14
Correspondence
Fig. 2.
3.
Heferetices MARTIFIELLt, F., MONTANT, J., HAZEAUX, c. & R EN A R DM . (1974) Penetration intra-crlnienne d’une
sonde gastrique A travers une dehiscence traumatique de la lame criblee. Cahiivs cl’anesrhksiologie 22, 345. ROCHET,D. ( 1976) Sonde gastrique intra-crlnienne Cahiers tl’cinc~sthdsiologic~,24, 833.
J . , NOZIK,D. & M A I H I E L IA, . (I975 Inadvertent introduction o f a nasogastric tube, a complication of severe maxillo-facial trauma. SttBACHtR,
Anesthesiology, 42, 100.
4. VALETTA, J. (1975) Sonde gastrique fourvoyee Cahicrs d’ani~sthh.sio/cJgie,23, 209.
Snakes, snake bites and trouble at Grantchester
I would like to make a comment on Drs Burgess and Shuttleworth’s letter on snakes and snake bites (Atiaesthesia, 1977,32,664). When I was in India in the RAMC between 1916 and 1919 I had an excellent book on snakes (written by Major Wall, I think) in which it was stated that each kind of snake had its own individual arrangement of scales (scale pattern); all types were clearly illustrated i n the book. Thus, as with finger prints, no type had the scale pattern of another type and, as each type always kept its own scale pattern, the identification of type was easy. I had t o treat only one bad snake bite (cobra o r Russel’s viper, not Krait as that was invariably fatal) and the patient was very ill for some I2 h or so and then recovered.
I feel that I must also draw attention to the error in the Editors comment ‘Editorial nostalgia for real time’. Rupert Brooke’s last line in ‘The Old Vicarage, Grantchester’ (the ‘1’ was omitted) is ‘And is there honey still for tea’. The addition of ‘shire’ to Cambridge also breaks the scansion in the other line quoted-a pity.
I Marbeck Close, Witiclwr, Berkshire SL4 5 R E .
STEPHkN COl k I N
Air Editorial apology
The Editor apologises-surely there can be no greater sin than omitting the ‘tea’ in Grantchester.
Unrecognised tracheo-oesophageal fistula
I would like to comment on the case of unrecognised tracheo-oesophageal fistula reported hy Dr Ng and his colleagues (Anaesthesia, 1977, 32, 31) and to make the following points. First, no premedication was used, even though this would have greatly reduced the ‘constant puddle of secretions in the pharynx and perilaryngeal areas’ described in the case report, and I would also have decreased the reported reduction in heart rate. I f a suitable sedative had been used as well it would have considerably decreased the patient’s agitation. Secondly,
if the patient’s acceptance of a local anaesthetic technique was in doubt (as would seem likely with Korsakow’s psychosis) it should not have been embarked upon. Thirdly, I would have thought that a respiratory depressant like Thalamonal was contraindicated in a chronic bronchitic. Fourthly, if anaesthesia is being induced, or as in this case the mode of induction changed, it is advisable to give a n adequate dosage at one time and not three separate small doses, otherwise the patient is unlikely to be sufficiently ‘deep’ to promote good
Corresponderice
conditions for intubation. In addition, suxamethonium is contraindicated in all cases where intubation is likely to be technically difficult and, further, if suxamethonium is to be given, despite the patient having possibly altered hepatic function, I fail to see any point in administering such a small dose since this is just giving rise to another possible source of difficulty. Finally, the anaesthetic described seems to be a mixture of three techniques, a fact which cannot enhance the anaesthetic management. Although with hindsight it is easier to point out errors 1 would suggest that an elective tracheostoniy under a local technique, or it this was unacceptable a tracheostomy with gaseous induction and maintenance of anaesthesia with a mask and airway was a more logical approach to the problem.
