893
Correspondence Laryngeal mask for failed intubation in emergency Caesarean section To the Editor: We wish to present a case of failed intubation in a short, obese patient for emergency c-section for fetal distress which was successfully managed by the early use of the Brain laryngeal mask (BLM).
airway for Caesarean section. Anaesthesia 1990; 45: 227-8. 2 Chadwick IS, Vohra A. Anaesthesia for emergency caesarean section using the Brain laryngeal airway. Anaesthesia 1989; 44: 261-2. 3 Calder L Ordman A J, Jakowski A, Crockard HA. The Brain laryngeal mask airway. An alternative to emergency tracheal intubation. Anaesthesia 1990; 45: 137-9. 4 Thompson KD, Ordman A J, Parkhouse N, Morgan BDG.
Use of the Brain laryngeal mask airway in anticipation of difficult intubation. Br J Plast Surg 1989; 42: 478-80.
Case report
A 37-yr-old woman, weighing 87 kg for a height of 155 cm, in her fifth pregnancy was presented for emergency Caesarean section for fetal distress. After the patient was placed in the left lateral decubitus on the operating table she was attached to ECG monitor, automatic BP monitor and pulse oximeter. After preoxygenation, the patient received alcuronium 0.03 mg" kg -l followed two minutes later by thiopentone sodium 4 mg. kg -l and succinylcholine 1.2 mg. kg -l, with cricoid pressure applied by a qualified assistant. Under direct laryngoscopy the visualization of the larynx was impossible and two attempts to intubate the trachea, one performed by a senior anaesthetist, failed. The lungs continued to be ventilated by mask with cricoid pressure maintained until a Brain laryngeal mask #4 was inserted easily without the use of an introducer or a laryngoscope. Anaesthesia continued uneventfully, with the patient making a full recovery. The use of the BLM in failed intubation in the obstetric patient proved to be life-saving in previous reported cases 1'2 and was extremely useful in our case. We feel that the decision to use a BLM during a failed intubation situation should be made very early. Perhaps the priorities of the various failed intubation drills should be changed and include the early introduction of BLM. Virgil Priscu MD Lilia Priscu MD David Stroker MD Department of Anesthesia Kaplan Hospital, Rehovot Affiliated to the Hebrew University and Hadassah-Jerusalem, Israel. REFERENCES l McClune S, Reagan M, Moore J. Laryngeal mask C A N J A N A E S T H 1992 / 3 9 : 8 / pp 893-6
Anaesthesia for outpatient TURP To the Editor: Transurethral prostatectomy (TURP) is a relatively recent addition to the range of surgery carried out on a daycare basis, l There is a lack of information in the literature regarding anaesthesia for this procedure in the outpatient setting. When TURP is performed as an inpatient procedure it is typically carried out under sub-arachnoid block but there has been concern regarding the suitability of this kind of anaesthesia for outpatient surgery because of the reported high incidence of postdural puncture headache (PDPH). 2 It was therefore decided to conduct post-discharge interviews with patients who had undergone outpatient TURPs to establish the incidence of side effects following SAB or general anaesthesia. One hundred and two consecutive patients were contacted by telephone four days following their surgery by an investigator blinded to the anaesthetic administered and answered a questionnaire designed to identify the occurrence of all commonly reported side effects of general and spinal anaesthesia. The hospital chart was then reviewed and the anaesthetic and recovery room course recorded. Fifty-five patients received SAB via a 25 or 27 gauge Quinke point needle and 47 received general anaesthesia consisting principally of thiopentone, nitrous oxide, narcotic and a volatile agent. Twenty-nine patients reported post-anaesthetic headaches, 16 after general anaesthesia and 13 after SAB. Three patients in each group reported severe headaches, those in the SAB group meeting the criteria for PDPH. None of the latter three
894
CANADIAN JOURNAL OF ANAESTHESIA
patients required medical attention for their headache. Backache was reported more frequently following SAB (14 patients) than general anaesthesia (five patients). Nausea or vomiting was twice as common after general anaesthesia as SAB and was more frequent following discharge (18 cases) than in the recovery room (seven cases). The mean duration of anaesthesia was longer for the group receiving SAB, 52 --- 12 minutes, compared to 45 ___ 15 min for the group receiving general anaesthesia. The time spent in the recovery room was the same for both groups. The incidence of PDPH in this study is similar to that reported by Neal et al. 3 and does not support the earlier contentions that SAB is unsuitable for outpatients. In carefully selected patients TURP is a suitable procedure for daycare units and either general anaesthesia or SAB is acceptable for this surgery. P.F. Fancourt-Smith MBFRCr'C P. Merrick BScN Vancouver, B.C. REFERENCES 1 McLoughlin MG, Kinahan TJ. Transurethral resection of
the prostate in the outpatient setting. J Urol 1990; 143: 951-2. 2 Flaaten H, Raeder J. Spinal anaesthesia for outpatient surgery. Anaesthesia 1985; 40:1108-11. 3 Neal JM, Bridenbaugh LD, Mulroy MF, Palmen BD.
