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Knowledge of the condition, appropriate monitoring and avoidance of precipitating factors and availability of antidote are key factors in managing a case of methemoglobinemia.
Knowledge of the condition, appropriate monitoring and avoidance of precipitating factors and availability of antidote are key factors in managing a case of methemoglobinemia.
Knowledge of the condition, appropriate monitoring and avoidance of precipitating factors and availability of antidote are key factors in managing a case of methemoglobinemia.
Indian Journal of Anaesthesia | Vol. 57 | Issue 4 | Jul-Aug 2013 428
Knowledge of the condition, appropriate monitoring and avoidance of the precipitating factors and availability of antidote are key factors in managing a case of methemoglobinemia. SushamaTandale,NandiniMDave,MadhuGarasia Department of Anaesthesiology, GS Medical College and KEM Hospital, Mumbai, Maharashtra, India Address for correspondence: Dr. Nandini M Dave, C 303, Presidential Towers, LBS Marg, Ghatkopar West, Mumbai - 400 086, Maharashtra, India. E-mail: nandini_dave@rediffmail.com REFERENCES 1. Hall DL, Moses MK, Weaver JM, Yanich JP, Voyles JW, Reed DN. Dental anesthesia management of methemoglobinemia- susceptible patients: A case report and review of literature. Anesth Prog 2004;51:24-7. 2. Wright RO, Lewander WJ, Woolf AD. Methemoglobinemia: Etiology, pharmacology, and clinical management. Ann Emerg Med 1999;34:646-56. 3. Kumar U, Aggarwal P, Handa R, Saxena R, Wali JP. Central cyanosis in a young man. Postgrad Med J 1999;75:693-6. 4. Firkin F, Chesterman C, Penington D, Rush B. The megaloblastic anemias. In: Firkin F, Chesterman C, Penington D, Rush B, editors. De Gruchys Clinical Haematology in Medical Practice. 5 th ed. Oxford University Press; 1990. p. 73. 5. Ralston AC, Webb RK, Runciman WB. Potential errors in pulse oximetry. III: Effects of interferences, dyes, dyshaemoglobins and other pigments. Anaesthesia 1991;46:291-5. 6. Guay J. Methemoglobinemia related to local anesthetics: A summary of 242 episodes. Anesth Analg 2009;108:837-45. cardiopulmonary diseases by lack of significant pulmonary and cardiac finding on history, examination and investigations and cyanosis, which fails to respond to supplemental oxygen. ABG reveals the classical saturation gap, with normal paO 2 despite cyanosis. [2]
Regardless of aetiology, symptoms appear depending on methemoglobin level in blood. Chocolate colour cyanosis presents at levels of 5-15% and appears early in anaemic patients. Nevertheless, at least 5 g of reduced haemoglobin must be present for cyanosis to be appreciated. At 30-40%, weakness, headache, dyspnoea, tachycardia and dizziness occurs. Patient will be lethargic, stuporous, confused and comatose at concentration of 55-60%. At 70% circulatory collapse occurs. [1,2] Intraoperative monitoring should ideally include co-oximetry, which detects the presence as well as quantifies methemoglobin level. [5] Pre-operative treatment with vitamin C helps in non-enzymatic reduction of methemoglobin. Injection methylene blue is the antidote and the dose is 1-2 mg/kg IV over 3-5 min. [2,3] It acts by increasing the level of NADH methemoglobin reductase, which helps in conversion of ferric ion to ferrous ion. Exchange transfusion and haemodialysis is indicated in severe cases. In acquired methemoglobinemia offending drug should be withdrawn and care should be taken to avoid further exposure to offending agent. Anaesthetic drugs, which induce methemoglobinemia are local anaesthetics, the caines (prilocaine, benzocaine, lidocaine, eutectic mixture of local anaesthetics cream), nitrous oxide, metoclopramide, nitroglycerine, sodium nitroprusside and should be avoided. [1,2] Predisposing factors for methemoglobinemia include age (infants under 6 months), the status of the area being sprayed or injected (inflamed areas and broken skin absorb more of the drug), concomitant use of other drugs which also have been implicated in causing methemoglobinemia and the genetic make-up of the patient (due to altered haemoglobin, G6PD deficiency or methemoglobin reductase enzyme deficiency). Use of local anaesthetic agents in lower doses may be an approach to be followed in this group of patients. [6]
Heightened awareness of proper dosing and the risk of methemoglobinemia is particularly important for clinicians involved in endoscopy, intubation, bronchoscopy or similar invasive procedures using topical anaesthetic-containing sprays. Access this article online Quick response code Website: www.ijaweb.org DOI: 10.4103/0019-5049.118525 Acaseoftriplevesseldisease posted forbuccal mucosal grafturethroplastyunder low dose spinal anaesthesia with dexmedetomedine Sir, We report a case of stricture urethra in a 59 years male undergoing buccal mucosal graft (BMG) urethroplasty for partial segmental stricture at [Downloadedfreefromhttp://www.ijaweb.orgonTuesday,November19,2013,IP:202.62.68.26]||ClickheretodownloadfreeAndroidapplicationforthisjournal Letters to Editor 429 Indian Journal of Anaesthesia | Vol. 57 | Issue 4 | Jul-Aug 2013 bulbourethral membrane, since buccal mucosa is the new gold standard for substitution urethroplasty. [1]
