BJA
Correspondence
Declaration of interest
with banding for oesophageal varices under general anaesthesia. It is known that maintaining the administration of shortacting opioids during emergence may safely and effectively suppress coughing during emergence.1 Hence, we chose remifentanil to attenuate these responses. Successful and uneventful intubation was achieved with an i.v. induction using lidocaine 1.5 mg kg21, propofol 2 mg kg21, and remifentanil 1 mg kg21 over 30 s, and suxamethonium chloride 1.5 mg kg21 to facilitate tracheal intubation. The tracheal tube cuff pressure was maintained at 30 cm H2O. The initial and continued remifentanil infusion rate throughout the operation was 0.125 mg kg21 min21. Maintenance was with nitrous oxide in oxygen (66:33) and sevoflurane adjusted to a total additive minimum alveolar concentration of 1.0. Variceal band ligation was performed with good decompression of varices and no intraprocedure complications. Extubation was performed when the patient opened her eyes and followed simple commands. The extubation was uneventful and without any substantial coughing or bucking. Approximately 1 h post-procedure, she began complaining of right upper eye lid swelling, right eye pain, and diplopia in left gaze. Ophthalmology consultation revealed that she had two lines of decreased vision in the right eye compared with the left eye, with normally reactive pupils of both eyes and no detection of an afferent pupillary defect. Intra-ocular pressure (IOP) was elevated in the right eye and extra-ocular muscle
None declared. J.-A. Lin* H.-T. Lu Taipei, Taiwan * E-mail: [email protected] 1 Gadson J. Monitoring and documentation. In: Hadzic A, ed. Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia. New York: McGraw-Hill, 2012; 71– 9 2 Abdallah FW, Chan VW. The paraneural compartment: a new destination? Reg Anesth Pain Med 2013; 38: 375–7 3 Perlas A, Lobo G, Lo N, Brull R, Chan VW, Karkhanis R. Ultrasoundguided supraclavicular block: outcome of 510 consecutive cases. Reg Anesth Pain Med 2009; 34: 171– 6 4 Tsui BC, Li LX, Pillay JJ. Compressed air injection technique to standardize block injection pressures. Can J Anaesth 2006; 53: 1098– 102
doi:10.1093/bja/aeu083
Subperiosteal haematoma after general anaesthesia Editor—Subperiosteal haematomas (SPH) are the orbital equivalent of an intracranial epidural haematoma and are typically the result of blunt orbital or facial trauma.1 We report the second known case of SPH after general anaesthesia and the first reported case in the anaesthesia literature. The patient, 5′ 4′′ , 72 kg, 51-yr-old female with a past medical history of stage IV liver cirrhosis, oesophageal varices, and thrombocytopenia underwent oesophago-gastro-doudenoscopy (OGD)
772
Fig 1 Non-contrast CT scan of the orbits demonstrating a hyperdense extraconal lesion consistent with haemorrhage in the superomedial aspect of the globe. This lesion is causing proptosis of the right globe and inferior displacement of the optic nerve, superior and medial rectus muscles, and superior oblique muscle. It is in close proximity to the orbital apex. (A) Coronal scan and (B) axial scan.
Downloaded from http://bja.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
inexpensive setting to monitor opening pressure during multiple needle redirection. The extra-cost includes a three-way stopcock (B. Braun Discofix, Germany), a low-dead space (1.4 ml) extension tube (Innovative Extension Set ETC018, Taiwan), and a 20 ml syringe (BD Plastipak, Spain), which total £0.7 (E0.8/ $1.1). The three-way stopcock has one male luer lock and two female luer connectors, one at the side and the other at the end. The extension tube connects the male luer lock to the patient. The test syringe is attached to the side female luer port and is ready to perform the pressure test when the three-way is turned on to the patient and the test syringe is held upright. Before local anaesthetic administration for a new needle tip location, opening pressure is tested simply by half-the-air at this setting (Fig. 1A). Local anaesthetic can then be injected into the space that has been tested (Fig. 1B). In addition to easy pressure monitoring, it also ensures that the total amount of local anaesthetic can be injected into the target site because the test syringe’s injectate consumed to hydrolocate the needle tip is the test volume (D5W or normal saline) instead of local anaesthetic. After injection of local anaesthetic, the volume of which retained in the dead space of the extension tube could be emptied by the volume in the test syringe.
