CURRENT LITERATURE

Reducing the Incidence of Non-A, Non-B Post-Trans- fusion Hepatitis By Testing Donor Blood For Alanine Aminotransferase: Economic Considerations Hombrook M, Dodd RY, Jacobs P, et al. N Engl J Med 307(21):1315, 1982

Recent studies have established a relation between ele- vated alanine aminotransferase (ALT) levels in donor blood and the incidence of non-A, non-B hepatitis in re- cipients of the blood. A study was undertaken to estimate the potential economic costs and benefits of a national program to screen donor blood for elevated levels of ALT. Benefits, defined as the expected costs of the hepatitis that would be avoided, ranged form $898 to $3 1,629 per 1,000 blood units collected. (This wide range reflected lack of information about the natural history of non-A, non-B hepatitis.) Costs were defined as the direct costs of testing and the indirect costs associated with loss of blood product, additional donor recruitment, and in- forming donors of their abnormal ALT levels. Costs ranged from $3,15 1 to $4,003 per 1,000 units. The results suggest that if prospective studies demonstrate the exclusion of blood with elevated ALT levels decreases the incidence of non-A, non-B hepatitis in recipients, the net economic impact of such a program may be positive. However, be- cause of major uncertainties about the medical conse- quences of non-A, non-B hepatitis, the benefit estimates are so broad that they preclude a definitive policy deci- sion.-MARION L. WAZNEY

Reprint requests to Dr. Hombrook: Division of Intramural Re- search, National Center for Health Services Research, Room 8- 50 A, Center Building, 3700 East-West Hwy, Hyattsville, MD 20782.

A Screening Device: Children at Risk for Dental Fears and Management Problems. Cuthbert MI, Melamed BG. ASDC J Dent Child 49:432, 1982

Fear of dental procedures is a well recognized problem. Many of these fears may be learned in childhood. The authors sought to study the distribution and etiology of dental fear of children in public schools. Children be- tween the ages of 5 and 14 were given a fifteen-item dental subscale of the Children’s Fear Survey Schedule (CFSS). The highest fear scores were reported for children ages 6 and 7. There was no overall difference between the scores of boys and girls. The ranking of the 15 items was also very similar for both sexes and for the various age groups. Fear of choking, injections, and drilling were ranked the highest by everyone. The authors suggest that this survey would aid dentists in choosing patient management tech- niques.-ALAN STOLL

cardiac work and, when excessive, may result in myo- cardial ischemia or infarction. Poorly controlled hyper- tensive patients are often relatively hypovolemic and, when exposed to anesthetic agents, become hypotensive. Hy- pertensive patients bleed more intraoperatively and have an increased incidence of arrhythmias.

Studies have shown that 22% of adult patients pre- senting for routine surgery have a history of hyperten- sion.

The risk of stroke is three to four times higher in pa- tients with systolic BP of 180 mm Hg compared with those with systolic BP of 130 mm Hg. The deferral of elective surgery is therefore recommended for systolic BP greater than 180 mm Hg. Deferral of elective surgery is also recommended for patients with diastolic BP greater than 110 mm Hg. A hypertensive patient that has not been previously evaluated should be referred to an internist.

The author advocates a well-conducted preoperative visit with the patient to allay anxiety and generous use of tranquilizers and narcotics for premeditation. Hyper- tensive patients frequently develop wide fluctuations in BP under anesthesia, particularly during induction, in- tubation, and recovery periods. Arterial monitoring is recommended for patients who are prone to such fluc- tuation. Rapid control of hypertensive episodes may re- quire use of potent vasodilators such as nitroprusside or nitroglycerine. Central venous pressure should be moni- tored for those patients in whom large blood loss and fluid shifts are anticipated. During induction, large boluses of intravenous agents should be avoided and the level of anesthesia should be gradually deepened. Myocardial de- pressant and peripheral vasodilating effects of inhala- tional anesthetics make them suitable for hypertensive patients. Epinephrine-containing solutions are best avoided in hypertensives. Intraoperative hypotension in hypertensives should be treated when mean BP pressure drops 20%.

When intraoperative hypertension occurs, a differential diagnosis should be considered, including light-anesthesia hypoxia, hypercapnia, metabolic acidosis, pheochromo- cytoma, increased intracranial pressure, and malignant hyperthermia. Treatment of intraoperative hypertension may consist of intravenous chlorpromazine, given in in- cremental doses of 2 mg, or administration of hydralazine in 5-mg increments 15 minutes apart until the desired ef- fect is obtained.

Signs of postoperative hypertension include pain, hy- poxia, hypercapnia, and fluid overload. Arterial blood gases may be monitored to reach a correct diagnosis, particu- larly if narcotics were given.-DAVID A. WALKER

Reprint requests to Dr. Finucane: Department of Anesthe- siology, Emory University School of Medicine, Atlanta, Georgia.

Reprint requests to Professor Melamed: Department of Clinical Psychology, J. Hillis Miller Health Center, Box J-165, University of Florida, Gainesville, FL 32610.

Laryngo-Tracheal Complications Following Intubation Anesthesia. Osgethorpe J, Ward P. Surg Ret 5:22, 1982

Anesthesia and Hypertension. Finucane BT. Anesthe- siology Review 9: 13, 1982

The National Health Survey describes patients with blood pressures greater than 160/95 as hypertensive. Re- cent literature reports that elevations in systolic BP carry with it significant risk for cerebral and cardiovascular ac- cidents. Hypertension heralds cardiac disease, increased

Advances in technique and materials for intubation an- esthesia have lowered the frequency of anesthesia-asso- ciated deaths to 0.2% of surgical mortality, but morbidity from anesthesia is still significant. Patients that are predis- posed to an increased incidence of laryngotracheal com- plications include infants who are prone to airway com- promise from periglottic edema, females who have smaller airways than males of the same size, patients with short

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