20 Bower Lane, Grenoside,
D.L. EDBRCOKE
Shefield. A reply
Thank you for the opportunity to respond to Dr D.L. Edbrooke’s comments. We certainly agree with Dr Edbrooke that the safest method of induction would have been via a tracheostomy and, in fact, this had been discussed with the patient’s family, who had refused, wishing the short remainder of the patient’s life to be lived with as few surgical procedures as possible. Nevertheless, feeling that any type of heavy sedation is contraindicated in a debilitated patient with a large retropharyngeal mass, as it increases the risk of both airway obstruction and aspiration of secretions, our primary concern was to ensure proper ventilation of the patient. Thus, we proceeded on the premise that if increased sedation became necessary, it could be accomplished by means of intravenous injections under controlled conditions in the operating room. Secondly, we wished to prevent a circulatory collapse resulting from the administration of deep anaesthesia to a debilitated patient, and indeed, there was a marked hypotensive effect produced in the patient by even the small amounts of anaesthetic administered. Following a premedication of 0.4 mg Atropine and 25 rng Phenergan administered I h prior to anaesthesia, an intravenous drip of Thalom-
75
onal (Droperidol and fentanyl50 : I , 10 ml in 500 rn 5 % dextrose) was started concurrently with the insertion of a 16 gauge catheter into the trachea via the cricothyroid membrane and subsequent ventilation of the patient with intermittent jets of oxygen. This method was adopted in preference to a single dose calculated on the basis of the patient’s body weight in order to titrate the dosage according to the patient’s individual requirements, thereby preventing any hypotension or apnea. A small dose of suxamethonium was administered as a relaxant to promote chest wall expansion, and t o decrease the dosage of Thalomonal, not to facilitate orotracheal intubation. We concur with Dr Edbrooke that suxamethonium is not the drug of choice in a case where intubation is likely to prove technically difficult. In the case discussed, normal tracheal intubation was not performed, and then with a great deal of difficulty, until transtracheal ventilation had proved inadequate, towards the end of the procedure Since most of Dr Edbrooke’s comments refer to this difficulty with tracheal intubation and to the lack of ideal intubating conditions, we would like to stress that the patient’s airway was secured via a transtracheal catheter prior to the increased administration of anaesthetic agents. Normally, the management of critically ill patients with a combination of topical and light general anaesthesia can be accomplished without difficulty. In this case, however, the presence of a tracheo-esophageal fistula under high pressure ventilation created a severe respiratory insufficiency. Our purpose in reporting this case was to suggest the possible existence of an asymptomatic tracheo-esophageal fistula in patients diagnosed with a retropharyngeal carcinoma. We were fortunate in being able to test the corrective measures suggested in our article in the case of another patient, diagnosed prior to surgery, and hope to report this later case in your columns soon.
THENY. Nti, Cetrfer, 1600 Divisadero Sweet, BULENTI . K I R I M L ~ Sun Francisco, California AND TAPAN D. DATTA Moirrrt Zion Hospital & Al~-.rIic~il
941 15. USA.
Saving costs of ECG monitoring ECG monitoring without recourse to normal body leads can be carried out using disposable plate electrodes at a cost of f75.00 per 100 (paediatric size). I n view of the escalating expense of disposable equipment even the most simple means of cutting costs must be explored. The disposable electrodes d o not withstand the rigours of repeated usage and
cannot be adequately cleaned if contaminated with blood, urine, etc. Accordingly, we have made our own electrode; this is constructed from a sheet of exposed X-ray film with three strips of foil gummed to it with ‘Evo-stik’ adhesive (Fig. I ) . Because this electrode is washable, by comparison with the disposable plate it can be used repeatedly, and to date
Correspondence
Fig. 2.
3.
Heferetices MARTIFIELLt, F., MONTANT, J., HAZEAUX, c. & R EN A R DM . (1974) Penetration intra-crlnienne d’une
sonde gastrique A travers une dehiscence traumatique de la lame criblee. Cahiivs cl’anesrhksiologie 22, 345. ROCHET,D. ( 1976) Sonde gastrique intra-crlnienne Cahiers tl’cinc~sthdsiologic~,24, 833.
J . , NOZIK,D. & M A I H I E L IA, . (I975 Inadvertent introduction o f a nasogastric tube, a complication of severe maxillo-facial trauma. SttBACHtR,
Anesthesiology, 42, 100.
4. VALETTA, J. (1975) Sonde gastrique fourvoyee Cahicrs d’ani~sthh.sio/cJgie,23, 209.
Snakes, snake bites and trouble at Grantchester
I would like to make a comment on Drs Burgess and Shuttleworth’s letter on snakes and snake bites (Atiaesthesia, 1977,32,664). When I was in India in the RAMC between 1916 and 1919 I had an excellent book on snakes (written by Major Wall, I think) in which it was stated that each kind of snake had its own individual arrangement of scales (scale pattern); all types were clearly illustrated i n the book. Thus, as with finger prints, no type had the scale pattern of another type and, as each type always kept its own scale pattern, the identification of type was easy. I had t o treat only one bad snake bite (cobra o r Russel’s viper, not Krait as that was invariably fatal) and the patient was very ill for some I2 h or so and then recovered.
I feel that I must also draw attention to the error in the Editors comment ‘Editorial nostalgia for real time’. Rupert Brooke’s last line in ‘The Old Vicarage, Grantchester’ (the ‘1’ was omitted) is ‘And is there honey still for tea’. The addition of ‘shire’ to Cambridge also breaks the scansion in the other line quoted-a pity.
I Marbeck Close, Witiclwr, Berkshire SL4 5 R E .
STEPHkN COl k I N
Air Editorial apology
The Editor apologises-surely there can be no greater sin than omitting the ‘tea’ in Grantchester.
