Monday, October 8, 2007

Experiences with Ether

Experiences with Ether
Dr. M. Mittal
Ex Director Professor, MAMC and GTB Hospital

My experience with Diethyl ether (ether). My first encounter with ether anaesthesia was in my final M.B.B.S. I was asked to administer open ether to a patient posted for emergency caeserrian section. My knowledge of ether was limited to a lecture on stages of anaesthesia. It was told that during the second stage the patient goes out of control. I was mortally afraid that how I will handle a fighting patient and manage the patient without causing harm to the mother and the baby. At that time the anaesthesia department was manned only by late Dr. Sushila Gaind at the Lady Harding Medical College. She was helped by a Registrar from the surgical departments by rotation. The patient had to anaesthelized and there anaesthetist was available. With my meager knowledge and encouragement from the obstetrician, I entered is very safe. It is very very difficult if not impossible to kill a patient with ether. I started pouring of drops on a schimmvel Busch mask from a small bottle (Belamy Gardner). Diagrams – I and II. To my surprise, the patient welcomed the move and devoured ether enthusiastically, and in no time she was breathing regularly and quietly. There was hardly any sign of struggle.
I wanted to be surgeon, so after my internship I left Lady Harding Medical College to join Irwin Hospital which had the best surgical department at the time. After completing one year housemanship in surgery, I joined as Assistant casualty medical officer as this was required to enable me to appear for F.R.C.S. During this period of job as ACMO I was posted in the department of Anaesthesia as there was acute shortage of staff. During this period I cleared primary F.R.C.S. examination from Calcutta in 1963. After my posting in anaesthesia I got interested in the subject and decided to do Final F.F.A.R.S instead of F.R.C.S. The use of muscle relaxants were rare. For pediatric patients, open ether was commonly used. Another common mode used for administering ether was the use of Flagg’s can (canister). It was improvised from an empty tin of trichlorecthylene. It is a simple Draw-over vaporizer with low resistance to breathing. Four/five holes were made near the upper end of the bottle and a tube was attached to the opening of the canister and this was attached to the endotracheal tube. The intubation was done under open ether. The method allowed the anaesthetist to be away from the patient, as required for adenoidectomies, tonsillectomies and gland biopsies in the neck.
Diagramme of Flags can.
In the sixties and early seventies in summer months Nitrons Oxide was not available and oxygen used to be in short supply. The gases were used for emergencies or poor risk patients. For other cases ether-air anaesthesia was the norm. This was provided by using E.M.O ether inhaler i.e. Epstein, Macintosh, Oxford ether inhaler. One of the senior anaesthetist Dr. Satinder singh advocated the use of E.M.O. ether inhaler even for mitral stenosis and prenmonectomies. After inducing with thiopentone and intubating the patient with succynile choline, the patient’s anaesthesia was maintained with ether by using E.M.O (short for E.M.O. ether inhaler). The patient was kept on spontaneous/controlled ventilation. The use of diathermy was allowed when surgical site was more than three feet or the wet towel was kept around the expiratory port/inspiratory leak valve to reduce the inflammability. Ether in air is not explosive.
Diagramme of E.M.O ether inhaler.
Utting described ether as one of the safest anaesthetic used. Millions of cases have been administered ether anaesthesia in India and the third world countries like African Continent without a fatality. Even today it is being used successfully in remote areas when N2O and O2 does not reach.
The decline of ether anaesthesia has been due to its inflammability and explosive nature when used with oxygen and Nitrous Oxide. The use of Diathermy has become almost universal in teaching hospitals/referral centres.
Have you ever thought why all the newer anaesthetics after halothane are ethers?
Two Alkyl radicles (R-O-R) joined by an oxygen atom. This is because of the good qualities of ether. Diethyl ether is a very good analgesic. The restlessness in the post operative period is minimum. The requirements for post operative analgesia (narcotics) is minimal. Ether does not sensatize myocardium to catecholamines thus does not produce cardiac dysrrhythmias. Ether does not cause liver or kidney damage beyond cloudy degeneration which is completely reversible in twenty four hours. It is an excellent bronchodilator. The thiopentone induction by passes the second stage (stage of turbulence) of anaesthesia. The use of relaxants reduces the requirement for ether. The nausea and vomiting is mainly dike to stomach inflation with gases when mask ventilation is used. It can be prevented by early endotracheal intubation by suing relaxants. The inflammability of diethyl ether has been reduced by addition of halozens like bromide and fluoride radicles. But this has lead to problem of fluoride face radicles. The newer halogenated ethers have lead to the problem of liver and kidney damage. Specialised vaporisors are required and this adds to the cost. The requirement for postoperative analgesia is increased. The narcotics are used routinely during and after anaesthesia.
Another good use of ether was for blind nasal intubation. In the days when sophisticated equipment like malleable fibreoptic laryngoscopes was not available, ether came to the rescue. After premedicating the patient with pethidine and atropine and locally anaesthetizing and vasoconstricting the nasal mucosa the patient of scoline. Anaesthesia was continued with ether by naso pharyngeal airway. This provided more time for difficult blind nasal intubation to succeed. Halothane anaesthesia was short lived and therefore not sufficient.
I can say from my experience of ether for thousands and thousands of patients successfully, that even today there is a place for its use in our country. We should continue to teach its use correctly to all those who are going to work in rural or remote areas of our country. I used to demonstrate the use of ether to medical students and new entrants to the department as late as late eighties. Do not hesitate to use it where other methods cannot be used or are not available.

“Hale ether”

19 comments:

Anonymous said...

A SALUTE TO THE LEGEND

DR S R KHAN said...

WONDERFULLY WRITTEN, MESSAGE IS CLEAR THAT WITH THE ADVENT OF NEW TECHNOLOGY ALMOST EVERY HOUR OF THE DAY WE MUSTNOT FORGET AND SHOULD NEVER NEGLECT OUR FOUNDATIONS, AFTERALL OLD IS GOLD AND IN A DEVELOPING COUNTRY LIKE OURS IT REMAINS A DEMAND OF THE HOUR THAT TEACHERS LIKE YOU SHOULD HELP THE BUDDING ANAESTHETISTS TO IMBIBE THE ROCK SOLID OLD TECHNIQUES OF SAFELY PUTTING THE PATIENTS TO SLEEP. THANK YOU MAM

Dr B. K. Verma said...

bkv90@123india.com
thank you mam for sharing your experiences, even we use ether very frequently at our hospital in a remote village in M.P. India.

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