- Email: [email protected]
Passing a reinforced gastric tube behind a non-ProSeal Laryngeal Mask Airway
386
Correspondence
In previously reported cases of subcutaneous emphysema of the eyelid, the postulated mechanism was air transmission through a lamina papyracea defect. In our case, the mechanism of the emphysema is unclear. Our patient had a properly placed ETT with an adequate seal, making it improbable for the airway pressure to be transmitted to the eyelid area. Therefore, the previously described mechanism is unlikely in this case. The most likely mechanism of eyelid subcutaneous emphysema in this patient was during the craniotomy; the periosteum was elevated down to the orbital rim, creating a dissection plane. After the operation, air almost certainly remained intracranially, as pneumocephalus is a nearly universal postoperative finding after craniotomy [8]. When the patient coughed against the ETT prior to extubation, intrathoracic pressure increased. This action could have caused an increase in arterial and central venous pressures, which resulted in an increased intracranial pressure (ICP). The change in ICP may have forced the intracranial air to travel into the previously created dissection plane in the scalp soft tissue, over the orbital rim, and into the eyelid to cause the subcutaneous emphysema. There is no consensus on management of subcutaneous emphysema of the eyelid. Most practitioners treat the condition expectantly, allowing the air to reabsorb spontaneously over the course of a few days to weeks. The use of antibiotics is unclear. Some practitioners prefer to administer prophylactic antibiotics when there is a concomitant surgical or dental procedure [5]. Although the condition is usually benign, it may have serious eye-threatening consequences, including optic nerve compression, which would manifest as decreased visual acuity. In these cases, decompression is necessary. Our patient had a normal cranial nerve examination, and the swelling was localized to the eyelid. Therefore, no further treatment was necessary. Andrea K. Girnius BS (Medical Student) Rafael Ortega MD (Professor) Department of Anesthesiology Boston University Medical Center Boston, MA 02118, USA E-mail address: [email protected] Lawrence S. Chin MD (Professor and Chair) Department of Neurosurgery Boston University Medical Center Boston, MA 02118, USA doi:10.1016/j.jclinane.2009.10.009
References [1] LeBlond RF, Brown DD, DeGowin RL. The chest: chest wall, pulmonary, and cardiovascular systems; The Breasts. In: LeBlond RF, Brown DD, DeGowin RL, editors. DeGowin's Diagnostic Examination. 9th ed. Boston: McGraw-Hill Cos.; 2009. p. 302-433.
[2] Chiu W, Lih M, Huang TY, Ku WC, Wang W. Spontaneous orbital subcutaneous emphysema after sneezing. Am J Emerg Med 2008;26: 382.e1-e2. [3] Sharma M. Aerocele (subcutaneous emphysema) of the eyelid. Indian J Ophthalmol 1978;30:180. [4] Celebioğlu S, Keser A, Ortak T. An unusual complication of rhinoplasty: subcutaneous emphysema. Br J Plast Surg 1998;51:266-7. [5] Rosh AJ, Sharma R. Orbital emphysema after nose-blowing. J Emerg Med 2008;34:327-9. [6] Cavuslu S, Oncul O, Gungor A, Kizilkaya E, Candan H. A case of recurrent subcutaneous emphysema as a complication of endotracheal intubation. Ear Nose Throat J 2004;83:485-8. [7] Toprak V, Keles GT, Kaygisiz Z, Tok D. Subcutaneous emphysema following severe vomiting after emerging from general anesthesia. Acta Anaesthesiol Scand 2004;48:917-8. [8] Reasoner DK, Todd MM, Scamman FL, Warner DS. The incidence of pneumocephalus after supratentorial craniotomy. Observations on the disappearance of intracranial air. Anesthesiology 1994;80: 1008-12.
