Letters to Editor
We would like to say again that ours is an experimental exercise and we recommend further evaluation of this technique against established methods based on anatomical landmarks and length of insertion, that are well-established in practice, for ease of insertion, time taken, and accuracy of placement. Manila Singh, Kapil Chaudhary, Rajeev Uppal Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, New Delhi, India Address for correspondence: Dr. Manila Singh, Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, E-349, East of Kailash, New Delhi - 110 065, India. E-mail: [email protected]
References 1.
2. 3.
4.
Calabria M, Zamboli P, D’Amelio A, Granata A, Di Lullo L, Floccari F, et al. Gruppo di Studio di Ecografia Renale della Societa’ Italiana di Nefrologia (SIN-GSER). Use of ECG-EC in the positioning of central venous catheters. G Ital Nefrol 2012;29:49-57. Peres PW. Positioning central venous catheters — A prospective survey. Anaesth Intensive Care 1990;18:536-9. Jain M, Rastogi B, Singh VP, Gupta K. Central venous catheter placement: An alternative of Certodyn® (Universal Adapter). Anesthesia: Essays and Researches 2011;5:242-3. Tibtech innovations, 2011. Available from: http://www.tibtech. com/conductivity.php [Last acces on 2013 Jun 01]. Access this article online Quick Response Code:
Website: www.joacp.org
A 40-year-old male ASA grade II patient presented with cough and breathing difficulty and inability to lie flat for last 6 months. On examination, dyspnea and bilateral rhonchi were present. CT thorax [Figure 1] showed a right paracentral mass (measuring 4.7 × 4.8 × 5 cm) causing narrowing of tracheal lumen suggestive of suspected lymph nodal mass/exophytic esophageal or tracheal wall lesion. The patient was planned for awake fiberoptic guided tracheal stenting in sitting position as a temporary measure. The patient was given inj Glycopyrrolate 0.2 mg intravenous and started on infusion dexmedetomidine 1 μg/kg over 20 minutes in the preoperative area under monitoring and then maintenance @ 0.5 μg/kg/hour continued in the operation theatre. The patient was monitored with Bispectral Index (Aspect Medical System. Norwood, USA) of 80-90 and Ramsay scoring (2-3). In the preoperative area, lignocaine nebulization was given by a face mask nebulizer. Inside operation theatre, after adequate oropharyngeal anesthesia was achieved superior laryngeal nerve block, intratracheal block, glossopharyngeal nerve block with lignocaine were given. The patient was administered O2 through nasal prongs @ 4 lit/min.When airway anesthesia was achieved, fiberoptic bronchoscope was introduced through orotracheal route and metallic self expandable stent (NITI-S, Taewood Medical, Seoul, Korea) was introduced at the level of obstruction under the vision and under fluoroscopy guidance [Figure 1]. The mass was found to be invading the tracheal wall and causing intraluminal, as well as extraluminal obstruction. The patient was hemodynamically stable. The patient was shifted to ICU on oxygen with Face Mask @ 6 lit/min. Stridor was relieved and patient was advised to follow up in the OPD after discharge. Tracheal stenosis can result from benign and malignant conditions. In advanced cases surgery would not be so helpful, but balloon dilatation and tracheal stenting has become an accepted method of palliation.[1] The need for anesthesia in these patients depends
DOI: 10.4103/0970-9185.137294
Successful tracheal stent placement for central airway obstruction using dexmedetomidine and regional airway anesthesia Sir, Anesthesia for tracheal stenting is challenging due to fear of loss of airway control. Here, we report a case of a successful awake tracheal stenting in sitting position using dexmedetomidine and airway block. 438
Figure 1: Tracheal stenosis and placement of stent
Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3
Letters to Editor
