Letters to Editor
Endotracheal Intubation Challenges to Oral Cavity – Prevention Strategy Sir, Emergency endotracheal intubation and less experienced staff probably increase the chance of traumatizing hard and soft oral tissues. Intraoral manipulation is necessary during general anesthesia involving endotracheal intubation during many craniofacial and maxillofacial surgeries. With reference to an excellent article published in your esteemed journal regarding treatment of Vallecular Cyst Using Conventional Laparoscopic Instruments,[1] I would like to add some vital information regarding endoscopic intubation challenges. Although laryngoscopy is a safe procedure and complications rarely occur, intraoral manipulation can produce damage to soft and hard tissues of the oral cavity, patient discomfort, and postoperative pain.[2,3] In Pediatrics, the more frequently studied lesions occurred during placement of the tracheal tube are dental traumas, with an incidence ranging from one case in 150 intubations to one in 2805 intubations.[4] In addition to forceful intubation or extubation, vigorous suctioning of posterior teeth, pressure‑induced damage to the adjacent tissues by insertion of the laryngeal mask airway (LMA), masseteric spasm derived by hypothermic‑induced shivering and biting forces against antagonist teeth or endotracheal tube (ETT) should all be taken into account. Hence, intubation, extubation and suctioning should be performed with great care. If the child has a loose tooth and avulsion or aspiration is deemed, a careful suturing of the affected tooth to the adjacent sound tooth just around the crown of the teeth may prevent avulsion and aspiration.[5] During the preoperative assessment, the anesthetist should enquire about loose teeth, unstable crowns, veneers, bridgework and any intra‑oral prostheses (dentures or orthodontic appliances). The patient should be warned about the potential for dental damage and its incidence, and any particular risk factors, either anesthetic or dental, should be identified and explained to the patient. Following an incident of perioperative dental damage, the goal is to obtain an immediate assessment and provide a fair
reimbursement for treating the injury. More detailed and comprehensive teaching courses for subspecialty fellows or nurses involved in critically ill pediatric patient care may warrant more professional insight into the different stages of dentitions, endotracheal intubation complications concerning hard and soft oral tissue damages and management options for when traumatic injury happens. The above‑mentioned details could help an oral surgeon and anesthetist in overcoming any dental hazards and a promising treatment pattern during surgery. Preetinder Singh, Samir Anand1
Department of Periodontology and Oral Implantology, SDD Hospital and Dental College, Barwala, Haryana, 1 Rayat and Bahra Dental College, Kharar, Mohali, chandigarh, Punjab, India. E‑mail: [email protected]
REFERENCES 1. Parelkar SV, Patel JL, Sanghvi BV, Joshi PB, Sahoo SK, Sampat N, et al. An Unusual Presentation of Vallecular Cyst with near Fatal Respiratory Distress and Management Using Conventional Laparoscopic Instruments. J Surg Tech Case Report 2012;4:118‑20. 2. Sowmya B, Raghavendra P. Management of dental trauma to a developing permanent tooth during endotracheal intubation. J Anaesthesiol Clin Pharmacol 2011;27:266‑8. 3. Ramesh S, Jayanthi R, Archana SR. Paediatric airway management: What is new?. Indian J Anaesth 2012;56:448‑53. 4. Souza N, Carvalho WB. Complications of tracheal intubation in pediatrics. Rev Assoc Med Bras. 2009;55:646-50. 5. Yasny JS. Perioperative dental considerations for the anesthesiologist. Anesth Analg 2009;108:1564‑73.
Access this article online Quick Response Code:
Website: www.jstcr.org
DOI: 10.4103/2006-8808.147265
A Useful Adjunct in Lower Limb Surgery Sir, Traditionally in certain cases for instance in plastic surgery, SHOs are tasked with harvested skin grafts, applying plaster casts and closing donor sites, as well as providing important assistance in the retraction of 70
tissues. As SHOs are less commonly seen in the theater compared to bygone years. [1] The senior author has developed a novel and useful technique for performing surgery in areas where typically an SHO could provide useful assistance [Figures 1-3].
