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Year : 2017  |  Volume : 61  |  Issue : 10  |  Page : 849-850  

Nil per oral instructions in chronic tobacco chewers: Are they enough?

Department Anaesthesiology, Sanjay Gandhi Postgraduate of Medical Sciences, Lucknow, Uttar Pradesh, India

Date of Web Publication12-Oct-2017

Correspondence Address:
Amit Rastogi
1/131, VipulKhand, Gomti Nagar, Lucknow - 226 010, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_262_17

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How to cite this article:
Rastogi A, Supriya, Sahu S, Haldar R. Nil per oral instructions in chronic tobacco chewers: Are they enough?. Indian J Anaesth 2017;61:849-50

How to cite this URL:
Rastogi A, Supriya, Sahu S, Haldar R. Nil per oral instructions in chronic tobacco chewers: Are they enough?. Indian J Anaesth [serial online] 2017 [cited 2020 Dec 1];61:849-50. Available from: https://www.ijaweb.org/text.asp?2017/61/10/849/216666


Tobacco has been used in India for centuries now and as of today, several products made of (or containing) tobacco are available in the Indian market. Smokeless tobacco (SLT) is available in different forms in India, such as khaini, gutkha, panmasala, mawa, etc. The Global Adult Tobacco Survey conducted in India in 2009–2010 involving those above 15 years of age revealed that SLT was the most common form of tobacco used in India. Prevalence of SLT use was 26% (33% of men and 18% of women) and that of daily use was 21%. The average age of initiation to SLT was 17.9 years which was similar to that for smoking.[1]

We present two patients posted for surgery who were SLT users and how their addiction could have led to life-threatening complications in the perioperative period.

Our first patient was a 22-year old female posted for emergency caesarean section (CS). An urgent pre-anaesthetic check-up was done which was unremarkable. We planned CS under subarachnoid block. After delivery of the baby, while the peritoneum was being sutured, the patient complained of nausea and she was offered a bowl to vomit in. To our surprise, the patient spat pan masala (a form of SLT) in the bowl which she had kept silently in her mouth all throughout the surgery. When questioned regarding the pan masala and breach of strict instructions to follow the nil per oral (NPO) orders, she replied that she had 'only kept it in her mouth and did not ingest it'.

Another patient was a 54-year- old male posted for diabetic foot debridement under ankle block. He too was a chronic tobacco chewer. The patient was taken into operating room (OR) and ankle block was administered; however it proved ineffective and we decided to proceed with general anaesthesia with laryngeal mask airway (LMA). After induction of general anaesthesia, when the patient's mouth was opened for LMA placement, we found khaini (a form of SLT) in vestibule of the lower lip. Immediately, khaini was removed and check laryngoscopy was done to examine the oral cavity. Check laryngoscopy revealed clear oral cavity, and thereafter, the LMA was inserted and surgery proceeded. In tpost-operative period, when we enquired from this patient regarding his non-compliance of the NPO instructions, his reply was almost similar to the first patient 'that he did not ingest the SLT and had just kept it in the mouth there by maintaining his NPO status'.

In India, a large proportion of the population chews tobacco, and the preponderance of this habit is found in the lower socio economic strata irrespective of age and gender. It is not uncommon that even after our strict advice to patients to maintain NPO status during a pre-anaesthetic check-up, some patients may continue consumption of SLT. Nicotine in SLT is absorbed through the mucosa and has a rapid onset of action. Nicotine of SLT also causes irritation of oral mucosa and increased salivation which might interfere with airway management; antisialogogues may be needed in SLT users. Nicotine causes increase in catecholamine level in the blood and reduced coronary blood flow.[2],[3] Oral nicotine also delays gastric emptying, and intragastric nicotine at and above neutral pH appears to have a mild stimulating effect on gastric acid output, while cigarette smoking suppresses acid output.[4]

It is therefore necessary for the attending anaesthesiologist to convey clearly to the SLT users in their local language 'not to consume any type of SLT' while explaining the NPO status. The main intention of writing this article is to make people aware that NPO status means 'nothing from mouth and also nothing in mouth'. We also want to emphasise about a routine oral cavity check before wheeling SLT addicts into OR to avoid similar incidences.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Gupta PC, Arora M, Sinha D, Asma S, Parascondola M. Smokeless Tobacco and Public Health in India an Executive Summary. Available from: http://www.searo.who.int/india/tobacco/smokeless_tobacco_and_public_health_in_india.pdf?ua=1. [Last accessed on 2017 Jun 27].  Back to cited text no. 1
Saha U. Tobacco interventions and anaesthesia – A review. Indian J Anaesth 2009;53:618-27.  Back to cited text no. 2
[PUBMED]  [Full text]  
Mishra A, Chaturvedi P, Datta S, Sinukumar S, Joshi P, Garg A, et al. Harmful effects of nicotine. Indian J Med PaediatrOncol 2015;36:24-31.  Back to cited text no. 3
Ivey KJ, Triggs EJ. Absorption of nicotine by the human stomach and its effect on gastric ion fluxes and potential difference. Am J Dig Dis 1978;23:809-14.  Back to cited text no. 4


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