- Email: [email protected]
A method of securing the Xomed endotracheal tube for accurate monitoring of the recurrent laryngeal nerve
Correspondence oxygen mixture. The anesthesia machine (Narkomed 2B; North American Dräger, Telford, PA, USA) used in the case was purchased in 1994. On the morning of the surgery, we checked the machine as usual. About 50 minutes after the operation had commenced, an abrupt, loud noise resembling the sound of crashing ocean waves was heard from inside the anesthesia machine. No change in pipeline pressure, flowmeter, oxygen concentration, or airway pressure was noted. As a precaution, we switched the patient to manual ventilation through the circle system to prevent exposure to high pressure. The remainder of the operation lasted 5 minutes, which was uneventful. Postoperatively, removal of a panel at the back of the anesthesia machine showed a hole in the oxygen line (Fig. 1), on which a written label indicating the year 1992 was discovered. The oxygen line was later replaced. The manufacturing company had checked the anesthetic machine regularly in our hospital. However, we hadn't checked whether the manufacturer's employee had opened the posterior panel of the anesthesia machine and changed the accessories. One study reported that the average lifespan of an anesthesia machine is about 15 years and varies with the user [1]. Incomplete or inappropriate repair, lack of training, nonfamiliarity, and absence of regular checks are the causes of decreased lifespan of the anesthesia machine. The machine discussed here was thought to be manufactured in 1992, and the oxygen line had remained unchanged for 20 years. Hyun Ju Jung MD (Associate Professor) Jong Bun Kim MD (Associate Professor) Kyong Shil Im MD (Assistant Professor) Sung Ah Cho (Assistant) Jae Myeong Lee MD (Assistant Professor) Department of Anesthesiology and Pain Medicine The Catholic University of Korea, College of Medicine Uijeongbu St. Mary's Hospital, Uijeongbu-City Seoul 480-130, South Korea E-mail address: [email protected]
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Fig. 1 The Xomed NIM electromyographic (EMG) tube and NIM-Response 2.0 Nerve Integrity Monitoring System (Medtronic Xomed, Inc., Jacksonville, FL USA), allowing immediate audible and visual feedback of mechanically-evoked potentials evoked by surgical manipulation of the laryngeal muscles. White arrows indicate two of the existing 4 wires of the Xomed tube surface electrodes exposed above the cuff, which come into direct contact with the mucosa of the vocal cords.
doi:10.1016/j.jclinane.2011.05.007
Reference [1] Kim WO, Kil HK, Kim KH. Survival analysis of EKG monitor and anesthesia machine in operating room. Korean J Anesthesiol 1993;26: 216-9.
A method of securing the Xomed endotracheal tube for accurate monitoring of the recurrent laryngeal nerve To the Editor: Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve (RLN) may reduce the probability of significant intraoperative injury to the vagus nerve or its branches. For some surgeons, this monitoring represents the
Fig. 2 Proper midline positioning of the Xomed endotracheal tube (Medtronic Xomed, Inc., Jacksonville, FL USA): 4 wire electrodes are positioned against the medial parts of the vocal cords. Reproduced with permissions from Eisele DW. Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve. Laryngoscope 1996;106:443-9.
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Correspondence maintained in the midline so as to assure precise alignment of the monitoring electrodes against the vocal cords (Fig. 2) and to prevent accidental axial rotation or lateral displacement of the tube [3,6]. We describe a technique to preserve proper positioning of the Xomed tube for accurate monitoring of the RLN. After noting depth of placement, the tube is moved with the operator’s finger to the midline. Tube positioning is next stabilized by two small, soft bite blocks placed deep inside the mouth over the tongue, and the tube is taped (Fig. 3A). A final step consists of taping the Xomed tube to the bite block as a unit (Fig. 3B). In our experience, this technique results in stable and reliable intraoperative EMG responses, providing superior feedback to the surgeon in identifying and preserving the RLN. Vladimir Nekhendzy MD (Clinical Associate Professor of Anesthesia) Jamie R. Lopez MD (Associate Professor of Neurology) Edward J. Damrose MD (Assistant Professor of Otolaryngology) Stanford University Medical Center Stanford, CA 94305, USA E-mail address: [email protected] doi:10.1016/j.jclinane.2011.05.009
References
Fig. 3 A. Step 1: Securing of the Xomed tube midline positioning with two soft bite blocks and small diameter tape. B. Step 2: Final securing of the Xomed tube midline by taping the Xomed tube and bite block assembly together with large plastic tape.
