Letters to the Editor
A Simple Device for Transtracheal
Ventilation
To the Editor: Failed intubation is one of the most frightening and life-threatening events in anesthesia. Knowledge and skill in the management of this event are essential to safe practice.’ During a recent teaching session in emergent artificial ventilation, we happened upon a quick, efficient method for tr-anstracheal delivery of oxygen (Oi). Our device (Figure 1) allows for simple, rapid, secure. and cost-effective assembly and use. We used Argyle (St. Louis, MO) 5 mm suction tubing intact. To one end we attached an endotracheal tube adapter (the commonly available 6.5. 7.0, and 7.5 mm sizes all work well) and
gas outlet on the anesthesia comiected ir Lo the ( ommon machine. I‘o the other end we attached a 14-gauge Luer lock intravenous (IV) catheter (with the needle removed) by simply pushing it into the suction tubing’s blue molded comjector. We then used the N-pounds-per-square-inch flush button to deliver transtracheal 0,. -1‘0 OLII-surprise, the molded ends of the suction tubing provided a secure t ~rbe adapter and connection to both the endotracheal the 14-gauge I\’ catheter. This system c-an be f‘urthei, modified to allow limited passive exhalation by cutting a small thumbhole in the suction tubing. The hole would be occluded during inhalation mtl open during exhalation. Many previous authors have described homemade devices irivol~irig connecting one end of an IV catheter to a svringe barrel and then to ;tn endotrachral tube COIInectar, and the other end to an anesthesia circuit or the COIIIIIIOII gas outlet tw means 01. some tubing.‘~: I‘hest devices were then ~lseci I0 oxygenate an apneic patient by puncturing the c~ricothyroid membrane with the 11, catheter. Although t.hese tleiices may t)e ef’f+ctive, the!, are not without limitations. (:onnecting an IL’ cathertaiand syringe barrel to an anesthetic circuit rest&s in a device that is bulky, difficult to hold, and, with so man\ interconnected parts. prone to blow apar-1 when the (ii flush button is activated. (:onnecting it to I he common gas outlet direct11 requires long rubing:, perhaps several IV extensions, w&h can be difficult to arr-arige and are prone to berome disconnected. Another ingenious device, described by Sprague;’ used capnograph tubing. Unfortunat.ely, the T-piece must be intermittently occluded to deliver 0,. This maneuver can be quite cumbersome. especially when using an anesthesia machine with the common gas outlet located toward the back of the machine. We believe that our device offers the advantage of simplicity. which can save crucial time and decrease the risk of malfunction.
Barbara Zucker-Pinchoff, MD Assistant Clinical Professor .Xssociate Director of Obstetrical Tushar Ramani, MD Anesthesiology Resident Figure 1. ‘l‘ranstracheal ventilation device. A = 14gauge intravenous catheter; B = 5 mm suction tubing; (: = endotracheal tube adapter. 342
J. Clin.
Anesth.,
vol. 4, July/August
1992
Deparunen~ .I‘he Mount New York,
:Inesthesia
of‘ i-Anesthesiology Sinai School of Medicinca NY 10029
Letters to the Editor
References
3. Meyer PD: Emergency transtrachealjet thesiology 1990;73:787-8.
I. Benumof JL, Scheller MS: The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthusioloe7. 1989;71:769-78. 2. Reich DL, Schwartz N: An easily assembled device for transtracheal oxygenation. Anesthesiology 3987;66:437.
4. Sprague DH: Transtracheal jet oxygenation from capnograph Anesthiolo~y 1990;73:788. monitoring components.
The Human Immunodeficiency
Virus: Knowledge
To the Editor: In reviewing the July/August 1991 issue of the Journal of Clinical Anrsthesiu, I was intrigued by Stevens et al’s article, “The Human Immunodeficiency Virus: Knowledge and Precautions Among Anesthesiology Personnel.“’ In view of professional and public attention to HIV, it is always surprising that adequate disease precautions are not taken by anesthesia personnel. In 1990, I had the opportunity to speak at a meeting sponsored by the University of Detroit Graduate Program in Nurse Anesthesiology. A student’s research paper in this area echoed the findings of Stevens et al. and led her to recommend that trainees be routinely evaluated on adherence to universal precautions as outlined by the Centers for Disease Control. We have since incorporated that recommendation into our clinical evaluation instrument used for student nurse-anesthetists at North Carolina Baptist Hospital. (Editor’s note: This instrument is available from the author.)
ventilation
and Precautions among Anesthesiology
system. Aries-
Personnel
While it may not be possible to break bad habits or “teach old dogs new tricks” 100% of the time through education or punitive action, perhaps evaluation will reinforce appropriate precautions in generations of anesthesia practitioners to come.
