Letters to Editor
an infant feeding tube 8 FG (Polymed, Poly Medicure Ltd., Rajasthan, India) through the ETT for suctioning. However, it could not be negotiated through the universal 15mm connector. On inspection, the connector was found to be blocked nearly 50% by a thin membranous diaphragm [Figure 1]. Replacement of the connector led to marked reduction in resistance and improvement in ventilation. The rest of the case proceeded uneventfully. After extubation, the ETT was inspected and was not found to have any other obstruction. The incident was informed to the hospital equipment purchase committee. Though rare, manufacturing defects in ETTs can be hazardous, especially, in a child as airway diameter is small. In addition, it is difficult to differentiate between a distorted capnograph due to obstruction from normal variant in children. Obstruction because of plastic membrane in the connector of cut resterilized, ETT has been reported.[1] Deformed connector,[2] plastic meniscus in ETT lumen[3] and kinking[4] have been observed as a cause of obstruction while using new pre‑packed ETTs. In view of multiple reports, administrators and societies of Anaesthesiologists must insist for strict quality control from manufacturers. These incidents have led to practice of examination of ETTs before intubation. However, this usually involves looking at the external surface, tip, Murphy’s eye and obvious obstruction through transparent tube. Less obtrusive defects can be easily missed. Membrane in opti‑port right angle connector of double lumen tube is also mentioned.[5] Our case signifies importance of visual inspection through the lumen of the ETT with connector from proximal to distal end prior to intubation to prevent untoward complications. In case of high airway pressures, one should check for patient related
problems, ETT obstruction and breathing circuit malfunction. If ruled out, one should not forget to look for rare causes like defective connector.
Anila D Malde, Ruchi A Jain Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India Address for correspondence: Dr. Anila D Malde, Block No. 3, Nagjibhai Mansion, Manubhai P. Vaidya Marg, Ghatkopar (East), Mumbai ‑ 400 077, Maharashtra, India. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
Ngan Kee WD. An unusual problem with an endotracheal tube. Anaesth Intensive Care 1993;21:247‑8. Shamshery C, Kannaujia A, Gautam S. Ventilation failure due to endotracheal tube T‑connector defect. Indian J Anaesth 2010;54:357‑8. Sofi K, El‑Gammal K. Endotracheal tube defects: Hidden causes of airway obstruction. Saudi J Anaesth 2010;4:108‑10. Chua WL, Ng AS. A defective endotracheal tube. Singapore Med J 2002;43:476‑8. Koshy T, Sinha PK, Vijayakumar A, Dash PK, Unnikrishnan KP. An unusual cause of high airway pressure and inadequate ventilation because of a defective connector despite accurate placement of a double‑lumen tube. J Cardiothorac Vasc Anesth 2006;20:627‑30. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.126842
Laryngeal mask airway supremeTM for difficult airway management and establishing ventilation in the intensive care unit Sir,
Figure 1: Distal (endotracheal) end of the defective endotracheal tube connector. Red pointed arrow is indicating a thin membranous diaphragm Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014
An 80‑year‑old male, in‑patient, known case of hypertension, insulin dependent diabetes mellitus, hemiplegia, chronic renal failure and bed ridden for 5 years, admitted with the complaints of fever and productive cough was shifted to the intensive care unit (ICU) following sudden decrease of consciousness and respiratory distress. Call was sent to the anaesthesiologist for emergency airway management. 91
Letters to Editor
The patient had a Glasgow Coma Scale of six, with respiratory distress and upper airway obstruction. He had a totally fixed neck, fixed flexion and rotational deformity of the head and neck with the chin rotated to the left [Figure 1]. The patient’s oxygen saturation on pulse oximetry (SpO2) on oxygen through the face mask, 60‑65%. The arterial blood gas showed paO2 of 54 mmHg, pCO2 of 114 mmHg and pH of 6.19. In view of the difficult intubation, call was sent for the flexible fibreoptic bronchoscope. With the bronchoscope about 15 min away, airway management were started. The patient was given fentanyl, 50 µg and propofol, 20 mg. Attempts at bag mask ventilation failed. Three attempts at laryngoscopy using Miller blades size three and four showed Cormack Lehane Grade IV view with an inability to intubate the trachea. The situation deteriorated into “cannot intubate, cannot ventilate”. Insertion of Classical Laryngeal Mask Airway™ (LMA; The Laryngeal Mask Airway Company, San Diego, California, USA) sizes three and four was tried. The LMAs kept slipping out and manual ventilation was not possible due to upper airway obstruction. By now the spO2 had dropped to 40‑45% with heart rate of about 40 beats/min. With the bronchoscope still not available, we used the Laryngeal Mask Airway Supreme™ (LMAS; The Laryngeal Mask Airway Company, San Diego, California, USA) size three. The fixed curvature facilitated introduction. It easily slid into place, was then fixed using its ‘Fixation Tab’. It remained stable in its place and allowed adequate ventilation. The patient was connected to the ventilator through the LMAS and ventilation initiated. In view of the patient’s unstable vital parameters it was decided to continue respiratory support through the LMAS and defer bronchoscopic intubation temporarily.
