- Email: [email protected]
A novel technique using the gum elastic bougie and video laryngoscope for intubation in an unanticipated difficult airway
Journal of Clinical Anesthesia (2012) 24, 675–680
Correspondence
BrainLAB interference with pulse oximetry during stereotactic brain biopsy To the Editor: A 64 year old woman with a right temporoparietooccipital lesion presented for frameless stereotactic brain biopsy. After an uneventful induction, the patient's bed was turned 90 degrees. The patient's pulse oximeter began to show an erratic pattern and oxygen saturation (SpO2) decreased from 100% to 82% - 85%. Palpated radial pulse correlated with electrocardiographic rhythm and the pulse oximeter was switched to a different adhesive probe (the LNOP®, adult size was used throughout; Masimo Corp., Irvine, CA, USA), on the opposite hand, but this action failed to alleviate the problem. The pulse oximeter transducer used in the operating room (OR) was a GE Healthcare product (Waukesha, WI, USA). A portable Masimo pulse oximeter (Masimo Corp.) was tried on each sensor bilaterally, with a similar result. At this point, suspicion pointed toward the neuronavigation device in the ORs as the source of the interference. The patient's right hand was covered by a double-folded towel. This intervention produced a usable signal and significantly decreased the interference, but it did not eliminate it. On final draping of the patient, the waveform returned to normal and showed no signs of interference. No further disturbance of pulse oximeter measurement was noted for the remainder of the case. The process of neuronavigation interfered with pulse oximeter performance in a study simulating the clinical setting [1]. As noted, the interference does not necessarily result in the disruption of SpO2 recognition. This study used the BrainLAB VectorVision® system (BrainLAB AG, Munich, Germany), which showed resolution of the interference by covering the sensor with tinfoil. A case report involving the Stealth Station Treatment Guidance SystemTM (Medtronic, Minneapolis, MN, USA) was reported [2]. Covering the sensor with cloth decreased the interference, but did not eliminate it, much like our own experience. Resolution of the disturbance was achieved in this incident by covering the sensor with the wrapper of a foillined isopropyl alcohol pad. BrainLAB neuronavigation uses a 880 nm infared light (personal correspondence with the manufacturer). Pulse oximetry relies on two wavelengths of light: 660 nm (red light, visible spectrum) is used to detect hemoglobin (Hb) level, while 9100952-8180/$ – see front matter. Published by Elsevier Inc.
940 nm of light (infrared) detects the oxygenated Hb portion, or HbO2 [2,3]. The interference of pulse oximetry by neuronavigation devices in the OR occurs in this infrared zone [2]. Disruption of pulse oximetry by neuronavigation results in either a poor waveform, false values, or both. Suspicion of interference from the devices is key. A simple cloth barrier may help produce a usable signal and multiple layers will eliminate the interference; a thin metal barrier such as aluminum foil may be a better alternative. Infrared light has a tendency to bounce off of solid objects, so that a direct path from the system to the sensor is not required [2]; thus, barriers constructed to improve pulse oximeter readings may need to fully encompass the sensor. Thomas E. Schulte MD (Assistant Professor) John R. Ohnoutka MD (Assistant Professor) Ankit Agrawal BS (Clinical Research Associate) Department of Anesthesiology University of Nebraska Medical Center Omaha, NE 68198-4455, USA E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2012.03.010
References [1] Mathes AM, Kreuer S, Schneider SO, Ziegeler S, Grundmann U. The performance of six pulse oximeters in the environment of neuronavigation. Anesth Analg 2008;107:541-4. [2] van Oostrom JH, Mahla ME, Gravenstein D. The Stealth Station Image Guidance System may interfere with pulse oximetry. Can J Anaesth 2005;52:379-82. [3] Jubran A. Pulse oximetry. Crit Care 1999;3:R11-7.
