BJA
Declaration of interest None declared. J. Raft* O. Rangeard C. Fritz L. Leufflen H. Bouaziz C. Meistelman Nancy, France * E-mail: [email protected] 1 Bouzinac A, Delbos A, Mazie`res M, Rontes O. Interest of ultrasound in the realization of thoracic paravertebral block in breast surgery. Ann Fr Anesth Reanim 2011; 30: 453–5
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2 Naja MZ, Ziade MF, El Rajab M, El Tayara K, Lo¨nnqvist PA. Varying anatomical injection points within the thoracic paravertebral space: effect on spread of solution and nerve blockade. Anaesthesia 2004; 59: 459– 63 3 Marhofer D, Marhofer P, Kettner SC, et al. Magnetic resonance imaging analysis of the spread of local anesthetic solution after ultrasound-guided lateral thoracic paravertebral blockade: a volunteer study. Anesthesiology 2013; 118: 1106– 12 4 Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. Single-injection paravertebral block compared to general anaesthesia in breast surgery. Acta Anaesthesiol Scand 1999; 43: 770–4
doi:10.1093/bja/aet398
Ultrasound diagnosis of nasogastric tube misplacement into the trachea during bypass surgery Editor—A nasogastric tube (NT) is commonly used to empty the stomach and to monitor the occurrence of bowel occlusion after major abdominal surgery. The incidence of misplacement of NTs into the airways ranges between 0.3% and 15%1 and is associated with significant morbidity and mortality.2 A 44-yr-old woman with a history of diabetes and obesity (BMI 50 kg m22) underwent gastric bypass. During surgery, an NT was inserted into the oesophagus through the nose to check for the absence of digestive fistula by administering 150 ml of methylene blue stain.3 No abnormality was noted during the procedure. At extubation, methylene blue stain was noted in the tracheal aspiration. Tracheal examination with ultrasound was used to check for misplacement of NT. A 5–10 MHz linear ultrasonography transducer (VividTM , General Electric, UK) was placed transversely on the anterior neck just above the suprasternal notch as described by Ma and colleagues.4 The presence of a hyperechoic artifact of the trachea ring (Fig. 1A, large arrow) and an abnormal hyperechoic artifact inside the trachea with posterior shadowing much narrower than usually generated by the trachea (Fig. 1A, dotted arrow) were suggestive of the presence of the NT in the trachea. The incorrect positioning of the NT was confirmed by chest X-ray. After NTremoval, ultrasound examination of the trachea was normal with a periodic resonance artifact and posterior shadowing behind the trachea ring (Fig. 1B, small arrows).5 Fortunately, the patient did not develop any alterations in gas exchange. This case illustrates the ability of ultrasound to identify NT misplacement faster than chest X-ray.
Declaration of interest None declared. T. Kerforne M. Chaillan L. Geraud O. Mimoz* Poitiers, France * E-mail: [email protected]
Downloaded from http://bja.oxfordjournals.org/ at Northern Kentucky University on June 15, 2015
in a lateral-to-medial direction guided by ultrasound [Sonosite Edge (Sonosite Inc., Bothell, WA, USA)] from the outer edge of the linear probe 15-6 MHz HFL50 (Sonosite Inc.) using an in-plane approach. The ultrasound probe was covered with a sterile cover CIV-FlexTM (CIVCO, IA, USA). There was no significant haemodynamic change during general anaesthesia and the post-anaesthesia care unit. Paracetamol 1 g and ketoprofen 50 mg were given intraoperatively. No other analgesics were required (visual analogue scale¼0/10). Eight segments cold tested, between T1 and T8, were covered by the PVB. Ten hours later, the patient experienced active bleeding at the operative site with an 8 cm haematoma. Considering that the patient did not have an empty stomach and there was still a persistent residual sensory block T1–8 cold tested (11 h after the PVB injection), it was suggested to use the persistent residual sensory block. To perform surgery, the patient and surgeon were both aware that, in the case of discomfort, it would be possible to give general anaesthesia with rapid sequence induction. This option was not necessary. The surgical haemostasis was performed over 30 min without any pain. It allowed the evacuation of a 50 ml haematoma, almost 5 cm in depth. The patient was not transfused. No postoperative analgesics were required. After this additional procedure, postoperative follow-ups were straightforward. This case illustrates the likely benefits of PVB, as a subsequent procedure for haemostasis can be performed using a persisting sensory block, without the need for general anaesthesia. Ropivacaine with avolume of 20 ml and aconcentration of 7.5 mg ml21 is usually used for an analgesic PVB for breast cancer surgery.1 The metameric coverage with a single injection correlates with the volume of local anaesthetic injected, but the anaesthetic effect is unpredictable.2 3 A single-shot PVB provides an incomplete sensory block for mastectomy without general anaesthesia or deep sedation.1 4 The sensory block of a single thoracic T3–T4 injection of 0.3 ml kg21 of 0.5% bupivacaine with epinephrine lasts at least 12 h.4 As can be seen in this case report, reintervention for haemostasis surgery was possible 11 h after the PVB, without general anaesthesia (single injection of 20 ml of 7.5 mg ml21 with eight segments covered). By doing so, general anaesthesia with rapid-sequence induction was avoided in this patient with a full stomach.
