Correspondence 5 I.min-’ from a circle system. Over a period of approximately 2 min the Spo, rose to 96%, and the patient became lucid. There was no worsening of her stridor during this time. A tracheostomy was performed uneventfully using local anaesthesia. This case demonstrates that there is no point in giving helium to patients with airway obstruction unless it can be given in conjunction with an appropriately high no,. This patient would have benefited more from a high
82 1
concentration of oxygen, easily administered from either the ward piped oxygen supply, or from a standard cylinder as found on operating theatre trolleys, while awaiting transfer to the operating theatre. The administration of helium, although well-intentioned and following standard teaching, was inappropriate. Victoria Infirmary,
S.R. HAYNES
Clasgow G42 9TY
‘Duck speech’ We have noted another cause for the high pitched ‘duck speech’ normally associated with phonation after inhalation of helium/oxygen mixtures. The patient was a 77-year-old man who had, 1 1 days previously, undergone transhiatal resection of an oesophageal carcinoma. He presented with a 24 h history of increasing dyspnoea and a more recent history of gross surgical emphysema of his neck and upper thorax. In addition the patient spoke with a voice indistinguishable from that described above. Nasal fibreoptic branchoscopy revealed surgical emphysema of the soft palate, pharynx and the whole of the trachea. The vocal cords were spared, but the tracheal aperture was
reduced to a slit by anterior and posterior submucosal swelling. Beyond the carina, both bronchial trees were normal. Further investigation showed an anastomotic breakdown with mediastinal abcess, but no airway leak. It is our supposition that the tracheal stenosis led to an accleration of air as the patient exhaled, forcing high velocity gas across the vocal cords and hence producing high frequency sound. Hope Hospital, Salford M6 8 H D
N.M. TIERNEY R. GLEW
Transdermal hyoscine We read with interest the paper by Semple et al. (Anaesthesia 1992; 47: 399-401) describing the use of transdermal hyoscine (Scopoderm TSS CIBA) with patientcontrolled analgesia (PCA). It is documented in the datasheet for Scopoderm TSS that the equilibration between absorption and excretion of hyoscine may not be reached until 6 h following application of the patch and, therefore, maximal antiemetic effect will not be reached until this time. In this study the patch was applied only 2 h pre-operatively, and it is possible that in the critical early postoperative period maximal plasma hyoscine levels and therefore antiemetic effect, had not been reached.
Clonidine-a We read the editorial ‘Clonidine-a horse or an ass’ with interest (AnaesthcJsia 1991; 46: 1003-4). To the extensive enumeration of the applications of clonidine to anaesthesia we suggest an addition of relevance to anesthetists working in Intensive Care. Clonidine in this respect has been used and recommended to attenuate the sympathetic overactivity of drug (especially alcohol) withdrawal states [I-31. In the difficult terrain of such clinical ‘Chevaux de Frise’ we have had occasion, when thoroughbreds have failed, to be glad of the clonidine ass. Muter Misericordiue Hospitril, Dublin 7
In our hospital, where PCA is routinely used following major gynaecological surgery, it is our practice to apply the Scopoderm TSS patch the evening prior to surgery. We have found the incidence of nausea and vomiting to be substantially less than that quoted by Semple et al., and it may be that further research into timing of patch application is warranted. St. Helier Hospital, Carshalton, Surrey SM5 IAA
L.J. MURDOCH M.H. WHEILDON
horse or an ass? References BAUMGARTNER GR, ROWEN RC. Clonidine vs. chlordiazepoxide in the management of acute alcohol withdrawal syndrome. Archives qf Inrernal Medicine 1987; 147: 1223-6. [2] GOLDMS, REDMONDDE, KLEBERHD. Clonidine blocks acute opiate withdrawal symptoms. Lancer 1978; ii: 599-602. A, Kox WJ. Clonidine in the treatment of [31 I P YAMPC. FORBES alcohol withdrawal in the Intensive Care Unit. Britbh Journul of Anuesrhesiu 1992; 68: 106-8.
