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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]


b 2. 3. 4.


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.


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

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DOI: 10.4103/0019-5049.149463



The big “little problem’’ with postoperative nausea and vomiting prophylaxis Sir,



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

Letters to Editor

fistulectomy for fistula‑in‑ano. On patient’s request, general anaesthesia (GA) was administered. Anaesthesia was induced with injection fentanyl 60 µg and propofol 100 mg and maintained with isoflurane to achieve an end tidal concentration of 1.5–2% in an oxygen/nitrous oxide mixture. Proseal® laryngeal mask airway was inserted and surgery was conducted under spontaneous respiration. Injection ondansetron 4 mg was administered for prevention of post‑operative nausea and vomiting (PONV). Intraoperatively, approximately 500 ml of Ringer lactate solution was administered. Surgery lasted for 20 min and remained uneventful. In post‑operative period, patient complained of severe headache which was more in the frontal area and was not positional. Patient gave no such history of headache in the past. Injection diclofenac 75 mg was given as intravenous (IV) infusion and on follow‑up, headache subsided completely in 6 h. Factors that may operate in regard to perioperative headache under GA include cerebral vasodilatation, any history of previous headache and administration of certain drugs. Cerebral vasodilatation may occur due to hypoxia, hypercarbia, dehydration, prolonged fasting period, caffeine withdrawal, hypertension, pre‑eclampsia and sepsis.[1] Pre‑operative headache and lack of sleep, the previous night are also strong predictors of post‑operative headache. None of these factors were present in our patient. Drugs such as antihypertensives (nitrates), steroids, metronidazole, muscle relaxants and 5 HT3 antagonists used in perioperative period can also cause headache in the post‑operative period.[1] On retrospective analysis, we speculated the cause of headache to be ondansetron, a 5 HT3 anatagonist in our patient. The recommended prophylactic dose of ondansetron is 4 mg with number needed to treat (NNT) of six for the prevention of vomiting (0–24 h) and NNT of seven for the antinausea effect.[2] However it may be associated with certain side effects e.g. headache, elevated liver enzymes and constipation etc. Headache following use of ondansetron for PONV prophylaxis has been reported earlier in literature.[3] The exact mechanism of this side effect is not known; however, it could be due to weak 5 HT1 antagonistic action. Various tools exist to stratify the risk of developing PONV; however, no uniform and standardised approach has been utilised to evaluate and manage PONV in clinical practice.[4] Apfel’s simplified risk score includes female sex, prior history of motion sickness or PONV, non‑smoking status and the use of post‑operative opioids Indian Journal of Anaesthesia | Vol. 59 | Issue 1 | Jan 2015

as the independent predictors. The estimated probability of PONV was 10%, 21%, 39%, and 78% with one, two, three, and four risk factors, respectively.[5] Prophylaxis with dexamethasone and serotonin antagonist and use of total IV anaesthetic technique are justified in patients with moderate to high risk (e.g. risk score 2/3/4).[4] However, it may not be warranted in patients at low risk as it may unnecessarily expose the patients to the risk of associated side effects.[6] On retrospective assessment, our patient’s baseline risk for PONV was found to be very low; hence, PONV prophylaxis was probably not required. We emphasize that Apfel scoring system should be used in all patients receiving GA. Drugs for PONV prophylaxis should be used in minimal effective doses only when the patient’s individual risk is sufficiently high as we must not forget that each antiemetic has its own side effects.

G Chilkoti, M Mohta, R Wadhwa, M Kumar Department of Anesthesiology and Critical Care, University College of Medical Sciences, Guru Teg Bahadur Hospital, Shahdara, New Delhi, India Address for correspondence: Dr. Rachna Wadhwa, Department of Anesthesiology and Critical Care, University College of Medical Sciences and Guru Teg Bahadur Hospital, Shahdara, New Delhi - 110 095, India. E‑mail: [email protected]

REFERENCES 1. Werrett G. Per‑operative headache. Update Anaesth 2002; Article 14. Available from: http://www.web.squ.edu.om/med‑lib/ med_cd/e_cds/health%20development/html/clients/WAWFSA/ html/u15/u15_T15.html. [Last accessed on 2014 May 21]. 2. Kovac AL. Prevention and treatment of postoperative nausea and vomiting. Drugs 2000;59:213‑43. 3. Singh V, Sinha A, Prakash N. Ondansetron‑induced migraine‑type headache. Can J Anaesth 2010;57:872‑3. 4. Rüsch D, Eberhart LH, Wallenborn J, Kranke P. Nausea and vomiting after surgery under general anesthesia: An evidence‑based review concerning risk assessment, prevention, and treatment. Dtsch Arztebl Int 2010;107:733‑41. 5. Apfel CC, Läärä E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: Conclusions from cross‑validations between two centers. Anesthesiology 1999;91:693‑700. 6. Carlisle JB, Stevenson CA. Drugs for preventing postoperative nausea and vomiting. Cochrane Database Syst Rev 2006; D004125. Access this article online Quick response code Website: www.ijaweb.org

DOI: 10.4103/0019-5049.149464


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