CORRESPON DENCE
Accidents in endotracheal intubation To the editor: Dr. N. Jackson begins his communication (Can Med Assoc J 118: 483, 1978) with a strange statement: "Tracheal stenosis is probably the most common complication of endotracheal intubation, and its prevention by the use of a tube equipped with an atraumatic umbrella valve has been advocated . . While subglottic edema and narrowing can occur in infants after prolonged nasotracheal intubation, in a lifetime of busy anesthetic practice I have never seen a case of tracheal stenosis following routine intubation. Surely a sore throat is the commonest complication one sees after an anesthetic tube has been passed. Is Dr. Jackson perhaps thinking of tracheal stenosis following tracheostomy? At any rate I fail to see what connection it has with the peculiar account of airway obstruction due to a spiral slit in a bent endotracheal tube. After induction and intubation following an injection of succinylcholine Dr. Jackson gave a long-acting relaxant, which he describes as "the main basis of anesthesia". He apparently expected spontaneous respiration to be established after administration of this paralysant, and after the patient became cyanosed he administered oxygen via the tube. When this method was unsuccessful he tried to give oxygen with the mask over the tube, the reason for which is unclear. He then gives a further dose of succinylcholine (does he not know the hazards of mixing two different groups of relaxants?), reintubates with a contributions to the correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
206
fresh tube and then states "the long- endured surgeons grumbling about acting relaxant produced the ex- inconvenience when things are not running smoothly, then he has had pected effect". I will make no further comment better luck than I have. If things on this unusual and unorthodox have always run smoothly for Dr. method of anesthesia, but I wonder Macartney it is probably because he why Dr. Jackson has omitted the only reads letters from people who are information of value; namely, the not perfect and who occasionally run type of tube, the material of composi- into difficulty. tion, the name of manufacturer, NOEL JACKSON, MB, BS whether the tube was new or used, P0 Box 850 Biggar, Sask and the method of sterilization. If defective tubes are being produced it would be helpful to know which ones Pilot study of high-protein, warrant concern. high-vitamin, low-carbohydrate, Finally, if Dr. Jackson really be- sugar-free diet lieves it is "inconvenient" to replace in learning-disabled children an obstructed tube in a restless cyanotic patient with a good one I will To the editor: I have just become certainly make a very large detour aware of the letter by Ruth Grekin around Biggar the next time I drive and Paul Cutler (Can Med Assoc through Saskatchewan, for fear I 1 117: 1367, 1977), in which they express disapproval of the "erronemay require surgery. ous, inconsistent and biased concluH.H. MACARTNEY, MB, B CII, FRCP[C] study they parti841 Fairfield Rd. sions" of the pilot Victoria, BC cipated in (Can Med Assoc 1 117: 212, 1977). Grekin and Cutler's disTo the editor: Dr. Macartney is ob- association from the experimental reviously a splendid, studious and in- port because the results did not supdustrious fellow. Writers always ap- port the use of vitamin megadoses is preciate readers, especially when they disquieting, but, of course, such acare alert to statements that are out tion is their prerogative. However, the remainder of their letter would be of place. In fact, the long-acting relaxant is laughable were their accusations not not administered until the effect of so serious. Grekin and Cutler's play on semthe succinylcholine has worn off; in the case described the long-acting antics is a weak, fanciful and blatant relaxant was not given until after the attempt to transform the study's negsecond tube had been inserted. Right- ative findings into positive results ly, Dr. Macartney discusses this. The simply because they wish them so. fault was in my description. There Casual observation of the test scores was no fault, however, in the delay does indicate that the experimental in administering a further dose of group gained on more variables than succinylcholine. This was the point the control group. The effect of vitaof my letter. This delay involved min therapy, however, irrespective of management of a patient who was how rigorous one may be at preexperimental finger-counting, cannot becoming extremely restless. As for that word "inconvenient", be determined simply by looking at I can only say that if, in his long the data. Without statistical verificaexperience, Dr. Macartney has never tion such raw data are totally devoid
CMA JOURNAL/AUGUST 12, 1978/VOL. 119
