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Iadt02i6p480 PDF
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are 10mg 100ml-1 and 3mg 100ml-1 respectively. These hypotension persists, intravenous infusion of plasma
are achieved after the ingestion of total dose of 3 gm for volume expanders and vasopressors is started. In refractory
short acting drugs and 5 gm for long acting drugs. The cases, steroids are given.
poisonous effect of barbiturates is potentiated by alcohol,
narcotics, tranquilisers and antidepressants. Death occurs 2. Measures to prevent absorption
from respiratory failure, severe hypotension, vasomotor a. Gastric lavage : If no more than 2-4 hours have
failure, non cardiogenic pulmonary oedema, hypothermia passed since ingestion of the barbiturate, gastric
(which aggravates shock) or oliguria with renal failure. lavage is done.2
Acute barbiturate intoxication should be clinically b. Activated charcoal : Is an inert non toxic adsorbent
evaluated to differentiate it from other forms of coma or which binds high molecular weight compounds due
central nervous injury. History of possible trauma, previous to intermolecular attractions. 1gKg-1 is administered
psychiatric illnesses, attempts at suicide and drug usage through nasogastric tube. Cathartic like magnesium
should be obtained with particular attention directed sulphate can be used along with it for further removal
towards the type, amount and time of drug ingestion, the of barbiturates but hypermagnesemia can occur.
duration of coma and associated ingestion of alcohol. 3. Measures for removal of barbiturates
Evidence of preexisting diseases such as hypertension, a. Frequent doses of activated charcoal : These adsorb
cirrhosis and diabetes mellitus should also be sought. In the barbiturates when they reenter the GIT through
our case there was no such history. enterohepatic circulation. 1gKg-1 initial dose is
Barbiturate poisoning is characterized by progressive followed by 0.5gkg-1 every 2-4 hours.3
CNS depression culminating in paralysis of brainstem and b. Forced diuresis with alkalinisation of urine: This
medulla. In early stages, patient is confused and lethargic is especially useful in long barbiturates which are
with poor coordination, ataxia and dysarthria. This largely excreted by the kidney. At high rates of
progresses on to deep unremitting coma, total areflexia urine flow (by the use of diuretics), the renal
and unresponsiveness to other stimuli as in our case. clearance of barbiturates is increased. Thus, it
Corneal reflexes are lost. Conjugate doll’s eye movement shortens the duration of coma and decreases plasma
are absent. Pupils are usually constricted but may dilate concentration of barbiturates. This should be avoided
in terminal phases. Pupillary response to light is minimal. in older patients as it can cause pulmonary oedema,
In late stages, respiration is feeble, shallow and irregular hyponatraemia and increase in ICP.
and hypotension occurs. Apnea and cardiac arrest may result. In addition to diuresis, phenobarbitol excretion can
Minimum laboratory evaluation include haematocrit, be enhanced ten fold by urinary alkalinization (pH
urine analysis mainly for ketone bodies, WBC and 7.8 -8.0). Alkalinising urine causes ionization of
differential counts. Plasma concentration of electrolytes, phenobarbitone after its filtration into renal tubular
blood urea, serum creatinine and liver function tests cells and trapping the agent, thereby inhibiting its
should be obtained. Chest X-ray and blood gas analysis re-absorption from renal tubules and increasing its
are mandatory. A blood sample should be sent for excretion.
measurement is of little value except to confirm the c. Haemodialysis and haemoperfusion: Is now being
presence of barbiturate in plasma. Serial measurements used extensively in treatment of barbiturate
provide a valuable guide to the adequacy of therapy. intoxication to increase rate of removal of
Management of barbiturate poisoning barbiturates. Single six hour haemodialysis can
remove an amount of barbiturate which is comparable
1. Cardiorespiratory support to that removed during 24 hours of sustained diuresis
A clear airway is ensured by thorough suctioning or peritoneal dialysis.
and insertion of oral airway. In addition, the passage of
Newer technique of lipid dialysis can extract long
barbiturates across the blood brain barrier into the central
acting drugs such as phenobarbitol in greater quantity.
nervous system may be facilitated during hypoventilation
Removal of short acting barbiturates is more limited
and respiratory acidosis. If the patient is comatose, prompt because of lower plasma concentrations and greater binding
intubation (without waiting for the PaO2 to fall to to plasma proteins.4 Our patient improved remarkably
dangerously low levels) is strongly advocated because of well after haemodialysis.
the fear of impending, worsening respiratory failure.
