Indian Journal of Critical Care Medicine February 2014 Vol 18 Issue 2
Interestingly, the use of reversal agents like naloxone itself has also been described as the primary cause of pulmonary edema.[5] Patients with opioid-induced NCPE and ARDS can have severe hypoxemia frequently needing invasive mechanical ventilation. An early orotracheal intubation should be considered in obtunded or severely hypoxemic patients. Following intubation, general management strategies used in any form of ARDS comprising of lung protective strategies of ventilation, appropriate PEEP and diuretics are used. Overall prognosis remains good with most patients recovering within 24 h. In summary, our case demonstrates an infrequently seen respiratory complication in opioid overdose. Timely management decisions about adequate use of reversal agents and considering early mechanical ventilation in severely hypoxemic patients can be lifesaving.
Himanshu Bhardwaj, Bhaskar Bhardwaj1, Ahmed Awab
Department of Medicine, Pulmonary and Critical Care Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, 1 Department of Pulmonary Medicine and Tuberculosis, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
Correspondence: Dr. Himanshu Bhardwaj, Departments of Medicine, Pulmonary and Critical Care Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, P. O. Box 26901, WP1310, OK 73190, USA. E-mail: [email protected]
References 1. 2. 3. 4. 5.
Daugherty LE. Extracorporeal membrane oxygenation as rescue therapy for methadone-induced pulmonary edema. Pediatr Emerg Care 2011;27:633-4. Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema: A case series. Chest 2001;120:1628-32. Katz S, Aberman A, Frand UI, Stein IM, Fulop M. Heroin pulmonary edema. Evidence for increased pulmonary capillary permeability. Am Rev Respir Dis 1972;106:472-4. Edston E, van Hage-Hamsten M. Anaphylactoid shock – A common cause of death in heroin addicts? Allergy 1997;52:950-4. Boyer EW. Management of opioid analgesic overdose. N Engl J Med 2012;367:146-55.
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DOI: 10.4103/0972-5229.126095
120
Angiographic catheter as airway exchange device through laryngeal airway mask in unanticipated difficult airway in emergency department Sir, Angiographic catheter (AC) is commonly used in intervention cardiology, but its application outside cardiac catheterization laboratory (CCL) is seldom reported. AC has been used for nasogastric tube insertion.[1] We used AC as an airway exchange catheter through ProSeal laryngeal airway mask (PLMA) in an unanticipated difficult airway in emergency department (ED). A 42-year-old man admitted at midnight to our ED with diagnosis of severe acute pancreatitis with respiratory failure with apparent normal airway. After preoxygenation rapid sequence intubation was tried with cricoid pressure but unable to intubate even after removal of cricoid pressure for a moment. Immediately airway was secured with size 4 PLMA. The patient needs definite airway for prolonged mechanical ventilation. But we did not have sophisticated airway gadgets in our resuscitation kit. Then we used a 9 Fr sterile AC (Medtronic, Minnesota, USA) with guide wire [Figure 1] lubricated with lignocaine 2% gelly as airway exchange catheter in airway port of PLMA [Figure 2] keeping suction catheter in gastric port. It passed smoothly into trachea and a tactile sensation was felt by keeping the palm on trachea. After 35 cm of insertion, PLMA was removed. Apnea oxygenation was supplied to the patient through the angiographic catheter after removing guide wire and an 8 mm internal diameter endotracheal tube (ET) was exchanged. ET confirmed with capnometry and 5-point chest auscultation. Repeated attempts of laryngoscopy for tracheal intubation in difficult airway are associated with decreased success, increase complications, and morbidities. Alternative airway devices like gum elastic bougies, rigid or flexible fiberoptic bronchoscope, intubating laryngeal mask airway (LMA), video laryngoscope, light wand, and cricothyroidotomy are very effective in this situation.[2].Airway management
Indian Journal of Critical Care Medicine February 2014 Vol 18 Issue 2
ability to oxygenate, and ventilate during exchange process. But the guidewire in it is too thin and soft for support. We used sterilized AC with atramatic guide wire which have same function as AIC but minimum cost and easily available from CCL. This AC was previously used for angiography but sterilized with 2% glutaraldehyde for 10 min before use in this patient.[5] In conclusion, emergency resuscitation and airway kit must contain classic LMA and LMA for rescue ventilation and oxygenation, while a resterilized AC can also be a useful gadget in difficult airway situation with limited resource.
