Letters to Editor
Reporting of such cases creates awareness among the health care professionals regarding this benign condition. It also emphasizes the need for proper hydration and smooth extubation to prevent the occurrence of anaesthesia mumps.
Divya Jain, Indu Bala, Deepak Dwivedi Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Divya Jain, H. No. 2036, Sector 21‑C, Chandigarh ‑ 160 022, India. E‑mail: [email protected]
REFERENCES 1. Attas M, Sabawala PB, Keats AS. Acute transient sialadenopathy during induction of anesthesia. Anesthesiology 1968;29:1050‑2. 2. Kumar KP, Kumar PK, Jagadesh G. Acute sialadenitis of parotid gland: Anaesthesia mumps. Indian J Anaesth 2014;58:97‑8. 3. Serin S, Kaya S, Kara CO, Baser S. A case of anesthesia mumps. Anesth Analg 2007;104:1005. 4. Mutaf M, Büyükgüral B. An unusual postoperative complication: Anesthesia mumps. Eur J Plast Surg 2007;29:335‑8. 5. Özdek A, Bayir Ö, Isik ME, Tatar EÇ, Saylam G, Korkmaz H. Anesthesia mumps resulting in temporary facial nerve paralysis after the auditory brainstem implantation in a 3‑year‑old child. Int J Pediatr Otorhinolaryngol 2014;78:159‑62. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139031
Infant feeding tube stiffened with guide wire as endotracheal tube exchanger and introducer in difficult airways! Sir, Paediatric airway is difficult because of large occiput, narrow nares, large tongue, narrow epiglottis, high larynx and narrow cricoid region. It is equally difficult to exchange endotracheal tubes (ETT) in children. ETT exchangers are easy to use, but they are not very safe because of their stiffness.[1] Fiberoptic Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
bronchoscopy (FOB) is one of the options to exchange ETT[2] but appropriate sizes are not readily available for children. The unexpected difficult pediatric airway can be handled by experienced anesthesiologists in a better way and the expected difficult airway requires dedicated anesthesia specialists, at specialized centers.[3] Here we report the use of infant feeding tube stiffened with guide wire as ETT exchanger in an infant. A 10‑month‑old girl weighing 3 kg, known case of Pierre Robin syndrome with cleft palate, was scheduled for atrial septal defect (ASD) closure and tongue lip adhesion. We anticipated difficult airway because of micrognathia, macroglossia, receding mandible and cleft palate. Detailed informed consent for failed intubation and tracheostomy was taken. Injection glycopyrrolate was administered as premedication. Difficult airway cart including stylet, laryngeal mask airways (LMAs), oropharyngeal airway and FOB were kept ready. Paediatric bougie was not available in the hospital. After shifting child to the operating room (OR) routine monitors such as electrocardiogram and pulse oximetry were attached. Child was preoxygenated and anesthetized using midazolam 0.2 mg/kg, fentanyl 3 mcg/kg and sevoflurane. Mask ventilation was adequate and suxamethonium bolus was administered at 1 mg/kg. First direct laryngoscopy with a curved blade revealed Cormack‑Lehane grade IV view and endotracheal (ET) intubation attempt failed. Second attempt with straight blade and stylet inside ETT also failed. LMA ventilation was out of our plan because of planned tongue lip adhesion procedure. Plan B was to attempt intubation with FOB. Till FOB was brought in OR, third attempt was made with direct laryngoscopy. Blind ET intubation was successful this time with size 3.0 portex ETT. There was a significant leak around ETT even with flexion of head and packing of oropharynx. This leak compelled us to exchange this 3.0 size ETT to 4.0 size tube. As appropriate bougie was unavailable, we inserted sterilized guide wire of 7.5 French gauze (FG) central venous catheter into infant feeding tube of size 7 FG after cutting its distal end. The guide‑wire made nasogastric tube little stiffer as a ETT exchanger. This newly made tube exchanger was inserted into size 3.0 mm ETT under aseptic precautions [Figure 1]. This ETT was removed, and size 4.0 portex ETT was railroaded over this newly made bougie. ASD closure was done on cardiopulmonary bypass. At the end of ASD closure, tongue lip adhesion was released, and he was extubated successfully and discharged from hospital. 501
Letters to Editor
Cardiovascular manifestations of perioperative acute urinary bladder over‑distension Figure 1: J tip guidewire and infant feeding tube with guidewire in situ
Literature addressing safe and effective airway exchangers are plentiful but many of the devices from various difficult airway protocols are still not readily available. Paediatric FOB may not be available in many setups and so could be the case with paediatric bougies or exchange catheters. There are various problems of ETT exchangers like trauma or tissue damage, mainly due to the associated stiffness.[4] There is one report where authors have used nasogastric tube as tracheal tube introducer.[5] However, smaller gauge nasogastric tube is very soft and pliable, thus may not have enough strength to use as an ETT introducer or exchanger. If we insert metallic, flexible guide wire into infant feeding tube it gives good strength, and this assembly may serve as a better ETT introducer or exchanger.
