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Correspondence  |   November 2000
Rapid Opioid Detoxification during General Anesthesia: Is Death Not a Significant Outcome?
Author Affiliations & Notes
  • Robert A. Whittington, M.D.
    *
  • *Columbia University
  • New York, New York.
  • raw9@columbia.edu
Article Information
Correspondence
Correspondence   |   November 2000
Rapid Opioid Detoxification during General Anesthesia: Is Death Not a Significant Outcome?
Anesthesiology 11 2000, Vol.93, 1363. doi:
Anesthesiology 11 2000, Vol.93, 1363. doi:
To the Editor:—
We found the article by Gold et al.  1 in the December 1999 issue of Anesthesiology, which described results with anesthesia-assisted rapid opioid detoxification (AROD) interesting. During the past decade, the practice of opioid detoxification during general anesthesia has become increasingly popular. Despite this, there is scant literature to document the advantages and disadvantages of this procedure. Therefore, Gold et al.  1 provide valuable information about patient selection, the anesthetic techniques used, and the degree of residual symptoms observed after the procedure. They also present preliminary information regarding abstinence rates after AROD. The authors should be commended for providing this clinically useful information.
Unfortunately, the authors do not include in the abstract that 1 of the 20 patients died between 34 and 41 h after the end of the procedure. Not until near the end of the Results section of the body of this article is the death mentioned. Obviously, death is a terrible complication and a significant finding, particularly because this is an experimental procedure. Moreover, the authors state in the Results section of the abstract:“all 20 patients were successfully detoxified with no adverse events.” This is outrageously misleading; in the hands of these authors, AROD has a mortality rate of 5% within 48 h; however, it seemed that the death was not directly the result of the administration of general anesthesia. Because of the absence of illicit drugs in the patient’s system at the time of death, death was in all likelihood related to effects of the precipitated withdrawal process.
We agree with the authors’ recommendation to provide continuous cardiac monitoring of AROD patients during their hospital stays. In a previous issue of Anesthesiology, Kienbaum et al.  , 2 reported profound increases in plasma epinephrine concentrations and cardiovascular stimulation during naloxone-precipitated opioid withdrawal during anesthesia. Even more recently, Allhoff et al.  3 concluded that ultrashort opiate detoxification is associated with a risk of QT-interval prolongation and bradycardia. Furthermore, these effects could be related to hypokalemia or the use of clonidine during the procedure. Because of the increase in circulating catecholamines and the likelihood of fluid and electrolyte loss during precipitated withdrawal, there is certainly the potential for a significant arrhythmia after AROD. Therefore, we also advocate the use of continuous monitoring (telemetry and pulse oximetry) during a hospital stay for AROD. We are conducting the first National Institutes of Health–funded (Bethesda, Maryland) randomized trial that compares the safety and effectiveness of AROD with two alternative methods of opioid detoxification, and we incorporate this monitoring for all AROD patients. Again (although this omission is far less serious), in the Conclusion section of the abstract, the authors do not mention the potential need for increased monitoring.
We recognize that editorial considerations limit the material that can be included in an abstract; these omissions from the abstract, however, are serious. Today, computerized literature searches often yield little more than the abstract of an article. As a result, the most significant findings from a study must be included in the abstract of the article. We therefore respectfully ask the editors to publish a correction to the abstract of this article. In a study designed to evaluate a novel, experimental procedure, such as AROD, can there be a more significant finding than death?
References
Gold CG, Cullen DJ, Gonzales S, Houtmeyers D, Dwyer M: Rapid opioid detoxification during general anesthesia. A nesthesiology 1999; 91: 1639–47Gold, CG Cullen, DJ Gonzales, S Houtmeyers, D Dwyer, M
Kienbaum P, Thurauf N, Michel MC, Scherbaum N, Gastpar M, Peters J: Profound increase in epinephrine concentration in plasma and cardiovascular stimulation after mu-opioid receptor blockade in opioid-addicted patients during barbiturate-induced anesthesia for acute detoxification. A nesthesiology 1998; 88: 1154–61Kienbaum, P Thurauf, N Michel, MC Scherbaum, N Gastpar, M Peters, J
Allhoff T, Renzig-Köhler K, Kienbaum P, Sack S, Scherbaum N: Electrocardiographic abnormalities during recovery from ultra-short opiate detoxification. Addiction Biology 1999; 4: 337–44Allhoff, T Renzig-Köhler, K Kienbaum, P Sack, S Scherbaum, N