Incidence of post dural puncture headache is similar between 22G Greene and 26G Quincke spinal needles. Anesthesiology 1989; 71: A678.
Double aortic arch presenting as massive haematemesis after removal of a nasogastric tube To the Editor: Double aortic arch is a rare but life-threatening, if misdiagnosed, condition. We report here a case with tetralogy of Fallot complicated by the missed diagnosis of double aortic arch. A 32-week, 2.0-kg female infant was delivered, and was noted to have a heart murmur. On day four of life, tachypnoea and cyanosis became evident. On day nine, she was admitted to our institute and an echocardiographic diagnosis of tetralogy of Fallot with pulmonary atresia, right PDA and right aortic arch was made. Infusion of prostagladin E~ was started for the treatment
of hypoxaemia because of suspected low pulmonary blood flow through the PDA. On day 48 hypercyanotic spells developed and a Blalock-Taussig shunt was placed to improve pulmonary blood flow. The infant slowly improved and on the eighth postoperative day the trachea was extubated. Since infants are obligate nose breathers, the NG tube (Salem sump tube 8 Fr, Argyle) was removed to improve gas exchange. However, removal of the NG tube resulted in massive pulsatile haemorrhage from the mouth and the nose which required transfusion of greater than the child's blood volume, reintubation and replacement of a larger NG tube (12 Fr). Then emergency right thoracotomy was performed for haemostasis. At this time a vascular ring of a double aortic arch and aortoesophageal fistula were present. Ligation and division of the left aortic arch distal of the left subclavian artery dramatically improved the ventilatary difficulty that had continued during positioning with the right side up. The orifices of the aorta and oesophagus were closed uneventfully. About 20-30% of patients with tetralogy of Fallot are complicated by aortic arch anomalies (a right aortic arch is the most common form and a vascular ring is uncommon). Twenty percent of vascular rings are complicated with congenital heart disease. ~'2 The NG tube in conjunction with a tight vascular ring and an endotracheal tube might have caused compression necrosis of the posterior wall of the oesophagus. We do not know whether this complication could have been avoided by using a smaller NG tube or by earlier tracheal extubation. It was fortunate that reintubation of a NG tube produced a good resolution in this case. N. Yahagi MD A. Nishikawa MD Y. Sai MD J. Matsui MD Yoshikuni Amakata MD Department of Anesthesiology and Intensive Care Unit Shiga University of Medical Science Ohtsu, 520-21 Shiga, Japan REFERENCES 1 Binet JP, Langlois J. Aortic arch anomalies in children
and infants. J Thorac Cardiovasc Surg 1977; 73: 248-52. 2 Keith JD, Rowe RD, Vlad P. Heart disease in infancy
and childhood. 3rd ed. New York: Macmillan, 1978.