on the patient’s condition and a communication between the anesthesiologist, surgeon and interventional radiologist is essential. C. Voscopoulos et al.[2] and Basem Abdalmalak et al.[3] have successfully used dexmedetomidine based technique in tracheobronchial stenting in the cases of central airway obstruction. Bergese SD et al.[4] evaluated the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation and they found that dexmedetomidine is effective as the primary sedative in the patients undergoing the awake fiberoptic intubation with difficult airway. In our case, as the patient was not able to lie down, it was challenging to maintain the airway as well as to make the anxious patient comfortable. Dexmedetomidine possesses anxiolytic, sedative, analgesic, and sympatholytic properties. The Federal Drug Administration has approved the use of dexmedetomidine as a sedative-analgesic and/or total anesthetic in adults and pediatric patients undergoing small minimally invasive procedures, with or without the need for tracheal intubation. It is a safe sedative alternative to benzodiazepine/ opioid combinations in the patients undergoing monitored anesthesia care for a multitude of procedures because of its analgesic, “cooperative sedation,” and lack of respiratory depression properties.[5] Dexmedetomidine, coupled with local anesthesia, provided excellent sedative and operative conditions for awake laryngeal framework procedures. To conclude, dexmedetomidine along with adequate airway anesthesia can be an alternative in awake tracheal stenting. Samarjit Dey, Prithwis Bhattacharyya, Jayanta Medhi1, Adarsha Karadi Nellappa Department of Anaesthesiology, 1Otolaryngology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India Address for correspondence: Dr. Samarjit Dey, Department of Anaesthesiology, NEIGRIHMS, Shillong, PIN - 793 018, Meghalaya, India. E-mail: [email protected]
References 1. 2.
3.
4.
Ramamani M, Raj S, Manickam P. Anaesthesia for tracheo-bronchial stenting-a report of two cases. Indian J Anaesth 2008;52211. Voscopoulos C, Kirk FL, Lovrincevic M, Lema M. The use of “High Dose” dexmedetomidine in a patient with critical tracheal stenosis and anterior mediastinal mass. Open Anesthesiol J 2011;5:42-9. Abdelmalak B, Marcanthony N, Abdelmalak J, Machuzak MS, Gildea TR, Doyle DJ. Dexmedetomidine for anesthetic management of anterior mediastinal mass. J Anesth 2010;24:607-10. Bergese SD, Candiotti KA, Bokesch PM, Zura A, Wisemandle W, Bekker AY, et al. A Phase IIIb, randomized, double-blind, placebocontrolled, multicenter study evaluating the safety and efficacy of
5.
dexmedetomidine for sedation during awake fiberoptic intubation. Am J Ther 2010;17:586-95. Grewal A. Dexmedetomidine: New avenues. J Anaesthesiol Clin Pharmacol 2011;27:297-302. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.137296
Tongue bite injury after use of transcranial electric stimulation motor-evoked potential monitoring Sir, Monitoring of motor-evoked potential (MEP) during spine surgery is considered a safe technique but potential hazards include bite injuries, possibility of hazardous stimulator output, patient movement induced injury, seizures, cardiac dysrhythmias, and epidural electrode-related complications.[1] Tongue and lip bite injuries are the most common reported complications during MEP monitoring with an incidence ranging from 0.2% to 0.63%.[1,2] Previous case reports have reported bite injuries including minor tongue lacerations, broken teeth, and even bitten endotracheal tube.[1] Thirty-seven-year-old, ASA physical status I, male with BMI 24.3 Kg/m2, was posted for L3-4 laminectomy and excision of L3 intradural tumor in the prone position with transcranial electric stimulation (TES) MEP monitoring. After induction of anesthesia and intubation, the endotracheal tube was taped to the right side and a soft bite block (rolled up gauze) was inserted in the midline. Surgery and anesthesia were uneventful and lasted two hours. Tracheal extubation was performed in the OR but the patient was mildly sedated. Postoperative examination of the oral cavity revealed a tongue hematoma on the left side [Figure 1]. He was reassured about the self-resolving nature of the hematoma and was advised oral care regimen. Risk factors for tongue injury during TES MEP monitoring include C3-4 focused stimulation that directly activates the temporalis muscle[3] and prone position (as in our patient) as it predisposes to tongue swelling.[4] The mechanism of tongue injury may involve both corticobulbar activation with
Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3
439
Copyright of Journal of Anaesthesiology Clinical Pharmacology 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.