Unrecognised tracheo-oesophageal fistula
I would like to comment on the case of unrecognised tracheo-oesophageal fistula reported hy Dr Ng and his colleagues (Anaesthesia, 1977, 32, 31) and to make the following points. First, no premedication was used, even though this would have greatly reduced the ‘constant puddle of secretions in the pharynx and perilaryngeal areas’ described in the case report, and I would also have decreased the reported reduction in heart rate. I f a suitable sedative had been used as well it would have considerably decreased the patient’s agitation. Secondly,
if the patient’s acceptance of a local anaesthetic technique was in doubt (as would seem likely with Korsakow’s psychosis) it should not have been embarked upon. Thirdly, I would have thought that a respiratory depressant like Thalamonal was contraindicated in a chronic bronchitic. Fourthly, if anaesthesia is being induced, or as in this case the mode of induction changed, it is advisable to give a n adequate dosage at one time and not three separate small doses, otherwise the patient is unlikely to be sufficiently ‘deep’ to promote good
Corresponderice
conditions for intubation. In addition, suxamethonium is contraindicated in all cases where intubation is likely to be technically difficult and, further, if suxamethonium is to be given, despite the patient having possibly altered hepatic function, I fail to see any point in administering such a small dose since this is just giving rise to another possible source of difficulty. Finally, the anaesthetic described seems to be a mixture of three techniques, a fact which cannot enhance the anaesthetic management. Although with hindsight it is easier to point out errors 1 would suggest that an elective tracheostoniy under a local technique, or it this was unacceptable a tracheostomy with gaseous induction and maintenance of anaesthesia with a mask and airway was a more logical approach to the problem.
20 Bower Lane, Grenoside,
D.L. EDBRCOKE
Shefield. A reply
Thank you for the opportunity to respond to Dr D.L. Edbrooke’s comments. We certainly agree with Dr Edbrooke that the safest method of induction would have been via a tracheostomy and, in fact, this had been discussed with the patient’s family, who had refused, wishing the short remainder of the patient’s life to be lived with as few surgical procedures as possible. Nevertheless, feeling that any type of heavy sedation is contraindicated in a debilitated patient with a large retropharyngeal mass, as it increases the risk of both airway obstruction and aspiration of secretions, our primary concern was to ensure proper ventilation of the patient. Thus, we proceeded on the premise that if increased sedation became necessary, it could be accomplished by means of intravenous injections under controlled conditions in the operating room. Secondly, we wished to prevent a circulatory collapse resulting from the administration of deep anaesthesia to a debilitated patient, and indeed, there was a marked hypotensive effect produced in the patient by even the small amounts of anaesthetic administered. Following a premedication of 0.4 mg Atropine and 25 rng Phenergan administered I h prior to anaesthesia, an intravenous drip of Thalom-
75
onal (Droperidol and fentanyl50 : I , 10 ml in 500 rn 5 % dextrose) was started concurrently with the insertion of a 16 gauge catheter into the trachea via the cricothyroid membrane and subsequent ventilation of the patient with intermittent jets of oxygen. This method was adopted in preference to a single dose calculated on the basis of the patient’s body weight in order to titrate the dosage according to the patient’s individual requirements, thereby preventing any hypotension or apnea. A small dose of suxamethonium was administered as a relaxant to promote chest wall expansion, and t o decrease the dosage of Thalomonal, not to facilitate orotracheal intubation. We concur with Dr Edbrooke that suxamethonium is not the drug of choice in a case where intubation is likely to prove technically difficult. In the case discussed, normal tracheal intubation was not performed, and then with a great deal of difficulty, until transtracheal ventilation had proved inadequate, towards the end of the procedure Since most of Dr Edbrooke’s comments refer to this difficulty with tracheal intubation and to the lack of ideal intubating conditions, we would like to stress that the patient’s airway was secured via a transtracheal catheter prior to the increased administration of anaesthetic agents. Normally, the management of critically ill patients with a combination of topical and light general anaesthesia can be accomplished without difficulty. In this case, however, the presence of a tracheo-esophageal fistula under high pressure ventilation created a severe respiratory insufficiency. Our purpose in reporting this case was to suggest the possible existence of an asymptomatic tracheo-esophageal fistula in patients diagnosed with a retropharyngeal carcinoma. We were fortunate in being able to test the corrective measures suggested in our article in the case of another patient, diagnosed prior to surgery, and hope to report this later case in your columns soon.
THENY. Nti, Cetrfer, 1600 Divisadero Sweet, BULENTI . K I R I M L ~ Sun Francisco, California AND TAPAN D. DATTA Moirrrt Zion Hospital & Al~-.rIic~il
941 15. USA.
Saving costs of ECG monitoring ECG monitoring without recourse to normal body leads can be carried out using disposable plate electrodes at a cost of f75.00 per 100 (paediatric size). I n view of the escalating expense of disposable equipment even the most simple means of cutting costs must be explored. The disposable electrodes d o not withstand the rigours of repeated usage and
cannot be adequately cleaned if contaminated with blood, urine, etc. Accordingly, we have made our own electrode; this is constructed from a sheet of exposed X-ray film with three strips of foil gummed to it with ‘Evo-stik’ adhesive (Fig. I ) . Because this electrode is washable, by comparison with the disposable plate it can be used repeatedly, and to date