BJA
Correspondence
Declaration of interest None declared. H. N. Saeed* M. V. Presta D. Yoo Maywood, IL, USA * E-mail: [email protected] 1 Aouad MT, Al-Alami A, Nasr VG, Souki FG, Zbeidy RA, Siddik-Sayyid SM. The effect of low-dose remifentanil on responses to the endotracheal tube during emergence from general anesthesia. Anesth Analg 2009; 108: 1157– 60 2 Anderson KK, Larson NH, Saga-Rumley SA, Hamed LM. Spontaneous orbital hemorrhage during general anesthesia and arthroplasty. J Clin Anesth 1994; 6: 145–7 3 Gunning KE, Collett BJ. Spontaneous retrobulbar haemorrhage following anaesthesia. Anaesthesia 1987; 42: 875– 6 4 Peden MC, Bhatti MT. Subperiosteal orbital hemorrhage complicating cardiac surgery. Cardiovasc Inter Rad 2004; 27: 294 – 6
doi:10.1093/bja/aeu084
Cognitive tool for dealing with unexpected difficult airway Editor—I would like to draw your attention to a novel cognitive tool for dealing with the unexpected difficult airway. The ‘Can’t Intubate, Can’t Ventilate’ airway crisis is arguably the most time-critical emergency that is encountered in the operating theatre. It is also one of the few causes of morbidity and mortality that are directly related to the conduct of anaesthesia. Therefore, considerable effort is made by the anaesthetic profession to establish guidelines and procedures to avoid failures in airway management. One important aspect of that work is the difficult airway algorithms that are published, and regularly revised, by national and regional bodies.1 2 All anaesthetists receive training in airway management and the use of different devices and adjuncts devised to facilitate it. Despite all this training and the existence of algorithms, clinicians sometimes fail to act quickly enough, or at all, to resolve the situation. The endpoint in all difficult airway algorithms— the emergency surgical airway (ESA)—is a very rare procedure, and it can be hard to overcome the resistance to perform it for an inexperienced or unprepared anaesthetist. Recognizing these obstacles to effective management of the failed airway, and also the fact that not all attempts at airway management are made in the operating theatre, two physicians have developed the Vortex Approach3 (http:// vortexapproach.com/Vortex_Approach/Vortex.html). The Vortex is meant to be used as a ‘high stakes cognitive aid’, that is, as an easy to remember guide to quick and focused decisionmaking in an airway emergency. It emphasizes the importance of establishing effective alveolar oxygen delivery and can be used regardless of which airway management strategy is chosen initially. The tool is presented as a funnel divided into three segments (Fig. 1), each representing one of the nonsurgical airway techniques—face mask, laryngeal mask, and tracheal tube. After an optimal attempt has been made using the planned technique, the operator proceeds with the next, while conceptually sliding down the slope of the funnel (hence the name ‘Vortex’). It is often necessary to make more than one attempt at each technique before declaring that an ‘optimal’ attempt has been made. Different manipulations, adjuncts, or both can then be used to improve the chances at success. When optimal attempts at all three nonsurgical techniques have been made, the operator moves into the centre and bottom of the funnel, which represents the ESA. The Vortex Approach thus helps the clinician to move forward, avoiding repeated attempts at methods that have already proven unsuccessful. I recently encountered an unexpected difficult airway, where I ended up performing an emergency tracheostomy— the first and hopefully last one of my career. Luckily, the patient survived neurologically intact. Even though the outcome would have been the same regardless of which difficult airway algorithm had been used, the simplicity of the Vortex made the decision-making faster and more focused. This was also noticed by the rest of the team members, who
773
Downloaded from http://bja.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
(EOM) testing revealed 75% motility restriction in supraduction and adduction of the right eye. She had significant swelling of the right upper and lower lids, and proptosis with a 5 mm protrusion of the right eye compared with the left eye. A CT scan that was obtained at that time was significant for a hyperdense lesion in the superomedial aspect of the right orbit consistent with haemorrhage (Fig. 1). Because of the decrease in vision and significant pain, the patient was taken to the operating theatre the same day by ophthalmology for an orbitotomy, and drainage of the right superior SPH of the orbital roof with drain placement. The surgery and postoperative course were uncomplicated. Immediately after operation, the patient’s vision was noted to be correctable by pinhole acuity to that of what the left eye was before operation, IOP of the right eye improved, and motility restriction of EOMs was noted to be unchanged. On the fourth postoperative day, the patient’s EOMs were markedly improved with minimal restriction in supraduction and adduction. The orbital drain was removed on the sixth postoperative day with no further complications. Our patient went on to have another OGD under general anaesthesia 3 months later. At that time, she had a platelet count of 35 000 U litre21 and she was given a platelet transfusion before the procedure. This OGD, and also two subsequent ones, was uneventful. Of note, all of these cases were performed without the use of a short-acting opioid infusion such as remifentanil. Several factors are likely to have contributed to the development of SPH in our patient and warrant further investigation. Although not to the extent of retrobulbar haemorrhage,2 – 4 we believe that SPH also merits recognition as a potential consequence of tracheal extubation after general anaesthesia.