Correspondence
BJA
Correspondence
1 Rassias AJ, Ball PA, Corwin HL. A prospective study of trachea pulmonary complications associated with the placement of narrowbore enteral feeding tubes. Crit Care 1998; 2: 25 –8 2 Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: review of safe practice. Interact Cardiovasc Thorac Surg 2005; 4: 429– 33 3 Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 1994; 4: 353–7 4 Ma G, Davis DP, Schmitt J, Vilke GM, Chan TC, Hayden SR. The sensitivity and specificity of transcricothyroid ultrasonography to confirm endotracheal tube placement in a cadaver model. J Emerg Med 2007; 32: 405–7 5 Drescher MJ, Conard FU, Schamban NE. Identification and description of esophageal intubation using ultrasound. Acad Emerg Med 2000; 7: 722–5
doi:10.1093/bja/aet399
Planned magnetic resonance imaging for a patient with a permanent pacemaker in situ with suspected spontaneous intracranial hypotension Editor—A female patient, aged 77 yr, with a past medical history of hypothyroidism, was admitted after gradual neurological deterioration over 6 weeks, including increasing confusion and unsteady gait. A permanent pacemaker (PPM) had been sited after collapse secondary to sinus arrest 2 weeks previously.
On examination, her Glasgow coma scale (GCS) was 13 with no localizing neurology. Computed tomography (CT) of the head demonstrated bilateral subdural collections with subfalcine and tonsillar herniation. Bilateral burr holes were drilled, revealing cerebrospinal fluid (CSF) collection not under pressure, rather than the expected subdural haematoma. This raised the possibility of spinal CSF leak, resulting in hygroma formation and brain compression. The GCS deteriorated to seven on day 3. Repeat CTs were unchanged and further investigation for spinal CSF leak by CT myelography or magnetic resonance imaging (MRI) was deemed necessary. The radiologist’s opinion was that CT myelography would cause unacceptable risk of potentially fatal brain herniation, as central and tonsillar herniation were present. The opinion of a cardiologist was sought regarding PPM and MRI. The PPM was interrogated and revealed 1:1 atrioventricular conduction with no evidence of distal conduction disease, suggesting the bradyarrhythmia leading to collapse was due to intracranial pathology rather than a primary cardiac cause. The cardiologists felt the risks of removal of the PPM outweighed the risks of MRI with PPM in situ. MRI was performed with neurointensivist and electrophysiologist presence after temporary reprogramming of the PPM. It revealed a dural tear at the level of the C2 cervical vertebra. The PPM was interrogated post-MRI and showed no parameters that required electrophysiologist alteration. Diagnosis enabled treatment with CT targeted C3 epidural blood patch (EBP) under general anaesthesia. There was rapid improvement over 48 h to GCS 14. The patient has since regained her pre-morbid state.
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Downloaded from http://bja.oxfordjournals.org/ at Northern Kentucky University on June 15, 2015
Fig 1 Ultrasound transversal view of the trachea [(A and B) Tracheal ring marked with large yellow arrow]. (A) With NT into the trachea (dotted yellow arrow). (B) After NTremoval, normal aspect of an empty trachea with a periodic resonance artifact and posterior shadowing behind the trachea ring (small yellow arrows).