Correspondence Laryngeal mask for failed intubation in emergency Caesarean section To the Editor: We wish to present a case of failed intubation in a short, obese patient for emergency c-section for fetal distress which was successfully managed by the early use of the Brain laryngeal mask (BLM).
airway for Caesarean section. Anaesthesia 1990; 45: 227-8. 2 Chadwick IS, Vohra A. Anaesthesia for emergency caesarean section using the Brain laryngeal airway. Anaesthesia 1989; 44: 261-2. 3 Calder L Ordman A J, Jakowski A, Crockard HA. The Brain laryngeal mask airway. An alternative to emergency tracheal intubation. Anaesthesia 1990; 45: 137-9. 4 Thompson KD, Ordman A J, Parkhouse N, Morgan BDG.
Use of the Brain laryngeal mask airway in anticipation of difficult intubation. Br J Plast Surg 1989; 42: 478-80.
Case report
A 37-yr-old woman, weighing 87 kg for a height of 155 cm, in her fifth pregnancy was presented for emergency Caesarean section for fetal distress. After the patient was placed in the left lateral decubitus on the operating table she was attached to ECG monitor, automatic BP monitor and pulse oximeter. After preoxygenation, the patient received alcuronium 0.03 mg" kg -l followed two minutes later by thiopentone sodium 4 mg. kg -l and succinylcholine 1.2 mg. kg -l, with cricoid pressure applied by a qualified assistant. Under direct laryngoscopy the visualization of the larynx was impossible and two attempts to intubate the trachea, one performed by a senior anaesthetist, failed. The lungs continued to be ventilated by mask with cricoid pressure maintained until a Brain laryngeal mask #4 was inserted easily without the use of an introducer or a laryngoscope. Anaesthesia continued uneventfully, with the patient making a full recovery. The use of the BLM in failed intubation in the obstetric patient proved to be life-saving in previous reported cases 1'2 and was extremely useful in our case. We feel that the decision to use a BLM during a failed intubation situation should be made very early. Perhaps the priorities of the various failed intubation drills should be changed and include the early introduction of BLM. Virgil Priscu MD Lilia Priscu MD David Stroker MD Department of Anesthesia Kaplan Hospital, Rehovot Affiliated to the Hebrew University and Hadassah-Jerusalem, Israel. REFERENCES l McClune S, Reagan M, Moore J. Laryngeal mask C A N J A N A E S T H 1992 / 3 9 : 8 / pp 893-6
Anaesthesia for outpatient TURP To the Editor: Transurethral prostatectomy (TURP) is a relatively recent addition to the range of surgery carried out on a daycare basis, l There is a lack of information in the literature regarding anaesthesia for this procedure in the outpatient setting. When TURP is performed as an inpatient procedure it is typically carried out under sub-arachnoid block but there has been concern regarding the suitability of this kind of anaesthesia for outpatient surgery because of the reported high incidence of postdural puncture headache (PDPH). 2 It was therefore decided to conduct post-discharge interviews with patients who had undergone outpatient TURPs to establish the incidence of side effects following SAB or general anaesthesia. One hundred and two consecutive patients were contacted by telephone four days following their surgery by an investigator blinded to the anaesthetic administered and answered a questionnaire designed to identify the occurrence of all commonly reported side effects of general and spinal anaesthesia. The hospital chart was then reviewed and the anaesthetic and recovery room course recorded. Fifty-five patients received SAB via a 25 or 27 gauge Quinke point needle and 47 received general anaesthesia consisting principally of thiopentone, nitrous oxide, narcotic and a volatile agent. Twenty-nine patients reported post-anaesthetic headaches, 16 after general anaesthesia and 13 after SAB. Three patients in each group reported severe headaches, those in the SAB group meeting the criteria for PDPH. None of the latter three
894
CANADIAN JOURNAL OF ANAESTHESIA
patients required medical attention for their headache. Backache was reported more frequently following SAB (14 patients) than general anaesthesia (five patients). Nausea or vomiting was twice as common after general anaesthesia as SAB and was more frequent following discharge (18 cases) than in the recovery room (seven cases). The mean duration of anaesthesia was longer for the group receiving SAB, 52 --- 12 minutes, compared to 45 ___ 15 min for the group receiving general anaesthesia. The time spent in the recovery room was the same for both groups. The incidence of PDPH in this study is similar to that reported by Neal et al. 3 and does not support the earlier contentions that SAB is unsuitable for outpatients. In carefully selected patients TURP is a suitable procedure for daycare units and either general anaesthesia or SAB is acceptable for this surgery. P.F. Fancourt-Smith MBFRCr'C P. Merrick BScN Vancouver, B.C. REFERENCES 1 McLoughlin MG, Kinahan TJ. Transurethral resection of
the prostate in the outpatient setting. J Urol 1990; 143: 951-2. 2 Flaaten H, Raeder J. Spinal anaesthesia for outpatient surgery. Anaesthesia 1985; 40:1108-11. 3 Neal JM, Bridenbaugh LD, Mulroy MF, Palmen BD.