A novel technique using the gum elastic bougie and video laryngoscope for intubation in an unanticipated difficult airway To the Editor: Tracheal intubation is one of the critical skills for an anesthesiologist, and to that end several tools have been developed to manage an airway after unsuccessful direct
676 laryngoscopy. The GlideScope (Verathon, Bothell, WA, USA) is one of many tools [1,2]. The few documented complications (including failed intubations) noted in the literature with regard to the GlideScope include an inability to pass the endotracheal tube (ETT) in an anterior airway and difficulty maneuvering the styletted ETT in the oropharynx [3]. In addition, attempts to intubate patients with anterior anatomy have been associated with oropharyngeal trauma [4]. There have been several small series and case report accounts of using variations to the standard stylet provided with the GlideScope. These include the use of an orally inserted gum elastic bougie [5], a fiberoptic bronchoscope [6], and a sharply curved malleable stylet [7]. We present a case describing a novel technique for intubation in an unanticipated, anteriorly displaced airway. A 70 year old ASA physical status 2 man presented for two-level lumbar fusion. His surgical history was limited to bilateral arthroscopy of his knees with general anesthesia with a laryngeal mask airway. He had no complications with his previous anesthesia. Preoperative examination of the patient's airway was not concerning for features associated with difficult intubation. Given the airway examination, we induced anesthesia with propofol and fentanyl after application of standard ASA monitors. The patient was easy to ventilate and succinylcholine was administered for muscle relaxation. The initial attempt at direct laryngoscopy (by an anesthesia resident) was unsuccessful with both the Macintosh 3.0 and Miller 2 blades. The resident indicated that the anatomy appeared to be anterior; attempts to displace the glottis posteriorly by external compression were not helpful. Subsequent direct laryngoscopy by the supervising anesthesiologist was similarly unsuccessful, even after attempting to pass an orally inserted gum elastic bougie anterior to the esophageal orifice. Bag mask ventilation was repeated, additional propofol was given, and a size 3 GlideScope was placed. Only the most posterior aspect of the arytenoid cartilage was visible with the video laryngoscope, and the GlideRite rigid stylet (Verathon) that was included with the GlideScope was not effective with a 7.0 ETT due to the anterior nature of the patient's airway anatomy. At this time, a gum elastic bougie was placed in the oropharynx, then advanced using the GlideScope without success due to the pronounced anterior anatomy. After another course of bag mask ventilation, the GlideScope was replaced and the same view of the arytenoids was re-obtained. A gum elastic bougie was advanced through the right naris, into the pharynx (Fig. 1). It was advanced slowly during visualization by the video laryngoscope, and the curvature enabled efficient advancment into the trachea. The ETT was then advanced and the cuff inflated, and bilateral breath sounds were confirmed. The intraoperative and postoperative courses were uncomplicated. There was no trauma to the nasal mucosa or oropharynx. The patient was informed for future reference that his airway presented a challenge to the anesthesia team. The technique described here is a novel use of a gum elastic bougie with a video laryngoscope in a patient with
Correspondence
Fig. 1 Cross-sectional diagram of relevant airway anatomy. Black areas=rendering of the video laryngoscope and gum elastic bougie. Shaded area from the tip of the laryngoscope to the posterior pharynx=visual field of the patient described. Note the course that a nasally inserted gum elastic bougie might take, resulting in successful intubation of an otherwise difficult airway.
