Letters to Editor
pre‑operatively. In our case, cyst handling during surgery caused the escape of hundreds of daughter cysts causing obstruction of both the lumens of DLT and patient suffered from repetitive episodes of desaturation. This obstruction of major airways made ventilation difficult and led to increased airway resistance and pressures causing barotrauma of the ventilated lung. During surgery, it was not evident due to open chest cavity, but after closure it manifested as pneumothorax of the ventilated lung leading to intercostal drain insertion. Barotrauma from excessive tidal volume and high airway pressure may occur if left sided, DLT is positioned distally such that the entire tidal volume is directed to only one lobe.[2] Nevertheless, peak airway pressures were not excessive in our case during initiation of OLV and FOB showed the tube to be in a good position. During the surgery, the malposition of DLT could not prevent the dependent lung against contamination of cyst contents and tube obstruction by hydatid cyst caused an excessive increase in airway pressure leading to barotrauma of the ventilated lung. It did not convert into tension pneumothorax due to open chest cavity at the time of surgery.[3] Patients undergoing thoracic surgery are at risk of increased airway resistance of dependent lung secondary to secretions and soft tissue obstruction. This produces potential for a ball valve effect, with limitation during expiration resulting in the overinflation of the lung.[4] We extubated the patient, which averted tension pneumothorax after chest closure. Spillage of laminated membrane could probably take place at any stage of anaesthesia, causing airway obstruction and further hypoxemia and asphyxia.[5] Hence, we conclude that one should be vigilant about post‑operative pneumothorax in complicated ruptured hydatid cyst of the lung.
Depinder Kaur, Saurabh Anand1, Prakash Sharma2, Ashwini Kumar2 Department of Anaesthesiology, SHK Medical College, NUH, Mewat, 1 Department of Anesthesia, Medanta - The Medicity, Gurgaon, Haryana, 2LRS Institute of Tuberculosis and Respiratory Diseases, New Delhi, India Address for correspondence: Dr. Depinder Kaur, T1/1301, Park View Residency Apts., Sec. 3, Palam Vihar, Gurgaon, Haryana, India. E‑mail: [email protected]
REFERENCES 1.
Kuzucu A, Soysal O, Ozgel M, Yologlu S. Complicated hydatid cysts of the lung: Clinical and therapeutic issues. Ann Thorac
Indian Journal of Anaesthesia | Vol. 59 | Issue 1 | Jan 2015
Surg 2004;77:1200‑4. Malik S, Shapiro WA, Jablons D, Katz JA. Contralateral tension pneumothorax during one‑lung ventilation for lobectomy: Diagnosis aided by fiberoptic bronchoscopy. Anesth Analg 2002;95:570‑2. 3. Katherine P, Mclvor W, Peter D. Intraoperative management for thoracotomy. In: Kaplan JA, editor. Thoracic Anesthesia. 3rd ed. Philadelphia: Churchill Livingston. 2003. 4. Alavia A, Aghajanzadeh M, Hejig M. Bronchoscopic extraction of a hydatid membrane in a 26‑year‑old woman with recurrent pneumonia; case report. Iran Red Crescent Med J (IRCMJ) 2010;12:68‑70. 5. Gupta R, Wadhawan S, Bhadoria P. Intraoperative endobronchial rupture of pulmonary hydatid cyst: An airway catastrophe. J Anaesthesiol Clin Pharmacol 2013;29:111‑3. 2.
Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.149461
Innovative way of making intubating laryngeal mask airway stabilizer rod Sir, Laryngeal mask airway (LMA) has become a standard device in the spectrum of gadgets for airway management. Intubating laryngeal mask airway (ILMA®, LMA‑fastrach®) is one of them. It was designed to overcome few difficulties of LMA‑classic® during tracheal intubation.[1,2] After the trachea is intubated successfully through ILMA, it is usually recommended to remove the ILMA.[3,4] The tracheal tube needs to be stabilized to prevent extubation during ILMA removal. A stabilizer rod (introducer, extender) is placed at the end of the tracheal tube and pushed inside while the ILMA is withdrawn. It is supplied along with the ILMA device. The initial price of ILMA is very high (Rs. 30,000 approximately). If it is used number of times, it becomes a cost effective choice. However, during repeated attempts of packing and sterilization, the stabilizer rod may get lost and rarely get damaged. If so, ILMA cannot be used for intubating purposes. Hence, we developed a stabilizer rod with some cheap disposable items available in the operating 59
Letters to Editor
room. We successfully used this ‘new’ stabilizing rod in intubating the trachea. We took a 6.5 mm internal diameter used red rubber noncuffed tracheal tube (Rusch, W. Germany), cut at 19 cm and then the bevel was also cut to make opening straight [Figure 1a]. A 16 French gauge nasogastric tube was also cut at the 20 cm length, and an old used disposable double lumen endobronchial tube stylet was introduced into the nasogastric tube [Figure 1b and c] to make the tube stiff. This unit was introduced into the prepared red rubber tracheal tube [Figure 1d] and the extra portion at the other end was cut [Figure 2a] and fixed with a rubber cap of antibiotic vial [Figure 2b] with adhesive glue. At the projected end, a cut suction catheter connector was inserted
with glue (‘Fevikwik’). A word of caution is to check the assembly before use for lose components. The extender made like this is comparable with that of the company make [Figure 2c]. This stabilizer (introducer, extender) can be as good as the original one [Figure 2d]. The cost of this is approximately less than Rs. 100 and can be reused number of times after autoclaving along with the ILMA.