Sandra M. Maree, CRNA, MEd Program Director Nurse Anesthesia Program Bowman Gray School of Medicine University Winston-Salem, NC 27103
of Wake Forest
Reference 1. Stevens
CK, Mentis SW, Downs JB: 7‘he human immunodeficiency virus: knowledge and precautions among anesthesiology personnel. j Cl& Anesth 1991 :3:266-75.
Frequency of Anesthetic Cardiac Arrest in Infants: Effect of Pediatric Anesthesiologists
To the Editor: I read with great interest the study by Keenan et al.1 and the accompanying editorial2 on the frequency of anesthetic cardiac arrests in infants recently published in this journal. Studies such as this could have serious negative implications on the future practice of anesthesia if taken at face value. While raising an interesting question, this study is seriously flawed; therefore, any conclusions reached are not valid. The most obvious shortcoming is the fact that this is a retrospective study. This issue is addressed in the discussion but seems to be minimized. In any nonrandomized trial, the problem of hidden bias may occur-that is, the two groups being studied may differ in characteristics that have not been measured. While physical characteristics, age, and weight are important, other unmeasured variables that may have caused the two groups
to be significantly different were not mentioned. These variables can be broadly classified as those pertaining to the anesthesia providers and those pertaining to the patient or surgery. Characteristics of the anesthesia providers that may have played an important role in the frequency of cardiac arrests in the two groups include American Board of Anesthesiologists certification status, experience level (years after training) of the supervising anesthesiologists, year in training of the residents, and pediatric experience level of the certified registered nurse-anesthetists (CRNAs). All of these variables are important but were not addressed. Furthermore, when one looks at characteristics of the patient and surgery, myriad possible confounding variables arise. These include potential differences in emergency uersuS nonemergency surgeries between the two groups. Emergency operations have been shown to be J. Clin.
Anesth.,
vol. 4, July/August
1992
343
A Simple Device for Transtracheal
Ventilation
To the Editor: Failed intubation is one of the most frightening and life-threatening events in anesthesia. Knowledge and skill in the management of this event are essential to safe practice.’ During a recent teaching session in emergent artificial ventilation, we happened upon a quick, efficient method for tr-anstracheal delivery of oxygen (Oi). Our device (Figure 1) allows for simple, rapid, secure. and cost-effective assembly and use. We used Argyle (St. Louis, MO) 5 mm suction tubing intact. To one end we attached an endotracheal tube adapter (the commonly available 6.5. 7.0, and 7.5 mm sizes all work well) and
gas outlet on the anesthesia comiected ir Lo the ( ommon machine. I‘o the other end we attached a 14-gauge Luer lock intravenous (IV) catheter (with the needle removed) by simply pushing it into the suction tubing’s blue molded comjector. We then used the N-pounds-per-square-inch flush button to deliver transtracheal 0,. -1‘0 OLII-surprise, the molded ends of the suction tubing provided a secure t ~rbe adapter and connection to both the endotracheal the 14-gauge I\’ catheter. This system c-an be f‘urthei, modified to allow limited passive exhalation by cutting a small thumbhole in the suction tubing. The hole would be occluded during inhalation mtl open during exhalation. Many previous authors have described homemade devices irivol~irig connecting one end of an IV catheter to a svringe barrel and then to ;tn endotrachral tube COIInectar, and the other end to an anesthesia circuit or the COIIIIIIOII gas outlet tw means 01. some tubing.‘~: I‘hest devices were then ~lseci I0 oxygenate an apneic patient by puncturing the c~ricothyroid membrane with the 11, catheter. Although t.hese tleiices may t)e ef’f+ctive, the!, are not without limitations. (:onnecting an IL’ cathertaiand syringe barrel to an anesthetic circuit rest&s in a device that is bulky, difficult to hold, and, with so man\ interconnected parts. prone to blow apar-1 when the (ii flush button is activated. (:onnecting it to I he common gas outlet direct11 requires long rubing:, perhaps several IV extensions, w&h can be difficult to arr-arige and are prone to berome disconnected. Another ingenious device, described by Sprague;’ used capnograph tubing. Unfortunat.ely, the T-piece must be intermittently occluded to deliver 0,. This maneuver can be quite cumbersome. especially when using an anesthesia machine with the common gas outlet located toward the back of the machine. We believe that our device offers the advantage of simplicity. which can save crucial time and decrease the risk of malfunction.