Accidents in endotracheal intubation To the editor: Dr. N. Jackson begins his communication (Can Med Assoc J 118: 483, 1978) with a strange statement: "Tracheal stenosis is probably the most common complication of endotracheal intubation, and its prevention by the use of a tube equipped with an atraumatic umbrella valve has been advocated . . While subglottic edema and narrowing can occur in infants after prolonged nasotracheal intubation, in a lifetime of busy anesthetic practice I have never seen a case of tracheal stenosis following routine intubation. Surely a sore throat is the commonest complication one sees after an anesthetic tube has been passed. Is Dr. Jackson perhaps thinking of tracheal stenosis following tracheostomy? At any rate I fail to see what connection it has with the peculiar account of airway obstruction due to a spiral slit in a bent endotracheal tube. After induction and intubation following an injection of succinylcholine Dr. Jackson gave a long-acting relaxant, which he describes as "the main basis of anesthesia". He apparently expected spontaneous respiration to be established after administration of this paralysant, and after the patient became cyanosed he administered oxygen via the tube. When this method was unsuccessful he tried to give oxygen with the mask over the tube, the reason for which is unclear. He then gives a further dose of succinylcholine (does he not know the hazards of mixing two different groups of relaxants?), reintubates with a contributions to the correspondence section are welcomed and if considered suitable will be published as space permits. They should be typewritten double-spaced and, except for case reports, should be no longer than 1½ manuscript pages.
206
fresh tube and then states "the long- endured surgeons grumbling about acting relaxant produced the ex- inconvenience when things are not running smoothly, then he has had pected effect". I will make no further comment better luck than I have. If things on this unusual and unorthodox have always run smoothly for Dr. method of anesthesia, but I wonder Macartney it is probably because he why Dr. Jackson has omitted the only reads letters from people who are information of value; namely, the not perfect and who occasionally run type of tube, the material of composi- into difficulty. tion, the name of manufacturer, NOEL JACKSON, MB, BS whether the tube was new or used, P0 Box 850 Biggar, Sask and the method of sterilization. If defective tubes are being produced it would be helpful to know which ones Pilot study of high-protein, warrant concern. high-vitamin, low-carbohydrate, Finally, if Dr. Jackson really be- sugar-free diet lieves it is "inconvenient" to replace in learning-disabled children an obstructed tube in a restless cyanotic patient with a good one I will To the editor: I have just become certainly make a very large detour aware of the letter by Ruth Grekin around Biggar the next time I drive and Paul Cutler (Can Med Assoc through Saskatchewan, for fear I 1 117: 1367, 1977), in which they express disapproval of the "erronemay require surgery. ous, inconsistent and biased concluH.H. MACARTNEY, MB, B CII, FRCP[C] study they parti841 Fairfield Rd. sions" of the pilot Victoria, BC cipated in (Can Med Assoc 1 117: 212, 1977). Grekin and Cutler's disTo the editor: Dr. Macartney is ob- association from the experimental reviously a splendid, studious and in- port because the results did not supdustrious fellow. Writers always ap- port the use of vitamin megadoses is preciate readers, especially when they disquieting, but, of course, such acare alert to statements that are out tion is their prerogative. However, the remainder of their letter would be of place. In fact, the long-acting relaxant is laughable were their accusations not not administered until the effect of so serious. Grekin and Cutler's play on semthe succinylcholine has worn off; in the case described the long-acting antics is a weak, fanciful and blatant relaxant was not given until after the attempt to transform the study's negsecond tube had been inserted. Right- ative findings into positive results ly, Dr. Macartney discusses this. The simply because they wish them so. fault was in my description. There Casual observation of the test scores was no fault, however, in the delay does indicate that the experimental in administering a further dose of group gained on more variables than succinylcholine. This was the point the control group. The effect of vitaof my letter. This delay involved min therapy, however, irrespective of management of a patient who was how rigorous one may be at preexperimental finger-counting, cannot becoming extremely restless. As for that word "inconvenient", be determined simply by looking at I can only say that if, in his long the data. Without statistical verificaexperience, Dr. Macartney has never tion such raw data are totally devoid
CMA JOURNAL/AUGUST 12, 1978/VOL. 119
