In Memoriam: Alexander Romagnoli.

Early in 1970, Alexander Romagnoli, MD, drove his Corvette from Montreal to Houston in less than 2 days. His plan was to observe cardiovascular anesthesia in preparation for starting a similar program at the Montreal General Hospital. Instead, he decided to be part of what he saw, and before the year's end, he was the newest member of our cardiovascular anesthesia group. Alex died on 29 August 2000. The intervening years of association with this uniquely and marvelously talented colleague were filled with episodes of this same seeming impetuosity, quick decisions leading to action at twice normal speed. For 3 decades his energy, enthusiasm, and imagination enriched our professional lives. Alex Romagnoli was born in 1923 in Florence, Italy, where he received all his early education, including a Doctor of Medicine degree from the University of Florence in 1949. His next 5 years were spent in England, acquiring graduate medical training in anesthesiology. In 1955, he moved to Canada as a Research Fellow in the Department of Pharmacology of McGill University, and while there he completed his training and certification in anesthesiology. Before moving to Houston, he held an academic appointment as Senior Lecturer in Anaesthesia at the University of Ottowa. In Houston, he was successively a member of the faculties of Baylor College of Medicine and the University of Texas Health Sciences Center. His final appointment was as Clinical Professor of Anesthesiology. Alex approached each day's work as an adventure in which he was the critical observer looking for a better way to achieve his goal. He was especially astute as a clinical observer. When any aspect of his patient care was not to his satisfaction, he devised a better-way hypothesis, which he was then eager to discuss and pursue. He generated these hypotheses with great regularity! His early pharmacologic research concerned adrenergic agents and blockers. Shortly after his arrival, this interest led him to introduce propranolol into our practice by demonstrating its effectiveness in treating a wide variety of intraoperative arrhythmias. He demonstrated propranolol's ability to delay the onset of stone heart, the irreversible ischemic myocardial contracture that developed after prolonged ischemic arrest, before the routine use of cardioplegia. His interest in myocardial protection continued, and by adding indocyanine green to cardioplegic solution, he demonstrated the inhomogeneous distribution of cardioplegic solution in the myocardium, even when vessels were unobstructed by disease. He then demonstrated homogeneous distribution by addition of papaverine or nitroglycerine to the solution. He called our attention to the hazard of preoperative withdrawal of propranolol and to the special value of this drug in patients with coronary artery disease. To study the pharmacokinetics of propranolol, he introduced the technique of gas chromatography into our laboratories and subsequently demonstrated in our patients the changes in atrial propranolol during drug withdrawal. For more than a decade, Alex and I collaborated in studies of narcotic agonist-antagonist analgesics, describing their respiratory and hemodynamic effects. At the time, morphine and fentanyl had replaced inhalation agents as the primary anesthetics for operations requiring cardiopulmonary bypass. We investigated these compounds as possible substitutes for mu-opioids in surgical patients both intra- and postoperatively. We were the 1st to describe in healthy subjects the ceiling effect on respiratory depression by all these mixed agonist-antagonist compounds. Alex was the 1st to describe the ceiling analgesic effects in anesthetized patients and the hypertensive effect of large doses. We successfully established a pharmacologic profile for this class of potent analgesic compounds by describing morphine-like effects in low dose and excitatory effects in high dose, including central nervous system activation. Alex's detailed observation of the effects of nalbuphine when used as an anesthetic supplement clearly demonstrated the unsuitability of this class of compounds for this purpose. We extended these studies in healthy subjects to the pharmacodynamics to a series of pure narcotic antagonists, using respiratory depression as the continuous measure. About this time, Alex became associated with the Department of Pharmacology of the University of Houston School of Pharmacy, initially because of their common interest in adrenergic agents. The relationship that developed proved extraordinarily productive in providing a clinical outlet for their primary interest in pharmacokinetics. In surgical patients, Alex and his collaborators described the pharmacokinetics of meperidine, fentanyl, papaverine, indocyanine green, and nifedipine. More importantly, they described the alterations in normal kinetics when patients underwent cardiopulmonary bypass, particularly the sequestration of fentanyl in the oxygenator circuit. During several years of this work, Alex directed the thesis research of a pharmacy graduate student, who earned his PhD on the basis of his high-quality work in our laboratory. Not surprisingly, this student succumbed to Alex's enthusiasm and charm, and, at great personal sacrifice, he subsequently went to medical school to become an anesthesiologist. He now practices in the pattern of his role model. Alex taught by example. He did not have the patience to be a kindly teacher—he was too full of information to organize it into a form that would be palatable to trainees. Yet he inspired trainees to emulate his extraordinary technical skills and to acquire his clinical acumen in dealing with adverse events before they became life threatening. He was especially gifted in the technical aspects of clinical anesthesia, as might be expected of someone who was also a gifted athlete. He devised our technique for cannulating the jugular bulb for repeated blood sampling during operation. When teaching how to cannulate the internal jugular vein, he always told trainees, “Just palpate it”—as he did before easily puncturing it. Neither the trainees nor his colleagues ever felt the internal jugular vein. Only Alex could. After reaching retirement age, Alex opted to work part time. Paradoxically, slowing down increased his enthusiasm and his hypothesis-generating capacity. He continued to read widely and to participate clinically and in our research program. His most recent interests related to the role of temperature and acid-base management in central nervous system complications after cardiopulmonary bypass. Abstracts of his work in progress were presented earlier this year and again at the meeting of the American Society of Anesthesiologists in October 2000. His remarkable energy and optimism did not fail until the last month of his illness. He still planned to continue these projects, to play tennis, to jog, to race his Corvette on the highways, and to exercise his dog and his superb shotgunner's eye on quail and grouse. All of these he did with much more skill than his mere mortal colleagues. Alex Romagnoli's contributions to cardiovascular anesthesiology and the Texas Heart Institute are evident from his published works. While not so evident, his contributions to the lives of those with whom he worked are no less. He was a consummate gentleman in his personal relationships, a delightful companion in any social arena, and a stimulating enthusiast to all his professional colleagues. Everyone who was fortunate enough to associate with Alex Romagnoli recognized his uniqueness and will sorely miss him.

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