Barbara Zucker-Pinchoff, MD Assistant Clinical Professor .Xssociate Director of Obstetrical Tushar Ramani, MD Anesthesiology Resident Figure 1. ‘l‘ranstracheal ventilation device. A = 14gauge intravenous catheter; B = 5 mm suction tubing; (: = endotracheal tube adapter. 342
J. Clin.
Anesth.,
vol. 4, July/August
1992
Deparunen~ .I‘he Mount New York,
:Inesthesia
of‘ i-Anesthesiology Sinai School of Medicinca NY 10029
Letters to the Editor
References
3. Meyer PD: Emergency transtrachealjet thesiology 1990;73:787-8.
I. Benumof JL, Scheller MS: The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthusioloe7. 1989;71:769-78. 2. Reich DL, Schwartz N: An easily assembled device for transtracheal oxygenation. Anesthesiology 3987;66:437.
4. Sprague DH: Transtracheal jet oxygenation from capnograph Anesthiolo~y 1990;73:788. monitoring components.
The Human Immunodeficiency
Virus: Knowledge
To the Editor: In reviewing the July/August 1991 issue of the Journal of Clinical Anrsthesiu, I was intrigued by Stevens et al’s article, “The Human Immunodeficiency Virus: Knowledge and Precautions Among Anesthesiology Personnel.“’ In view of professional and public attention to HIV, it is always surprising that adequate disease precautions are not taken by anesthesia personnel. In 1990, I had the opportunity to speak at a meeting sponsored by the University of Detroit Graduate Program in Nurse Anesthesiology. A student’s research paper in this area echoed the findings of Stevens et al. and led her to recommend that trainees be routinely evaluated on adherence to universal precautions as outlined by the Centers for Disease Control. We have since incorporated that recommendation into our clinical evaluation instrument used for student nurse-anesthetists at North Carolina Baptist Hospital. (Editor’s note: This instrument is available from the author.)
ventilation
and Precautions among Anesthesiology
system. Aries-
Personnel
While it may not be possible to break bad habits or “teach old dogs new tricks” 100% of the time through education or punitive action, perhaps evaluation will reinforce appropriate precautions in generations of anesthesia practitioners to come.
Sandra M. Maree, CRNA, MEd Program Director Nurse Anesthesia Program Bowman Gray School of Medicine University Winston-Salem, NC 27103
of Wake Forest
Reference 1. Stevens
CK, Mentis SW, Downs JB: 7‘he human immunodeficiency virus: knowledge and precautions among anesthesiology personnel. j Cl& Anesth 1991 :3:266-75.
Frequency of Anesthetic Cardiac Arrest in Infants: Effect of Pediatric Anesthesiologists
To the Editor: I read with great interest the study by Keenan et al.1 and the accompanying editorial2 on the frequency of anesthetic cardiac arrests in infants recently published in this journal. Studies such as this could have serious negative implications on the future practice of anesthesia if taken at face value. While raising an interesting question, this study is seriously flawed; therefore, any conclusions reached are not valid. The most obvious shortcoming is the fact that this is a retrospective study. This issue is addressed in the discussion but seems to be minimized. In any nonrandomized trial, the problem of hidden bias may occur-that is, the two groups being studied may differ in characteristics that have not been measured. While physical characteristics, age, and weight are important, other unmeasured variables that may have caused the two groups
to be significantly different were not mentioned. These variables can be broadly classified as those pertaining to the anesthesia providers and those pertaining to the patient or surgery. Characteristics of the anesthesia providers that may have played an important role in the frequency of cardiac arrests in the two groups include American Board of Anesthesiologists certification status, experience level (years after training) of the supervising anesthesiologists, year in training of the residents, and pediatric experience level of the certified registered nurse-anesthetists (CRNAs). All of these variables are important but were not addressed. Furthermore, when one looks at characteristics of the patient and surgery, myriad possible confounding variables arise. These include potential differences in emergency uersuS nonemergency surgeries between the two groups. Emergency operations have been shown to be J. Clin.
Anesth.,
vol. 4, July/August
1992
343