After 1½ h of ventilatory support through the LMAS the spO2 improved to 85‑90%, with paO2 of 83.2 mmHg, pcO2 of 48 mmHg and pH of 7.14. The LMAS was then removed and the trachea successfully intubated orally by flexible fibreoptic intubation under local anaesthesia and sedation. The American Society of Anesthesiologists Difficult Airway Algorithm stresses on the use of the LMA in difficult airway management.[1] In view of the failure of the LMA and the deteriorating condition we used the LMAS as a rescue airway device. The LMAS is a sterile latex free single use supraglottic device, made of medical grade polyvinyl chloride. The second seal gastric inlet allows passive or active suctioning of the gastric tract and prevents insufflation during ventilation. The elliptical and anatomical shaped airway tube allows easy insertion.[2] The oval shape matches the shape of the mouth and reduces rotation in the pharynx. The strengthened cuff prevents infolding and the epiglottic fins prevent airway obstruction from down folding of the epiglottis.[3] These superior design characteristics of the LMAS allowed easy insertion and prevented rotation in an anatomically distorted airway, while the ‘Fixation Tab’ allowed secure stabilisation and fixing. We were faced with dual difficulty of airway control and initiating ICU ventilation. We chose the LMA over the Proseal™ as we believed that the preformed curve would facilitate insertion and the fixation tab would allow secure fixation, allowing us to achieve our dual aims of airway control and ventilatory device.
Mohd Saif Ghaus Department of Anaesthesiology, Dr. Ahmed Abanamy Hospital, Riyadh, Saudi Arabia Address for correspondence: Dr. Mohd Saif Ghaus, C/o Dr. Ahmed Abanamy Hospital, Near Exit 9, Al Hamra, P.O. Box 91395, Riyadh - 11633, Saudi Arabia. E‑mail: [email protected]
REFERENCES 1.
Figure 1: X-ray showing the distorted airway anatomy 92
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251‑70. 2. Verghese C, Ramaswamy B. LMA‑Supreme – A new single‑use LMA with gastric access: A report on its clinical efficacy. Br J Anaesth 2008;101:405‑10. Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014
Letters to Editor 3.
van Zundert A, Brimacombe J. The LMA supreme – A pilot study. Anaesthesia 2008;63:209‑10. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.126843
Low dose spinal with epidural volume extension for renal transplantation in a patient with uremic cardiomyopathy Sir,
The patient was kept nil per oral for 8 h and received all his antihypertensive drugs as premedication 2 h prior to surgery with a sip of water. In the operating room routine monitoring were attached. Peripheral venous, right radial arterial and right internal jugular vein cannulations were performed under local anaesthesia. The patient was preloaded with normal saline (5 ml/kg body weight [BW]) and combined spinal epidural (CSE) administered in L3‑4 interspace in sitting position by midline approach, using 18G CSE set (needle through needle, Portex, Smiths medical ASD Inc., USA). Intrathecal drug administration consisted of 7.5 mg heavy bupivacaine mixed with 25 mcg fentanyl. Epidural catheter was fixed at 7 cm on the skin surface. The patient was turned supine position with slight head down position. After careful aspiration of epidural catheter, 10 ml of 0.9% saline was injected through the catheter over 30 s. A sensory block to pinprick to T6 was achieved within 5 min. Heart rate, arterial blood pressure, SpO2 and temperature were monitored continuously and blood gas samples were obtained every 60 min intra‑operatively. Oxygen was given to patient through nasal cannula at the rate of 2 L/min and sedated with injection midazolam 0.04 mg/kg BW. A repeat bolus of 5 ml of 0.5% plain bupivacaine was administered after 90 min through the epidural catheter. Injection methylprednisolone 500 mg and mannitol (20%) 0.5 g/kg BW were administered before the release of vascular clamp.