M Hanumantha Rao, A Muralidhar, AV Subbarao, PM Vasudevan Department of Anesthesiology, Critical Care and Pain Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India Address for correspondence: M. Hanumantha Rao, Department of Anesthesiology, Critical Care and Pain Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati ‑ 517 507, Andhra Pradesh, India. E‑mail: [email protected]
REFERENCES 1. a
b 2. 3. 4.
c
Brain AI, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997;79:704‑9. Brinkschmidt TE, Kesei K, Hoch C. Controlled study of laryngeal mask versus tracheal tube for paediatric anaesthesia in strabismus surgery in 122 patients. Br J Anaesth 1997;78:101. Brimacombe J, Keller C, Berry A. Pharyngolaryngeal morbidity with the intubating laryngeal mask airway. Anaesthesia 1998;53:1231. Brimacombe J, Keller C. Pharyngeal mucosal pressures. In reply. Anesthesiology 2000;92:621.
d
Figure 1: (a) Used endobrocheal tube stylet, nasogastric tube cut at 20cm, 6.5 mm ID red rubber uncuffed tube cut at 19 cm and bevel straightend. (b) Endobronchial tube stylet is being introduced into nasgastric tube. (c) Stylet fully inserted into nasogastric tube. (d) Styleted nasogastric tube is introduced fully into red rubber tube
Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.149463
a
b
The big “little problem’’ with postoperative nausea and vomiting prophylaxis Sir,
c
d
Figure 2: (a) The extra portion of nasogastric tube is cut. (b) Fixation of the rubber cork with adhesive glue. (c) Comparison of stabilizer rod made [top] with original one. (d) Use of the stabilizer in successful intubation 60
We wish to report a case of severe headache in the immediate post‑operative period in 35 years old, 56 kg, smoker, American Society of Anaesthesiologists physical status I, male patient scheduled for Indian Journal of Anaesthesia | Vol. 59 | Issue 1 | Jan 2015
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.
pre‑operatively. In our case, cyst handling during surgery caused the escape of hundreds of daughter cysts causing obstruction of both the lumens of DLT and patient suffered from repetitive episodes of desaturation. This obstruction of major airways made ventilation difficult and led to increased airway resistance and pressures causing barotrauma of the ventilated lung. During surgery, it was not evident due to open chest cavity, but after closure it manifested as pneumothorax of the ventilated lung leading to intercostal drain insertion. Barotrauma from excessive tidal volume and high airway pressure may occur if left sided, DLT is positioned distally such that the entire tidal volume is directed to only one lobe.[2] Nevertheless, peak airway pressures were not excessive in our case during initiation of OLV and FOB showed the tube to be in a good position. During the surgery, the malposition of DLT could not prevent the dependent lung against contamination of cyst contents and tube obstruction by hydatid cyst caused an excessive increase in airway pressure leading to barotrauma of the ventilated lung. It did not convert into tension pneumothorax due to open chest cavity at the time of surgery.[3] Patients undergoing thoracic surgery are at risk of increased airway resistance of dependent lung secondary to secretions and soft tissue obstruction. This produces potential for a ball valve effect, with limitation during expiration resulting in the overinflation of the lung.[4] We extubated the patient, which averted tension pneumothorax after chest closure. Spillage of laminated membrane could probably take place at any stage of anaesthesia, causing airway obstruction and further hypoxemia and asphyxia.[5] Hence, we conclude that one should be vigilant about post‑operative pneumothorax in complicated ruptured hydatid cyst of the lung.
Depinder Kaur, Saurabh Anand1, Prakash Sharma2, Ashwini Kumar2 Department of Anaesthesiology, SHK Medical College, NUH, Mewat, 1 Department of Anesthesia, Medanta - The Medicity, Gurgaon, Haryana, 2LRS Institute of Tuberculosis and Respiratory Diseases, New Delhi, India Address for correspondence: Dr. Depinder Kaur, T1/1301, Park View Residency Apts., Sec. 3, Palam Vihar, Gurgaon, Haryana, India. E‑mail: [email protected]
REFERENCES 1.
