568
Operator and assistant positions during cardiac catheterisation via femoral (left) and brachial (right)
The radiation dose to the operator averaged 20-6 pSv per case of
cardiac catheterisation via the femoral approach, and 55-7(iSv when
the brachial approach was used (p < 0-0001). The 99% confidence
interval for the difference of 35-1 J..lSV was 25-9-44-3 )iSv. Figures
for the assistant nurse were, respectively, 6-3 )iSv and 12-8 )iSv, and
the 99% confidence interval for the difference of 6-5 (iSv was
3-4-9-6 pSv.
The radiation doses given here are high because we included
many cases with very long screening times. In our hospital cardiac
catheterisations via the femoral approach outnumber those via the
brachial approach by about9 to 1, and the arm route is used for
investigation of more complex valvular disease. This ratio is not
reflected in the selected series discussed here (table). How much of
the greater radiation dose during catheterisation via the brachial
approach is due to the greater proximity of the operators to the
radiation source and how much is due to the lack of a protective
shield is uncertain. A new catheterisation laboratory was installed in
our hospital after the above study period, and this has a screen that
can be used for both methods of cardiac catheterisation. Preliminary
data suggest no significant difference between the radiation doses
(30Sv with the femoral approach [n = 20], 45Sv with the
brachial [n = 22]; 99% confidence interval for 15 )iSv difference
- 16-4 to 46-4p.Sv). We recommend the use of radiation protection
shields suited to catheterisation via the brachial approach.
We thank Mrs Anne Allington, Mrs Ann Dixon-Brown, and Sister Belinda
Boulton for their assistance.
Department of Cardiovascular Medicine, A. PIPILIS
University of Oxford, O. ORMEROD
John Radcliffe Hospital,
Oxford OX3 9DU, UK L. B. TAN
1. Jeans SP, Faulkner K, Love HG, Bardsley RA. An investigation of the radiation dose
to staff during cardiac radiological studies. Br J Radiol 1985; 58: 419-28.
Right-to-left shunt and neurological
decompression sickness in divers
SiR,&mdash;Moon and Wilmshurst2 and their colleagues have
demonstrated, with contrast echocardiography, a high frequency
of right-to-left shunt in divers who have had neurological
decompression sickness (DCS). This shunt has been presumed to
be due to a patent foramen ovale. There are no firm guidelines (only
much discussion and controversy) on the further management of
divers who prove to have a shunt. Because of these studies1.2we now
routinely screen all divers who present to our hyperbaric unit with
neurological DCS for evidence of a right-to-left shunt. We here
report our results.
Since October, 1989, we have examined 17 male and 2 female
divers (mean age 31-4 years, range 22-52) who presented to our
hyperbaric unit with neurological DCS; 7 were recreational and 12
were professional divers. 9 of these 19 divers had had previous
neurological DCS. Echocardiographic studies were done with a
routes.
’Vingmed CFM 700’ imaging system. Microbubbles were
generated in 8-10 ml normal saline or 5% dextrose by the
two-syringe and three-way tap methodand were injected rapidly
via a 19-gauge butterfly needle in the dorsum of the hand.
Initially, up to three injections were given with the subject
breathing quietly and normally. If no shunt was demonstrated, up
to another three injections were given with the subject performing a
Valsalva manoeuvre. If any bubbles were seen in the left heart, no
further injections were given. A result was judged positive if any
bubbles were seen in the left heart. We made no attempt to quantify
the size of the shunt. All the studies were recorded on videotape and
subsequently re-analysed: no new shunts were identified.
In this series of 19 patients, 6 proved to have a right-to-left shunt.
3 of these 6 had had neurological DCS. The incidence of
right-to-left shunt was 31-6% (95% confidence intervals,
126-565%). The 32% frequency that Wilmshurst found in his
control group of 63 divers who had not had DCS is within this
range, as is the 18% reported in a healthy population of 76
non-divers also investigated by this method.4 Our findings are at
variance with the 66 % frequency of shunt found by Wilmshurst in
29 divers with neurological DCS (chi-squared test, p < 005).
Our findings do not support the hypothesis that a shunt
demonstrated in this way predisposes divers to neurological DCS.
We suggest that recommendations on the management of divers
with such a shunt should be delayed until there is conclusive
evidence. A further large controlled study is indicated, which we
propose to do.