Journal of Surgical Technique and Case Report | Jul-Dec 2014 | Vol-6 | Issue-2
Letters to Editor
Figure 1: A sharps bin
Figure 2: Sharps bin placed in sterile mayo cover
where assistance may be needed. Not having juniors present adds to operating time, limits training and teaching opportunities and also increases the operating surgeon’s fatigue.[1] This adjunct can aide better positioning for the lower limb and facilitates safe[2] and efficient surgery. Zeeshan Ahmad, Marcus J Davies1
Department of Plastic Surgery, UHCW, Coventry, Warks, CV2 2BF, 1Department of Plastic Surgery, QVH, East Grinstead, East Sussex, UK. E-mail: [email protected]
REFERENCES Figure 3: Bin placed under lower limb for better exposure, support and positioning
Through use of a sterile Mayo cover, an empty, un‑used sharps bin is placed into it. The surgeon then wraps the bin in the cover such that full sterility in maintained. The device can then be used to prop up legs or arms when performing surgery with the knowledge that the limb is elevated and secure, whilst maintaining good surgical access in a sterile fashion.
1. 2.
Ahmed M, Arora S, Tiew S, Hayden J, Sevdalis N, Vincent C, et al. Building a safer foundation: The lessons learnt patient safety training programme. BMJ Qual Saf 2014;23:78‑86. Five Steps to Safer Surger y, National Patient Safety Agency. Available from: http://www.patientsafetyfirst.nhs.uk/ashx/Asset. ashx?path=/How‑to‑guides‑2008‑09‑19/NRLS‑1291‑How_to_guide_ fi ~ urgery‑2010.12.20‑v1%5B1%5D.pdf. [Last accessed on 20 Sep 2013]. Access this article online Quick Response Code:
Website: www.jstcr.org
DOI: 10.4103/2006-8808.147266
Having juniors in theater is very important for the future of the surgery, as well as for the operating surgeon, especially
Use of Labels on Local Anaesthetic Syringes Sir, Using local anesthetic particularly in high‑turnover surgery such as day‑case local anesthetic lists (skin cancer and hand surgery) for anesthesia, blood‑less fields (with adrenaline) and post‑operative pain relief are common practice. Local and regional anesthetic allows
high turnover, arguably safer and more resource efficient approach to such surgery and also enables patients to have a relatively pain free recovery in the first few hours of the post‑operative period. However using local anesthetic is not free from risk. Side‑effects including circumoral tingling, dizziness and palpitations are just some of the
Journal of Surgical Technique and Case Report | Jul-Dec 2014 | Vol-6 | Issue-2
71
Copyright of Journal of Surgical Technique & Case Report is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Endotracheal Intubation Challenges to Oral Cavity – Prevention Strategy Sir, Emergency endotracheal intubation and less experienced staff probably increase the chance of traumatizing hard and soft oral tissues. Intraoral manipulation is necessary during general anesthesia involving endotracheal intubation during many craniofacial and maxillofacial surgeries. With reference to an excellent article published in your esteemed journal regarding treatment of Vallecular Cyst Using Conventional Laparoscopic Instruments,[1] I would like to add some vital information regarding endoscopic intubation challenges. Although laryngoscopy is a safe procedure and complications rarely occur, intraoral manipulation can produce damage to soft and hard tissues of the oral cavity, patient discomfort, and postoperative pain.[2,3] In Pediatrics, the more frequently studied lesions occurred during placement of the tracheal tube are dental traumas, with an incidence ranging from one case in 150 intubations to one in 2805 intubations.[4] In addition to forceful intubation or extubation, vigorous suctioning of posterior teeth, pressure‑induced damage to the adjacent tissues by insertion of the laryngeal mask airway (LMA), masseteric spasm derived by hypothermic‑induced shivering and biting forces against antagonist teeth or endotracheal tube (ETT) should all be taken into account. Hence, intubation, extubation and suctioning should be performed with great care. If the child has a loose tooth and avulsion or aspiration is deemed, a careful suturing of the affected tooth to the adjacent sound tooth just around the crown of the teeth may prevent avulsion and aspiration.[5] During the preoperative assessment, the anesthetist should enquire about loose teeth, unstable crowns, veneers, bridgework and any intra‑oral prostheses (dentures or orthodontic appliances). The patient should be warned about the potential for dental damage and its incidence, and any particular risk factors, either anesthetic or dental, should be identified and explained to the patient. Following an incident of perioperative dental damage, the goal is to obtain an immediate assessment and provide a fair
reimbursement for treating the injury. More detailed and comprehensive teaching courses for subspecialty fellows or nurses involved in critically ill pediatric patient care may warrant more professional insight into the different stages of dentitions, endotracheal intubation complications concerning hard and soft oral tissue damages and management options for when traumatic injury happens. The above‑mentioned details could help an oral surgeon and anesthetist in overcoming any dental hazards and a promising treatment pattern during surgery. Preetinder Singh, Samir Anand1
Department of Periodontology and Oral Implantology, SDD Hospital and Dental College, Barwala, Haryana, 1 Rayat and Bahra Dental College, Kharar, Mohali, chandigarh, Punjab, India. E‑mail: [email protected]
REFERENCES 1. Parelkar SV, Patel JL, Sanghvi BV, Joshi PB, Sahoo SK, Sampat N, et al. An Unusual Presentation of Vallecular Cyst with near Fatal Respiratory Distress and Management Using Conventional Laparoscopic Instruments. J Surg Tech Case Report 2012;4:118‑20. 2. Sowmya B, Raghavendra P. Management of dental trauma to a developing permanent tooth during endotracheal intubation. J Anaesthesiol Clin Pharmacol 2011;27:266‑8. 3. Ramesh S, Jayanthi R, Archana SR. Paediatric airway management: What is new?. Indian J Anaesth 2012;56:448‑53. 4. Souza N, Carvalho WB. Complications of tracheal intubation in pediatrics. Rev Assoc Med Bras. 2009;55:646-50. 5. Yasny JS. Perioperative dental considerations for the anesthesiologist. Anesth Analg 2009;108:1564‑73.
