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Letters to Editor

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.
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.
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.
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
despite cyanosis.

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
Intraoperative monitoring should ideally include
co-oximetry, which detects the presence as well
as quantifies methemoglobin level.
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.
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
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.

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.
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posted forbuccal mucosal
grafturethroplastyunder low
dose spinal anaesthesia with
We report a case of stricture urethra in a 59 years
male undergoing buccal mucosal graft (BMG)
urethroplasty for partial segmental stricture at
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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.

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
and transurethral resection of prostrate.
lead ECG and central venous pressure monitoring was
done along with all other routine protocol. Epidural
catheter was introduced at L
level and catheter was
directed downward and tip was fixed at L
Then spinal anaesthesia was given in L
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
, which would be sufficient for BMG
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.
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.
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and dosage
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.”
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
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