Patients of renal failure presenting for renal transplant have number of co‑morbid conditions namely anaemia, fluid overload, cardiovascular compromise, electrolytes and acid base imbalance, secondary hyperparathyroidism, gastrointestinal and central nervous system symptoms. Prolonged exposure to uremic toxins has been demonstrated to affect myocardial contractility leading to uremic cardiomyopathy.[1] Such changes affect the course of anaesthesia during renal transplantation. The technique of anaesthesia chosen should have minimal cardiovascular effects along with preservation of the function of transplanted organ. We present here a case of uremic cardiomyopathy for renal transplantation managed successfully with low dose spinal with epidural volume extension (EVE).
The surgical procedure lasted 3½ h. The patient was haemodynamically stable in the peri‑operative period. The patient was shifted to intensive care unit after surgery, where epidural infusion with 0.125% bupivacaine and 2 µg/ml fentanyl at the rate of 5 ml/h was initiated for post‑operative analgesia.
A 22‑year‑old male patient of renal failure, on maintenance haemodialysis presented for live donor renal transplantation. Patient was found to be controlled hypertensive on medication (tablet nifedipine 20 mg TDS, tablet clonidine 100 µg BD and tablet carvedilol 3.125 mg BD) of a heart rate 52/min, blood pressure 160/100 mm Hg, cardiomegaly in X‑ray chest and left ventricular hypertrophy in electrocardiography. Echocardiography revealed global hypokinesia, dilated left ventricle (LV), trivial aortic regurgitation/tricuspid regurgitation and left ventricle ejection fraction 25%. An arteriovenous fistula for haemodialysis was present in left forearm. Pre‑operative heparin free haemodialysis was performed on day before surgery.
Patients of poor LV function presenting for renal transplantation are a challenge in peri‑operative period. Anaesthetics goals include avoidance of drug induced myocardial depression, maintaining preload and afterload as well as renal perfusion and avoidance of nephrotoxic drugs. General anaesthesia leads to dose related cardiovascular depression, arrhythmia and congestive cardiac failure. Spinal anaesthesia may lead to intense haemodynamic variability secondary to sympathetic blockade as well as limited duration of action. Epidural anaesthesia is an option but may be associated with patchy effect. Recent evidence suggests that CSE anaesthesia (CSEA) is a good alternative for renal transplantation.[2]
Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014
93
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.
an infant feeding tube 8 FG (Polymed, Poly Medicure Ltd., Rajasthan, India) through the ETT for suctioning. However, it could not be negotiated through the universal 15mm connector. On inspection, the connector was found to be blocked nearly 50% by a thin membranous diaphragm [Figure 1]. Replacement of the connector led to marked reduction in resistance and improvement in ventilation. The rest of the case proceeded uneventfully. After extubation, the ETT was inspected and was not found to have any other obstruction. The incident was informed to the hospital equipment purchase committee. Though rare, manufacturing defects in ETTs can be hazardous, especially, in a child as airway diameter is small. In addition, it is difficult to differentiate between a distorted capnograph due to obstruction from normal variant in children. Obstruction because of plastic membrane in the connector of cut resterilized, ETT has been reported.[1] Deformed connector,[2] plastic meniscus in ETT lumen[3] and kinking[4] have been observed as a cause of obstruction while using new pre‑packed ETTs. In view of multiple reports, administrators and societies of Anaesthesiologists must insist for strict quality control from manufacturers. These incidents have led to practice of examination of ETTs before intubation. However, this usually involves looking at the external surface, tip, Murphy’s eye and obvious obstruction through transparent tube. Less obtrusive defects can be easily missed. Membrane in opti‑port right angle connector of double lumen tube is also mentioned.[5] Our case signifies importance of visual inspection through the lumen of the ETT with connector from proximal to distal end prior to intubation to prevent untoward complications. In case of high airway pressures, one should check for patient related
problems, ETT obstruction and breathing circuit malfunction. If ruled out, one should not forget to look for rare causes like defective connector.
