Histamine release with vecuronium

The recent case report on the anaesthetic problems associated with diabetic gastroparesis (Anaesthesia 1984; 3 9 468-9) was interesting. There are a few points that may be of value which 1 would like to make. The presence of autonomic neuropathy markedly increases the risk to the diabetic patient during anaesthesia’ for reasons that remain obscure although cardiorespiratory arrest has been postulated. The presence of large amounts of gastric contents during anaesthesia is. as the authors point out, potentially lethal for the diabetic with gastroparesis. Drugs such as metoclopramide and domepridone* do not, in my experience, cause a significant reduction in the gastric residue, although 1 agree it is worth trying them in the elective patient. Extended pre-operative fasting may help the problem; but this does tend to be cumulative and prolonged reduction in fluid intake after 1800 hours on a daily basis has sometimes proved beneficial. If there is any doubt about the efficacy of treatments tried. it is important to use a nasogastric tube with regular aspiration, when the airway is unprotected. The patient mentioned was not insulin-dependent and the problems are compounded when this is the case. Autonomic neuropathy may also be manifest as hypoglycaemic unawareness due to loss of the usual protective reflexes. These patients may at the same time be brittle diabetics who will go into ketoacidosis very rapidly. Vomiting, for either of these reasons, and clouding of consciousness complicate this problem. Such diabetic patients should be well controlled before surgery is undertaken and great care should be taken to ensure that the control remains good throughout the surgical period. To achieve this, there should be close liaison between the anaesthetist, physician and surgeon.