Halothane: the last word?

SIR Ð I would appreciate Dr Harry Wark's opinion as a leading authority on inhalational anaesthetics. After the publication of our editorial containing criticisms of sevōurane (1), we have been under considerable pressure from colleagues in paediatric anaesthesia who we feel are campaigning to attack our credibility. Anaesthesia literature contains scienti®cally questionable statements such as `the superior pharmacology of sevo ̄urane' and also many colleagues are afraid to use halothane because of possible medicolegal consequences if a causal relationship with halothane anaesthesia and jaundice should occur. We read, with a great deal of satisfaction, the Editorial by Wark on the use of halothane in paediatric anaesthesia (2) because it coincides exactly with our views. Our clinical experience leads us to use halothane more frequently again for patients with irritable airways in spite of accusations from manufacturers that we are exposing children to liver damage with its use. There were vehement discussions on the same topic when en ̄urane was ®rst introduced into clinical practice. At my hospital, we rely on the authority of the investigations of Wark (3) rather than the case reports of Hals et al. and Whitburn et al. (4,5) and the editorial by Walton (6). From our clinical practice, we are convinced that halothane is safe in prepubertal children since we have not had a single case of hepatitis in 120 000 cases of which more than 2000 were repeated halothane anaesthetics. We have been unnerved by the opinion of Murat (7) which suggests that if we use halothane in childhood we are exposing the patients to possible liver damage later in life if there is a repeated exposure to an inhalational agent. We agree with Donelly that there is no scienti®c evidence for this view (8). On the other hand, we are increasingly concerned about the side-effects of sevo ̄urane on the central nervous system. In 1997, we looked at more than 400 children randomized to receive halothane or sevo ̄urane and found a higher incidence of emergence delirium in the sevo group. We also have the reports of 15 parents who are mostly paediatric nurses who describe personality changes in their children for several days postoperatively, but with a sudden change back to normal. We also observed two greatly agitated infants in our PICU after exposure to sevo ̄urane where the nurses thought the patients might be brain damaged. The recovery room nurses continue to complain about the high incidence of emergence delirium even in patients with good pain relief. We also had two patients who developed convulsions and board-like rigidity during sevo ̄urane induction, one of which desaturated before venous access could be established. The important question still remains. Is halothane safe in prepubertal children, even with repeated exposure?