Sukhen Samanta, Sujay Samanta1, Arvind Kumar Baronia1, Abhishek Jha2
Figure 1: Angiographic catheter with guidewire
Department of Anesthesia and Critical Care (Trauma Centre), Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, 1Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 2Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Correspondence: Dr. Sukhen Samanta, 17 Dr A N Paul Lane, Bally, Howrah - 711 201, West Bengal, India. E-mail: [email protected]
References 1. 2.
Figure 2: Angiography catheter inside ProSeal laryngeal airway mask
3.
in ED is often more difficult than operation theater due to unavailability of difficult airway gadgets, improper environment, and untrained medical stuff. As an intubation conduit LMA is used in different way like blind ET passage after proper LMA placement, using a premounted ET in LMA, bougie-aided intubation via LMA, light wand-aided intubation through LMA, fiberscope aided intubation via LMA, and so on. PLMA having narrower airway tube will not allow to pass larger ET, but absence of aperture bar allow smooth passage of AC. Above all, PLMAs have gastric drainage tube to reduced incidence of aspiration, prevent gastric insufflation, and allow ventilation with higher pressure as it was required in our patient. People used fiberoptic aided intubation through the LMA-Supreme using an Aintree Intubating Catheter (AIC) in manikin.[3] Cook et al.,[4] reported seven case of difficult intubation via PLMA using AIC. AIC are long length, atraumatic,
4. 5.
Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconscious intubated patient. N Am J Med Sci 2013;5:68-70. Combes X, Jabre P, Margenet A, Merle JC, Leroux B, Dru M, et al. Unanticipated difficult airway management in the prehospital emergency setting: Prospective validation of an algorithm. Anesthesiology 2011;114:105-10. Joffe AM, Liew EC. Intubation through the LMA-Supreme: A pilot study of two techniques in a manikin. Anaesth Intensive Care 2010;38:33-8. Cook TM, Seller C, Gupta K, Thornton M, O›Sullivan E. Non-conventional uses of the Aintree Intubating Catheter in management of the difficult airway. Anaesthesia 2007;62:169-74. Rutala WA, Weber DJ. Healthcare infection control practices advisory committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008. Available from: http://www.cdc.gov/ hipac/pdf/guidelines/Disinfection_Nov_2008.pdf [Last accessed on 2010 Apr 20].
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DOI: 10.4103/0972-5229.126096
121
Copyright of Indian Journal of Critical Care Medicine 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.
Interestingly, the use of reversal agents like naloxone itself has also been described as the primary cause of pulmonary edema.[5] Patients with opioid-induced NCPE and ARDS can have severe hypoxemia frequently needing invasive mechanical ventilation. An early orotracheal intubation should be considered in obtunded or severely hypoxemic patients. Following intubation, general management strategies used in any form of ARDS comprising of lung protective strategies of ventilation, appropriate PEEP and diuretics are used. Overall prognosis remains good with most patients recovering within 24 h. In summary, our case demonstrates an infrequently seen respiratory complication in opioid overdose. Timely management decisions about adequate use of reversal agents and considering early mechanical ventilation in severely hypoxemic patients can be lifesaving.
Himanshu Bhardwaj, Bhaskar Bhardwaj1, Ahmed Awab
Department of Medicine, Pulmonary and Critical Care Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, 1 Department of Pulmonary Medicine and Tuberculosis, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
Correspondence: Dr. Himanshu Bhardwaj, Departments of Medicine, Pulmonary and Critical Care Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, P. O. Box 26901, WP1310, OK 73190, USA. E-mail: [email protected]
References 1. 2. 3. 4. 5.
Daugherty LE. Extracorporeal membrane oxygenation as rescue therapy for methadone-induced pulmonary edema. Pediatr Emerg Care 2011;27:633-4. Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema: A case series. Chest 2001;120:1628-32. Katz S, Aberman A, Frand UI, Stein IM, Fulop M. Heroin pulmonary edema. Evidence for increased pulmonary capillary permeability. Am Rev Respir Dis 1972;106:472-4. Edston E, van Hage-Hamsten M. Anaphylactoid shock – A common cause of death in heroin addicts? Allergy 1997;52:950-4. Boyer EW. Management of opioid analgesic overdose. N Engl J Med 2012;367:146-55.
