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Year : 2019  |  Volume : 20  |  Issue : 1  |  Page : 52-53

“Gul addiction” a challenge for the anesthesiologists

Department of Anaesthesiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Web Publication6-May-2019

Correspondence Address:
Dr. Sapna Bathla
H. No. 88, 2nd Floor, C Block, Lajpat Nagar, Delhi - 110 024
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/TheIAForum.TheIAForum_59_18

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How to cite this article:
Choudhuri P, Bathla S, Nayar P, Rana P. “Gul addiction” a challenge for the anesthesiologists. Indian Anaesth Forum 2019;20:52-3

How to cite this URL:
Choudhuri P, Bathla S, Nayar P, Rana P. “Gul addiction” a challenge for the anesthesiologists. Indian Anaesth Forum [serial online] 2019 [cited 2023 Jun 2];20:52-3. Available from: http://www.theiaforum.org/text.asp?2019/20/1/52/257683


Tobacco, one of the most common forms of substance abuse, causes wide-spread spectrum of health hazards. It is available both in smoking and smokeless forms. Smokeless tobacco (SLT) is very popular because of its wide availability, low cost, the misconception of having its medicinal benefits and the belief of having relatively harmless effects in comparison to smoking tobacco.[1] Evidence suggests SLT contains more nicotine than smoking tobacco.[2] “Gul” is a form of SLT mainly used for providing relief in toothache. It contains powdered tobacco leaves, molasses, and other ingredients.[3]

A 69-year-old, 70 kg male with “benign prostatic hyperplasia” was posted for “transurethral resection of prostate” surgery. The patient was a known hypertensive on tablet telmisartan (40 mg) with a 2-year-old history of cerebrovascular accident with residual right-sided weakness and slurring of speech. He had quit alcohol for the past 2 years. Magnetic resonance imaging brain showed ischemic changes in the deep periventricular and bilateral frontoparietal region. Other investigations and vitals were within normal limits.

After taking informed consent and confirming adequate fasting, the patient was brought to the operating theater where monitors were attached, and intravenous access was secured. Considering patient's neurodeficits, general anesthesia was preferred. After preoxygenation and premedication with intravenous midazolam (0.02 mg/kg) and fentanyl citrate (1.5 μg/kg), induction was attempted with intravenous etomidate 0.3 mg/kg. However, the patient could not be induced. Then, etomidate was given up to a total dose of 40 mg along with inhalation of sevoflurane. Induction was not successful, though the hemodynamic profile was stable. The procedure was abandoned for further evaluation. Discreet questioning revealed patient's addiction to “Gul” which he used six to seven times a day for a toothache for the past 5 years. Neurophysician documented his motor power as four out of five (right side) and five out of five (left side) with normal sensory function.

Two weeks after, the patient was rescheduled, but the plan of anesthesia was changed to subarachnoid block in view of the previous anesthetic history. Subarachnoid block was given at L3–L4 level with 11 mg hyperbaric bupivacaine with 10 mg of fentanyl in the left lateral position. The height of subarachnoid block was attained up to T10, and the whole procedure went uneventfully.

The nicotine component of SLT causes catecholamine release and increases atherogenesis. It interacts with nicotinic acetylcholine receptors and stimulates dopaminergic transmission, which is responsible for mood elevation.[4] Chronic stimulation by nicotine causes desensitization of GABAergic neurons.[5] This might have been the reason behind induction failure as etomidate acts at GABAA receptor enhancing the inhibitory effects on neurotransmission. Any mode of induction of anesthesia bypassing the GABAergic pathway could be an option; as in this case, the subarachnoid block was found to be successful. After extensive literature search, very limited information could be extracted on Gul. The general population does not consider Gul to have addiction potential like smoking tobacco resulting in nondisclosure of it during preanesthetic evaluation. Hence, any history of addiction to SLT should be emphasized as a separate entity during preanesthetic evaluation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


Authors would like to thank all doctors of the department of Urosurgery, Department of Neuromedicine and the patient and his relatives.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Siddiqi K, Dogar O, Rashid R, Jackson C, Kellar I, O'Neill N, et al. Behaviour change intervention for smokeless tobacco cessation: Its development, feasibility and fidelity testing in Pakistan and in the UK. BMC Public Health 2016;16:501.  Back to cited text no. 1
Available from: http://www.nlm.nih.gov/medlineplus/smokelesstobacco.html/. [Last accessed on 2007 Jul 14].  Back to cited text no. 2
Sinha DN, Bajracharya B, Khadka BB, Rinchen S, Bhattad VB, Singh PK, et al. Smokeless tobacco use in Nepal. Indian J Cancer 2012;49:352-6.  Back to cited text no. 3
[PUBMED]  [Full text]  
US Department of Health and Human Services. Mental Health. Available from: http://www.samhsa.gov/data/2k12/MHUS2010/MHUS-2010.pdf. [Last accessed on 2014 Sep 27].  Back to cited text no. 4
Mansvelder HD, McGehee DS. Cellular and synaptic mechanisms of nicotine addiction. J Neurobiol 2002;53:606-17.  Back to cited text no. 5


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