" / would have everie man write what he knowes and no more.

"—MONTAIGNE

BRITISH JOURNAL OF ANAESTHESIA

VOLUME 53, No. 5 MAY 1981

Whihu every effort u made by the publisher* and editorial committee to see that no inaccurate or misleading dau, opinion or statement appeari in tha Journal, they
wish to make it clear that the data and opinions appearing in the articles and advertisements herein are the responsibility of the contributor or advertiser concerned.
Accordingly, the publishers and the editorial committee and their respective employers, officer* and agents accept no liability whatsoever for the consequence* of any
*uch inaccurate or misleading data, opinion or statement Whilst every effort b made to ensure that drug doses and other quantities are presented accurately, readers
are advised that new methods and techniques involving drug usage, and described wirhin this Journal, should only be followed in conjunction with the drug
manufacturer's own published literature

EDITORIAL
ANTICHOLINERGIC PREMEDICATION AND REGURGITATION

The use of anticholinergic drugs for premedica-
tion in adults is controversial. Over the past
decade, their use has declined considerably, al-
though in a recent survey it was found that 62% of
anaesthetists in Great Britain still routinely pre-
scribed these drugs (Mirakhur et al., 1978), mainly
for the stated purpose of reducing secretions, both
salivary and bronchial. Although anticholinergic
actions were formerly of great importance, par-
ticularly when diethyl ether enjoyed a vogue, the
use of non-irritant volatile anaesthetic agents, and
a smooth unhurried approach to induction of
anaesthesia minimize problems induced by exces-
sive secretomotor activity. Moreover, it is well
recognized that the dry rnouth and paralysis of
ocular accommodation produced by atropine are
very unpleasant for the patient.
Another claimed advantage for anticholinergic
premedication is the protection this affords against
vagal overactivity, although the predominant re-
sponses of laryngoscopy, intubation and surgery
are sympathetic in origin rather than parasympa-
thetic (Prys-Roberts et al., 1971). Hyosdne has
been promoted for both its antiemetic and amnesic
properties, although there are more specific and
effective drugs available for both purposes. A
marked disadvantage is that it may produce rest-
lessness, especially in elderly patients.
There is, however, one situation in which there
is a good indication for the use of anticholinergic
drugs before endotracheal intubation: where re-
peated doses of suxamethonium are used. In the
1973-75 Confidential Enquiry into Maternal
Deaths there were two deaths attributed to "mis-
use of drugs". In both patients atropine was
avoided^ although in one instance tacrine was
administered in combination with suxa-
methonium, and in the second the relaxant was
used in repeated doses. Both patients developed
bradycardia which progressed to cardiac arrest.
The major anaesthesia-related cause of maternal
deaths has consistently been pulmonary aspiration
consequent upon vomiting or regurgitation. This
has stimulated interest among anaesthetists in a
structure termed the lower oesophageal sphincter.
This is an area at the lower end of the oesophagus
which is maintained at a higher resting pressure
than the intragastric pressure. Although it cannot
be denned anatomically, simple manometry allows
a description of its length and tone and it is
generally agreed that the sphincter plays a major
role in preventing gastro-oesophageal reflux
(Cohen and Harris, 1971). Other mechanisms
including the gastro-oesophageal angle, the oeso-
phago-phrenic ligament and the crura of the
diaphragm are now thought to play minor roles in
preventing gastro-oesophageal reflux. It is im-
portant to appreciate that it is not the tone of the
LOS itself which prevents reflux, but the pres-
sure difference between the stomach and the
oesophagus; this is termed the barrier pressure.
There is enormous variation in barrier pressures
in normal individuals. Although a correlation
between gastro—oesophageal reflux and decreased
barrier pressure has been reported (Haddad,
1970), there is considerable overlap between bar-
rier pressures of normal subjects and those of
patients with reflux. It is not possible, therefore, to
define a threshold of barrier pressure below which
reflux would occur in an individual patient. The
diagnosis of an incompetent sphincter can be made
only by using a pH electrode in the oesophagus to
monitor reflux of dilute acid placed in the stomach
and not by pressure manometry of the lower
446 EDITORIAL
oesophageal sphincter. Nonetheless, common
sense dictates that a reduction in barrier pressure is
likely to be associated with increased risk of reflux.
It seems prudent, therefore, to consider the effects
of anaesthetic drugs and techniques on lower
oesophageal sphincter function.
The anticholinergic drugs in standard anaesthe-
tic doses—atropine 0.6 mg i.v., hyoscine 0.4 mg
i.v. and glycopyrrolate 0.3mg i.v.—have all been
shown to decrease barrier pressure by similar
magnitudes (Brock-Utne et al., 1977; Brock-Utne
et al., 1978). The effects of atropine and glycopyr-
rolate are evident 3 min after i.v. injection and the
decreases in barrier pressure are sustained for at
least 40 min (Cotton and Smith, 1981; Cotton and
Smith, in preparation). Moreover, in a study of
anticholinergics with simultaneous reflux testing
using an oesophageal pH electrode, evidence was
produced to suggest that these drugs do cause
reflux. In 16 healthy volunteers given either at-
ropine 0.6mg i.v. or hyoscine 0.4mg i.v., barrier
pressure was found to decrease in all subjects,
whilst free reflux occurred in two subjects and
stress-induced reflux was evident in another four
(Brock-Utne et al., 1977). Although all these
studies have utilized the i.v. route of administra-
tion, it is reasonable to assume that premedication
by the i.m. route merely invokes a difference in
magnitude of response.
Of the other premedicant drugs which have
been studied, pethidine and morphine are known
to decrease barrier pressure. Moreover, it is con-
ceivable that the combination of each with an
anticholinergic may have additive effects on the
LOS. The effect of diazepam is uncertain; in one
study a decrease in barrier pressure was observed
with doses ranging from 2.5 to lOmg i.v. (Hall et
al., 1975), whilst Weirauch and colleagues (1979)
found no effect occurred until a total dose of 20 mg
i.v. had been given, whereupon barrier pressure
increased.
Thus, some of the drugs used commonly for
premedication decrease barrier pressure and may
increase the risk of regurgitation and subsequent
pulmonary aspiration. Although there have been
many suggestions that protection against these
events may be obtained by the concurrent admini-
stration of metoclopramide, Cotton and Smith
(1981) have demonstrated that a standard dose of
lOmg i.v. merely attenuates and does not com-
pletely abolish the deleterious effects of atropine
0.6mg i.v. on lower oesophageal sphincter tone.
It is probably preferable to avoid the routine use
of anticholinergic drugs for premedication, pri-
marily because of their unpleasant subjective ef-
fects. In addition, the reduction in lower oeso-
phageal sphincter tone is undesirable. It is con-
cluded that the only indication for routine admini-
stration of an anticholinergic in adults before
endotracheal intubation is when a repeat dose of
suxamethonium is to be administered. Obviously,
there are occasions when a vagal bradycardia may
be anticipated, for example during ophthalmic
surgery or when large doses of halothane are to be
administered, but it would seem more logical and
effective to detect bradycardia by careful monitor-
ing and counter it by the use of appropriate doses
of i.v. atropine.
B. R. Cotton
G. Smith
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Welman, S., Dimopoulos, G. E., and Moshal, M. G. (1977).
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sphincter. Anaesth. Intens. Care, 5, 223.
Welman, S., Dimopoulos, G. E., Moshal, M. G., and
Downing, J. W. (1978). The effect of glycopyrrolate on the
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