Analeptic Drugs
Dehydration is corrected by CVP guided fluid These have minimal role now a days because under
therapy depending on the serum electrolyte reports. If their influence, true clinical assessment of patient becomes
482 INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2002
impossible. Also, they are associated with side effects We were able to save our patient because of immediate
like convulsions, cardiac arrhythmias, vomiting, control of ventilation, temperature maintenance, early
hyperpyrexia. prevention of renal damage and haemodialysis.
Supportive care References
The most important aspect of management in these 1. Ellenhorn MJ, Barceloux DG. Diagnosis and treatment of
cases is close observation and quality nursing care. human poisoning. In : Medical toxicology. New York: Elsevier,
Prophylactic antibiotics should be started. Good oral 1988.
hygiene, temperature maintenance, and posture change at 2. Hall AH. Gastrointestinal decontaminations: Shifting through
regular intervals. supportive therapeutic options. Emerg Med Reports 1991;
12: 171-8.
Usually, recovery from barbiturate coma is without
neurologic deficit even after severe poisoning. Our patient 3. Birnbaumer D. Poisonings and ingestions. In : Bongard ES,
Sue Dy, editor. Current Critical Care Diagnosis and Treatment.
also recovered fully without any deficit. The rarity of
London: Appleton and Lange, 1994: 686-715.
permanent damage after barbiturate coma precludes
immediate establishment of adequate pulmonary ventilation 4. Henderson LW, Merrill JP. Treatment of barbiturate
intoxication. Ann Intern Med 1966; 64: 876.
as well as control of shock to be of prime importance.
CORRESPONDENCE
Letters to Editor
To, So many societies in anaesthesiology, have they
The Editor, ever proceeded more than holding conferences and issuing
Indian Journal of Anaesthesia. journals (IJA.2002; 46(5): 414). It may be appreciated if
ISA takes responsibility to –
Sir, 1. Review and form a proper curriculum for
Apropos “Undergraduate Anaesthesia Education”, undergraduate and postgraduate students.
kudos to MCI for recognizing the importance of ana
2. Define the curriculum of superspecialities – cardiac,
esthesiology for undergraduate courses. In a country like
neuro, paediatric, intensive care, pain, obstretrics.
ours, which needs primary care physicians to treat common
Encouraging more institutions to offer certificate
diseases and to make arrangements for referrals, knowledge
courses in the same and recognizing these by an
of basic and advanced life support management,
executive body of ISA after thoroughly checking
resuscitation and critical care support; monitoring; trauma,
the credentials.
disaster and airway management and lastly, awareness of
basic pharmacology and pain management is important. 3. Issuing guidelines for a safe anaesthetic practice in
A medical student should be able to demonstrate a Indian set up – both at tertiary and primary centers.
successful basic and advance life support management 4. Encouraging well planned research that will benefit
before obtaining a medical degree. this science.
Can the anaesthesiologists’ take the entire blame for 5. Reaching out to society. Encouraging anaesthesiologists
not making this discipline more popular amongst to teach basic life support in schools and institutions
undergraduates? Most of the theatres are managed by residents and to make people more aware of disaster and
and senior residents in anaesthesiology under supervision of trauma management.
consultants who may be found in coffee room with their An anaesthesiologist has a distinct identity, as is
irrelevant discussions or preparing the manuscript of a every specialist in medical education. Can we manage
research paper. Some junior consultants may take it as a Integrated Medical Teaching programmes? A paediatrician
privilege to enter operation theatre at night during an cannot administer anaesthesia and same holds true vice
emergency case. How may consultants go for pre-operative versa. There are many milestones to be covered in this
check ups and post anaesthesia recovery and pain relief to glorious field.
the patient? Adding irrelevance to already existing literature,
repeating same old things and providing nothing new and Yours truly,
creating unnecessary doubts will only harm the speciality.
The onus lies on the faculty in the discipline of anaesthesiology Dr. Abhinav Gupta, M.D., D.N.B.
to make the undergraduate students more aware of this D.N.B.Fellow in Cardiac Anaesthesiology
science in whatever time slot allotted. New Delhi.