“I
T. O’CONNOR D. PHELAN
Medicolegal and nursing practice in the private sector Three mcdicolegal considerations merit attention. Firstly, the surgicalianaesthetic Consent Form. What is the legal standing of this document? Practice in the private sector varies widely. Some very reputable hospitals d o not insist on its completion. Others, through the agency of their
nurses, will not countenance surgery without it. It can be argued that a proposed operation is a contract between the patient and the surgeon, and legally this contract has nothing to do with the hospital, since the surgeon is not its employee in this context. Is it no more than a n uncertain
822
Correspondence
safeguard for each party, especially important in such areas as amputation, cosmetic surgery and minors? Has the Consent Form ever been supported or tested in the courts? Secondly, when checking the patient at the doors of the operating threatre, it is now standard practice to interrogate the patient about his/her identity, allergies, false teeth . . . Quite apart from the stress to a patient who may have been premedicated to allay his anxiety, what view would a court take of answers given under the influence of a powerful sedative? Should not the initial check in his/her room suffice, with no more than a second identity check by wrist-band on arrival in the operating theatre? Compassion too has a place in medical practice. Finally, there is wide variation in nursing responsibility. Some hospitals allow the nurse to administer a drug which has not been prescribed on the drug chart, provided the order (by telephone) is repeated to another nurse, and later confirmed in writing. Others, and especially perhaps less distinguished centres, will not even allow the patient an
aspirin unless it is prescribed in writing, though one clinic waives this rule if the doctor also speaks to the pharmacist! What is the law? How curiously this contrasts with intensive care units which could not function without the enormous responsibility allowed their excellent nurses. I understand from the Royal College of Nursing that despite recent legislation neither National Health Service nor private (?including intensive care) nurses are allowed to prescribe anything. But does this also mean they are not allowed to accept verbal instructions? A strange situation for highly trained and esteemed colleagues. I strongly suspect that private hospitals are especially scrupulous in adhering to the letter of the law for fear of losing their licence, a fear enhanced by such episodes as the ‘kidney’ scandal.
20 Hocroft Avenue, London NW2 2EH
A. GILSTON
A simple solution Most anaesthetists are familiar with the problem of pulse oximeters either not giving any readings or only intermittently when they are needed most. These situations include hypotension and/or hypovolaemia with consequent poor peripheral perfusion [ 11, movement artifacts leading to false readings, hypothermia with the inability of the pulse oximeter to detect a pulse, vasoconstrictor infusions and during cardiac bypass [2]. Hypothermia is a common problem and no good solution seems to be available. Dipping the hand in warm water for a few minutes may help, but is a very short-term solution. Locally applied vasodilating creams are sometimes recommended to enhance the pulse signal in low-amplitude states [3]. We have now tried and tested a method which has always worked, unless the patient is also hypovolaemic and hypotensive. Take a disposable hand glove and fill it with warm water (not hot) and place it in the patient’s hand in such a way that the patients hand grasps the glove in a similar way as one clasps two hands together. Having done this, wait for
about 2 min and apply the pulse oximeter probe to the finger; the plethysmography signal will return almost instantly. It is important to keep the glove in place throughout the period otherwise subsequent hypothermia will cause the signal to disappear again. This is a simple solution, which we learnt from our nurses and that has always worked.
University Hospital, S-581 8S Linkoping,
Sweden References [I] VEGFORSM, LINDBERG L-G, LENNMARKEN C. The influence of changes in blood flow on the accuracy of pulse oximetry in humans. Acta Anaesthesiologica Scandinavica 1992; 36: 346-9. [2] KELLEHERJF. Pulse oximetry-a review. Journal of Clinical Monitoring 1989; 5: 31-62. [3] PAYNE JP, SEVERINGHAUS JW, eds. Pulse oximetry. Dorchester: Springer-Verlag, 1986: 45.
Nasal intubation and pharyngoplasty-a A major cause of defective speech associated with congenital cleft palate is the nasal escape of air during speech. Advances in surgical technique for cleft palate closure have to a large extent overcome this problem. However, a small number of patients, following repair of the palate, have poor speech due to palatal incompetence. The most satisfactory surgical procedure to overcome palatal incompetence is the operation of pharyngoplasty. Various techniques are described but the most effective are those using a superiorly based flap from the superior constrictor muscle reflected and attached to the upper surface of the soft palate, leaving two lateral slits to form the nasal airway. Pharyngoplasty, when necessary, is carried out in infancy. Some of these children will require wisdom teeth
A. GUPTA M. VEGFORS
word of warning
extraction in early adult life, an operation often carried out under general anaesthesia with nasotracheal intubation. Few of these patients will be aware of the details of their past surgery and will not give an accurate or adequate history. Normal clinical examination of the mouth is unlikely to reveal that a pharyngoplasty has been carried out. Anaesthetists and oral surgeons should be aware that patients with repaired cleft palates may have had a pharyngoplasty and that nasal intubation of the trachea may be impossible. 10 Normanby Close, Putney, London SW15 2RL 3 Thornley Drive, Ipswich IP4 3LR
J. BROADWAY E.S. BROADWAY
A knot for anaesthetists Surgeons, sailors and fishermen all have knots which are essential to their work and which they would each claim for themselves alone, although that claim is not always justifiable. Until now anaesthetists have not had a knot which they could claim for themsleves.