On evaluation, patient gave a history of myocardial infarction 6 years back, with angiographic findings of 100% block in left anterior descending artery and 70% block in right coronary artery 60% block in left circumflex arteryalong with ostial lesions and diffuse atherosclerosis of all vessels, suggesting of triple vessel disease. As patient was not willing to accept the high risk associated with coronary artery bypass graft surgery as explained by the surgeons, he was not operated. Electrocardiography revealed signs of left ventricular hypertrophy. Patient was a known diabetic since 18 years and hypertensive since 8 years. His echo findings were left ventricular hypertrophy, mild aortic stenosis, moderate diastolic dysfunction with ejection fraction 36% and moderate mitral regurgitation, mild pulmonary hypertension and mild tricuspid regurgitation. Patient was instructed to discontinue antiplatelet medication 7 days prior and insulin on the day of surgery. Pre - operative vitals and haematological parameters were within normal limits. According to guidelines 2007 on perioperative cardiovascular evaluation and care for non - cardiac surgery, infrainguinal procedures can be performed under spinal or epidural anaesthesia with minimal hemodynamic changes if neuraxial blockade is limited to those dermatomes. Studies have shown that combined spinal-epidural anaesthesia, using low doses of local anaesthetics with additives, is effective and reduces the incidence of hypotension in caesarean section [2-4] and transurethral resection of prostrate. [5] 12 lead ECG and central venous pressure monitoring was done along with all other routine protocol. Epidural catheter was introduced at L 1 -L 2 level and catheter was directed downward and tip was fixed at L 3 -L 4 level. Then spinal anaesthesia was given in L 4 -L 5 space. Patient received 2.5 mL of 0.25% bupivacaine (1.25 mL of 0.5% bupivacaine with 1.25 mL of 5% dextrose). In addition, 5 mic of dexmedetomedine was added. BMG was taken under local infiltration of 10 mL of 1% lignocaine and 100 mic of intravenous fentanyl without any hemodynamic alterations. Neither changes in blood pressure nor ECG changes were noticed. After 2 hours, 10 mL of 0.375% ropivacaine and 50 mic of fentanyl was given as epidural bolus. After 1 hour of bolus dose, a continuous epidural infusion was started with 0.2% ropivacaine 2 mic/ mL of fentanyl at the rate of 7 mL/hour and continued up to 48 hours postoperatively. Low dose spinal and epidural anaesthesia in cardiac patient offer better response in-terms of maintaining hemodynamic stability, level of anaesthesia achieved would not be more than T 10 , which would be sufficient for BMG urethroplasty. RPrabhavathi,PNarasimhaReddy, TSChandraSekhar,VivekTMenacherry Department of Anaesthesia, Narayana Medical College Hospital, Chinthareddy Palem, Nellore, Andhra Pradesh, India Address for correspondence: Dr. R Prabhavathi, Department of Anaesthesia, Narayana Medical College Hospital, Chinthareddy Palem, Nellore - 522 014, Andhra Pradesh, India. E-mail: prabhavathi95gmc@gmail.com REFERENCES 1. Bhargava S, Chapple CR. Buccal mucosal urethroplasty: Is it the new gold standard? BJU Int 2004;93:1191-3. 2. Van de Velde M, Berends N, Spitz B, Teunkens A, Vandermeersch E. Low-dose combined spinal-epidural anaesthesia v/s conventional epidural anaesthesia for Caesarean section in pre-eclampsia: A retrospective analysis. Eur J Anaesthesiol 2004;21:454. 3. Choi DH, Ahn HJ, Kim JA. Combined low-dose spinal-epidural anesthesia versus single-shot spinal anesthesia for elective cesarean delivery. Int J Obstet Anesth 2006;15:13-7. 4. Roofthooft E, Van de Velde M. Low-dose spinal anaesthesia for Caesarean section to prevent spinal-induced hypotension. Curr Opin Anaesthesiol 2008;21:259-62. 5. Kim SY, Cho JE, Hong JY, Koo BN, Kim JM, Kil HK. Comparison of intrathecal fentanyl and sufentanil in low-dose dilute bupivacaine spinal anaesthesia for transurethral prostatectomy. Br J Anaesth 2009;103:750-4. Access this article online Quick response code Website: www.ijaweb.org DOI: 10.4103/0019-5049.118526 Comment:Ondansetron:Timing and dosage Sir, We read with interest an article titled comparative electrocardiographic effects of intravenous ondansetron and granisetron in patients undergoing surgery for carcinoma breast: A prospective single-blind randomized trial. [1] In the article the authors divided patient post-surgery into 2 groups randomly. One of them received ondansetron 8 mg and the other granisteron 1 mg [Downloadedfreefromhttp://www.ijaweb.orgonTuesday,November19,2013,IP:202.62.68.26]||ClickheretodownloadfreeAndroidapplicationforthisjournal