Access this article online Quick Response Code:
Website: www.jstcr.org
DOI: 10.4103/2006-8808.147265
A Useful Adjunct in Lower Limb Surgery Sir, Traditionally in certain cases for instance in plastic surgery, SHOs are tasked with harvested skin grafts, applying plaster casts and closing donor sites, as well as providing important assistance in the retraction of 70
tissues. As SHOs are less commonly seen in the theater compared to bygone years. [1] The senior author has developed a novel and useful technique for performing surgery in areas where typically an SHO could provide useful assistance [Figures 1-3].
Journal of Surgical Technique and Case Report | Jul-Dec 2014 | Vol-6 | Issue-2
Letters to Editor
Figure 1: A sharps bin
Figure 2: Sharps bin placed in sterile mayo cover
where assistance may be needed. Not having juniors present adds to operating time, limits training and teaching opportunities and also increases the operating surgeon’s fatigue.[1] This adjunct can aide better positioning for the lower limb and facilitates safe[2] and efficient surgery. Zeeshan Ahmad, Marcus J Davies1
Department of Plastic Surgery, UHCW, Coventry, Warks, CV2 2BF, 1Department of Plastic Surgery, QVH, East Grinstead, East Sussex, UK. E-mail: [email protected]
REFERENCES Figure 3: Bin placed under lower limb for better exposure, support and positioning
Through use of a sterile Mayo cover, an empty, un‑used sharps bin is placed into it. The surgeon then wraps the bin in the cover such that full sterility in maintained. The device can then be used to prop up legs or arms when performing surgery with the knowledge that the limb is elevated and secure, whilst maintaining good surgical access in a sterile fashion.
1. 2.
Ahmed M, Arora S, Tiew S, Hayden J, Sevdalis N, Vincent C, et al. Building a safer foundation: The lessons learnt patient safety training programme. BMJ Qual Saf 2014;23:78‑86. Five Steps to Safer Surger y, National Patient Safety Agency. Available from: http://www.patientsafetyfirst.nhs.uk/ashx/Asset. ashx?path=/How‑to‑guides‑2008‑09‑19/NRLS‑1291‑How_to_guide_ fi ~ urgery‑2010.12.20‑v1%5B1%5D.pdf. [Last accessed on 20 Sep 2013]. Access this article online Quick Response Code:
Website: www.jstcr.org
DOI: 10.4103/2006-8808.147266
Having juniors in theater is very important for the future of the surgery, as well as for the operating surgeon, especially
Use of Labels on Local Anaesthetic Syringes Sir, Using local anesthetic particularly in high‑turnover surgery such as day‑case local anesthetic lists (skin cancer and hand surgery) for anesthesia, blood‑less fields (with adrenaline) and post‑operative pain relief are common practice. Local and regional anesthetic allows
high turnover, arguably safer and more resource efficient approach to such surgery and also enables patients to have a relatively pain free recovery in the first few hours of the post‑operative period. However using local anesthetic is not free from risk. Side‑effects including circumoral tingling, dizziness and palpitations are just some of the
Journal of Surgical Technique and Case Report | Jul-Dec 2014 | Vol-6 | Issue-2
71
Copyright of Journal of Surgical Technique & Case Report is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