Passing a reinforced gastric tube behind a non-ProSeal Laryngeal Mask Airway To the Editor: Various instruments have been passed into the gastrointestinal tract behind the classic Laryngeal Mask Airway (LMA Classic; Intavent Direct, Maidenhead, UK). Although more difficult than the ProSeal LMA, the potential space behind the cuff allows insertion of larger instruments. Four studies in adults involving the LMA Classic showed a low success rate for passage of a gastric tube behind the LMA Classic cuff (40-55%) [1]. This finding was attributed to the soft and flexible nature of the gastric tube [2]. Amitabh and colleagues reported nasal passage of a cuffed red rubber tracheal tube (ETT) behind the LMA cuff into the upper esophagus, followed by railroading of the gastric tube through it to achieve nasogastric intubation [3]. The use of a reinforced gastric tube to assist insertion of a nasogastric tube behind a properly positioned LMA is presented. A 43 year-old man was scheduled for laparoscopic cholecystectomy during general anesthesia. Following three failed attempts to intubate the trachea, a size 4.0 LMA Classic was inserted to secure the airway successfully. On insertion of trochar, the surgeon noticed the patient's distended stomach and requested gastric decompression. An attempt to pass a well lubricated size 6.5 internal diameter (ID) polyvinyl chloride (PVC) ETT via the right nostril to achieve nasogastric tube placement, failed as the ETT became impacted against the posterior pharyngeal wall. A second attempt to pass the ETT into the pharynx led to dislodgement of the LMA. The gastric tube (Romsons Sci&Surg, Ltd., Agra, India) was primed with a modified ureteric guidewire [4]. This reinforced gastric tube was passed through the right nostril with simultaneous deflation of the LMA cuff. This tube was easily negotiated into the esophagus. The ureteric guidewire was removed and positioning was confirmed by auscultation over the epigastrium; gastric decompression was achieved. Postoperative
Correspondence
387
examination of the patient showed injury to the posterior pharyngeal wall, which was managed conservatively. The second case was a 50 year-old woman undergoing laparoscopic cholecystectomy. After failed intubation attempts, her airway was secured with a size 3 LMA Classic. The surgeon requested evacuation of gastric contents. A well lubricated size 6.5 ID PVC ETT was passed through the right nostril into the nasopharynx, then into the hypopharynx with simultaneous deflation of the LMA cuff. The gastric tube was passed through the nasotracheal tube. However, despite all efforts, we failed to advance the gastric tube beyond a distance of 30 cm, which was equal to the ETT length. The ETT was removed and the gastric tube was primed with a modified ureteric guidewire and passed via the right nostril; it was easily negotiated into the esophagus. The position was confirmed by auscultation over the epigastrium and gastric decompression was achieved. Nasal passage of an ETT is associated with nasal and pharyngeal mucosal trauma and bleeding [5]. In the first case, pushing the ETT led to dislodgement of the LMA. In the second case, the bevel of the ETT probably got lodged against the LMA/pharyngeal mucosa, leading to failure to negotiate the gastric tube. The literature is replete with cases of severe injury when PVC tubes are passed blindly [6]. Use of a reinforced nasogastric tube is safe and avoids injuries associated with ETT passage through the nose. Deflating the LMA cuff creates a channel behind the cuff through which any instrument inserted nasally must traverse to reach the stomach. The gastric tube is of smaller diameter; hence even a small channel would suffice to allow passage of this thin yet firm and flexible gastric tube, in contrast to the need for a channel of a larger diameter for ETT passage. We have used this technique in 10 patients and were successful in all but one patient, in whom it was successful on the second attempt from the opposite nostril.
[3]
[4] [5] [6]
and how to make them enter the esophagus. Anesthesiology 1999;91: 137-43. Dutta A, Ganguly N, Sood J, Kumra V. Intraoperative nasogastric tube insertion with non-ProSeal laryngeal mask in place. Anesth Analg 2006;102:1294-5. Mahajan R, Gupta R, Sharma A. Insertion of a nasogastric tube using a modified ureteric guide. J Clin Anesth 2009;21:387-8. Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003;58:249-56. Bartlett DS, Grace R, Newell S. Perforation of and intubation through the palatoglossal fold. Anaesth Intensive Care 2009;37:481-3.