We would like to say again that ours is an experimental exercise and we recommend further evaluation of this technique against established methods based on anatomical landmarks and length of insertion, that are well-established in practice, for ease of insertion, time taken, and accuracy of placement. Manila Singh, Kapil Chaudhary, Rajeev Uppal Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, New Delhi, India Address for correspondence: Dr. Manila Singh, Department of Anaesthesia and Intensive Care, Govind Ballabh Pant Hospital, E-349, East of Kailash, New Delhi - 110 065, India. E-mail: [email protected]
References 1.
2. 3.
4.
Calabria M, Zamboli P, D’Amelio A, Granata A, Di Lullo L, Floccari F, et al. Gruppo di Studio di Ecografia Renale della Societa’ Italiana di Nefrologia (SIN-GSER). Use of ECG-EC in the positioning of central venous catheters. G Ital Nefrol 2012;29:49-57. Peres PW. Positioning central venous catheters — A prospective survey. Anaesth Intensive Care 1990;18:536-9. Jain M, Rastogi B, Singh VP, Gupta K. Central venous catheter placement: An alternative of Certodyn® (Universal Adapter). Anesthesia: Essays and Researches 2011;5:242-3. Tibtech innovations, 2011. Available from: http://www.tibtech. com/conductivity.php [Last acces on 2013 Jun 01]. Access this article online Quick Response Code:
Website: www.joacp.org
A 40-year-old male ASA grade II patient presented with cough and breathing difficulty and inability to lie flat for last 6 months. On examination, dyspnea and bilateral rhonchi were present. CT thorax [Figure 1] showed a right paracentral mass (measuring 4.7 × 4.8 × 5 cm) causing narrowing of tracheal lumen suggestive of suspected lymph nodal mass/exophytic esophageal or tracheal wall lesion. The patient was planned for awake fiberoptic guided tracheal stenting in sitting position as a temporary measure. The patient was given inj Glycopyrrolate 0.2 mg intravenous and started on infusion dexmedetomidine 1 μg/kg over 20 minutes in the preoperative area under monitoring and then maintenance @ 0.5 μg/kg/hour continued in the operation theatre. The patient was monitored with Bispectral Index (Aspect Medical System. Norwood, USA) of 80-90 and Ramsay scoring (2-3). In the preoperative area, lignocaine nebulization was given by a face mask nebulizer. Inside operation theatre, after adequate oropharyngeal anesthesia was achieved superior laryngeal nerve block, intratracheal block, glossopharyngeal nerve block with lignocaine were given. The patient was administered O2 through nasal prongs @ 4 lit/min.When airway anesthesia was achieved, fiberoptic bronchoscope was introduced through orotracheal route and metallic self expandable stent (NITI-S, Taewood Medical, Seoul, Korea) was introduced at the level of obstruction under the vision and under fluoroscopy guidance [Figure 1]. The mass was found to be invading the tracheal wall and causing intraluminal, as well as extraluminal obstruction. The patient was hemodynamically stable. The patient was shifted to ICU on oxygen with Face Mask @ 6 lit/min. Stridor was relieved and patient was advised to follow up in the OPD after discharge. Tracheal stenosis can result from benign and malignant conditions. In advanced cases surgery would not be so helpful, but balloon dilatation and tracheal stenting has become an accepted method of palliation.[1] The need for anesthesia in these patients depends
DOI: 10.4103/0970-9185.137294
Successful tracheal stent placement for central airway obstruction using dexmedetomidine and regional airway anesthesia Sir, Anesthesia for tracheal stenting is challenging due to fear of loss of airway control. Here, we report a case of a successful awake tracheal stenting in sitting position using dexmedetomidine and airway block. 438
Figure 1: Tracheal stenosis and placement of stent
Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3
Letters to Editor