Shankar V Kadam, Shyam Y Dhake, Kshiti J Doshi, Kamlesh B Tailor Department of Pediatric Cardiac Anaesthesia, Congenital Heart Disease Division, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, Maharashtra, India Address for correspondence: Dr. Kadam Shankar Vithalrao, Department of Pediatric Cardiac Anaesthesia, Congenital Heart Disease Division, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai ‑ 400 053, Maharashtra, India. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
Novella J. Intraoperative nasotracheal to orotracheal tube change in a patient with Klippel‑Feil syndrome. Anaesth Intensive Care 1995;23:402‑3. Hartmannsgruber MW, Rosenbaum SH. Safer endotracheal tube exchange technique. Anesthesiology 1998;88:1683. Engelhardt T, Weiss M. A child with a difficult airway: What do I do next? Curr Opin Anaesthesiol 2012;25:326‑32. deLima LG, Bishop MJ. Lung laceration after tracheal extubation over a plastic tube changer. Anesth Analg 1991;73:350‑1. Suhasini T, Murthy NV, Rao SM. Nasogastric tube as a tracheal tube introducer. Anaesthesia 1995;50:270. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139032
502
Sir, Bladder over‑distension may lead to undesirable autonomic manifestations such as vomiting, bradycardia, hypotension, hypertension, cardiac dysrhythmias, or even asystole.[1] We report two clinically diverse cardiovascular presentations of acute bladder over‑distension. Case 1: A 64‑year‑old male, with no associated comorbidities, was scheduled for transurethral resection of the prostate (TURP). Spinal anaesthesia was administered (2 ml heavy bupivacaine 0.5% plus fentanyl 10 µg). T8 level of sensory blockade was achieved. The intraoperative period was uneventful. In the recovery room, the patient was stable, heart rate (HR) 84/min, blood pressure (BP) 126/80 mmHg, SpO2 99% and sensory block at T8 level. One hour later, the patient became restless, anxious, and diaphoretic. HR was 44/min, BP 90/60 mmHg, SpO2 98%. Atropine 0.6 mg intravenous (IV) was administered. Abdominal examination revealed a grossly distended bladder (up to umbilicus). The tri‑way urinary catheter lumen draining the bladder was blocked (blood clots) while bladder irrigation with saline continued, resulting in acute bladder over‑distension. Bladder irrigation was discontinued. Patency of the draining catheter was established, and 650 ml of urine/saline was drained. Level of block had regressed to T10. The patient experienced relief and became haemodynamically stable. Case 2: A 45‑year‑old, female was scheduled for staging laparotomy for ovarian malignancy under general anaesthesia. Pre‑anaesthetic evaluation was unremarkable. Standard anaesthetic technique was used. Intra‑operatively, patient’s vitals remained stable and but her urine output was only 30 ml at 1.5 h. Fluid administered was adequate, and the bladder was not distended. A fluid challenge (500 ml Ringer’s lactate) was administered followed by furosemide (10 mg) IV. Otherwise, patient had received crystalloid (3000 ml), colloid (500 ml) and blood (one unit). Patient had lost one litre of blood intraoperatively. Surgery lasted 3.5 h. The patient remained haemodynamically stable (HR: 62-76/min, BP: 110/76-126/82 mmHg). Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Copyright of Indian Journal of Anaesthesia 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.
Reporting of such cases creates awareness among the health care professionals regarding this benign condition. It also emphasizes the need for proper hydration and smooth extubation to prevent the occurrence of anaesthesia mumps.