Kuzucu A, Soysal O, Ozgel M, Yologlu S. Complicated hydatid cysts of the lung: Clinical and therapeutic issues. Ann Thorac
Indian Journal of Anaesthesia | Vol. 59 | Issue 1 | Jan 2015
Surg 2004;77:1200‑4. Malik S, Shapiro WA, Jablons D, Katz JA. Contralateral tension pneumothorax during one‑lung ventilation for lobectomy: Diagnosis aided by fiberoptic bronchoscopy. Anesth Analg 2002;95:570‑2. 3. Katherine P, Mclvor W, Peter D. Intraoperative management for thoracotomy. In: Kaplan JA, editor. Thoracic Anesthesia. 3rd ed. Philadelphia: Churchill Livingston. 2003. 4. Alavia A, Aghajanzadeh M, Hejig M. Bronchoscopic extraction of a hydatid membrane in a 26‑year‑old woman with recurrent pneumonia; case report. Iran Red Crescent Med J (IRCMJ) 2010;12:68‑70. 5. Gupta R, Wadhawan S, Bhadoria P. Intraoperative endobronchial rupture of pulmonary hydatid cyst: An airway catastrophe. J Anaesthesiol Clin Pharmacol 2013;29:111‑3. 2.
Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.149461
Innovative way of making intubating laryngeal mask airway stabilizer rod Sir, Laryngeal mask airway (LMA) has become a standard device in the spectrum of gadgets for airway management. Intubating laryngeal mask airway (ILMA®, LMA‑fastrach®) is one of them. It was designed to overcome few difficulties of LMA‑classic® during tracheal intubation.[1,2] After the trachea is intubated successfully through ILMA, it is usually recommended to remove the ILMA.[3,4] The tracheal tube needs to be stabilized to prevent extubation during ILMA removal. A stabilizer rod (introducer, extender) is placed at the end of the tracheal tube and pushed inside while the ILMA is withdrawn. It is supplied along with the ILMA device. The initial price of ILMA is very high (Rs. 30,000 approximately). If it is used number of times, it becomes a cost effective choice. However, during repeated attempts of packing and sterilization, the stabilizer rod may get lost and rarely get damaged. If so, ILMA cannot be used for intubating purposes. Hence, we developed a stabilizer rod with some cheap disposable items available in the operating 59
Letters to Editor
room. We successfully used this ‘new’ stabilizing rod in intubating the trachea. We took a 6.5 mm internal diameter used red rubber noncuffed tracheal tube (Rusch, W. Germany), cut at 19 cm and then the bevel was also cut to make opening straight [Figure 1a]. A 16 French gauge nasogastric tube was also cut at the 20 cm length, and an old used disposable double lumen endobronchial tube stylet was introduced into the nasogastric tube [Figure 1b and c] to make the tube stiff. This unit was introduced into the prepared red rubber tracheal tube [Figure 1d] and the extra portion at the other end was cut [Figure 2a] and fixed with a rubber cap of antibiotic vial [Figure 2b] with adhesive glue. At the projected end, a cut suction catheter connector was inserted
with glue (‘Fevikwik’). A word of caution is to check the assembly before use for lose components. The extender made like this is comparable with that of the company make [Figure 2c]. This stabilizer (introducer, extender) can be as good as the original one [Figure 2d]. The cost of this is approximately less than Rs. 100 and can be reused number of times after autoclaving along with the ILMA.
M Hanumantha Rao, A Muralidhar, AV Subbarao, PM Vasudevan Department of Anesthesiology, Critical Care and Pain Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India Address for correspondence: M. Hanumantha Rao, Department of Anesthesiology, Critical Care and Pain Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati ‑ 517 507, Andhra Pradesh, India. E‑mail: [email protected]
REFERENCES 1. a
b 2. 3. 4.
c
Brain AI, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask. II: A preliminary clinical report of a new means of intubating the trachea. Br J Anaesth 1997;79:704‑9. Brinkschmidt TE, Kesei K, Hoch C. Controlled study of laryngeal mask versus tracheal tube for paediatric anaesthesia in strabismus surgery in 122 patients. Br J Anaesth 1997;78:101. Brimacombe J, Keller C, Berry A. Pharyngolaryngeal morbidity with the intubating laryngeal mask airway. Anaesthesia 1998;53:1231. Brimacombe J, Keller C. Pharyngeal mucosal pressures. In reply. Anesthesiology 2000;92:621.
d
Figure 1: (a) Used endobrocheal tube stylet, nasogastric tube cut at 20cm, 6.5 mm ID red rubber uncuffed tube cut at 19 cm and bevel straightend. (b) Endobronchial tube stylet is being introduced into nasgastric tube. (c) Stylet fully inserted into nasogastric tube. (d) Styleted nasogastric tube is introduced fully into red rubber tube
Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.149463
a
b
The big “little problem’’ with postoperative nausea and vomiting prophylaxis Sir,
c
d
Figure 2: (a) The extra portion of nasogastric tube is cut. (b) Fixation of the rubber cork with adhesive glue. (c) Comparison of stabilizer rod made [top] with original one. (d) Use of the stabilizer in successful intubation 60
We wish to report a case of severe headache in the immediate post‑operative period in 35 years old, 56 kg, smoker, American Society of Anaesthesiologists physical status I, male patient scheduled for Indian Journal of Anaesthesia | Vol. 59 | Issue 1 | Jan 2015
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.