Reproducible peaked T wave due to transfusion via central venous catheter in an infant To the Editor: Cardiac arrest associated with hyperkalemia during transfusion has been reported [1]. Transfusion-related hyperkalemia depends not only on the potassium concentration in the blood product, but also on volume and rate of transfusion [1]. It has also been suggested that transfusion via the central venous catheter contributes to a more concentrated potassium load to the heart, especially in pediatric patients [1,2]. Compared with stored blood units, fresh blood units, which have a lower potassium concentration, seem to be rarely related to hyperkalemia during transfusion [2,3]. However, we report a reproducible peaked T wave that was probably due to transfusion of fresh umbilical cord blood. A one day-old, 1,400 gram baby girl (gestational age = 25 wks), delivered by Cesarean section, was scheduled for left pneumonectomy for a giant congenital cystic adenomatoid malformation (CCAM). Prenatal ultrasonographic assessment had already shown several anomalies, including the giant CCAM. At delivery, umbilical cord blood was collected for autologous transfusion. Immediately after delivery, the infant's trachea was intubated and controlled
Rajesh Mahajan MD (Associate Professor) Amit Manhas MD (Senior Resident) Department of Anesthesia ASCOMS, Jammu, J&K, India E-mail address: [email protected] Rahul Gupta MD Senior Resident Department of Hepatology PGIMER, Chandigarh, India doi:10.1016/j.jclinane.2009.10.010
References [1] Brimacombe AJ. Conduit to respiratory and gastrointestinal tracts. In: Brimacombe JR, editor. Laryngeal Mask Anesthesia: Principles and Practice. 2nd ed. London: W.B. Saunders Co., Ltd.; 2005. p. 153-76. [2] Ozer S, Benumof JL. Oro- and nasogastric tube passage in intubated patients: fiberoptic description of where they go at the laryngeal level
Fig. 1 Central venous (CV) and arterial blood (A) access using umbilical vein and artery. CCAM = congenital cystic adenomatoid malformation.
Correspondence
In previously reported cases of subcutaneous emphysema of the eyelid, the postulated mechanism was air transmission through a lamina papyracea defect. In our case, the mechanism of the emphysema is unclear. Our patient had a properly placed ETT with an adequate seal, making it improbable for the airway pressure to be transmitted to the eyelid area. Therefore, the previously described mechanism is unlikely in this case. The most likely mechanism of eyelid subcutaneous emphysema in this patient was during the craniotomy; the periosteum was elevated down to the orbital rim, creating a dissection plane. After the operation, air almost certainly remained intracranially, as pneumocephalus is a nearly universal postoperative finding after craniotomy [8]. When the patient coughed against the ETT prior to extubation, intrathoracic pressure increased. This action could have caused an increase in arterial and central venous pressures, which resulted in an increased intracranial pressure (ICP). The change in ICP may have forced the intracranial air to travel into the previously created dissection plane in the scalp soft tissue, over the orbital rim, and into the eyelid to cause the subcutaneous emphysema. There is no consensus on management of subcutaneous emphysema of the eyelid. Most practitioners treat the condition expectantly, allowing the air to reabsorb spontaneously over the course of a few days to weeks. The use of antibiotics is unclear. Some practitioners prefer to administer prophylactic antibiotics when there is a concomitant surgical or dental procedure [5]. Although the condition is usually benign, it may have serious eye-threatening consequences, including optic nerve compression, which would manifest as decreased visual acuity. In these cases, decompression is necessary. Our patient had a normal cranial nerve examination, and the swelling was localized to the eyelid. Therefore, no further treatment was necessary. Andrea K. Girnius BS (Medical Student) Rafael Ortega MD (Professor) Department of Anesthesiology Boston University Medical Center Boston, MA 02118, USA E-mail address: [email protected] Lawrence S. Chin MD (Professor and Chair) Department of Neurosurgery Boston University Medical Center Boston, MA 02118, USA doi:10.1016/j.jclinane.2009.10.009
References [1] LeBlond RF, Brown DD, DeGowin RL. The chest: chest wall, pulmonary, and cardiovascular systems; The Breasts. In: LeBlond RF, Brown DD, DeGowin RL, editors. DeGowin's Diagnostic Examination. 9th ed. Boston: McGraw-Hill Cos.; 2009. p. 302-433.