on the patient’s condition and a communication between the anesthesiologist, surgeon and interventional radiologist is essential. C. Voscopoulos et al.[2] and Basem Abdalmalak et al.[3] have successfully used dexmedetomidine based technique in tracheobronchial stenting in the cases of central airway obstruction. Bergese SD et al.[4] evaluated the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation and they found that dexmedetomidine is effective as the primary sedative in the patients undergoing the awake fiberoptic intubation with difficult airway. In our case, as the patient was not able to lie down, it was challenging to maintain the airway as well as to make the anxious patient comfortable. Dexmedetomidine possesses anxiolytic, sedative, analgesic, and sympatholytic properties. The Federal Drug Administration has approved the use of dexmedetomidine as a sedative-analgesic and/or total anesthetic in adults and pediatric patients undergoing small minimally invasive procedures, with or without the need for tracheal intubation. It is a safe sedative alternative to benzodiazepine/ opioid combinations in the patients undergoing monitored anesthesia care for a multitude of procedures because of its analgesic, “cooperative sedation,” and lack of respiratory depression properties.[5] Dexmedetomidine, coupled with local anesthesia, provided excellent sedative and operative conditions for awake laryngeal framework procedures. To conclude, dexmedetomidine along with adequate airway anesthesia can be an alternative in awake tracheal stenting. Samarjit Dey, Prithwis Bhattacharyya, Jayanta Medhi1, Adarsha Karadi Nellappa Department of Anaesthesiology, 1Otolaryngology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India Address for correspondence: Dr. Samarjit Dey, Department of Anaesthesiology, NEIGRIHMS, Shillong, PIN - 793 018, Meghalaya, India. E-mail: [email protected]
References 1. 2.
3.
4.
Ramamani M, Raj S, Manickam P. Anaesthesia for tracheo-bronchial stenting-a report of two cases. Indian J Anaesth 2008;52211. Voscopoulos C, Kirk FL, Lovrincevic M, Lema M. The use of “High Dose” dexmedetomidine in a patient with critical tracheal stenosis and anterior mediastinal mass. Open Anesthesiol J 2011;5:42-9. Abdelmalak B, Marcanthony N, Abdelmalak J, Machuzak MS, Gildea TR, Doyle DJ. Dexmedetomidine for anesthetic management of anterior mediastinal mass. J Anesth 2010;24:607-10. Bergese SD, Candiotti KA, Bokesch PM, Zura A, Wisemandle W, Bekker AY, et al. A Phase IIIb, randomized, double-blind, placebocontrolled, multicenter study evaluating the safety and efficacy of
5.
dexmedetomidine for sedation during awake fiberoptic intubation. Am J Ther 2010;17:586-95. Grewal A. Dexmedetomidine: New avenues. J Anaesthesiol Clin Pharmacol 2011;27:297-302. Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.137296
Tongue bite injury after use of transcranial electric stimulation motor-evoked potential monitoring Sir, Monitoring of motor-evoked potential (MEP) during spine surgery is considered a safe technique but potential hazards include bite injuries, possibility of hazardous stimulator output, patient movement induced injury, seizures, cardiac dysrhythmias, and epidural electrode-related complications.[1] Tongue and lip bite injuries are the most common reported complications during MEP monitoring with an incidence ranging from 0.2% to 0.63%.[1,2] Previous case reports have reported bite injuries including minor tongue lacerations, broken teeth, and even bitten endotracheal tube.[1] Thirty-seven-year-old, ASA physical status I, male with BMI 24.3 Kg/m2, was posted for L3-4 laminectomy and excision of L3 intradural tumor in the prone position with transcranial electric stimulation (TES) MEP monitoring. After induction of anesthesia and intubation, the endotracheal tube was taped to the right side and a soft bite block (rolled up gauze) was inserted in the midline. Surgery and anesthesia were uneventful and lasted two hours. Tracheal extubation was performed in the OR but the patient was mildly sedated. Postoperative examination of the oral cavity revealed a tongue hematoma on the left side [Figure 1]. He was reassured about the self-resolving nature of the hematoma and was advised oral care regimen. Risk factors for tongue injury during TES MEP monitoring include C3-4 focused stimulation that directly activates the temporalis muscle[3] and prone position (as in our patient) as it predisposes to tongue swelling.[4] The mechanism of tongue injury may involve both corticobulbar activation with
Journal of Anaesthesiology Clinical Pharmacology | July-September 2014 | Vol 30 | Issue 3
439
Copyright of Journal of Anaesthesiology Clinical Pharmacology 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.