unanticipated anterior glottic anatomy. Success was achieved by taking advantage of the alignment of the nasopharynx and glottis. Fig. 1 depicts cross-sectional anatomy relevant to intubation. The darkened portion extending from the video laryngoscope camera to the posterior pharynx indicates the approximate visual field often encountered in a patient with anterior glottic displacement. The image also shows how a nasally inserted gum elastic bougie is advanced anterior in such a patient to facilitate intubation. The intubation of patients with anterior anatomy has been shown with a combination of video laryngoscope and fiberoptic bronchoscope [6]; this technique provides an alternative method of intubation when a fiberoptic scope may not be readily available. The supervising anesthesiologist has used this technique subsequently when called to emergency rescue intubations outside the operative theater. While the authors do not recommend first attempting this technique in an emergency, when the provider is facile with the procedure, it may prove useful in any clinical setting. William R. Hand MD (Assistant Professor) Brandon M. Sutton MD (Resident Physician) Department of Anesthesia & Perioperative Medicine Medical University of South Carolina Charleston SC 29425, USA E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2012.03.011
Correspondence
677
References [1] Rai MR, Dering A, Verghese C. The Glidescope system: a clinical assessment of performance. Anaesthesia 2005;60:60-4. [2] Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology 2011;114:34-41. [3] Cooper RM. Complications associated with the use of the Glidescope videolaryngoscope. Can J Anaesth 2007;54:54-7. [4] Puchner W, Drabauer L, Kern K, et al. Indirect versus direct laryngoscopy for routine nasotracheal intubation. J Clin Anesth 2011;23:280-5. [5] Nielsen AA, Hope CB, Bair AE. GlideScope Videolaryngoscopy in the Simulated Difficult Airway: Bougie vs Standard Stylet. West J Emerg Med 2010;11:426-31. [6] Sharma D, Kim LJ, Ghodke B. Successful airway management with combined use of Glidescope videolaryngoscope and fiberoptic bronchoscope in a patient with Cowden syndrome. Anesthesiology 2010;113: 253-5. [7] Walls RM, Samuels-Kalow M, Perkins A. A new maneuver for endotracheal tube insertion during difficult GlideScope intubation. J Emerg Med 2010;39:86-8.
Manufacturing error in a propofol vial: glass within glass To the Editor: Propofol is used extensively in modern-day anesthesia practice and for sedation in the intensive care unit [1]. Several problems with the use of propofol have been documented. While some, such as pain on injection, infectious risk, and propofol infusion syndrome are genuinely attributable to the effects of propofol, certain other problems, such as coring of the propofol vial and embolization of the rubber piece, are due largely to manufacturing deficiencies [2–5]. We wish to report another manufacturing error with the propofol vial during the care of a 54 year old man who was scheduled for ureteroscopy with general anesthesia. The plan for induction of anesthesia was to use propofol. During preoxygenation, the entire contents of a vial of propofol (Troypofol; Troikaa Pharmaceuticals, Ltd., Uttarkhand, India) were emptied into a 20 mL syringe. It was noticed that the propofol vial contained a glass shard that measured roughly 1 cm × 0.5 cm (Fig. 1). This clear glass shard was invisible due to its transparency when the vial was full. It was detected inside the propofol vial only at the end of aspiration of all of the drug. The contents withdrawn from the vial were discarded. Errors may occur in any field despite stringent guidelines, recommendations, and quality control measures. The propofol manufacturers are planning to incorporate a camera with suitable resolution to detect a transparent shard of glass within the vials prior to loading onto the washing machine (packing area). Since propofol is a white emulsion, it is very easy to miss any foreign body (especially if that object is transparent) that might be present in the vial until the vial is emptied.
Fig. 1 Left: side view and Right: end-on view of the glass propofol vial. Note the glass shard inside the vial, which was visible only after complete aspiration of the drug.
Goneppanavar Umesh MD (Assistant Professor) Navdeep Kaur MD (Assistant Professor) Department of Anaesthesiology, Kasturba Medical College Manipal 576 104, Karnataka State, India E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2012.03.012
References [1] McKeage K, Perry CM. Propofol: a review of its use in intensive care sedation of adults. CNS Drugs 2003;17:235-72. [2] Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2000;90:963-9. [3] Nichols RL, Smith JW. Bacterial contamination of an anesthetic agent. N Engl J Med 1995;333:184-5. [4] Vasile B, Rasulo F, Candiani A, Latronico N. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med 2003;29:1417-25. [5] Riess ML, Strong T. Near-embolization of a rubber core from a propofol vial. Anesth Analg 2008;106:1020-1.
Drug shortages: implications on pediatric anesthesia practice and management resources To the Editor: Drug shortages have become a public health and patient care issue, as many reports have detailed the impact of decreased drug availability on patient care. This impact has become significant in nearly all aspects of medicine, including investigational drug trials. Healthcare institutions are struggling to manage limited supplies of critical medicines [1-5]. The problem has become so great that the federal government is involved and legislation has been drafted to prevent shortages of critical medications [6].