Department of Cardiology, STEPHEN J. CROSS
Aberdeen Royal Infirmary,
LESLEY F. THOMSON
Aberdeen AB9 2ZD, UK;
and Hyperbaric Medicine Unit, KEVIN P. JENNINGS
Aberdeen Royal Infirmary THOMAS G. SHIELDS
1. Moon RE, Camporesi EM, Kisslo JA. Patent foramen ovale and decompression
sickness in divers. Lancet 1989; i: 513-14
2. Wilmshurst PT, Byme JC, Webb-Peploe JC. Relation between interatrial shunts and
decompression sickness in divers. Lancet 1989; ii: 1302-05.
3. Lechat PH, Mas JL, Lascault G, et al Prevalence of patent foramen ovale in patients
with stroke. N Engl JMed 1988; 318: 1148-52.
4. Lynch JJ, Schuchard GH, Gross CM, Warm LS. Prevalence of right to left atrial
shunting in a healthy population: detection by Valsalva manoeuvre contrast
echocardiography. Am J Cardiol 1984; 53: 1478-80.
Antibiotics for marine vibrios
SIR,-Your editorial (July 28, p 215) notes that most Vibrio species
are sensitive to chloramphenicol, gentamicin, and tetracycline, and
suggests that the quinolones should be evaluated. We tested 244
marine vibrios (18 V vulnificus) from nine different species against
23 antibiotics, including the quinolones ofloxacin, norfloxacin,
enoxacin, pefloxacin, and ciprofloxacin.’ Ciprofloxacin was the
most active, and only 1 isolate (a 1 parahaemolyticus) was resistant
to 1 mg/1. Almost all strains were also sensitive to chloramphenicol,
tetracycline, gentamicin, amikacin, cefotaxime, ceftazidime,
 569

aztreonam, and imipenem. However, a few isolates of some species, RESULTS OF NEONATAL INTENSIVE CARE UNIT QUESTIONNAIRE
especially Vparahaemolyticus and Valginolyticus, showed unusual
and multiple resistance to some of these drugs, including resistance
to chloramphenicol and tetracycline. 1 of the Vvulnificus strains was
resistant to cefotaxime and 4 to aztreonam.
Halophilic vibrios grew poorly or not at all on sensitivity-testing
media incubated at 37&deg;C without the addition of salt, but inocula of
10 colony-forming units grow well on unsupplemented Mueller-
Hinton agar incubated at 30&deg;C. Since these are unusual test
conditions it is important to include Vibrio controls. We have
published results for USA and UK standard strains to aid
inter-laboratory comparisons.1
V vulnificus is the most common cause of fatal spreading
necrotising lesions among the vibrios,2,3 but they have also been seen
with V parahaemolyticus, V alginolyticus, and V damsela.3-f> Your
editorial notes that adequate surgical debridement is important for
soft tissue infections and we would strongly endorse this. No
antibiotic will penetrate dead tissue and in these life-threatening
conditions emergency debridement or amputation is essential.
Blind therapy with reliable systemic drugs is also required, and, on
the basis of our results and anecdotal clinical experience, the
aminoglycosides, ceftazidime, imipenem, or the quinolones should
be effective.
Department of Microbiology,
United Medical and Dental Schools,
Guy’s Hospital,
London SE1 7RT, UK G. L. FRENCH
1. French GL, Woo ML, Hui YW, Chan KY. Antimicrobial susceptibilities of
halophilic vibrios. J Antimicrob Chemother 1989; 24: 183-94.
2. Woo ML, Patrick WGD, Simon MTP, French GL. Necrotising fasciitis caused by
Vibrio vulnificus. J Clin Pathol 1984; 37: 1301-04.