[2] Chiu W, Lih M, Huang TY, Ku WC, Wang W. Spontaneous orbital subcutaneous emphysema after sneezing. Am J Emerg Med 2008;26: 382.e1-e2. [3] Sharma M. Aerocele (subcutaneous emphysema) of the eyelid. Indian J Ophthalmol 1978;30:180. [4] Celebioğlu S, Keser A, Ortak T. An unusual complication of rhinoplasty: subcutaneous emphysema. Br J Plast Surg 1998;51:266-7. [5] Rosh AJ, Sharma R. Orbital emphysema after nose-blowing. J Emerg Med 2008;34:327-9. [6] Cavuslu S, Oncul O, Gungor A, Kizilkaya E, Candan H. A case of recurrent subcutaneous emphysema as a complication of endotracheal intubation. Ear Nose Throat J 2004;83:485-8. [7] Toprak V, Keles GT, Kaygisiz Z, Tok D. Subcutaneous emphysema following severe vomiting after emerging from general anesthesia. Acta Anaesthesiol Scand 2004;48:917-8. [8] Reasoner DK, Todd MM, Scamman FL, Warner DS. The incidence of pneumocephalus after supratentorial craniotomy. Observations on the disappearance of intracranial air. Anesthesiology 1994;80: 1008-12.
Passing a reinforced gastric tube behind a non-ProSeal Laryngeal Mask Airway To the Editor: Various instruments have been passed into the gastrointestinal tract behind the classic Laryngeal Mask Airway (LMA Classic; Intavent Direct, Maidenhead, UK). Although more difficult than the ProSeal LMA, the potential space behind the cuff allows insertion of larger instruments. Four studies in adults involving the LMA Classic showed a low success rate for passage of a gastric tube behind the LMA Classic cuff (40-55%) [1]. This finding was attributed to the soft and flexible nature of the gastric tube [2]. Amitabh and colleagues reported nasal passage of a cuffed red rubber tracheal tube (ETT) behind the LMA cuff into the upper esophagus, followed by railroading of the gastric tube through it to achieve nasogastric intubation [3]. The use of a reinforced gastric tube to assist insertion of a nasogastric tube behind a properly positioned LMA is presented. A 43 year-old man was scheduled for laparoscopic cholecystectomy during general anesthesia. Following three failed attempts to intubate the trachea, a size 4.0 LMA Classic was inserted to secure the airway successfully. On insertion of trochar, the surgeon noticed the patient's distended stomach and requested gastric decompression. An attempt to pass a well lubricated size 6.5 internal diameter (ID) polyvinyl chloride (PVC) ETT via the right nostril to achieve nasogastric tube placement, failed as the ETT became impacted against the posterior pharyngeal wall. A second attempt to pass the ETT into the pharynx led to dislodgement of the LMA. The gastric tube (Romsons Sci&Surg, Ltd., Agra, India) was primed with a modified ureteric guidewire [4]. This reinforced gastric tube was passed through the right nostril with simultaneous deflation of the LMA cuff. This tube was easily negotiated into the esophagus. The ureteric guidewire was removed and positioning was confirmed by auscultation over the epigastrium; gastric decompression was achieved. Postoperative
Correspondence
387
examination of the patient showed injury to the posterior pharyngeal wall, which was managed conservatively. The second case was a 50 year-old woman undergoing laparoscopic cholecystectomy. After failed intubation attempts, her airway was secured with a size 3 LMA Classic. The surgeon requested evacuation of gastric contents. A well lubricated size 6.5 ID PVC ETT was passed through the right nostril into the nasopharynx, then into the hypopharynx with simultaneous deflation of the LMA cuff. The gastric tube was passed through the nasotracheal tube. However, despite all efforts, we failed to advance the gastric tube beyond a distance of 30 cm, which was equal to the ETT length. The ETT was removed and the gastric tube was primed with a modified ureteric guidewire and