Anesthetic management for magnetic resonance imaging in a pediatric patient addicted to palm wine: An alcoholic beverage.

The incidence of drug and alcohol abuse is on rise despite increasing awareness and education about health hazards related to it. Anesthesiologist may come across patients with alcohol abuse in elective as well as emergency situations. We report a rare case of excessive requirement of anesthetics in a pediatric patient of only six years for MRI, addicted to palm wine, an alcoholic beverage created from the sap of various species of palm tree.

INTRODUCTION

Through the past few years, the incidence of drug and alcohol abuse is on rise despite increasing awareness and education about health hazards related to it. An anesthesiologist may come across patients with alcohol abuse in elective, as well as emergency situations, and excessive drug dosage requirement may be of concern in these patients. However, alcoholic beverage consumption as a cause of excessive requirement of anesthetic in a pediatric patient is not reported.

According to the data available about drug and substance abuse in India 13.1% of the people involved in, are below 20 years. The five most common drugs being abused by children in India are heroin, opium, alcohol, cannabis, and propoxyphene. According to one survey out of all alcohol, cannabis and opium users, 21%, 3% and 0.1% are below the age of 18 years.[1]

CASE REPORT

We report a rare case of only 6-year-old child with a weight of 15 kg, addicted to palm wine, an alcoholic beverage created from the sap of various species of palm tree. The child was admitted with complaints of progressive weakness of all the four limbs over last 1-year.

He was born at full term by normal vaginal delivery and developed all the mile stones normally up to the age of 5 years. The child was investigated, and all the laboratory reports were within normal range. Electroneuromyography showed severe sensory motor polyradiculopathy of demyelinating type. For further evaluation, plain magnetic resonance imaging (MRI) brain was advised. MRI was planned under monitored anesthesia care (MAC) with intravenous (iv) sedation as the child was uncooperative. After confirmation of nil by oral status, iv access secured and basic monitoring including electrocardiogram, heart rate, noninvasive blood pressure, SpO2 connected. The child was sedated with injection midazolam 0.025 mg/kg iv and injection propofol 30 mg slow iv. A facemask with oxygen 2 L/min applied. The child was well sedated and maintained spontaneous regular breathing with adequate tidal volume with stable vitals. MRI started, but after about 5 min only child became awake and started moving. Top up with 0.025 mg/kg midazolam and 10 mg propofol were given but the child did not cooperate. Another top up with 10 mg propofol was given and the child was sedated. Before the MRI could have been restarted again in 2–3 min only child became awake. Again 10 mg bolus of propofol iv was given. The child became apneic and SpO2 decreased to 80%. Procedure stopped, jaw thrust applied, and child ventilated with the face mask, SpO2 improved. The child was paralyzed with injection rocuronium 10 mg and intubated with size 5 uncuffed endotracheal tubes, and maintained with intermittent positive pressure ventilation, air: O2 mixture and sevoflurane. On completion of the procedure, neuromuscular block antagonized with injection neostigmine 0.75 mg with glycopyrrolate 0.2 mg. Recovery was good with vitals stable.

DISCUSSION

There is a marked rise in therapeutic and diagnostic procedures done outside the operating rooms, in modern day practice. Being a noninvasive procedure and its role in achieving the diagnosis, the number of MRI scans is increased markedly.[2] Duration of MRI scan may vary from 15 to 45 min as per the diagnostic requirement. The procedure is very noisy, and the patient has to go inside the scanner which may be scary for pediatric patients. So the children need to be sedated to control their anxiety, to provide good amnesia, analgesia, and complete immobility during the scan. Quality of final image may be affected adversely if the patient moves at any time during the scan. Usually, combination of pharmaceutical agents in minimum doses should be used to achieve the necessary level of sedation. Drugs combinations and their doses are always a matter of debate and depend on the case scenario and choice of the anesthetist.

Midazolam is a commonly used drug for procedural sedation and analgesia in pediatric patients 0.025–0.05 mg/kg iv 3 min before the procedure, not to exceed a total cumulative dose of 0.4 mg/kg. Prolonged sedation and risk of hypoventilation may be associated with the higher doses. Because of its short duration of action midazolam is always used in combination with fentanyl, phenobarbital, ketamine, or propofol. Propofol is a preferred drug for pediatric sedation because of its properties of rapid onset of action, effective anesthesia, rapid emergence, and prevention of nausea and vomiting.[345] Usually, in pediatric patients MAC sedative dose of propofol is 1–1.5 mg/kg iv (loading dose) followed by 0.25–0.5 mg/kg iv 3–5 min whenever needed.

The child reported here was sedated with midazolam 0.025 mg/kg iv and a loading dose of propofol 2 mg/kg slow iv. He was well sedated with stable vitals initially but in the next 5 min only he started moving and became uncooperative. Thereafter, he required frequent top ups of midazolam and propofol and became apneic with a fall in SpO2 to 80%. Although the child was immediately intubated and at the end of the procedure neuromuscular block completely reversed without any adverse sequelae. But the doses required by the child of 15 kg were really of concern. On further questioning in the postoperative period, parents revealed that child had a regular habit of consuming one cup of local drink (kallu) regularly for last 1-year. Parents told that whenever the child used to become irritable, to calm him down he was given a cup of drink by them. Palm wine is an alcoholic beverage obtained from the sweet sap of a various species of palms, as the Palmyra, date palms, and palms. It is known by various names in different parts of India like kallu in South India, palm toddy, or toddy/tadi in North India. Palm wine contains approximately 4.5% alcohol.

There is an increase in dose requirement of anesthetic agents in patients with chronic alcohol consumption.[6] It may be due to enzyme induction specifically cytochrome P-450 2E1 and may be due to the development of cross tolerance. Enzyme induction due to chronic alcoholism increases the effectiveness of detoxifying pathways and enhances the detoxification of alcohol, sedatives, and narcotics.[78] This may lead to reduced clinical response and increase in the effective doses of propofol, thiopentone and opioids, etc., Similar may be the effect which we noted in our case. These increased anesthetic requirements to keep the patient deeply sedated can be of concern in patients of cardiomyopathy, heart failure, or dehydration as it can exacerbate the risk of cardiovascular instability.

The incidence illustrates a rare and unexpected cause of increased requirement of anesthetic drugs in a pediatric patient.

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Conflicts of interest

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