3. Howard RJ, Pessa ME, Brennaman BH, Ramphal R. Necrotizing soft-tissue important is the comfort that can be given by non-pharmacological
infections caused by marine vibrios. Surgery 1985; 98: 126-30. measures,though these cannot deal adequately with intense pain
4. Johnson DE, Weinberg L, Ciarkowski J, West P, Colewell RR. Wound infection
from traumatic procedures. The results from the fmal question in
caused by Kanagawa-negative Vibrio parahaemolyticus. J Clin Microbiol 1984; 20:
811-12. our survey point towards poor pain assessment. It is likely that
5. Bonner JR, Coker AS, Berryman CR, Pollack HM. Spectrum of vibno infections in a improved training can overcome this problem. Finally, we should
Gulf Coast community. Ann Intern Med 1983; 99: 464-69. recall that the Latin infans, from which the word infant derives,
6. Coffey JA, Hams RL, Rutledge MJ, Bradshaw MW, Williams TW. Vibrio damsela:
means speechless, and strive to ensure that babies in our care do not
another potentially virulent marine vibrio J Infect Dis 1986; 153: 800-01.
suffer.
Pain relief in neonatal intensive care This study was undertaken as a research project during the neonatal intensive
care course at the National Maternity Hospital, Dublin. We would like to
SIR,-We believe that the need for pain relief in sick babies has been thank the staff of the neonatal units in the Republic of Ireland and UK who
insufficiently recognised.l,2 This is despite the fact that it is generally made this study possible.
accepted that babies feel pain as much as older children or adults.3,4 National Maternity Hospital, JANE TOHILL
To assess pain relief practice in neonatal intensive care units we
Hollis Street, Dublin, Ireland OLIVE MCMORROW
sent questionnaires to 21 units in the UK and Ireland. The
1. Owens ME. Pain in infancy. Conceptual and methodological issues. Pain 1984; 20:
questionnaire was addressed to the "Sister in charge of the unit", 213-30.
who was asked to discuss it with all staff. Results from the 17 2. Owens ME, Todd EM. Pain in infancy. Neo-natal reaction to heel lance. Pain 1984;
questionnaires returned are shown in the table. 20: 77-86.
It appears that while all units in this survey accept that babies 3. Hatch DJ. Analgesia in the neonate. Br Med J 1987; 294: 920.
4. Bray RJ. Management of preoperative pain. Child Hosp Up-date 1988; May: 1565-72.
experience pain, alleviation of pain is given a low priority. Policies 5. Allingham L. Pain in the neonate. Midwives Chronicle 1989; Feb: 54-56.
for pain relief are poorly defined, only 2 units having a written
policy. In 75% or more of cases no analgesia was given for Growth and nutrition in children with
necrotising enterocolitis and meningitis. There was a strong feeling
that analgesia is underprescribed by doctors and a significant cerebral palsy
minority felt that, even when prescribed, analgesics are SiR,&mdash;Your May 26 editorial prompted us to look more closely at
underadministered by nurses. our data on a total population (n 897) of low-birthweight infants
=

We feel that doctors and nurses should translate their awareness
of pain in the newborn into concrete procedures for alleviation. The
nurse delegated to care for the baby has an important role in looking
for behavioural manifestations of distress. These are important
observations and should not be dismissed by other staff making
casual observations. There should be a written policy on every
neonatal unit with regard to pain relief otherwise it will frequently
not be administered. Doctors should not underprescribe and nurses
should not be afraid to administer. While the provision of adequate
analgesia may cause problems (eg, apnoea and abolition of helpful
clinical signs), this should not preclude its use when warranted.
After receiving a narcotic, babies should be observed closely, and a
narcotic antagonist and oxygen should be near at hand. Traumatic
procedures should not be undertaken without the use of analgesia,
except in dire emergencies; for example, the chest wall should be
infiltrated with lignocaine before insertion of a drain. Greater use
can be made of local anaesthetic sprays and creams. Equally
(less than 1750 g) born in Scotland in 1984.’ Of the surviving cohort,
611 (96%) have been reviewed at the age of 4i years, with Amiel
Tison and Stewart’s2 standardised neuromotor assessment, and
including measures of growth and cognitive function which will be
reported in full shortly.
The distributions of height, head circumference, and, in
particular, weight centiles showed pronounced shifts to the left; the
distribution of weight centiles was related to birthweight (figure).
Patients were classified in three groups according to neuromotor
impairment: those with neuromotor signs only; those with a
moderate disability; and those with severe disability. Among the
children whose motor deficit was accompanied by severe disability
there was a U-shaped distribution in head circumference; the
distribution of height showed a striking shift to the left, and more
than 30% were below the 3rd centile. There was a slight shift to the
left in weight, with no children at or above the 90th centile at 4z
years (figure).