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Letters to Editor
inspiratory halothane concentration) and secondly, of
salbutamol having reached the trachea in an adequate
dose (denoted by endtidal halothane concentration).
Besides salbutamol sulphate, beclomethasone
dipropionate and triamcinolone acetonide aerosol
inhalers also use HFA134a as propellant. HFA134a is
also being used as a preanaesthetic vapocoolant spray. In
the 1990s, it began replacing dichlorodifluoromethane
(Freon) in domestic refrigerators and automobile
air conditioners as a hightemperature refrigerant.[3]
It replaced chlorofluorocarbons as a propellant in
inhalers in December 2008, in compliance with the
United Nations Environment Program protocol on
ozone depleting substances.[4,5] This is because it
has an insignificant ozone depletion potential and a
negligible acid rain potential.[3]
This propellant has been shown to be safe and
nonanaesthetic in standard inhaler doses.[4] HFA134a
may result in microsomal enzyme induction.[5]
Defluorination of HFA134a has been seen in rat
hepatocytes.[6] Due to molecular similarity between
halothane (CF3CHClBr) and propellant(CF3CH2F),
further research is warranted into halothaneassociated
hepatitis due to antitrifluoroacetyl antibodies after
repeated administration or longterm use. Because
of its high global warming potential (100yearsGWP
equals 1430), HFA123a has been banned from use in
Europe since 2011(starting with cars), to be completely
phased out by 2017.[3,7,8] Thus, the quest for the ideal
propellant for pressurised metered dose inhalers does
not end with HFAs.
Shagun Bhatia Shah, Uma Hariharan,
Ajay Kumar Bhargava
Department of Anaesthesia, Rajiv Gandhi Cancer Institute and
Research Centre, Rohini, NewDelhi, India
Address for correspondence:
Dr.Shagun Bhatia Shah,
H. No.174175, Ground Floor, Pocket17, Sector24,
Rohini, NewDelhi110085, India.
Email:drshagun_2010@rediffmail.com
REFERENCES
1. ShulmanM, SadoveMS. 1,1,1,2tetrafluoroethane: An
inhalation anesthetic agent of intermediate potency. Anesth
Analg 1967;46:62935.
2. LevinPD, LevinD, AvidanA. Medical aerosol propellant
interference with infrared anaesthetic gas monitors. Br J
Anaesth 2004;92:8659.
3. FranklinJ. The atmospheric degradation and impact
of 1,1,1,2-tetrafluoroethane (hydrofluorocarbon 134a).
Chemosphere 1993;27:1565601.
4. HuchonG, HofbauerP, CannizzaroG, IaconoP, WaldF.
Comparison of the safety of drug delivery via HFAand
260
CFCmetered dose inhalers in CAO. Eur Respir J 2000;15:6639.
5. Surbrook SE Jr, OlsonMJ. Dominant role of cytochrome
P4502E1 in human hepatic microsomal oxidation of the
CFCsubstitute 1,1,1,2tetrafluoroethane. Drug Metab Dispos
1992;20:51824.
6. OlsonMJ, ReidyCA, JohnsonJT. Defluorination of
1,1,1,2tetrafluoroethane(R134a) by rat hepatocytes. Biochem
Biophys Res Commun 1990;166:13907.
7. ForsterP, RamaswamyV, ArtaxoP, BerntsenT, BettsR,
FaheyDW, etal. Changes in atmospheric constituents and in
radiative forcing. In: SolomonPK, editor. Climate Change 2007:
The Physical Science Basis. 1sted. Cambridge: Cambridge
University Press; 2007. p.235336.
8. RigbyM, PrinnRG, ODohertyS, MillerBR, IvyD, MuhleJ,
et al. Recent and future trends in synthetic greenhouse gas
radioactive forcing. Geophys Res Lett 2014;41:262330.
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DOI:
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New approach to treat an old
problem: Mannitol for post dural
puncture headache!
Sir,
Postdural puncture headache(PDPH) is as old as
spinal anaesthesia and was described by Bier during
his initial attempts to produce the cessation of
impulses from lower half of the body.[1] As with time,
the technique was refined, the needles got smaller,
the needles got different shapes and this led to the
incidence being reduced drastically. Also with the
development of anaesthesiology as a speciality, PDPH
was recognised as an entity and management protocols
were developed to prevent and manage it specifically.
