Correspondence 5I I
BOC Madey Servoveat
Possible hazards
We wish to draw attention to faults in the Manley
Servovent Model MS Ventilator which we feel could,
under certain circumstances, be hazardous to patients
because it may deliver a significantly smaller tidal
volume than indicated.
A casual observation that the tidal volume scale
was reading 100 ml a t the end of the ‘inspiratory’
phase during ventilation of patients during anaesthesia
prompted investigation of the other 13 models of this
ventilator in use at our hospital. Initially it was found
that seven of them demonstrated this problem (range
5C200 ml); subsequently the fault has developed on
more of the ventilators. The malfunction was only
apparent when they were being used to ventilate
patients but not when disconnected and cycled to
atmosphere.
It also become evident during our investigation that
many of our ventilators delivered considerably less than
the preset tidal volume under a variety of conditions,
for reasons other than those stated above. This was
particularly so where compliances and flow resistances
were set to values which were worse than those noted
for a normal person, but, nevertheless, not disimilar
to those sometimes met during clinical practice. We
have measured tidal volumes <400 ml when the
ventilator was set to 700 ml. The internal compliance,
and to some extent the tension to which the driving
springs used within the ventilator are deliberately set,
to avoid an excessive ventilation pressure being
achieved, may account for a proportion of the dis-
crepancy noted. There was, however, a wide range
in the performance of the ventilators tested under
identical conditions; some of the ventilators delivered
tidal volumes within 10% of the preset figure.
A 25-year-old male presented for replacement of a
cranial bone flap, following full recovery from a head
injury several months previously. He was a well-
controlled epileptic on phenytoin (100 mg tds) and
was otherwise fit and well. He had no previous history
of asthma, was not atopic and was a non-smoker.
He was unpremedicated and a 21G butterfly needle
was inserted into a vein in the back of his hand.
Induction was with thiopentone (7 mg/kg) followed
by atracurium (0.5 mg/kg). His lungs were then hyper-
ventilated for 2 minutes with nitrous oxide and oxygen,
during which time his vocal cords and trachea were
sprayed with 5 ml of 4% lignocaine. A 9.0 nun latex
reinforced tracheal tube was then introduced.
It was immediately apparent that there was broncho-
spasm with bilateral wheezes, which resolved after 5
minutes with the introduction of 0.5% halothane. It
The variation, in part, would appear to be accounted
for by ‘wear and tear’ on various moving pivots witbin
the ventilator. Our ventilators had been in use less
than 3 years when these problems were first noted.
Service and maintenance has been according to the
manufacturer’s schedule. We are given to understand
that replacement of the worn parts will be expensive.
Following some discussion, BOC Medishield have
now defined certain tolerances to be met under varying
load conditions; unfortunately, no reasonable toler-
ances could be met for the zero mark on the ventilator
scale and it is to be removed.
This ventilator is assumed by many and stated by
Mushin’ to function normally as a volume-cycled
machine but, in our experience, there are many condi-
tions where this has not been the case, even including,
more recently, intermittent stalling of the ventilator.
The problems encountered when using this apparatus
demonstrate the importance of checking and testing
ventilators under the load conditions and at driving
pressures which may be found during clinical use. We
would be interested to hear of problems of a similar
nature that have been found by others using the Manley
Servovent .
University Department of S.L. SNOWDON
Anaesthesia, S.J. KING
P.O.Box 147.
Liverpool L69 3BX
Reference
1. MUSHIN ww, RENDELL-BAKERL,THOMPSON
Pw,MAPLE-
SON W. Auromaric Yenfilarion of the Lungs. 3rd cd.
Oxford: Blackwell Scientific Publications, 1982.
was also noted that the back of his hand was erythe-
matous with a wheal along the line of the vein which
was typical of drug-induced histamine release. His
cardiovascular system had remained stable with no
hypotension.
The question arises as to which of the drugs had
caused the release of histamine. since thiopentone,
lignocaine and atracurium have all been reported to
do so.
