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Department of Anesthesiology and Intensive Care, All India Institute of Medical Sciences, New Delhi, India, darlongv{at}yahoo.com
To the Editor:
Organophosphates are widely used pesticides (1). Acute poisoning, asthma induced by chronic exposure, and long-term respiratory sequelae have been documented after organophosphate exposure (2–4). We report the first case of intraoperative bronchospasm after preoperative organophosphate inhalation.
Two young ASA physical status I males were scheduled for percutaneous nephrolithostomy in succession in the same operating room. Both were exposed to Propuxur insecticide spray in the ward on the night before surgery. Neither had a history of allergies or respiratory problems. Both had good exercise tolerance. All preoperative investigations including chest and CVS examinations were unremarkable. One was a salesman and a nonsmoker and the other was a teacher and occasional smoker (2–3 cigarettes/day for 3 years).
Anesthesia was induced in the first patient with IV morphine 100 µg/kg, followed 5 min later by thiopentone 300 mg. Anesthesia was induced in the second patient with IV fentanyl 1 µg/kg, followed 3 min later by propofol 120 mg. Neuromuscular blockade was facilitated with vecuronium bromide 0.1 mg/kg. The patients were both given 50% N2O and O2 with 1.5% isoflurane by mask. After 4 min, laryngoscopy was performed and the trachea was intubated without event. After intubation, peak airway pressures increased in both patients from 16 to 40 cm H2O. On auscultation, diffuse bilateral inspiratory and expiratory wheezes were heard in both patients. Saturation dropped from 100% to 85%. Isoflurane and N2O were switched off and ventilation continued with 100% O2. Ten puffs (1000 µg) of salbutamol were given through the endotracheal tube. Xylocard 20 mg and hydrocortisone 200 mg were injected IV. Suctioning of the endotracheal tube revealed tenacious mucoid secretions. After several minutes saturation returned to 100% and wheezes disappeared on auscultation. Halothane and N2O were started and surgery continued. The hemodynamics, saturation, ETco2, and airway pressures remained stable. The first patient also had a second episode of bronchospasm on extubation. The episode resolved within 1 min after administering 5 puffs of salbutamol. The postoperative course of both the patients was unremarkable. Similar complaints were also noted in patients from the same ward scheduled for the adjoining operating room.
A severe attack of bronchospasm occurring intraoperatively can be a major life-threatening event (5). We had two healthy patients who developed bronchospasm intraoperatively. After excluding the common causes of intraoperative bronchospasm (6), we could attribute these episodes to inhalation of Propuxur on the night before surgery. These sprays are done routinely in our hospital for vector control. This is the first report of adverse effects from this insecticide.
Propuxur, a carbamate organophosphate, reversibly inhibits enzyme acetyl cholinesterase. This increases the levels of acetylcholine, causing airway hyperreactivity (4,7,8). Heavy exposure can induce bronchospasm (2,9). Development of severe asthma after exposure to small doses of these compounds without systemic toxicity has been reported (3,4). However, it is intriguing that the patients did not manifest signs of organophosphate toxicity on the ward. Once anesthesia was induced and trachea intubated, the bronchial irritability and spasm came to light.
We postulate that the increased airway reactivity caused by Propuxur inhalation might have triggered bronchospasm once the airway was stimulated by introducing an endotracheal tube. Even in the absence of overt signs of toxicity, bronchial hyperreactivity and intraoperative bronchospasm can occur. Hence, pesticide spray should be avoided in closed hospital wards.
References
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