Divya Jain, Indu Bala, Deepak Dwivedi Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India Address for correspondence: Dr. Divya Jain, H. No. 2036, Sector 21‑C, Chandigarh ‑ 160 022, India. E‑mail: [email protected]
REFERENCES 1. Attas M, Sabawala PB, Keats AS. Acute transient sialadenopathy during induction of anesthesia. Anesthesiology 1968;29:1050‑2. 2. Kumar KP, Kumar PK, Jagadesh G. Acute sialadenitis of parotid gland: Anaesthesia mumps. Indian J Anaesth 2014;58:97‑8. 3. Serin S, Kaya S, Kara CO, Baser S. A case of anesthesia mumps. Anesth Analg 2007;104:1005. 4. Mutaf M, Büyükgüral B. An unusual postoperative complication: Anesthesia mumps. Eur J Plast Surg 2007;29:335‑8. 5. Özdek A, Bayir Ö, Isik ME, Tatar EÇ, Saylam G, Korkmaz H. Anesthesia mumps resulting in temporary facial nerve paralysis after the auditory brainstem implantation in a 3‑year‑old child. Int J Pediatr Otorhinolaryngol 2014;78:159‑62. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139031
Infant feeding tube stiffened with guide wire as endotracheal tube exchanger and introducer in difficult airways! Sir, Paediatric airway is difficult because of large occiput, narrow nares, large tongue, narrow epiglottis, high larynx and narrow cricoid region. It is equally difficult to exchange endotracheal tubes (ETT) in children. ETT exchangers are easy to use, but they are not very safe because of their stiffness.[1] Fiberoptic Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
bronchoscopy (FOB) is one of the options to exchange ETT[2] but appropriate sizes are not readily available for children. The unexpected difficult pediatric airway can be handled by experienced anesthesiologists in a better way and the expected difficult airway requires dedicated anesthesia specialists, at specialized centers.[3] Here we report the use of infant feeding tube stiffened with guide wire as ETT exchanger in an infant. A 10‑month‑old girl weighing 3 kg, known case of Pierre Robin syndrome with cleft palate, was scheduled for atrial septal defect (ASD) closure and tongue lip adhesion. We anticipated difficult airway because of micrognathia, macroglossia, receding mandible and cleft palate. Detailed informed consent for failed intubation and tracheostomy was taken. Injection glycopyrrolate was administered as premedication. Difficult airway cart including stylet, laryngeal mask airways (LMAs), oropharyngeal airway and FOB were kept ready. Paediatric bougie was not available in the hospital. After shifting child to the operating room (OR) routine monitors such as electrocardiogram and pulse oximetry were attached. Child was preoxygenated and anesthetized using midazolam 0.2 mg/kg, fentanyl 3 mcg/kg and sevoflurane. Mask ventilation was adequate and suxamethonium bolus was administered at 1 mg/kg. First direct laryngoscopy with a curved blade revealed Cormack‑Lehane grade IV view and endotracheal (ET) intubation attempt failed. Second attempt with straight blade and stylet inside ETT also failed. LMA ventilation was out of our plan because of planned tongue lip adhesion procedure. Plan B was to attempt intubation with FOB. Till FOB was brought in OR, third attempt was made with direct laryngoscopy. Blind ET intubation was successful this time with size 3.0 portex ETT. There was a significant leak around ETT even with flexion of head and packing of oropharynx. This leak compelled us to exchange this 3.0 size ETT to 4.0 size tube. As appropriate bougie was unavailable, we inserted sterilized guide wire of 7.5 French gauze (FG) central venous catheter into infant feeding tube of size 7 FG after cutting its distal end. The guide‑wire made nasogastric tube little stiffer as a ETT exchanger. This newly made tube exchanger was inserted into size 3.0 mm ETT under aseptic precautions [Figure 1]. This ETT was removed, and size 4.0 portex ETT was railroaded over this newly made bougie. ASD closure was done on cardiopulmonary bypass. At the end of ASD closure, tongue lip adhesion was released, and he was extubated successfully and discharged from hospital. 501
Letters to Editor
Cardiovascular manifestations of perioperative acute urinary bladder over‑distension Figure 1: J tip guidewire and infant feeding tube with guidewire in situ
Literature addressing safe and effective airway exchangers are plentiful but many of the devices from various difficult airway protocols are still not readily available. Paediatric FOB may not be available in many setups and so could be the case with paediatric bougies or exchange catheters. There are various problems of ETT exchangers like trauma or tissue damage, mainly due to the associated stiffness.[4] There is one report where authors have used nasogastric tube as tracheal tube introducer.[5] However, smaller gauge nasogastric tube is very soft and pliable, thus may not have enough strength to use as an ETT introducer or exchanger. If we insert metallic, flexible guide wire into infant feeding tube it gives good strength, and this assembly may serve as a better ETT introducer or exchanger.