Therefore while the patient was still anaesthetised,
skin tests were performed on these drugs. Aliquots
of 0.1 ml atracurium (0.1 mg), thiopentone (2.5 mg)
and lignocaine (0.1 mg) were each injected intra-
dermally into the forearm skin, together with 0.1 ml
gallamine (4 mg), tubocurarine (1 mg) and a control
of normal saline. Within five minutes the atracurium
had produced a 2 cm wheal with a 6 cm flare, which
5 12 Correspondence
was still visible 45 minutes later. There was no reaction
to any of the other d r u g indicating that the patient
was specifically hypersensitive to atracurium. There
was no cross sensitivity with the other muscle relaxants,
gallamine and tubocurarine, both of which are known
to retease histamine readily. This result suggests that
the bronchospasm may also have been due to
atracurium.
The data sheet for atracurium reports that hypo-
tension due to histamine release may occur, but no
The operation of pharyngolaryngooesophagectomy
allied with the socalled 'stomach pull-up' has for many
ycars ban a main interest of this Hospital and some
100 patients have now been so treated. In 1971, I
described my earlier experience of the releated anaes-
thetic problems.' These have not changed. There are
some points on which I should like to take issue with
Dr Plaot ( A ~ ~ t l i e s1982;
i a 31.1211-3).
Pleural darnage was found in six patients for whom
I would again advocate routine bilateral pleural drain-
age. Happily, there w m no deaths. It would be helpful
to know if this statement refers to death in the operating
theatre, before discharge from hospital, or during
follow-up.
Thc danger of rupture of the trachea is alwayspresent
but ventilation with 100%oxygen will lead to awareness
and the method recommended seems to be a recipe
for surgicaIemphysema. No mention is made of electro-
cardiographic monitoring which is essential during the
mediaJtinal mobilisation. One presumes it is used.
The rcfmmcc to possible thyroid damage is mislead-
ing. Total thyroidectomy which includes the para-
thyroids should be performed and therefore special
attention nceds to be paid in the ensuing months to
calcium metabolism.2
This procedure has been carried out on 92 patients
in the academic unit at this hospital, with an operative
mortality in potantidy curable cases of 8.277 @FN
Harrison, p ~ o n acommunication).
l The clinical result
is aroUraging and it is the operation of choice in
patients with hypopharyngeal and postcricoid cancer.
Sucofiis howmr, demands an experienced team.
Reference
The Royal National Throat,Nose H.A. CONDON 1. Lmr 2, QONG GB. C t m T, LE J, Lm KH, WONGJ.
and Em Hosptal* Anaesthesia for operations for carcinoma of the esophagus.
Gray's lnn R o d ,
L u n h WCIX8DA.
mention is made of bronchospasm.
Atracurium has advantages over existing muscle
relaxants, Hoffman degradation and non-accumula-
tive properties and may well become increasingly
popular. However, in susceptible patients, is it possible
that bronchospasm may prove to be a problem?
Department of Anaeslhesia. J.P. SALE
The Royal Free Hospital,
Hampstead, London N W3
The contribution by Dr Plant (Anaesthesia 1982; 37:
1211-3) is interesting and informative. The visit to
Hong Kong by the author and her surgeon (Miss
Mannell) is well remembered. They deserve high praise
for achieving a 100% survival rate in all of their ten
patients.
In some parts of China and South East Asia,
including Hong Kong, the prevalence of carcinoma
of the oesophagus is quite high. In the Department
of Surgery, University of Hong Kong out of 142000
patients admitted between the years 1964-1980, 1800
had carcinoma of the oesophagus. Of these, 162 were
in the hypopharynx and cervical oesophagus and were
treated by a type of operation similar to the one
described. The remaining 1638 had lesions in other
parts of the oesophagus and all 1800 had surgical and
anaesthetic management which has been reported else-
where.' In some centres (including Hong Kong) the
surgeons do not like a preliminary tracheostomy which
interferes with the dissection in the neck unless it is
absolutely unavoidable. Therefore tracheal intubation
is always attempted, mostly under topical analgesia.
This procedure may be quite difficult at times and
while some anaesthetists are skilled in 'blind' naso-
tracheal intubation, others may prefer t o use an
intubating flexible fibreoptic laryngoscope.
Department of Surgery, 2. LETT
University of Hong Kong.
Queen Mary Hospital,
Hong Kong
InIernational Surgery 1982; 6'1: 129-34.
A reply
Thank you for the opportunity to discuss the points
raised by Dr Condon.
Since submission of my paper concerning Anaes-
thesia for pharyngolaryngo-oesophagectomy, a total
of 18 cases have now been performed at Baragwanath
Hospital. The mortality rate, which we d e h e as death
before discharge, has remained WL.