Access this article online Quick Response Code: Website: www.ijccm.org
DOI: 10.4103/0972-5229.126095
120
Angiographic catheter as airway exchange device through laryngeal airway mask in unanticipated difficult airway in emergency department Sir, Angiographic catheter (AC) is commonly used in intervention cardiology, but its application outside cardiac catheterization laboratory (CCL) is seldom reported. AC has been used for nasogastric tube insertion.[1] We used AC as an airway exchange catheter through ProSeal laryngeal airway mask (PLMA) in an unanticipated difficult airway in emergency department (ED). A 42-year-old man admitted at midnight to our ED with diagnosis of severe acute pancreatitis with respiratory failure with apparent normal airway. After preoxygenation rapid sequence intubation was tried with cricoid pressure but unable to intubate even after removal of cricoid pressure for a moment. Immediately airway was secured with size 4 PLMA. The patient needs definite airway for prolonged mechanical ventilation. But we did not have sophisticated airway gadgets in our resuscitation kit. Then we used a 9 Fr sterile AC (Medtronic, Minnesota, USA) with guide wire [Figure 1] lubricated with lignocaine 2% gelly as airway exchange catheter in airway port of PLMA [Figure 2] keeping suction catheter in gastric port. It passed smoothly into trachea and a tactile sensation was felt by keeping the palm on trachea. After 35 cm of insertion, PLMA was removed. Apnea oxygenation was supplied to the patient through the angiographic catheter after removing guide wire and an 8 mm internal diameter endotracheal tube (ET) was exchanged. ET confirmed with capnometry and 5-point chest auscultation. Repeated attempts of laryngoscopy for tracheal intubation in difficult airway are associated with decreased success, increase complications, and morbidities. Alternative airway devices like gum elastic bougies, rigid or flexible fiberoptic bronchoscope, intubating laryngeal mask airway (LMA), video laryngoscope, light wand, and cricothyroidotomy are very effective in this situation.[2].Airway management
Indian Journal of Critical Care Medicine February 2014 Vol 18 Issue 2
ability to oxygenate, and ventilate during exchange process. But the guidewire in it is too thin and soft for support. We used sterilized AC with atramatic guide wire which have same function as AIC but minimum cost and easily available from CCL. This AC was previously used for angiography but sterilized with 2% glutaraldehyde for 10 min before use in this patient.[5] In conclusion, emergency resuscitation and airway kit must contain classic LMA and LMA for rescue ventilation and oxygenation, while a resterilized AC can also be a useful gadget in difficult airway situation with limited resource.
Sukhen Samanta, Sujay Samanta1, Arvind Kumar Baronia1, Abhishek Jha2
Figure 1: Angiographic catheter with guidewire
Department of Anesthesia and Critical Care (Trauma Centre), Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, 1Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 2Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
Correspondence: Dr. Sukhen Samanta, 17 Dr A N Paul Lane, Bally, Howrah - 711 201, West Bengal, India. E-mail: [email protected]
References 1. 2.
Figure 2: Angiography catheter inside ProSeal laryngeal airway mask
3.
in ED is often more difficult than operation theater due to unavailability of difficult airway gadgets, improper environment, and untrained medical stuff. As an intubation conduit LMA is used in different way like blind ET passage after proper LMA placement, using a premounted ET in LMA, bougie-aided intubation via LMA, light wand-aided intubation through LMA, fiberscope aided intubation via LMA, and so on. PLMA having narrower airway tube will not allow to pass larger ET, but absence of aperture bar allow smooth passage of AC. Above all, PLMAs have gastric drainage tube to reduced incidence of aspiration, prevent gastric insufflation, and allow ventilation with higher pressure as it was required in our patient. People used fiberoptic aided intubation through the LMA-Supreme using an Aintree Intubating Catheter (AIC) in manikin.[3] Cook et al.,[4] reported seven case of difficult intubation via PLMA using AIC. AIC are long length, atraumatic,
4. 5.
Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconscious intubated patient. N Am J Med Sci 2013;5:68-70. Combes X, Jabre P, Margenet A, Merle JC, Leroux B, Dru M, et al. Unanticipated difficult airway management in the prehospital emergency setting: Prospective validation of an algorithm. Anesthesiology 2011;114:105-10. Joffe AM, Liew EC. Intubation through the LMA-Supreme: A pilot study of two techniques in a manikin. Anaesth Intensive Care 2010;38:33-8. Cook TM, Seller C, Gupta K, Thornton M, O›Sullivan E. Non-conventional uses of the Aintree Intubating Catheter in management of the difficult airway. Anaesthesia 2007;62:169-74. Rutala WA, Weber DJ. Healthcare infection control practices advisory committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities, 2008. Available from: http://www.cdc.gov/ hipac/pdf/guidelines/Disinfection_Nov_2008.pdf [Last accessed on 2010 Apr 20].
Access this article online Quick Response Code: Website: www.ijccm.org
DOI: 10.4103/0972-5229.126096
121
Copyright of Indian Journal of Critical Care Medicine 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.