Anila D Malde, Ruchi A Jain Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India Address for correspondence: Dr. Anila D Malde, Block No. 3, Nagjibhai Mansion, Manubhai P. Vaidya Marg, Ghatkopar (East), Mumbai ‑ 400 077, Maharashtra, India. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
Ngan Kee WD. An unusual problem with an endotracheal tube. Anaesth Intensive Care 1993;21:247‑8. Shamshery C, Kannaujia A, Gautam S. Ventilation failure due to endotracheal tube T‑connector defect. Indian J Anaesth 2010;54:357‑8. Sofi K, El‑Gammal K. Endotracheal tube defects: Hidden causes of airway obstruction. Saudi J Anaesth 2010;4:108‑10. Chua WL, Ng AS. A defective endotracheal tube. Singapore Med J 2002;43:476‑8. Koshy T, Sinha PK, Vijayakumar A, Dash PK, Unnikrishnan KP. An unusual cause of high airway pressure and inadequate ventilation because of a defective connector despite accurate placement of a double‑lumen tube. J Cardiothorac Vasc Anesth 2006;20:627‑30. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.126842
Laryngeal mask airway supremeTM for difficult airway management and establishing ventilation in the intensive care unit Sir,
Figure 1: Distal (endotracheal) end of the defective endotracheal tube connector. Red pointed arrow is indicating a thin membranous diaphragm Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014
An 80‑year‑old male, in‑patient, known case of hypertension, insulin dependent diabetes mellitus, hemiplegia, chronic renal failure and bed ridden for 5 years, admitted with the complaints of fever and productive cough was shifted to the intensive care unit (ICU) following sudden decrease of consciousness and respiratory distress. Call was sent to the anaesthesiologist for emergency airway management. 91
Letters to Editor
The patient had a Glasgow Coma Scale of six, with respiratory distress and upper airway obstruction. He had a totally fixed neck, fixed flexion and rotational deformity of the head and neck with the chin rotated to the left [Figure 1]. The patient’s oxygen saturation on pulse oximetry (SpO2) on oxygen through the face mask, 60‑65%. The arterial blood gas showed paO2 of 54 mmHg, pCO2 of 114 mmHg and pH of 6.19. In view of the difficult intubation, call was sent for the flexible fibreoptic bronchoscope. With the bronchoscope about 15 min away, airway management were started. The patient was given fentanyl, 50 µg and propofol, 20 mg. Attempts at bag mask ventilation failed. Three attempts at laryngoscopy using Miller blades size three and four showed Cormack Lehane Grade IV view with an inability to intubate the trachea. The situation deteriorated into “cannot intubate, cannot ventilate”. Insertion of Classical Laryngeal Mask Airway™ (LMA; The Laryngeal Mask Airway Company, San Diego, California, USA) sizes three and four was tried. The LMAs kept slipping out and manual ventilation was not possible due to upper airway obstruction. By now the spO2 had dropped to 40‑45% with heart rate of about 40 beats/min. With the bronchoscope still not available, we used the Laryngeal Mask Airway Supreme™ (LMAS; The Laryngeal Mask Airway Company, San Diego, California, USA) size three. The fixed curvature facilitated introduction. It easily slid into place, was then fixed using its ‘Fixation Tab’. It remained stable in its place and allowed adequate ventilation. The patient was connected to the ventilator through the LMAS and ventilation initiated. In view of the patient’s unstable vital parameters it was decided to continue respiratory support through the LMAS and defer bronchoscopic intubation temporarily.
After 1½ h of ventilatory support through the LMAS the spO2 improved to 85‑90%, with paO2 of 83.2 mmHg, pcO2 of 48 mmHg and pH of 7.14. The LMAS was then removed and the trachea successfully intubated orally by flexible fibreoptic intubation under local anaesthesia and sedation. The American Society of Anesthesiologists Difficult Airway Algorithm stresses on the use of the LMA in difficult airway management.[1] In view of the failure of the LMA and the deteriorating condition we used the LMAS as a rescue airway device. The LMAS is a sterile latex free single use supraglottic device, made of medical grade polyvinyl chloride. The second seal gastric inlet allows passive or active suctioning of the gastric tract and prevents insufflation during ventilation. The elliptical and anatomical shaped airway tube allows easy insertion.[2] The oval shape matches the shape of the mouth and reduces rotation in the pharynx. The strengthened cuff prevents infolding and the epiglottic fins prevent airway obstruction from down folding of the epiglottis.[3] These superior design characteristics of the LMAS allowed easy insertion and prevented rotation in an anatomically distorted airway, while the ‘Fixation Tab’ allowed secure stabilisation and fixing. We were faced with dual difficulty of airway control and initiating ICU ventilation. We chose the LMA over the Proseal™ as we believed that the preformed curve would facilitate insertion and the fixation tab would allow secure fixation, allowing us to achieve our dual aims of airway control and ventilatory device.
Mohd Saif Ghaus Department of Anaesthesiology, Dr. Ahmed Abanamy Hospital, Riyadh, Saudi Arabia Address for correspondence: Dr. Mohd Saif Ghaus, C/o Dr. Ahmed Abanamy Hospital, Near Exit 9, Al Hamra, P.O. Box 91395, Riyadh - 11633, Saudi Arabia. E‑mail: [email protected]
REFERENCES 1.