Correspondence
Declaration of interest
with banding for oesophageal varices under general anaesthesia. It is known that maintaining the administration of shortacting opioids during emergence may safely and effectively suppress coughing during emergence.1 Hence, we chose remifentanil to attenuate these responses. Successful and uneventful intubation was achieved with an i.v. induction using lidocaine 1.5 mg kg21, propofol 2 mg kg21, and remifentanil 1 mg kg21 over 30 s, and suxamethonium chloride 1.5 mg kg21 to facilitate tracheal intubation. The tracheal tube cuff pressure was maintained at 30 cm H2O. The initial and continued remifentanil infusion rate throughout the operation was 0.125 mg kg21 min21. Maintenance was with nitrous oxide in oxygen (66:33) and sevoflurane adjusted to a total additive minimum alveolar concentration of 1.0. Variceal band ligation was performed with good decompression of varices and no intraprocedure complications. Extubation was performed when the patient opened her eyes and followed simple commands. The extubation was uneventful and without any substantial coughing or bucking. Approximately 1 h post-procedure, she began complaining of right upper eye lid swelling, right eye pain, and diplopia in left gaze. Ophthalmology consultation revealed that she had two lines of decreased vision in the right eye compared with the left eye, with normally reactive pupils of both eyes and no detection of an afferent pupillary defect. Intra-ocular pressure (IOP) was elevated in the right eye and extra-ocular muscle
None declared. J.-A. Lin* H.-T. Lu Taipei, Taiwan * E-mail: [email protected] 1 Gadson J. Monitoring and documentation. In: Hadzic A, ed. Hadzic’s Peripheral Nerve Blocks and Anatomy for Ultrasound-Guided Regional Anesthesia. New York: McGraw-Hill, 2012; 71– 9 2 Abdallah FW, Chan VW. The paraneural compartment: a new destination? Reg Anesth Pain Med 2013; 38: 375–7 3 Perlas A, Lobo G, Lo N, Brull R, Chan VW, Karkhanis R. Ultrasoundguided supraclavicular block: outcome of 510 consecutive cases. Reg Anesth Pain Med 2009; 34: 171– 6 4 Tsui BC, Li LX, Pillay JJ. Compressed air injection technique to standardize block injection pressures. Can J Anaesth 2006; 53: 1098– 102
doi:10.1093/bja/aeu083
Subperiosteal haematoma after general anaesthesia Editor—Subperiosteal haematomas (SPH) are the orbital equivalent of an intracranial epidural haematoma and are typically the result of blunt orbital or facial trauma.1 We report the second known case of SPH after general anaesthesia and the first reported case in the anaesthesia literature. The patient, 5′ 4′′ , 72 kg, 51-yr-old female with a past medical history of stage IV liver cirrhosis, oesophageal varices, and thrombocytopenia underwent oesophago-gastro-doudenoscopy (OGD)
772
Fig 1 Non-contrast CT scan of the orbits demonstrating a hyperdense extraconal lesion consistent with haemorrhage in the superomedial aspect of the globe. This lesion is causing proptosis of the right globe and inferior displacement of the optic nerve, superior and medial rectus muscles, and superior oblique muscle. It is in close proximity to the orbital apex. (A) Coronal scan and (B) axial scan.
Downloaded from http://bja.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
inexpensive setting to monitor opening pressure during multiple needle redirection. The extra-cost includes a three-way stopcock (B. Braun Discofix, Germany), a low-dead space (1.4 ml) extension tube (Innovative Extension Set ETC018, Taiwan), and a 20 ml syringe (BD Plastipak, Spain), which total £0.7 (E0.8/ $1.1). The three-way stopcock has one male luer lock and two female luer connectors, one at the side and the other at the end. The extension tube connects the male luer lock to the patient. The test syringe is attached to the side female luer port and is ready to perform the pressure test when the three-way is turned on to the patient and the test syringe is held upright. Before local anaesthetic administration for a new needle tip location, opening pressure is tested simply by half-the-air at this setting (Fig. 1A). Local anaesthetic can then be injected into the space that has been tested (Fig. 1B). In addition to easy pressure monitoring, it also ensures that the total amount of local anaesthetic can be injected into the target site because the test syringe’s injectate consumed to hydrolocate the needle tip is the test volume (D5W or normal saline) instead of local anaesthetic. After injection of local anaesthetic, the volume of which retained in the dead space of the extension tube could be emptied by the volume in the test syringe.