Shankar V Kadam, Shyam Y Dhake, Kshiti J Doshi, Kamlesh B Tailor Department of Pediatric Cardiac Anaesthesia, Congenital Heart Disease Division, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai, Maharashtra, India Address for correspondence: Dr. Kadam Shankar Vithalrao, Department of Pediatric Cardiac Anaesthesia, Congenital Heart Disease Division, Kokilaben Dhirubhai Ambani Hospital and Research Centre, Mumbai ‑ 400 053, Maharashtra, India. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
Novella J. Intraoperative nasotracheal to orotracheal tube change in a patient with Klippel‑Feil syndrome. Anaesth Intensive Care 1995;23:402‑3. Hartmannsgruber MW, Rosenbaum SH. Safer endotracheal tube exchange technique. Anesthesiology 1998;88:1683. Engelhardt T, Weiss M. A child with a difficult airway: What do I do next? Curr Opin Anaesthesiol 2012;25:326‑32. deLima LG, Bishop MJ. Lung laceration after tracheal extubation over a plastic tube changer. Anesth Analg 1991;73:350‑1. Suhasini T, Murthy NV, Rao SM. Nasogastric tube as a tracheal tube introducer. Anaesthesia 1995;50:270. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.139032
502
Sir, Bladder over‑distension may lead to undesirable autonomic manifestations such as vomiting, bradycardia, hypotension, hypertension, cardiac dysrhythmias, or even asystole.[1] We report two clinically diverse cardiovascular presentations of acute bladder over‑distension. Case 1: A 64‑year‑old male, with no associated comorbidities, was scheduled for transurethral resection of the prostate (TURP). Spinal anaesthesia was administered (2 ml heavy bupivacaine 0.5% plus fentanyl 10 µg). T8 level of sensory blockade was achieved. The intraoperative period was uneventful. In the recovery room, the patient was stable, heart rate (HR) 84/min, blood pressure (BP) 126/80 mmHg, SpO2 99% and sensory block at T8 level. One hour later, the patient became restless, anxious, and diaphoretic. HR was 44/min, BP 90/60 mmHg, SpO2 98%. Atropine 0.6 mg intravenous (IV) was administered. Abdominal examination revealed a grossly distended bladder (up to umbilicus). The tri‑way urinary catheter lumen draining the bladder was blocked (blood clots) while bladder irrigation with saline continued, resulting in acute bladder over‑distension. Bladder irrigation was discontinued. Patency of the draining catheter was established, and 650 ml of urine/saline was drained. Level of block had regressed to T10. The patient experienced relief and became haemodynamically stable. Case 2: A 45‑year‑old, female was scheduled for staging laparotomy for ovarian malignancy under general anaesthesia. Pre‑anaesthetic evaluation was unremarkable. Standard anaesthetic technique was used. Intra‑operatively, patient’s vitals remained stable and but her urine output was only 30 ml at 1.5 h. Fluid administered was adequate, and the bladder was not distended. A fluid challenge (500 ml Ringer’s lactate) was administered followed by furosemide (10 mg) IV. Otherwise, patient had received crystalloid (3000 ml), colloid (500 ml) and blood (one unit). Patient had lost one litre of blood intraoperatively. Surgery lasted 3.5 h. The patient remained haemodynamically stable (HR: 62-76/min, BP: 110/76-126/82 mmHg). Indian Journal of Anaesthesia | Vol. 58 | Issue 4 | Jul-Aug 2014
Copyright of Indian Journal of Anaesthesia 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.