Correspondence
BrainLAB interference with pulse oximetry during stereotactic brain biopsy To the Editor: A 64 year old woman with a right temporoparietooccipital lesion presented for frameless stereotactic brain biopsy. After an uneventful induction, the patient's bed was turned 90 degrees. The patient's pulse oximeter began to show an erratic pattern and oxygen saturation (SpO2) decreased from 100% to 82% - 85%. Palpated radial pulse correlated with electrocardiographic rhythm and the pulse oximeter was switched to a different adhesive probe (the LNOP®, adult size was used throughout; Masimo Corp., Irvine, CA, USA), on the opposite hand, but this action failed to alleviate the problem. The pulse oximeter transducer used in the operating room (OR) was a GE Healthcare product (Waukesha, WI, USA). A portable Masimo pulse oximeter (Masimo Corp.) was tried on each sensor bilaterally, with a similar result. At this point, suspicion pointed toward the neuronavigation device in the ORs as the source of the interference. The patient's right hand was covered by a double-folded towel. This intervention produced a usable signal and significantly decreased the interference, but it did not eliminate it. On final draping of the patient, the waveform returned to normal and showed no signs of interference. No further disturbance of pulse oximeter measurement was noted for the remainder of the case. The process of neuronavigation interfered with pulse oximeter performance in a study simulating the clinical setting [1]. As noted, the interference does not necessarily result in the disruption of SpO2 recognition. This study used the BrainLAB VectorVision® system (BrainLAB AG, Munich, Germany), which showed resolution of the interference by covering the sensor with tinfoil. A case report involving the Stealth Station Treatment Guidance SystemTM (Medtronic, Minneapolis, MN, USA) was reported [2]. Covering the sensor with cloth decreased the interference, but did not eliminate it, much like our own experience. Resolution of the disturbance was achieved in this incident by covering the sensor with the wrapper of a foillined isopropyl alcohol pad. BrainLAB neuronavigation uses a 880 nm infared light (personal correspondence with the manufacturer). Pulse oximetry relies on two wavelengths of light: 660 nm (red light, visible spectrum) is used to detect hemoglobin (Hb) level, while 9100952-8180/$ – see front matter. Published by Elsevier Inc.
940 nm of light (infrared) detects the oxygenated Hb portion, or HbO2 [2,3]. The interference of pulse oximetry by neuronavigation devices in the OR occurs in this infrared zone [2]. Disruption of pulse oximetry by neuronavigation results in either a poor waveform, false values, or both. Suspicion of interference from the devices is key. A simple cloth barrier may help produce a usable signal and multiple layers will eliminate the interference; a thin metal barrier such as aluminum foil may be a better alternative. Infrared light has a tendency to bounce off of solid objects, so that a direct path from the system to the sensor is not required [2]; thus, barriers constructed to improve pulse oximeter readings may need to fully encompass the sensor. Thomas E. Schulte MD (Assistant Professor) John R. Ohnoutka MD (Assistant Professor) Ankit Agrawal BS (Clinical Research Associate) Department of Anesthesiology University of Nebraska Medical Center Omaha, NE 68198-4455, USA E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2012.03.010
References [1] Mathes AM, Kreuer S, Schneider SO, Ziegeler S, Grundmann U. The performance of six pulse oximeters in the environment of neuronavigation. Anesth Analg 2008;107:541-4. [2] van Oostrom JH, Mahla ME, Gravenstein D. The Stealth Station Image Guidance System may interfere with pulse oximetry. Can J Anaesth 2005;52:379-82. [3] Jubran A. Pulse oximetry. Crit Care 1999;3:R11-7.