Declaration of interest None declared. J. Raft* O. Rangeard C. Fritz L. Leufflen H. Bouaziz C. Meistelman Nancy, France * E-mail: [email protected] 1 Bouzinac A, Delbos A, Mazie`res M, Rontes O. Interest of ultrasound in the realization of thoracic paravertebral block in breast surgery. Ann Fr Anesth Reanim 2011; 30: 453–5
1032
2 Naja MZ, Ziade MF, El Rajab M, El Tayara K, Lo¨nnqvist PA. Varying anatomical injection points within the thoracic paravertebral space: effect on spread of solution and nerve blockade. Anaesthesia 2004; 59: 459– 63 3 Marhofer D, Marhofer P, Kettner SC, et al. Magnetic resonance imaging analysis of the spread of local anesthetic solution after ultrasound-guided lateral thoracic paravertebral blockade: a volunteer study. Anesthesiology 2013; 118: 1106– 12 4 Pusch F, Freitag H, Weinstabl C, Obwegeser R, Huber E, Wildling E. Single-injection paravertebral block compared to general anaesthesia in breast surgery. Acta Anaesthesiol Scand 1999; 43: 770–4
doi:10.1093/bja/aet398
Ultrasound diagnosis of nasogastric tube misplacement into the trachea during bypass surgery Editor—A nasogastric tube (NT) is commonly used to empty the stomach and to monitor the occurrence of bowel occlusion after major abdominal surgery. The incidence of misplacement of NTs into the airways ranges between 0.3% and 15%1 and is associated with significant morbidity and mortality.2 A 44-yr-old woman with a history of diabetes and obesity (BMI 50 kg m22) underwent gastric bypass. During surgery, an NT was inserted into the oesophagus through the nose to check for the absence of digestive fistula by administering 150 ml of methylene blue stain.3 No abnormality was noted during the procedure. At extubation, methylene blue stain was noted in the tracheal aspiration. Tracheal examination with ultrasound was used to check for misplacement of NT. A 5–10 MHz linear ultrasonography transducer (VividTM , General Electric, UK) was placed transversely on the anterior neck just above the suprasternal notch as described by Ma and colleagues.4 The presence of a hyperechoic artifact of the trachea ring (Fig. 1A, large arrow) and an abnormal hyperechoic artifact inside the trachea with posterior shadowing much narrower than usually generated by the trachea (Fig. 1A, dotted arrow) were suggestive of the presence of the NT in the trachea. The incorrect positioning of the NT was confirmed by chest X-ray. After NTremoval, ultrasound examination of the trachea was normal with a periodic resonance artifact and posterior shadowing behind the trachea ring (Fig. 1B, small arrows).5 Fortunately, the patient did not develop any alterations in gas exchange. This case illustrates the ability of ultrasound to identify NT misplacement faster than chest X-ray.
Declaration of interest None declared. T. Kerforne M. Chaillan L. Geraud O. Mimoz* Poitiers, France * E-mail: [email protected]
Downloaded from http://bja.oxfordjournals.org/ at Northern Kentucky University on June 15, 2015
in a lateral-to-medial direction guided by ultrasound [Sonosite Edge (Sonosite Inc., Bothell, WA, USA)] from the outer edge of the linear probe 15-6 MHz HFL50 (Sonosite Inc.) using an in-plane approach. The ultrasound probe was covered with a sterile cover CIV-FlexTM (CIVCO, IA, USA). There was no significant haemodynamic change during general anaesthesia and the post-anaesthesia care unit. Paracetamol 1 g and ketoprofen 50 mg were given intraoperatively. No other analgesics were required (visual analogue scale¼0/10). Eight segments cold tested, between T1 and T8, were covered by the PVB. Ten hours later, the patient experienced active bleeding at the operative site with an 8 cm haematoma. Considering that the patient did not have an empty stomach and there was still a persistent residual sensory block T1–8 cold tested (11 h after the PVB injection), it was suggested to use the persistent residual sensory block. To perform surgery, the patient and surgeon were both aware that, in the case of discomfort, it would be possible to give general anaesthesia with rapid sequence induction. This option was not necessary. The surgical haemostasis was performed over 30 min without any pain. It allowed the evacuation of a 50 ml haematoma, almost 5 cm in depth. The patient was not transfused. No postoperative analgesics were required. After this additional procedure, postoperative follow-ups were straightforward. This case illustrates the likely benefits of PVB, as a subsequent procedure for haemostasis can be performed using a persisting sensory block, without the need for general anaesthesia. Ropivacaine with avolume of 20 ml and aconcentration of 7.5 mg ml21 is usually used for an analgesic PVB for breast cancer surgery.1 The metameric coverage with a single injection correlates with the volume of local anaesthetic injected, but the anaesthetic effect is unpredictable.2 3 A single-shot PVB provides an incomplete sensory block for mastectomy without general anaesthesia or deep sedation.1 4 The sensory block of a single thoracic T3–T4 injection of 0.3 ml kg21 of 0.5% bupivacaine with epinephrine lasts at least 12 h.4 As can be seen in this case report, reintervention for haemostasis surgery was possible 11 h after the PVB, without general anaesthesia (single injection of 20 ml of 7.5 mg ml21 with eight segments covered). By doing so, general anaesthesia with rapid-sequence induction was avoided in this patient with a full stomach.