BJA
Correspondence
Declaration of interest None declared. H. N. Saeed* M. V. Presta D. Yoo Maywood, IL, USA * E-mail: [email protected] 1 Aouad MT, Al-Alami A, Nasr VG, Souki FG, Zbeidy RA, Siddik-Sayyid SM. The effect of low-dose remifentanil on responses to the endotracheal tube during emergence from general anesthesia. Anesth Analg 2009; 108: 1157– 60 2 Anderson KK, Larson NH, Saga-Rumley SA, Hamed LM. Spontaneous orbital hemorrhage during general anesthesia and arthroplasty. J Clin Anesth 1994; 6: 145–7 3 Gunning KE, Collett BJ. Spontaneous retrobulbar haemorrhage following anaesthesia. Anaesthesia 1987; 42: 875– 6 4 Peden MC, Bhatti MT. Subperiosteal orbital hemorrhage complicating cardiac surgery. Cardiovasc Inter Rad 2004; 27: 294 – 6
doi:10.1093/bja/aeu084
Cognitive tool for dealing with unexpected difficult airway Editor—I would like to draw your attention to a novel cognitive tool for dealing with the unexpected difficult airway. The ‘Can’t Intubate, Can’t Ventilate’ airway crisis is arguably the most time-critical emergency that is encountered in the operating theatre. It is also one of the few causes of morbidity and mortality that are directly related to the conduct of anaesthesia. Therefore, considerable effort is made by the anaesthetic profession to establish guidelines and procedures to avoid failures in airway management. One important aspect of that work is the difficult airway algorithms that are published, and regularly revised, by national and regional bodies.1 2 All anaesthetists receive training in airway management and the use of different devices and adjuncts devised to facilitate it. Despite all this training and the existence of algorithms, clinicians sometimes fail to act quickly enough, or at all, to resolve the situation. The endpoint in all difficult airway algorithms— the emergency surgical airway (ESA)—is a very rare procedure, and it can be hard to overcome the resistance to perform it for an inexperienced or unprepared anaesthetist. Recognizing these obstacles to effective management of the failed airway, and also the fact that not all attempts at airway management are made in the operating theatre, two physicians have developed the Vortex Approach3 (http:// vortexapproach.com/Vortex_Approach/Vortex.html). The Vortex is meant to be used as a ‘high stakes cognitive aid’, that is, as an easy to remember guide to quick and focused decisionmaking in an airway emergency. It emphasizes the importance of establishing effective alveolar oxygen delivery and can be used regardless of which airway management strategy is chosen initially. The tool is presented as a funnel divided into three segments (Fig. 1), each representing one of the nonsurgical airway techniques—face mask, laryngeal mask, and tracheal tube. After an optimal attempt has been made using the planned technique, the operator proceeds with the next, while conceptually sliding down the slope of the funnel (hence the name ‘Vortex’). It is often necessary to make more than one attempt at each technique before declaring that an ‘optimal’ attempt has been made. Different manipulations, adjuncts, or both can then be used to improve the chances at success. When optimal attempts at all three nonsurgical techniques have been made, the operator moves into the centre and bottom of the funnel, which represents the ESA. The Vortex Approach thus helps the clinician to move forward, avoiding repeated attempts at methods that have already proven unsuccessful. I recently encountered an unexpected difficult airway, where I ended up performing an emergency tracheostomy— the first and hopefully last one of my career. Luckily, the patient survived neurologically intact. Even though the outcome would have been the same regardless of which difficult airway algorithm had been used, the simplicity of the Vortex made the decision-making faster and more focused. This was also noticed by the rest of the team members, who
773
Downloaded from http://bja.oxfordjournals.org/ at Simon Fraser University on June 7, 2015
(EOM) testing revealed 75% motility restriction in supraduction and adduction of the right eye. She had significant swelling of the right upper and lower lids, and proptosis with a 5 mm protrusion of the right eye compared with the left eye. A CT scan that was obtained at that time was significant for a hyperdense lesion in the superomedial aspect of the right orbit consistent with haemorrhage (Fig. 1). Because of the decrease in vision and significant pain, the patient was taken to the operating theatre the same day by ophthalmology for an orbitotomy, and drainage of the right superior SPH of the orbital roof with drain placement. The surgery and postoperative course were uncomplicated. Immediately after operation, the patient’s vision was noted to be correctable by pinhole acuity to that of what the left eye was before operation, IOP of the right eye improved, and motility restriction of EOMs was noted to be unchanged. On the fourth postoperative day, the patient’s EOMs were markedly improved with minimal restriction in supraduction and adduction. The orbital drain was removed on the sixth postoperative day with no further complications. Our patient went on to have another OGD under general anaesthesia 3 months later. At that time, she had a platelet count of 35 000 U litre21 and she was given a platelet transfusion before the procedure. This OGD, and also two subsequent ones, was uneventful. Of note, all of these cases were performed without the use of a short-acting opioid infusion such as remifentanil. Several factors are likely to have contributed to the development of SPH in our patient and warrant further investigation. Although not to the extent of retrobulbar haemorrhage,2 – 4 we believe that SPH also merits recognition as a potential consequence of tracheal extubation after general anaesthesia.