Securing a tracheal tube is a common problem for anaesthetists, either in the operating theatre or in the Intensive Care Unit. Some people use elastoplast or other sticky tape, but this is not always reliable or suitable. Narrow bandage or cotton tape is probably used most
82 1
concentration of oxygen, easily administered from either the ward piped oxygen supply, or from a standard cylinder as found on operating theatre trolleys, while awaiting transfer to the operating theatre. The administration of helium, although well-intentioned and following standard teaching, was inappropriate. Victoria Infirmary,
S.R. HAYNES
Clasgow G42 9TY
‘Duck speech’ We have noted another cause for the high pitched ‘duck speech’ normally associated with phonation after inhalation of helium/oxygen mixtures. The patient was a 77-year-old man who had, 1 1 days previously, undergone transhiatal resection of an oesophageal carcinoma. He presented with a 24 h history of increasing dyspnoea and a more recent history of gross surgical emphysema of his neck and upper thorax. In addition the patient spoke with a voice indistinguishable from that described above. Nasal fibreoptic branchoscopy revealed surgical emphysema of the soft palate, pharynx and the whole of the trachea. The vocal cords were spared, but the tracheal aperture was
reduced to a slit by anterior and posterior submucosal swelling. Beyond the carina, both bronchial trees were normal. Further investigation showed an anastomotic breakdown with mediastinal abcess, but no airway leak. It is our supposition that the tracheal stenosis led to an accleration of air as the patient exhaled, forcing high velocity gas across the vocal cords and hence producing high frequency sound. Hope Hospital, Salford M6 8 H D
N.M. TIERNEY R. GLEW
Transdermal hyoscine We read with interest the paper by Semple et al. (Anaesthesia 1992; 47: 399-401) describing the use of transdermal hyoscine (Scopoderm TSS CIBA) with patientcontrolled analgesia (PCA). It is documented in the datasheet for Scopoderm TSS that the equilibration between absorption and excretion of hyoscine may not be reached until 6 h following application of the patch and, therefore, maximal antiemetic effect will not be reached until this time. In this study the patch was applied only 2 h pre-operatively, and it is possible that in the critical early postoperative period maximal plasma hyoscine levels and therefore antiemetic effect, had not been reached.
Clonidine-a We read the editorial ‘Clonidine-a horse or an ass’ with interest (AnaesthcJsia 1991; 46: 1003-4). To the extensive enumeration of the applications of clonidine to anaesthesia we suggest an addition of relevance to anesthetists working in Intensive Care. Clonidine in this respect has been used and recommended to attenuate the sympathetic overactivity of drug (especially alcohol) withdrawal states [I-31. In the difficult terrain of such clinical ‘Chevaux de Frise’ we have had occasion, when thoroughbreds have failed, to be glad of the clonidine ass. Muter Misericordiue Hospitril, Dublin 7
In our hospital, where PCA is routinely used following major gynaecological surgery, it is our practice to apply the Scopoderm TSS patch the evening prior to surgery. We have found the incidence of nausea and vomiting to be substantially less than that quoted by Semple et al., and it may be that further research into timing of patch application is warranted. St. Helier Hospital, Carshalton, Surrey SM5 IAA
L.J. MURDOCH M.H. WHEILDON
horse or an ass? References BAUMGARTNER GR, ROWEN RC. Clonidine vs. chlordiazepoxide in the management of acute alcohol withdrawal syndrome. Archives qf Inrernal Medicine 1987; 147: 1223-6. [2] GOLDMS, REDMONDDE, KLEBERHD. Clonidine blocks acute opiate withdrawal symptoms. Lancer 1978; ii: 599-602. A, Kox WJ. Clonidine in the treatment of [31 I P YAMPC. FORBES alcohol withdrawal in the Intensive Care Unit. Britbh Journul of Anuesrhesiu 1992; 68: 106-8.
