CORRESPONDENCE
Darwin’s work should stay firmly in
the realm of scientific mechanisms.
A G Johnson
Academic Surgical Unit, Floor K, Royal
Hallamshire Hospital, Sheffield S10 2JF, UK
1 Radcliffe Richards J. Darwin the
philosopher? Lancet 2001; 358: 1118.
Risk of deliberately
induced anthrax outbreak
Sir—Dlawer Ala’Aldeen seems
confused in his Oct 27 commentary1
about treaties controlling chemical and
biological weapons. There are separate
treaties for each category.
The Chemical Weapons Convention
(CWC) of 1993, includes a verification
protocol that is fully implemented,2
and destruction of chemical weapons is
proceeding. This process is slow for
obvious reasons of safety, and the
economic difficulties of Russia are
causing further delay.
The 1972 Biological and Toxin
Weapons Convention (BTWC) bans
the manufacture and use of biological
weapons. The BTWC was indeed
breached by Iraq, but the CWC did
not exist at the time of the Gulf war.
The use of chemical weapons against
the Kurds was illegal under the 1927
Geneva Convention, but this
Convention did not ban possession. As
Ala’Aldeen states, the BTWC has no
verification protocol. One was to have
been agreed at the review conference,
Nov 17–Dec 9, 2001, but was rejected
by the US government. This rejection
is said to be on the (contradictory?)
grounds that the protocol will be
ineffective and that it will affect the
commercial confidentiality of the US
biotechnology industry.
US research itself has been
described, however, as testing the
limits of the BTWC.3 If a verification
protocol were in force, and it was
thought that the recent anthrax
outbreak in the USA was the
responsibility of another state party, a
challenge inspection could have been
called for. Attempts are being made
after the review conference to save the
BTWC from collapse,2 but the
effectiveness of the convention in
preventing biowarfare is likely to be
reduced for some time.
Douglas Holdstock
Medact, London N19 4DJ, UK
1 Ala’Aldeen D. Risk of deliberately induced
anthrax outbreak. Lancet 2001; 358:
1386–88.
2 Heap B. Scientists against biological
weapons. Science 2001; 294: 1417.
3 Ashraf H. US biological defence research
under the spotlight. Lancet 2001; 358: 895.
532
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Monitored anaesthesia in
elderly ophthalmic patients
Sir—Monitored anaesthesia care
(MAC) is frequently used in ophthalmic
surgery. Most patients are elderly and
have varying degrees of coexisting
medical illnesses. We present a few
practical difficulties and their possible
solutions in such patients that have
received little attention.
There are several difficulties with
sedation in the operating room. Timing
of sedation is important; it should
always be given after the completion of
the local block, since the surgeon needs
cooperation of the patient while doing
the block, such as, looking ahead
towards a fixed point in the ceiling to
keep the eyes in neutral position.
Sedation should be titrated carefully,
taking into account the patient’s age,
weight, associated systemic illnesses,
and the duration of the procedure.1 It is
better to start with smaller dose that can
be repeated if required. There is a thin
line between conscious sedation and
undesired deep sedation. The latter
sometimes occurs because of
oversedation; we discourage attempts to
compensate for partially effective blocks.
Most of the elderly patients go to
sleep immediately after administration
of sedatives and start snoring, which can
lead to stopping of respiratory effort.
Snoring has two adverse features—
audible disturbance to the surgeon and,
more alarmingly, the tongue falling
backwards and leading to hypercarbia
and sympathetic activation,2 followed by
a startle reaction of sudden awakening
with vigorous head and upper body
movements. This phenomenon,
occurring during a critical surgical step,
especially under the microscope, can
have disastrous consequences.
Elderly men who are undergoing
longer procedures, such as, vitrectomy
may feel the urge to urinate because of a
full bladder or increased frequency of
urine, which makes them anxious and
restless. The underlying disorder might
be the prostatic enlargement, com-
pounded by inadvertent excessive
intravenous fluid administration intra-
operatively, which is occasionally
required in such procedures. We had to
catheterise a patient intraoperatively to
make him comfortable and cooperative
so we could complete the procedure.
Patients should be asked to void
urine before surgery, and use of
intraoperative intravenous fluids should
be limited.
S K Malhotra, Amitabh Dutta, *Amod Gupta
Departments of Anaesthesia and Intensive Care,
and *Ophthalmology, Postgraduate Institute of
Medical Education and Research, Chandigarh
160012, India
(e-mail: drskmalhotra@yahoo.com)
THE LANCET • Vol 359 • February 9, 2002 • www.thelancet.com
1 Darling E. Practical consideration in sedating
the elderly. Crit Care Nurs Clin North Am
1997; 9: 371–80.
2 Somers VK, Mark AL, Zavala DC,
Abboud FM. Contrasting effects of hypoxia
and hypercapnia on ventilation and
sympathetic activity in humans. J Appl Physiol
1989; 67: 2101–06.
NHS: and the tap goes
drip, drip, drip
Sir—In an attempt to curtail costs
while delivering a comprehensive and
modern service to all, the UK National
Health Service (NHS) has relied on
organisations such as National
Institutes for Clinical Excellence and
the Commission for Health
Improvement to produce evidence-
based guidelines and monitor their
implementations. These guidelines
have been met with various degrees of
resistance and criticism. Although such
institutions may prove helpful in
maintaining the cost effectiveness of
health delivery in an organisation with
limited financial resources, we should
not forget that the NHS financial
burdens are not limited to drugs,
staffing, and medical equipment.
In our operating theatre we are
fortunate to have access to coffee and
tea. We noticed that the sink next to
the coffee and tea machines was
leaking, and had been for several
weeks, yet none of the 50 or more staff
who regularly use the facilities
(including us) had reported this leak.
We decided to measure the rate of
water loss before reporting it to the
appropriate department for repair.
Simply by use of a jug and our watches,
we calculated that the leak was
resulting in a 1000 L loss per day.
When we contacted our local water
provider, we were informed that supply
and drainage of such volume would
cost UK£1.94 (79 p for supply, 105 p
for drainage) per day. Thus the water
leak would have cost £708.10 for
1 year. We could assume that the leak
would not have continued for a year,
but leaking taps such as ours are
prevalent.
We have the equivalent of 57·2 full
time staff in the operating rooms, and
are hoping that the savings will be used
to provide every theatre staff with a
£10 book token so as to boost morale.
Paying attention to such details, and
repairing them in a timely fashion, may
be a financially rewarding exercise for
the NHS Trusts, and perhaps even the
staff.
*Ali Tavakkolizadeh, Hans Van Leenhoff
Department of Surgery, West Suffolk Hospital,
Bury St Edmunds, Suffolk IP33 2QZ, UK