Page 146 - JSOM Summer 2018

Ether, like any drug, has both pros and cons associated with its support a population of 60 million people, whereas Uganda
use. The major drawback with ether has always been its high had 13 anesthesiologists and 330 other anesthesia providers
flammability, which led to the preferred use of the newer inha- supporting a population of 27 million. 10
lational anesthetics (e.g., halothane, isoflurane, sevoflurane).
5
Ether burns clear; if ignited, it produces invisible flames. Cost and Training
9
Hence, ether’s production and storage remain major concerns. The lack of funding available in developing countries often rules
It is not recommended in any situation that you try to create out the availability of advanced inhalational anesthetics, com-
your own ether: Just say no to such YouTube videos. Ether is plicated vaporizer machines that require supplemental air flow,
heavier than air and will settle on and travel across the ground, and expensive monitoring modalities common in the developed
possibly finding an ignition source, such as open flame or elec- world. This leads to less complicated and less expensive dra-
tric cautery. Ether reacts to light, which causes the formation wover vaporizer systems. Therefore, the less expensive inhala-
9
of peroxide crystals over time that are highly volatile and ex- tional anesthetics that are also drawover capable are ether and
plosive. Therefore, ether originally was stored in tin cans and, halothane. A liter of halothane costs $140, whereas the same
later, in dark amber jars to prevent the peroxide crystal forma- amount of ether costs $10. Halothane and ether can be deliv-
2
tion. Ether’s high lipid solubility leads to a slow uptake; it may ered through a simple drawover; however, halothane depresses
6
take 10–15 minutes to induce anesthesia in a patient using an cardiac output and respiratory drive, and so requires supple-
open drop mask method and will take longer to wear off, espe- mental oxygen and advanced cardiac monitoring to be delivered
cially the longer the patient is under ether anesthesia. Ether has safely. In most developing areas, these tools will not be present.
a high incidence of nausea and vomiting, even during Guedel’s New recommendations for the widespread distribution and use
stage II. Ether is pungent and irritates the airway, which may of ether in the developing world to decrease cost and increase
cause excessive secretions requiring pretreatment with atropine safety improve the probability of finding ether in these areas.
or glycopyrrolate, when possible.
Practice
The advantages of ether include its safe delivery in less-experi-
enced hands; measurable anesthesia levels (i.e., Guedel’s stages Before performing anesthesia or sedation with ether, good
of anesthesia); ease of delivery (e.g., open drop mask method, preparation is required. Patient monitoring concerns are al-
ether jar); bronchodilation; stimulation of respirations, sym- ways present. The MSMAID mnemonic—machine, suction,
pathomimetic, and analgesic; and the fact that it is a complete monitors, airway, intravenous, drugs—should be followed as
anesthetic. Ether stimulates the sympathetic nervous system much as possible, even in austere environments. Machine, in
2
much like ketamine, which maintains blood pressure and heart this case, is the mask or, hopefully, a way to give a positive
rate even at much deeper stages of anesthesia. Thus, ether has a pressure breath. Suction may be as simple as a turkey baster
safe profile: Apnea occurs long before cardiovascular collapse. to remove secretions from the airway, which are associated
Chloroform, on the other hand, is characterized by apnea and with the adverse effects of nausea and vomiting associated
cardiovascular collapse occurring in rapid succession; this led with ether use. Monitors are important as well. A pulse ox-
to chloroform falling out of favor due to many reported anes- imeter, if available, is vital; however, never forget that the
thetic deaths. The fact that ether causes respiratory stimulation most important monitor is you, the provider, and your ob-
and bronchodilation, while not optimal, allows for the safe ad- servation of the physical signs described by Guedel. Airway
ministration of ether without supplemental oxygen. 2 supplies range from the simplest to more advanced, and
intravenous or interosseous access is suggested, if possible.
Ether by itself provides analgesia, during and, for a time, after Useful drugs, in addition to ether, include antinausea drugs
the ether delivery has been completed. Finally, ether provides such as ondansetron, and antisialagogues such as atropine or
muscle relaxation for surgical procedures, especially at the glycopyrolate.
stage III, plane III level. The amnesia, analgesia, and muscle re-
laxation that ether provides while maintaining cardiovascular Methods of Delivery
stability led to ether being referred to as a complete anesthetic.
Open drop mask method
The open drop mask method requires creating a circular wire
Application
holder, similar to a Schimmelbusch mask (Figure 3), to hold
Developing Countries four to six 4 × 4 gauze pads for placement over the mouth and
Ether remained the standard for general anesthesia until the
1960s and 1970s, when the fluorinated hydrocarbons halo- FIGURE 3 Schimmelbusch mask.
thane, isoflurane, and sevoflurane were developed. These new
agents negated the flammability concern and reduced the inci-
dence of nausea and vomiting. However, they are expensive to
produce and include a host of additional complicated problems,
leading to the need for more advanced monitoring systems.
2
The simplicity and safety of ether methods were replaced with
complicated vaporizer systems and monitors. These systems
are expensive and require more training for the provider to ad-
minister anesthesia safely. With the developing countries of the Courtesy of Christie Morgans Photography.
world not having the money or training modalities to support
modern methods of administering anesthesia, they have tended
to use older techniques. A 2007 study showed that the United
Kingdom had approximately 12,000 anesthesia providers to

144 | JSOM Volume 18, Edition 2/Summer 2018