76 Brief Review Illicit use of modem M. Yamashita MD, A. Matsuki MD, T. Oyama MD volatile anaesthetics Sixteen reported cases of abuse of modern volatile anaes- Case reports thetics are summarized. Twelve of the sixteen subjects The reported cases are summarized in the Table. died. Halothane was ingested or injected intravenously Four typical cases are presented. for s~icidal purpose, and sniffed for mood elevation. 1. Ingestion of halothane for suicidal purpose. Abuse of raodern volatile anaesthetics deserves more A 48-year-old female (patient 1) ingested 250 ml attention than it has received M the past. of halothane for suicidal purpose. The patient was comatose when brought to hospital. She vomited Key words food remains which smelled strongly of halothane. ANAESTHETICS, VOLATILE: halothane, enflurane, Cardiac arrest occurred following aspiration of the abuse. SUICIDE: vomitus. She was successfully resuscitated and mechanically ventilated, One hour and fifty minutes after admission, the patient regained consciousness and obeyed simple orders, and began to "fight" the ventilator. The endotracheal tube was removed. Drug abuse among hospital personnel ~-s especially However, one hour later, the blood pressure had anaesthesia personnel 6-8 has been identified as a fallen to 70 nunHg, consciousness was lost, and the major problem. Ward and Saidman 8 reported 325 patient was reintubated. After 36 hours of mechani- instances of narcotic abuse among anaesthesia cal ventilation, she gained consciousness. Subse- personnel, and 30 deaths secondary to drug abuse in quently, she was weaned from the ventilator and 235 confirmed cases. discharged from the hospital in two weeks. At Alcohol, narcotics, barbiturates, tranquilizers, follow ap examination, no abnormalities in liver and nitrous oxide have been implicated in these function tests were documented. 1o reports, t-s with less attention to volatile anaes- 2. Intravenous injection of halothane for suicidal thetics. purpose. Modern volatile anaesthetics have also been A 42-year-old man (patient 4) was admitted to abused, 9-j9 most commonly by operating room hospital within an hour of intravenous self-admini- personnel. 11-13"~s Several deaths due to halo- stration of 9 ml of liquid halothane. He was coma- thanr t.12.14-1s and enflurane 13 abuse have been tose and cyanotic. There were extensive crepita- reported. By reviewing these reported cases, we tions over both lung fields. The patient was treated hope to draw to the anaesthetists' attention the illi- with mechanical ventilation, with 5 cm H20 of cit use of modem volatile anaesthetics, before it PEEP. becomes beyond our control. Although his level of consciousness improved transiemly, he became hypotensive with peripheral vasoconstriction and profound sinus bradycardia, followed by asystole. Autopsy showed grossly From the Department of Anaesthesiology, Hkosaki oedematous lungs. 18 University, School of Medicine, Hirosaki, Japan. 3. Sniffing of halothane for a "high" sensation. Address correspondence to: M. Yamashita MD, A 26-year-old male anaesthetist (patient 6) was Department of Anaesthesiology, Hirosaki University, found dead in the prone position on a mattress at School of Medicine, Hirosald, 036, Japan. home. He was holding a 25 x 30 cm polyvinyl bag CAN ANAESTH SOC J 1984 i 31: I ! pp76-79 TABLE Reported eases of abuse Blood Patient Age Made of concentration Reference no. (years) Sex Occupation AgetJt administration Purpose Outcome (mgLIOOml) no. 1 48 F ? Halotharte Ingestion Suicide Recovered ] 0 2 28 M ? Halothane Ingestion Suicide Recovered 10 3 19 M Hospital employee Halothane Ingestion Suicide Died 65 14 4 42 M ? Halothai~ Intravenous injection Died 0.79 18 5 42 M Surgeon Halothane Sniffing Mood elevation Died 11 6 26 M Anaesthetisl Halothane Sniffing Mood elevation Died 20 11 7 24- M OR technician H~lothane Sniffing Died 15 8 28 M ER technician Halothane Sniffing Died 15 9 22 M OR technician Halothane Sniffing Died 15 10 21 M ? Halothane Sniffing Died 16, 17 11 20 M Navy corpsman Halothane Sniffing (?) Died 16, 17 12 19 M ? Halothanc Open-drop Died 20 9 13 25 F OR technician Halothane Sniffing Mood elevation Died 12 14 25 F OR technician Halothane Sniffing Recovered 12 15 23 F OR technician Halothane Sniffing Recovered 12 ] 6 29 F Student nurse Enflurane Topical application Treatnaent of Died 13 anaesthetist Herpes Simplex Labialis 78 CANADIAN ANAESTHETISTS ' SOCIETY JOURNAL with a gauze pad in it at his mouth. He was a known sedatives;6 however, it can be predicted that this alcoholic and halothane abuser. The halothane incidence of abuse of volatile anaesthetics will concentration in the blood at autopsy was 20rag/ increase. Abuse of narcotics and sedatives is now 100ml. II widely known, and strict control of these drugs will 4. Misuse of enflurane. force the abusers to seek alternative drugs. They A 29-year-old student nurse anaesthetist (patient may find halothane or enflurane good alternatives, 16) obtained a full 250 