Figure 1: X-ray showing the distorted airway anatomy 92
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2013;118:251‑70. 2. Verghese C, Ramaswamy B. LMA‑Supreme – A new single‑use LMA with gastric access: A report on its clinical efficacy. Br J Anaesth 2008;101:405‑10. Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014
Letters to Editor 3.
van Zundert A, Brimacombe J. The LMA supreme – A pilot study. Anaesthesia 2008;63:209‑10. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.126843
Low dose spinal with epidural volume extension for renal transplantation in a patient with uremic cardiomyopathy Sir,
The patient was kept nil per oral for 8 h and received all his antihypertensive drugs as premedication 2 h prior to surgery with a sip of water. In the operating room routine monitoring were attached. Peripheral venous, right radial arterial and right internal jugular vein cannulations were performed under local anaesthesia. The patient was preloaded with normal saline (5 ml/kg body weight [BW]) and combined spinal epidural (CSE) administered in L3‑4 interspace in sitting position by midline approach, using 18G CSE set (needle through needle, Portex, Smiths medical ASD Inc., USA). Intrathecal drug administration consisted of 7.5 mg heavy bupivacaine mixed with 25 mcg fentanyl. Epidural catheter was fixed at 7 cm on the skin surface. The patient was turned supine position with slight head down position. After careful aspiration of epidural catheter, 10 ml of 0.9% saline was injected through the catheter over 30 s. A sensory block to pinprick to T6 was achieved within 5 min. Heart rate, arterial blood pressure, SpO2 and temperature were monitored continuously and blood gas samples were obtained every 60 min intra‑operatively. Oxygen was given to patient through nasal cannula at the rate of 2 L/min and sedated with injection midazolam 0.04 mg/kg BW. A repeat bolus of 5 ml of 0.5% plain bupivacaine was administered after 90 min through the epidural catheter. Injection methylprednisolone 500 mg and mannitol (20%) 0.5 g/kg BW were administered before the release of vascular clamp.
Patients of renal failure presenting for renal transplant have number of co‑morbid conditions namely anaemia, fluid overload, cardiovascular compromise, electrolytes and acid base imbalance, secondary hyperparathyroidism, gastrointestinal and central nervous system symptoms. Prolonged exposure to uremic toxins has been demonstrated to affect myocardial contractility leading to uremic cardiomyopathy.[1] Such changes affect the course of anaesthesia during renal transplantation. The technique of anaesthesia chosen should have minimal cardiovascular effects along with preservation of the function of transplanted organ. We present here a case of uremic cardiomyopathy for renal transplantation managed successfully with low dose spinal with epidural volume extension (EVE).
The surgical procedure lasted 3½ h. The patient was haemodynamically stable in the peri‑operative period. The patient was shifted to intensive care unit after surgery, where epidural infusion with 0.125% bupivacaine and 2 µg/ml fentanyl at the rate of 5 ml/h was initiated for post‑operative analgesia.
A 22‑year‑old male patient of renal failure, on maintenance haemodialysis presented for live donor renal transplantation. Patient was found to be controlled hypertensive on medication (tablet nifedipine 20 mg TDS, tablet clonidine 100 µg BD and tablet carvedilol 3.125 mg BD) of a heart rate 52/min, blood pressure 160/100 mm Hg, cardiomegaly in X‑ray chest and left ventricular hypertrophy in electrocardiography. Echocardiography revealed global hypokinesia, dilated left ventricle (LV), trivial aortic regurgitation/tricuspid regurgitation and left ventricle ejection fraction 25%. An arteriovenous fistula for haemodialysis was present in left forearm. Pre‑operative heparin free haemodialysis was performed on day before surgery.
Patients of poor LV function presenting for renal transplantation are a challenge in peri‑operative period. Anaesthetics goals include avoidance of drug induced myocardial depression, maintaining preload and afterload as well as renal perfusion and avoidance of nephrotoxic drugs. General anaesthesia leads to dose related cardiovascular depression, arrhythmia and congestive cardiac failure. Spinal anaesthesia may lead to intense haemodynamic variability secondary to sympathetic blockade as well as limited duration of action. Epidural anaesthesia is an option but may be associated with patchy effect. Recent evidence suggests that CSE anaesthesia (CSEA) is a good alternative for renal transplantation.[2]
Indian Journal of Anaesthesia | Vol. 58| Issue 1 | Jan-Feb 2014
93
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.