A novel technique using the gum elastic bougie and video laryngoscope for intubation in an unanticipated difficult airway To the Editor: Tracheal intubation is one of the critical skills for an anesthesiologist, and to that end several tools have been developed to manage an airway after unsuccessful direct
676 laryngoscopy. The GlideScope (Verathon, Bothell, WA, USA) is one of many tools [1,2]. The few documented complications (including failed intubations) noted in the literature with regard to the GlideScope include an inability to pass the endotracheal tube (ETT) in an anterior airway and difficulty maneuvering the styletted ETT in the oropharynx [3]. In addition, attempts to intubate patients with anterior anatomy have been associated with oropharyngeal trauma [4]. There have been several small series and case report accounts of using variations to the standard stylet provided with the GlideScope. These include the use of an orally inserted gum elastic bougie [5], a fiberoptic bronchoscope [6], and a sharply curved malleable stylet [7]. We present a case describing a novel technique for intubation in an unanticipated, anteriorly displaced airway. A 70 year old ASA physical status 2 man presented for two-level lumbar fusion. His surgical history was limited to bilateral arthroscopy of his knees with general anesthesia with a laryngeal mask airway. He had no complications with his previous anesthesia. Preoperative examination of the patient's airway was not concerning for features associated with difficult intubation. Given the airway examination, we induced anesthesia with propofol and fentanyl after application of standard ASA monitors. The patient was easy to ventilate and succinylcholine was administered for muscle relaxation. The initial attempt at direct laryngoscopy (by an anesthesia resident) was unsuccessful with both the Macintosh 3.0 and Miller 2 blades. The resident indicated that the anatomy appeared to be anterior; attempts to displace the glottis posteriorly by external compression were not helpful. Subsequent direct laryngoscopy by the supervising anesthesiologist was similarly unsuccessful, even after attempting to pass an orally inserted gum elastic bougie anterior to the esophageal orifice. Bag mask ventilation was repeated, additional propofol was given, and a size 3 GlideScope was placed. Only the most posterior aspect of the arytenoid cartilage was visible with the video laryngoscope, and the GlideRite rigid stylet (Verathon) that was included with the GlideScope was not effective with a 7.0 ETT due to the anterior nature of the patient's airway anatomy. At this time, a gum elastic bougie was placed in the oropharynx, then advanced using the GlideScope without success due to the pronounced anterior anatomy. After another course of bag mask ventilation, the GlideScope was replaced and the same view of the arytenoids was re-obtained. A gum elastic bougie was advanced through the right naris, into the pharynx (Fig. 1). It was advanced slowly during visualization by the video laryngoscope, and the curvature enabled efficient advancment into the trachea. The ETT was then advanced and the cuff inflated, and bilateral breath sounds were confirmed. The intraoperative and postoperative courses were uncomplicated. There was no trauma to the nasal mucosa or oropharynx. The patient was informed for future reference that his airway presented a challenge to the anesthesia team. The technique described here is a novel use of a gum elastic bougie with a video laryngoscope in a patient with
Correspondence
Fig. 1 Cross-sectional diagram of relevant airway anatomy. Black areas=rendering of the video laryngoscope and gum elastic bougie. Shaded area from the tip of the laryngoscope to the posterior pharynx=visual field of the patient described. Note the course that a nasally inserted gum elastic bougie might take, resulting in successful intubation of an otherwise difficult airway.
unanticipated anterior glottic anatomy. Success was achieved by taking advantage of the alignment of the nasopharynx and glottis. Fig. 1 depicts cross-sectional anatomy relevant to intubation. The darkened portion extending from the video laryngoscope camera to the posterior pharynx indicates the approximate visual field often encountered in a patient with anterior glottic displacement. The image also shows how a nasally inserted gum elastic bougie is advanced anterior in such a patient to facilitate intubation. The intubation of patients with anterior anatomy has been shown with a combination of video laryngoscope and fiberoptic bronchoscope [6]; this technique provides an alternative method of intubation when a fiberoptic scope may not be readily available. The supervising anesthesiologist has used this technique subsequently when called to emergency rescue intubations outside the operative theater. While the authors do not recommend first attempting this technique in an emergency, when the provider is facile with the procedure, it may prove useful in any clinical setting. William R. Hand MD (Assistant Professor) Brandon M. Sutton MD (Resident Physician) Department of Anesthesia & Perioperative Medicine Medical University of South Carolina Charleston SC 29425, USA E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jclinane.2012.03.011
Correspondence
677
References [1] Rai MR, Dering A, Verghese C. The Glidescope system: a clinical assessment of performance. Anaesthesia 2005;60:60-4. [2] Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D, Brambrink AM. Routine clinical practice effectiveness of the Glidescope in difficult airway management: an analysis of 2,004 Glidescope intubations, complications, and failures from two institutions. Anesthesiology 2011;114:34-41. [3] Cooper RM. Complications associated with the use of the Glidescope videolaryngoscope. Can J Anaesth 2007;54:54-7. [4] Puchner W, Drabauer L, Kern K, et al. Indirect versus direct laryngoscopy for routine nasotracheal intubation. J Clin Anesth 2011;23:280-5. [5] Nielsen AA, Hope CB, Bair AE. GlideScope Videolaryngoscopy in the Simulated Difficult Airway: Bougie vs Standard Stylet. West J Emerg Med 2010;11:426-31. [6] Sharma D, Kim LJ, Ghodke B. Successful airway management with combined use of Glidescope videolaryngoscope and fiberoptic bronchoscope in a patient with Cowden syndrome. Anesthesiology 2010;113: 253-5. [7] Walls RM, Samuels-Kalow M, Perkins A. A new maneuver for endotracheal tube insertion during difficult GlideScope intubation. J Emerg Med 2010;39:86-8.