passed via the right nostril; it was easily negotiated into the esophagus. The position was confirmed by auscultation over the epigastrium and gastric decompression was achieved. Nasal passage of an ETT is associated with nasal and pharyngeal mucosal trauma and bleeding [5]. In the first case, pushing the ETT led to dislodgement of the LMA. In the second case, the bevel of the ETT probably got lodged against the LMA/pharyngeal mucosa, leading to failure to negotiate the gastric tube. The literature is replete with cases of severe injury when PVC tubes are passed blindly [6]. Use of a reinforced nasogastric tube is safe and avoids injuries associated with ETT passage through the nose. Deflating the LMA cuff creates a channel behind the cuff through which any instrument inserted nasally must traverse to reach the stomach. The gastric tube is of smaller diameter; hence even a small channel would suffice to allow passage of this thin yet firm and flexible gastric tube, in contrast to the need for a channel of a larger diameter for ETT passage. We have used this technique in 10 patients and were successful in all but one patient, in whom it was successful on the second attempt from the opposite nostril.
[3]
[4] [5] [6]
and how to make them enter the esophagus. Anesthesiology 1999;91: 137-43. Dutta A, Ganguly N, Sood J, Kumra V. Intraoperative nasogastric tube insertion with non-ProSeal laryngeal mask in place. Anesth Analg 2006;102:1294-5. Mahajan R, Gupta R, Sharma A. Insertion of a nasogastric tube using a modified ureteric guide. J Clin Anesth 2009;21:387-8. Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery. Anaesthesia 2003;58:249-56. Bartlett DS, Grace R, Newell S. Perforation of and intubation through the palatoglossal fold. Anaesth Intensive Care 2009;37:481-3.
Reproducible peaked T wave due to transfusion via central venous catheter in an infant To the Editor: Cardiac arrest associated with hyperkalemia during transfusion has been reported [1]. Transfusion-related hyperkalemia depends not only on the potassium concentration in the blood product, but also on volume and rate of transfusion [1]. It has also been suggested that transfusion via the central venous catheter contributes to a more concentrated potassium load to the heart, especially in pediatric patients [1,2]. Compared with stored blood units, fresh blood units, which have a lower potassium concentration, seem to be rarely related to hyperkalemia during transfusion [2,3]. However, we report a reproducible peaked T wave that was probably due to transfusion of fresh umbilical cord blood. A one day-old, 1,400 gram baby girl (gestational age = 25 wks), delivered by Cesarean section, was scheduled for left pneumonectomy for a giant congenital cystic adenomatoid malformation (CCAM). Prenatal ultrasonographic assessment had already shown several anomalies, including the giant CCAM. At delivery, umbilical cord blood was collected for autologous transfusion. Immediately after delivery, the infant's trachea was intubated and controlled
Rajesh Mahajan MD (Associate Professor) Amit Manhas MD (Senior Resident) Department of Anesthesia ASCOMS, Jammu, J&K, India E-mail address: [email protected] Rahul Gupta MD Senior Resident Department of Hepatology PGIMER, Chandigarh, India doi:10.1016/j.jclinane.2009.10.010
References [1] Brimacombe AJ. Conduit to respiratory and gastrointestinal tracts. In: Brimacombe JR, editor. Laryngeal Mask Anesthesia: Principles and Practice. 2nd ed. London: W.B. Saunders Co., Ltd.; 2005. p. 153-76. [2] Ozer S, Benumof JL. Oro- and nasogastric tube passage in intubated patients: fiberoptic description of where they go at the laryngeal level
Fig. 1 Central venous (CV) and arterial blood (A) access using umbilical vein and artery. CCAM = congenital cystic adenomatoid malformation.