PDPH is less prevalent than before because of
various reasons, primarily due to finer needles and
better techniques.[2] Obstetric patients undergoing
caesarean sections under spinal anaesthesia are the
most common subgroup to experience PDPH, and it is
usually devastating for them, particularly after a trying
surgical period and therefore they are usually unable
to enjoy motherhood(especially primigravida).[35] I
have had the opportunity to learn from Bishop Conrad
Memorial Hospital(Khairabad, Uttar Pradesh) a novel
approach to tackle this age old problem. The staff
Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
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Letters to Editor
used mannitol infusions to treat PDPH successfully
for years with much success. If postoperative patient
complains of headache that is characteristic of PDPH,
20% mannitol(100ml) is given over h intravenously
and followed by 100ml on a 12 hourly basis. The first
dose of mannitol usually settles the PDPH over68h
and no analgesics are required thereafter. Intravenous
fluids are given to the patient as per normal body
requirement, and input/output chart is maintained.
Frequent assessment is done and after 48h it is
unusual to need mannitol infusions. Ihad adopted
this practice while I was employed there and continue
to do so. Ialso extend this to patients who have had
a dural puncture on attempting epidural technique
with a Tuohy needle, to preempt the PDPH that
develops in them. In another case, mannitol infusion
was successfully used by the author to treat a patient
who developed unilateral facial nerve palsy after
caesarean section under spinal anaesthesia, 4days
after discharge. At the time of readmission, unilateral
facial palsy was well established, and patient was
greatly stressed. After institution of mannitol therapy,
it vanished by the 3rdday, and she was discharged with
no neurological deficit. The postulation and possibly
the reason for improvement in the PDPH status is
mannitol draws fluid from inside the neurons and glia,
by osmotic diuresis, thereby the actual effective weight
of the brain is reduced and it refloats in an improved
cerebrospinal fluid volume. This relieves the pressure
or traction on the meninges and vessels at the base of
the brain that causes PDPH and thus mitigates it.[6] I
have not found any side effects of mannitol therapy in
patients who were given this therapy. Can this be the
best noninvasive option to reduce PDPH in patients?
This management method has not been described
before in any scientific journal or text. Studies can be
carried out to establish/refute this claim and to know
the risks associated with this approach.
MM Rizvi, Raj Bahadur Singh, RK Tripathi,
Sister Immaculate1
Department of Anaesthesiology and Critical Care, Eras Lucknow
Medical College and Hospital, 1Department of OB and G, BCM
Hospital, Khairabad, Lucknow, Uttar Pradesh, India
Address for correspondence:
Dr.Raj Bahadur Singh,
Department of Anaesthesiology and Critical Care, Eras Lucknow
Medical College and Hospital, Lucknow226003, Uttar Pradesh, India.
Email:virgodocraj36@yahoo.co.in
REFERENCES
1. Bier A. Experiments on the cocainization of the spinal cord.
Deutsch Z Chir 1899;51:361-9.
Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
2. LeeJA. Arthur Edward James Barker 18501916. British
pioneer of regional analgesia. Anaesthesia 1979;34:88591.
3. ChadwickHS. An analysis of obstetric anesthesia cases from
the American society of anesthesiologists closed claims project
database. Int J Obstet Anesth 1996;5:25863.
4. VandamLD, DrippsRD. Longterm followup of patients who
received 10,098 spinal anesthetics; syndrome of decreased
intracranial pressure(headache and ocular and auditory
difficulties). JAm Med Assoc 1956;161:58691.
5. SechzerPH. Postspinal anesthesia headache treated with
caffeine. PartII: Intracranial vascular distention, a key factor.
Curr Ther Res 1979;26:4408.
6. AminiSamanJ, KarbasfrushanA, AhmadiA,
BazarganHejaziS. Intravenous mannitol for treatment of
abducens nerve paralysis after spinal anesthesia. Int J Obstet
Anesth 2011;20:2712.
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DOI:
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Prevention of migration of
endotracheal tubes used for
aided nasogastric tube placement
in anaesthetized patients
Sir,
During bariatric surgery procedures, the
anaesthesiologists help facilitate proper placement
of nasogastric tubes (NGTs) and bougies to size the
gastric pouch. They help perform leak tests with
saline, methylene blue or air to ensure stapleline or
anastomotic integrity. They ensure complete removal
of all gastric tubes before gastric division to avoid
unplanned stapling and transection of these tubes. After
the surgery is performed, they reinsert the NGT tube
under vision watching the monitor carefully while the
tube is advanced to avoid disruption of the anastomosis.
NGT insertion in an anaesthetised patient is however a
very cumbersome procedure for the anaesthesiologist
with the need to burrow under sterile drapes to
approach the oral cavity and the need to use a
laryngoscope and Magills forceps to advance the tube
12 cms at a time to avoid coiling in the oropharynx
because of the flexibility and slippery nature of a
lubricated NGT through the compromised lumen of
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