Correspondence
BJA
Correspondence
1 Rassias AJ, Ball PA, Corwin HL. A prospective study of trachea pulmonary complications associated with the placement of narrowbore enteral feeding tubes. Crit Care 1998; 2: 25 –8 2 Pillai JB, Vegas A, Brister S. Thoracic complications of nasogastric tube: review of safe practice. Interact Cardiovasc Thorac Surg 2005; 4: 429– 33 3 Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 1994; 4: 353–7 4 Ma G, Davis DP, Schmitt J, Vilke GM, Chan TC, Hayden SR. The sensitivity and specificity of transcricothyroid ultrasonography to confirm endotracheal tube placement in a cadaver model. J Emerg Med 2007; 32: 405–7 5 Drescher MJ, Conard FU, Schamban NE. Identification and description of esophageal intubation using ultrasound. Acad Emerg Med 2000; 7: 722–5
doi:10.1093/bja/aet399
Planned magnetic resonance imaging for a patient with a permanent pacemaker in situ with suspected spontaneous intracranial hypotension Editor—A female patient, aged 77 yr, with a past medical history of hypothyroidism, was admitted after gradual neurological deterioration over 6 weeks, including increasing confusion and unsteady gait. A permanent pacemaker (PPM) had been sited after collapse secondary to sinus arrest 2 weeks previously.
On examination, her Glasgow coma scale (GCS) was 13 with no localizing neurology. Computed tomography (CT) of the head demonstrated bilateral subdural collections with subfalcine and tonsillar herniation. Bilateral burr holes were drilled, revealing cerebrospinal fluid (CSF) collection not under pressure, rather than the expected subdural haematoma. This raised the possibility of spinal CSF leak, resulting in hygroma formation and brain compression. The GCS deteriorated to seven on day 3. Repeat CTs were unchanged and further investigation for spinal CSF leak by CT myelography or magnetic resonance imaging (MRI) was deemed necessary. The radiologist’s opinion was that CT myelography would cause unacceptable risk of potentially fatal brain herniation, as central and tonsillar herniation were present. The opinion of a cardiologist was sought regarding PPM and MRI. The PPM was interrogated and revealed 1:1 atrioventricular conduction with no evidence of distal conduction disease, suggesting the bradyarrhythmia leading to collapse was due to intracranial pathology rather than a primary cardiac cause. The cardiologists felt the risks of removal of the PPM outweighed the risks of MRI with PPM in situ. MRI was performed with neurointensivist and electrophysiologist presence after temporary reprogramming of the PPM. It revealed a dural tear at the level of the C2 cervical vertebra. The PPM was interrogated post-MRI and showed no parameters that required electrophysiologist alteration. Diagnosis enabled treatment with CT targeted C3 epidural blood patch (EBP) under general anaesthesia. There was rapid improvement over 48 h to GCS 14. The patient has since regained her pre-morbid state.
1033
Downloaded from http://bja.oxfordjournals.org/ at Northern Kentucky University on June 15, 2015
Fig 1 Ultrasound transversal view of the trachea [(A and B) Tracheal ring marked with large yellow arrow]. (A) With NT into the trachea (dotted yellow arrow). (B) After NTremoval, normal aspect of an empty trachea with a periodic resonance artifact and posterior shadowing behind the trachea ring (small yellow arrows).