Manufacturing error in a propofol vial: glass within glass To the Editor: Propofol is used extensively in modern-day anesthesia practice and for sedation in the intensive care unit [1]. Several problems with the use of propofol have been documented. While some, such as pain on injection, infectious risk, and propofol infusion syndrome are genuinely attributable to the effects of propofol, certain other problems, such as coring of the propofol vial and embolization of the rubber piece, are due largely to manufacturing deficiencies [2–5]. We wish to report another manufacturing error with the propofol vial during the care of a 54 year old man who was scheduled for ureteroscopy with general anesthesia. The plan for induction of anesthesia was to use propofol. During preoxygenation, the entire contents of a vial of propofol (Troypofol; Troikaa Pharmaceuticals, Ltd., Uttarkhand, India) were emptied into a 20 mL syringe. It was noticed that the propofol vial contained a glass shard that measured roughly 1 cm × 0.5 cm (Fig. 1). This clear glass shard was invisible due to its transparency when the vial was full. It was detected inside the propofol vial only at the end of aspiration of all of the drug. The contents withdrawn from the vial were discarded. Errors may occur in any field despite stringent guidelines, recommendations, and quality control measures. The propofol manufacturers are planning to incorporate a camera with suitable resolution to detect a transparent shard of glass within the vials prior to loading onto the washing machine (packing area). Since propofol is a white emulsion, it is very easy to miss any foreign body (especially if that object is transparent) that might be present in the vial until the vial is emptied.
Fig. 1 Left: side view and Right: end-on view of the glass propofol vial. Note the glass shard inside the vial, which was visible only after complete aspiration of the drug.
Goneppanavar Umesh MD (Assistant Professor) Navdeep Kaur MD (Assistant Professor) Department of Anaesthesiology, Kasturba Medical College Manipal 576 104, Karnataka State, India E-mail address: [email protected] http://dx.doi.org/10.1016/j.jclinane.2012.03.012
References [1] McKeage K, Perry CM. Propofol: a review of its use in intensive care sedation of adults. CNS Drugs 2003;17:235-72. [2] Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2000;90:963-9. [3] Nichols RL, Smith JW. Bacterial contamination of an anesthetic agent. N Engl J Med 1995;333:184-5. [4] Vasile B, Rasulo F, Candiani A, Latronico N. The pathophysiology of propofol infusion syndrome: a simple name for a complex syndrome. Intensive Care Med 2003;29:1417-25. [5] Riess ML, Strong T. Near-embolization of a rubber core from a propofol vial. Anesth Analg 2008;106:1020-1.
Drug shortages: implications on pediatric anesthesia practice and management resources To the Editor: Drug shortages have become a public health and patient care issue, as many reports have detailed the impact of decreased drug availability on patient care. This impact has become significant in nearly all aspects of medicine, including investigational drug trials. Healthcare institutions are struggling to manage limited supplies of critical medicines [1-5]. The problem has become so great that the federal government is involved and legislation has been drafted to prevent shortages of critical medications [6].