Incidence of post dural puncture headache is similar between 22G Greene and 26G Quincke spinal needles. Anesthesiology 1989; 71: A678.
Double aortic arch presenting as massive haematemesis after removal of a nasogastric tube To the Editor: Double aortic arch is a rare but life-threatening, if misdiagnosed, condition. We report here a case with tetralogy of Fallot complicated by the missed diagnosis of double aortic arch. A 32-week, 2.0-kg female infant was delivered, and was noted to have a heart murmur. On day four of life, tachypnoea and cyanosis became evident. On day nine, she was admitted to our institute and an echocardiographic diagnosis of tetralogy of Fallot with pulmonary atresia, right PDA and right aortic arch was made. Infusion of prostagladin E~ was started for the treatment
of hypoxaemia because of suspected low pulmonary blood flow through the PDA. On day 48 hypercyanotic spells developed and a Blalock-Taussig shunt was placed to improve pulmonary blood flow. The infant slowly improved and on the eighth postoperative day the trachea was extubated. Since infants are obligate nose breathers, the NG tube (Salem sump tube 8 Fr, Argyle) was removed to improve gas exchange. However, removal of the NG tube resulted in massive pulsatile haemorrhage from the mouth and the nose which required transfusion of greater than the child's blood volume, reintubation and replacement of a larger NG tube (12 Fr). Then emergency right thoracotomy was performed for haemostasis. At this time a vascular ring of a double aortic arch and aortoesophageal fistula were present. Ligation and division of the left aortic arch distal of the left subclavian artery dramatically improved the ventilatary difficulty that had continued during positioning with the right side up. The orifices of the aorta and oesophagus were closed uneventfully. About 20-30% of patients with tetralogy of Fallot are complicated by aortic arch anomalies (a right aortic arch is the most common form and a vascular ring is uncommon). Twenty percent of vascular rings are complicated with congenital heart disease. ~'2 The NG tube in conjunction with a tight vascular ring and an endotracheal tube might have caused compression necrosis of the posterior wall of the oesophagus. We do not know whether this complication could have been avoided by using a smaller NG tube or by earlier tracheal extubation. It was fortunate that reintubation of a NG tube produced a good resolution in this case. N. Yahagi MD A. Nishikawa MD Y. Sai MD J. Matsui MD Yoshikuni Amakata MD Department of Anesthesiology and Intensive Care Unit Shiga University of Medical Science Ohtsu, 520-21 Shiga, Japan REFERENCES 1 Binet JP, Langlois J. Aortic arch anomalies in children
and infants. J Thorac Cardiovasc Surg 1977; 73: 248-52. 2 Keith JD, Rowe RD, Vlad P. Heart disease in infancy
and childhood. 3rd ed. New York: Macmillan, 1978.
