium chloride and with 10 min of additional bypass the myocardium functioned well with inotropic support (isoprenaline 1.0 p.g/min). 10 min after discontinuation of the bypass the serum-potassium was 6.2 mmol/1, and it fell over the next 2 h to below the prebypass level of 4.4 mmol. After this incident the records of 45 con-
name.
Manor
House, Wolferton, King’s Lynn, Norfolk PE31 6HA
C. P. PETCH
ZINC CONTENT OF AMINOACID SOLUTIONS
SIR,-Dr Van Caillie and colleagues (July 22, p. 200) have drawn attention to the requirement of patients for zinc supplements even during short periods of parenteral nutrition, especially patients with a gastrointestinal fistula. They showed that the mean zinc content of one brand of aminoacid solution (’Vamin’ series) was 9.9 (range 1.5-15.6) mol/1. Assuming that about 1 1 of this solution is given daily, this represents only about a quarter of the normal daily requirement. Though it is possible to add zinc supplements to a regimen on an ad-hoc basis for those patients whose plasma-zinc becomes low, we recommend commercially prepared zinc-containing solutions for three reasons: it is disadvantageous for a patient to wait for clinical or laboratory evidence of deficiency; adding to nutrient solutions on the ward raises the risk of sepsis ; and it is possible for ad-hoc prescribing to lead to lethal overdose.2 rational to give a standard daily zinc supplement and we use a dextrose solution containing trace metals developed in collaboration with Travenol Laboratories Ltd. ’Electrolyte Solution A’ contains 20% weight/volume dextrose, zinc (40 mol), calcium (7-5 mmol), and magnesium (9-0 mmol) per 500 ml bottle. We gave this solution to 76 surgical patients who needed parenteral nutrition and found zinc supplements necessary in only one instance. The same idea has been applied to the provision of available phosphate. Although some aminoacid solutions contain adequate amounts of this radical, ’Electrolyte Solution B’ is available : this contains dextrose (20% weight/volume), phosphate (30 mmol), and potassium (30 mmol) per 500 ml bottle. This approach may be appropriate for other trace elements such as copper and selenium. However, the case for the addition of these trace metals during short-term or medium-term parenteral nutrition is as yet less strong. It
seems more
Surgical Unit, St. Mary’s Hospital Medical School, London W2
1. 2.
Guillain, G.J. belge Neurol. Psychiat. 1938, 38, 322. Brock, A., Reid, H., Glazer, G. Br. med. J. 1977,i, 1390.
B. W. ELLIS L. P. FIELDING H. A. F. DUDLEY
Change in serum-potassium (rnrnoL4) before potassium patients on cardiopulmonary bypass.
in
Mean+2 S.E.M.
secutive patients were examined to determine the influence of preoperative treatment on serum-potassium during standard cardiopulmonary bypass. 16 patients had been treated with j3 blockers (12 propranolol, 4 oxprenolol) until the evening before operation (group 1); 18 had been treated with digitalis and diuretics until 48 h before surgery (group 2); and group 3 contained 11 patients who were not receiving drugs before operation. Anaesthesia, fluid therapy, priming of the heart-lung machine, and cardioplegic arrest were managed according to a strict protocol, including inhalational induction of anaesthesia, avoidance of respiratory alkalosis, and profound myocardial hypothermia using a recirculating technique. There were no significant differences in fluid or electrolyte administration to the patients in the three groups. None of the patients received stored blood before or during cardiopulmonary bypass, and there were no significant differences in the serum-potassium level before bypass or in the blood gas and acid-base determininations before and during bypass. The last serum-potassium measurement before potassium supplements were given was compared with the prebypass level (see figure). The serum-potassium fell in patients treated before operation with digitalis and diuretics (mean fall 0.51 mmol/1) and in patients not receiving any drugs (mean fall 0.21 mmol/1), confirming other reports of serum-potassium
381
changes during cardiopulmonary bypass.’ However, the serum-potassium rose in patients on -blocking drugs by 0-92 mmol/1. The difference between group 1 and groups 2 and 3 is significant (p