ml bottle of enflurane and for since at present volatile anaesthetics are not care- the next three hours was observed with a gauze pad fully controlled, and practically anyone in an to which she had applied the enflurane. She believed operating room can remove a bottle of halothane or that the topical application of enflurane might cure enflurane. Nitrous oxide has been widely abused, herpes simplex on her lower lip. About an hour especially among dentists, and student dentists,4'~ later, she was found in a women's rest room but the volatile anaesthetics, packaged in small slumped over while sitting on a commode. Her bottles, are much easier to carry away than a heavy forearms were crossed on her knees and her head nitrous oxide cylinder. rested on her forearms over her lap. The enflurane The danger of abuse of modem volatile anaes- bottle was empty. Resuscitation was unsuccessful. thetics requires careful control of drugs, As Spencer Autopsy findings were normal except that appre- and Raasch 16'17 state, it is important that every ciable amounts of enflurane were found in the skin, effort be made to prevent future deaths from abuse gastric contents, blood and lung. t3 of modem volatile anaesthetics. First, everyone associated with the clinical use of these agents must Discussion be aware of the potential for abuse and the occur- Halothane was ingested for suicidal purpose by rence of sudden death during abuse. Secondly, an three patients (1,2, 3) and injected intravenously by educational effor~ should be made to acquaint patient 4. Patients 1 and 2 ingested 250 mt of medical personnel with the danger of abuse of these halothane, but recovered, while patient 3 ingested agents. Thirdly, access to these drugs should be only 35 ml but died. This suggests that even when a restricted to anaesthetists for their immediate use. patient has ingested 250 ml of halothane, if the Abuse of modern volatile anaesthetics deserves timing and treatment are appropriate, survival is more attention than it has received in the past. possible. Absorption of halothane continues from the gastrointestinal tract, therefore mechanical Addendum hyperventilation, hastening pulmonary elimination Since completion of this review, an additional case of halothane must be instituted. 1~ Intravenously has been reported. A 35-year old hospital technician injected halothane is very toxic, damages pulmo- ingested halothane and lapsed into coma. He nary vessels and leads to acute pulmonary oedema recovered uneventfully following intensive suppor- and death. In'2~ tive care. Some subjects sniffed halothane in order to get a "high" sensation~ 11 , 12 Several died, probably due to (Wig J, Chakravarty S, Krishnanmrthy K, Mehla D airway obstruction or cardiac arrhythmias.l 1.15-17,19 Coma following ingestion of halothane. Its successful Habitual sniffing of halothane has been reported to management. Anaesthesia 1983; 38: 552-5.) induce "hepatitis", 12 and a death due to hepatic failure. 12 We must pay more attention to the illicit use of References volatile anaesthetics, since in addition to these case 1 AMA Counci! on Mental Health. The sick physician- reports of abuse, numerous unreported cases likely impairment by psychiatric disorders, including alco- exist. Most of the reported abusers are hospital- holism and drug dependence. JAMA 1973; 223: related personnel, such as operating-room tech- 684-7. nicians, emergency-room technicians, student nurse 2 Bressler B. Suicide and drag abuse in the medical anaesthetists, surgeons, and anaesthetists. The cur- community. Suicide Life Threat Behav 19761 6: rent incidence of abuse of volatile anaesthetics 169-78. appears low compared to abuse of narcotics or 3 GreenRC, Jr, CarroltJG, Buxton WD. Drug addle- Yamasbita elal.: ILLICIT USE OF MODERN VOLATILE ANAESTHETICS 79 tion among physicians. The Virginia experience. Rtsum6 3AMA 1976; 236: 1372-5. On rapporte 16 cas d'abus d'agents anesth3siques 4 Rosenberg 1t, Orkin FK, Springstead J. Abuse of volatils modernes. Douze des 16 patients sont ddcdd~s. nitrous oxide. Anesth Analg 1979; 58: 104-6. L'halothane a 3t~ ingdr~ ou auto-inject3 par vole intra- 5 Paulson GW. "Recreational" misuse of nitrous veineuse dans un but suicidaire ou inhal~ pour provoquer oxide. ~I Am Dent Assoc i979; 98: 410-1. une sensation de bien-drre. On pense que l'abus des 6 Gravenstein JS, Kory WP, Mark.~ RG. Drag abuse agents d'inhalation modernes m3rite plus d'attention by anesthesia personnel. Anesth Analg 1983; 62: qu'il ne lui en a dt~ accord3 duns le passe. 467-72. 7 Farley WJ, Talbott GD. Anesthesiology and addic- tion~ Anesth Analg t983; 62:465-6 8 WardCF, SaidmanLt. Controllcdsabstancesabuse: a survey of training programs 1970-1980; final results and comment. Anesthesiology 1981; 55: A346. 9 Block S. Rosenblatt R. A halothane-abuse fatality. Anesthesiology 1980; 52: 524. 10 Curelaru l, Stanciu ST, Nicolau V, Fuhrer H, llliescu M. A case of recovery, from coma produced by the ingestion of 250 rrd of halothane.