British Journal of Anaesthesia 112 (4): 756–74 (2014)
CORRESPONDENCE Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre
Declaration of interest None declared. G. Dempsey* J. Snell R. Coathup T. Jones Liverpool, UK *E-mail: [email protected]
Declaration of interest None declared. T. W. Mackie* A. Skinner Middlesbrough, UK *E-mail: [email protected] 1 Dempsey GA, Snell JA, Coathup R, Jones TM. Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre. Br J Anaesth 2013; 111: 594–9
1 Dempsey GA, Snell JA, Coathup R, Jones TM. Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre. Br J Anaesth 2013; 111: 594–9
doi:10.1093/bja/aeu063
doi:10.1093/bja/aeu062
Critical illness-related corticosteroid insufficiency in cardiogenic shock Anaesthesia for retrosternal thyroidectomy Reply from the authors Editor—Thank you for the opportunity to reply to Drs Mackie and Skinner. To answer the points raised in their letter regarding the case of difficult intubation discussed within our report,1 this was indeed the only case managed with an inhalation induction. Direct laryngoscopy after induction of anaesthesia revealed a grade 3 Cormack and Lehane view of the larynx. Cricoid pressure was applied, but the view remained unchanged. Bag/mask ventilation of the lungs was attempted at this stage but was unsuccessful. Subsequently, the airway became obstructed. At this point, the patient was repositioned and a Guedel airway was inserted both to no effect. Direct laryngoscopy
Editor—We read with interest the case report regarding critical illness-related cortico-steroid insufficiency (CIRCI) from Aslam and colleagues,1 particularly as it is published in the same issue of the BJA as our review on the hypothalamic –pituitary – adrenal (HPA) axis in critical illness and major surgery.2 The case report clearly illustrates the current problems with our understanding of the HPA axis at this time and how difficult it is to diagnose and treat CIRCI, if indeed such thing exists at all. While we are delighted that there was a good outcome for the patient, this case report clearly demonstrates why robust studies of HPA axis function in critical illness are still required. First, a cortisol level of 8 mg dl21 (220 nmol litre21) is within the ‘normal’ range.3 There is no clear evidence that haemodynamic compromise occurs with anything other than absolute cortisol deficiency around the time of major surgery
& The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://bja.oxfordjournals.org/ at GWU on July 7, 2015
Editor—We read the publication by Dempsey and colleagues1 with interest. We have a few questions about the report which we hope the authors can clarify. First, what events actually occurred surrounding the one case of failed intubation. If we followed correctly, they were the only patient undergoing an inhalation induction. What prompted the change from i.v. induction? Do the authors think that this influenced events? Secondly, regarding laryngoscopy and intubation, was there a poor view or was the view good but passing the tube impossible? Does the case in Table 3 marked as failed under laryngoscopy equate to a grade 4 view and is this the case in question? Thirdly, in the discussion, the authors make reference to a low incidence of difficult intubation. Is one in 20 (5%) not regarded as a high incidence? We would be grateful for more information regarding these difficult cases, so we can learn further from others’ experience.
was repeated using a McCoy laryngoscope; however, the laryngeal view remained unchanged. Two attempts at tracheal intubation using a bougie were made; neither of which were successful. A laryngeal mask airway was inserted, again, to no effect. Thereafter, a surgical airway was embarked upon. This is the case referred to in Table 3 within the paper. In retrospect, it is possible that the inhalation induction contributed to the difficulties encountered in that a lack of neuromuscular block may have led to suboptimal laryngeal views. Inhalation induction of anaesthesia would not be our preferred option for management of such cases. The statement relating to low incidence of tracheal intubation was specifically in reference to those cases undergoing i.v. induction of anaesthesia within the setting of an operating theatre exclusively used for head and neck procedures (the patient referred to above was not), where, in general, the incidence of the difficult airway is inevitably higher.
CORRESPONDENCE Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre
Declaration of interest None declared. G. Dempsey* J. Snell R. Coathup T. Jones Liverpool, UK *E-mail: [email protected]
Declaration of interest None declared. T. W. Mackie* A. Skinner Middlesbrough, UK *E-mail: [email protected] 1 Dempsey GA, Snell JA, Coathup R, Jones TM. Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre. Br J Anaesth 2013; 111: 594–9
1 Dempsey GA, Snell JA, Coathup R, Jones TM. Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre. Br J Anaesth 2013; 111: 594–9
doi:10.1093/bja/aeu063
doi:10.1093/bja/aeu062
Critical illness-related corticosteroid insufficiency in cardiogenic shock Anaesthesia for retrosternal thyroidectomy Reply from the authors Editor—Thank you for the opportunity to reply to Drs Mackie and Skinner. To answer the points raised in their letter regarding the case of difficult intubation discussed within our report,1 this was indeed the only case managed with an inhalation induction. Direct laryngoscopy after induction of anaesthesia revealed a grade 3 Cormack and Lehane view of the larynx. Cricoid pressure was applied, but the view remained unchanged. Bag/mask ventilation of the lungs was attempted at this stage but was unsuccessful. Subsequently, the airway became obstructed. At this point, the patient was repositioned and a Guedel airway was inserted both to no effect. Direct laryngoscopy
Editor—We read with interest the case report regarding critical illness-related cortico-steroid insufficiency (CIRCI) from Aslam and colleagues,1 particularly as it is published in the same issue of the BJA as our review on the hypothalamic –pituitary – adrenal (HPA) axis in critical illness and major surgery.2 The case report clearly illustrates the current problems with our understanding of the HPA axis at this time and how difficult it is to diagnose and treat CIRCI, if indeed such thing exists at all. While we are delighted that there was a good outcome for the patient, this case report clearly demonstrates why robust studies of HPA axis function in critical illness are still required. First, a cortisol level of 8 mg dl21 (220 nmol litre21) is within the ‘normal’ range.3 There is no clear evidence that haemodynamic compromise occurs with anything other than absolute cortisol deficiency around the time of major surgery
& The Author [2014]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://bja.oxfordjournals.org/ at GWU on July 7, 2015
Editor—We read the publication by Dempsey and colleagues1 with interest. We have a few questions about the report which we hope the authors can clarify. First, what events actually occurred surrounding the one case of failed intubation. If we followed correctly, they were the only patient undergoing an inhalation induction. What prompted the change from i.v. induction? Do the authors think that this influenced events? Secondly, regarding laryngoscopy and intubation, was there a poor view or was the view good but passing the tube impossible? Does the case in Table 3 marked as failed under laryngoscopy equate to a grade 4 view and is this the case in question? Thirdly, in the discussion, the authors make reference to a low incidence of difficult intubation. Is one in 20 (5%) not regarded as a high incidence? We would be grateful for more information regarding these difficult cases, so we can learn further from others’ experience.
was repeated using a McCoy laryngoscope; however, the laryngeal view remained unchanged. Two attempts at tracheal intubation using a bougie were made; neither of which were successful. A laryngeal mask airway was inserted, again, to no effect. Thereafter, a surgical airway was embarked upon. This is the case referred to in Table 3 within the paper. In retrospect, it is possible that the inhalation induction contributed to the difficulties encountered in that a lack of neuromuscular block may have led to suboptimal laryngeal views. Inhalation induction of anaesthesia would not be our preferred option for management of such cases. The statement relating to low incidence of tracheal intubation was specifically in reference to those cases undergoing i.v. induction of anaesthesia within the setting of an operating theatre exclusively used for head and neck procedures (the patient referred to above was not), where, in general, the incidence of the difficult airway is inevitably higher.