“I
T. O’CONNOR D. PHELAN
Medicolegal and nursing practice in the private sector Three mcdicolegal considerations merit attention. Firstly, the surgicalianaesthetic Consent Form. What is the legal standing of this document? Practice in the private sector varies widely. Some very reputable hospitals d o not insist on its completion. Others, through the agency of their
nurses, will not countenance surgery without it. It can be argued that a proposed operation is a contract between the patient and the surgeon, and legally this contract has nothing to do with the hospital, since the surgeon is not its employee in this context. Is it no more than a n uncertain
822
Correspondence
safeguard for each party, especially important in such areas as amputation, cosmetic surgery and minors? Has the Consent Form ever been supported or tested in the courts? Secondly, when checking the patient at the doors of the operating threatre, it is now standard practice to interrogate the patient about his/her identity, allergies, false teeth . . . Quite apart from the stress to a patient who may have been premedicated to allay his anxiety, what view would a court take of answers given under the influence of a powerful sedative? Should not the initial check in his/her room suffice, with no more than a second identity check by wrist-band on arrival in the operating theatre? Compassion too has a place in medical practice. Finally, there is wide variation in nursing responsibility. Some hospitals allow the nurse to administer a drug which has not been prescribed on the drug chart, provided the order (by telephone) is repeated to another nurse, and later confirmed in writing. Others, and especially perhaps less distinguished centres, will not even allow the patient an
aspirin unless it is prescribed in writing, though one clinic waives this rule if the doctor also speaks to the pharmacist! What is the law? How curiously this contrasts with intensive care units which could not function without the enormous responsibility allowed their excellent nurses. I understand from the Royal College of Nursing that despite recent legislation neither National Health Service nor private (?including intensive care) nurses are allowed to prescribe anything. But does this also mean they are not allowed to accept verbal instructions? A strange situation for highly trained and esteemed colleagues. I strongly suspect that private hospitals are especially scrupulous in adhering to the letter of the law for fear of losing their licence, a fear enhanced by such episodes as the ‘kidney’ scandal.
20 Hocroft Avenue, London NW2 2EH
A. GILSTON
A simple solution Most anaesthetists are familiar with the problem of pulse oximeters either not giving any readings or only intermittently when they are needed most. These situations include hypotension and/or hypovolaemia with consequent poor peripheral perfusion [ 11, movement artifacts leading to false readings, hypothermia with the inability of the pulse oximeter to detect a pulse, vasoconstrictor infusions and during cardiac bypass [2]. Hypothermia is a common problem and no good solution seems to be available. Dipping the hand in warm water for a few minutes may help, but is a very short-term solution. Locally applied vasodilating creams are sometimes recommended to enhance the pulse signal in low-amplitude states [3]. We have now tried and tested a method which has always worked, unless the patient is also hypovolaemic and hypotensive. Take a disposable hand glove and fill it with warm water (not hot) and place it in the patient’s hand in such a way that the patients hand grasps the glove in a similar way as one clasps two hands together. Having done this, wait for
about 2 min and apply the pulse oximeter probe to the finger; the plethysmography signal will return almost instantly. It is important to keep the glove in place throughout the period otherwise subsequent hypothermia will cause the signal to disappear again. This is a simple solution, which we learnt from our nurses and that has always worked.
University Hospital, S-581 8S Linkoping,
Sweden References [I] VEGFORSM, LINDBERG L-G, LENNMARKEN C. The influence of changes in blood flow on the accuracy of pulse oximetry in humans. Acta Anaesthesiologica Scandinavica 1992; 36: 346-9. [2] KELLEHERJF. Pulse oximetry-a review. Journal of Clinical Monitoring 1989; 5: 31-62. [3] PAYNE JP, SEVERINGHAUS JW, eds. Pulse oximetry. Dorchester: Springer-Verlag, 1986: 45.
Nasal intubation and pharyngoplasty-a A major cause of defective speech associated with congenital cleft palate is the nasal escape of air during speech. Advances in surgical technique for cleft palate closure have to a large extent overcome this problem. However, a small number of patients, following repair of the palate, have poor speech due to palatal incompetence. The most satisfactory surgical procedure to overcome palatal incompetence is the operation of pharyngoplasty. Various techniques are described but the most effective are those using a superiorly based flap from the superior constrictor muscle reflected and attached to the upper surface of the soft palate, leaving two lateral slits to form the nasal airway. Pharyngoplasty, when necessary, is carried out in infancy. Some of these children will require wisdom teeth
A. GUPTA M. VEGFORS
word of warning
extraction in early adult life, an operation often carried out under general anaesthesia with nasotracheal intubation. Few of these patients will be aware of the details of their past surgery and will not give an accurate or adequate history. Normal clinical examination of the mouth is unlikely to reveal that a pharyngoplasty has been carried out. Anaesthetists and oral surgeons should be aware that patients with repaired cleft palates may have had a pharyngoplasty and that nasal intubation of the trachea may be impossible. 10 Normanby Close, Putney, London SW15 2RL 3 Thornley Drive, Ipswich IP4 3LR
J. BROADWAY E.S. BROADWAY
A knot for anaesthetists Surgeons, sailors and fishermen all have knots which are essential to their work and which they would each claim for themselves alone, although that claim is not always justifiable. Until now anaesthetists have not had a knot which they could claim for themsleves.
Securing a tracheal tube is a common problem for anaesthetists, either in the operating theatre or in the Intensive Care Unit. Some people use elastoplast or other sticky tape, but this is not always reliable or suitable. Narrow bandage or cotton tape is probably used most