standard of care during surgery of the brainstem, skull base, thyroid, and parathyroid glands [1-4]. The Xomed endotracheal tube (Medtronic Xomed, Inc., Jacksonville, FL USA) incorporates surface electromyography (EMG) electrodes (Fig. 1), allowing continuous audible and visual intraoperative EMG monitoring of the laryngeal muscles [5]. Key to the success of such monitoring, however, rests with the anesthesiologist: the Xomed tube must be
[1] Brennan J, Moore EJ, Shuler KJ. Prospective analysis of the efficacy of continuous intraoperative nerve monitoring during thyroidectomy, parathyroidectomy, and parotidectomy. Otolaryngol Head Neck Surg 2001;124:537-43. [2] Otto RA, Cochran CS. Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation in predicting postoperative nerve paralysis. Ann Otol Rhinol Laryngol 2002;111:1005-7. [3] Jackson LE, Roberson Jr JB. Vagal nerve monitoring in surgery of the skull base: a comparison of efficacy of three techniques. Am J Otol 1999;20:649-56. [4] Mikuni N, Satow T, Taki J, Nishida N, Enatsu R, Hashimoto N. Endotracheal tube electrodes to map and monitor activities of the vagus nerve intraoperatively. Technical note. J Neurosurg 2004;101:536-40. [5] Eisele DW. Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve. Laryngoscope 1996;106:443-9. [6] Djohan RS, Rodriguez HE, Connolly MM, Childers SJ, Braverman B, Podbielski FJ. Intraoperative monitoring of recurrent laryngeal nerve function. Am Surg 2000;66:595-7.
259
Fig. 1 The Xomed NIM electromyographic (EMG) tube and NIM-Response 2.0 Nerve Integrity Monitoring System (Medtronic Xomed, Inc., Jacksonville, FL USA), allowing immediate audible and visual feedback of mechanically-evoked potentials evoked by surgical manipulation of the laryngeal muscles. White arrows indicate two of the existing 4 wires of the Xomed tube surface electrodes exposed above the cuff, which come into direct contact with the mucosa of the vocal cords.
doi:10.1016/j.jclinane.2011.05.007
Reference [1] Kim WO, Kil HK, Kim KH. Survival analysis of EKG monitor and anesthesia machine in operating room. Korean J Anesthesiol 1993;26: 216-9.
A method of securing the Xomed endotracheal tube for accurate monitoring of the recurrent laryngeal nerve To the Editor: Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve (RLN) may reduce the probability of significant intraoperative injury to the vagus nerve or its branches. For some surgeons, this monitoring represents the
Fig. 2 Proper midline positioning of the Xomed endotracheal tube (Medtronic Xomed, Inc., Jacksonville, FL USA): 4 wire electrodes are positioned against the medial parts of the vocal cords. Reproduced with permissions from Eisele DW. Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve. Laryngoscope 1996;106:443-9.
260
Correspondence maintained in the midline so as to assure precise alignment of the monitoring electrodes against the vocal cords (Fig. 2) and to prevent accidental axial rotation or lateral displacement of the tube [3,6]. We describe a technique to preserve proper positioning of the Xomed tube for accurate monitoring of the RLN. After noting depth of placement, the tube is moved with the operator’s finger to the midline. Tube positioning is next stabilized by two small, soft bite blocks placed deep inside the mouth over the tongue, and the tube is taped (Fig. 3A). A final step consists of taping the Xomed tube to the bite block as a unit (Fig. 3B). In our experience, this technique results in stable and reliable intraoperative EMG responses, providing superior feedback to the surgeon in identifying and preserving the RLN. Vladimir Nekhendzy MD (Clinical Associate Professor of Anesthesia) Jamie R. Lopez MD (Associate Professor of Neurology) Edward J. Damrose MD (Assistant Professor of Otolaryngology) Stanford University Medical Center Stanford, CA 94305, USA E-mail address: [email protected] doi:10.1016/j.jclinane.2011.05.009
References
Fig. 3 A. Step 1: Securing of the Xomed tube midline positioning with two soft bite blocks and small diameter tape. B. Step 2: Final securing of the Xomed tube midline by taping the Xomed tube and bite block assembly together with large plastic tape.
standard of care during surgery of the brainstem, skull base, thyroid, and parathyroid glands [1-4]. The Xomed endotracheal tube (Medtronic Xomed, Inc., Jacksonville, FL USA) incorporates surface electromyography (EMG) electrodes (Fig. 1), allowing continuous audible and visual intraoperative EMG monitoring of the laryngeal muscles [5]. Key to the success of such monitoring, however, rests with the anesthesiologist: the Xomed tube must be
[1] Brennan J, Moore EJ, Shuler KJ. Prospective analysis of the efficacy of continuous intraoperative nerve monitoring during thyroidectomy, parathyroidectomy, and parotidectomy. Otolaryngol Head Neck Surg 2001;124:537-43. [2] Otto RA, Cochran CS. Sensitivity and specificity of intraoperative recurrent laryngeal nerve stimulation in predicting postoperative nerve paralysis. Ann Otol Rhinol Laryngol 2002;111:1005-7. [3] Jackson LE, Roberson Jr JB. Vagal nerve monitoring in surgery of the skull base: a comparison of efficacy of three techniques. Am J Otol 1999;20:649-56. [4] Mikuni N, Satow T, Taki J, Nishida N, Enatsu R, Hashimoto N. Endotracheal tube electrodes to map and monitor activities of the vagus nerve intraoperatively. Technical note. J Neurosurg 2004;101:536-40. [5] Eisele DW. Intraoperative electrophysiologic monitoring of the recurrent laryngeal nerve. Laryngoscope 1996;106:443-9. [6] Djohan RS, Rodriguez HE, Connolly MM, Childers SJ, Braverman B, Podbielski FJ. Intraoperative monitoring of recurrent laryngeal nerve function. Am Surg 2000;66:595-7.