LETTERS TO THE EDITOR
Fig 2. The DLT is stabilized with a bow-tie at the biiurcation of the DLT connector.
single maneuver for proper positioning and manipulation. contaminated, wet, and slippery environment is avoided.
The time-consuming
struggle of untying multiple knots in a
Edmond Cohen, MD Robert Koom, MD
Department of Anesthesiology Mount Sinai Medical Center New York, NY
A Simple Underwater
Seal Apparatus
for Use in Emergencies
To the Editor:
Occasionally during the perioperative period a spontaneous or iatrogenic pneumothorax may occur with serious consequences, particularly if the diagnosis is made late and insertion of an effective underwater seal is delayed. The object of this letter is to present a simple apparatus that may be used in an emergency, while awaiting more definitive treatment. The supplies that are needed are al1 readily available in any operating room (Fig 1). These include a 14-gauge 2%-in intravenous (IV) catheter, a 250-mL glass bottle or plastic IV solution container (the glass bottle is preferred), a straight hemostat clamp, plastic pressure tubing, an Wgauge or larger needle, and a scissors. The 250-mL container is first prepared by removing either the metal tap and the metal diaphragm of the glass bottle or the white stopper of the plastic container. A sterile, straight hemostat clamp is then introduced into the bottle through the rubber at the top of the bottle or the outlet of the plastic container. The female end of the pressure tubing is cut off with the scissors, and that end is introduced into the fluid (wel1 below the fluid level) with the help of the hemostat clamp. After the skin is appropriately cleaned, the 1Cgauge IV catheter is inserted into the pleura1 cavity on the affected side.
196
LETTERS TO THE EDITOR
Fig 1. The equipment necessary for the rapid construction of an underwater seal apparatus includes a Iarge-bore (Wgauge) IV catheter, a 250.mL glass bottle of IV fluid, plastic pressure tubing, an 18.gauge or larger needle, a straight sterile hemostat clamp, and a scissors.
This is usually done through the second intercostal space in the midclavicular line, taking care not to injure the intercostal bundle. The proximate end of the needle is then attached to the male adapter of the pressure tubing, which in turn is attached to the underwater seal bottle. The large-bore needle (> Wgauge) is inserted through the rubber on the top of the bottle or through the drip injection port of the plastic container. The 14-gauge catheter can now be secured into position on the chest with a silk suture. The glass bottle or plastic container is placed on the floor or taped into place on the operating table or drip stand. Lastly, al1 connections are secured with tape (Fig 2). This method is a modification of the technique described by Holmes and Mark, which was used in the treatment of pneumothorax in the newborn.’ They used a 250-mL glass bottle that had glass tubing attached to the rubber outlet, extending inside the bottle almost to the bottom. These bottles are no longer manufactured. Therefore, we present this modification of their technique, which can be used with materials now available.
197
LETTERS TO THE EDITOR
This technique is a simple, safe, and dependable means of producing underwater seal drainage for patients of any age with spontaneous pneumothorax. Al1 the equipment needed is readily available in the operating room. Therefore, a workable underwater seal apparatus can be functioning within minutes in the event of a life-threatening pneumothorax. John G. Broek-Utne, FFASA Jay B. Brodsky, MD Gordon Haddow, MB
Department
of Anesthesia
James B.D. Mark, MD
Department of Surgery Stanford University Medical Center Stanford, CA REFERENCE 1. Holmes
SL, Mark JBD: A simple apparatus
for underwater
Vancomycin
seal in pneumothorax
and the Red-Man
of the newborn.
J Pediatr
Surg 3:87-88, 1968
Syndrome
To the Editor:
In a recent case report, “Cardiovascular Collapse and Refractory Bronchospasm Following Administration of Vancomycin, Esmolol, and Heparin,” Bloom et al state in the Discussion that “Vancomycin is an aminoglycoside antibiotic; thus, it shares the potential toxicity that this group possesses as a whole.“’ In fact, vancomycin is not an aminoglycoside antibiotic, but is a glycopolypeptide that is unrelated to al1 other antibiotics.*.3 Moreover, the quoted side effects of “fever, nausea, pain on injection with or without phlebitis . . .” are relatively rare adverse effects of the aminoglycoside antibiotics.4 Nephrotoxicity, although a complication encountered with both classes of antibiotics, is now infrequent with the newer, more pure preparations of vancomycin.3.5 Finally, one wonders whether the rarity with which the “red-man syndrome” has been reported in the cardiac anesthesia literature is related to the not uncommon practice of giving both H,- and H,-blockers prior to the induction of anesthesia and the administration of vancomycin. As correctly noted by the authors, pretreatment with histamine antagonists may prevent the occurrence of this syndrome. Christopher O’Connor, MD
Department of Anesthesia Massachusetts Genera1 Hospita1 Boston. MA REFERENCES 1. Bloom B, Chalmers PC, Danker PR, et al: Cardiovascular collapse and refractory bronchospasm following administration of vancomycin, esmolol, and heparin. J Cardiothorac Anesth 3:748749,1989 2. Lietman PS: Aminoglycosides and spectinomycin: Aminocyclitols, in Mandell G, Douglas R, Bennett J (eds): Principles and Practice of Infectieus Diseases (ed 2). New York, NY, Wiley, 1985, pp 192-206 3. Fekety R: Vancomycin, in Mandell G, Douglas R, Bennett J
(eds): Principles and Practice of Infectieus York, NY, Wiley, 1985, pp 232-235
Diseases
(ed 2). New
4. Sande M, Mandell G: Antimicrobial agents: The aminoglycosides, in Goodman L, Gilman A, Rall T, Murad F (eds): The Pharmacological Basis of Therapeutics (ed 7). New York, NY, MacMillian, 1985, pp 1160-1170 5. Hermans PE, Wilhelm 62:901-905, 1987
MP: Vancomycin.
Mayo Clin Proc
Fig 2. The DLT is stabilized with a bow-tie at the biiurcation of the DLT connector.
single maneuver for proper positioning and manipulation. contaminated, wet, and slippery environment is avoided.
The time-consuming
struggle of untying multiple knots in a
Edmond Cohen, MD Robert Koom, MD
Department of Anesthesiology Mount Sinai Medical Center New York, NY
A Simple Underwater
Seal Apparatus
for Use in Emergencies
To the Editor:
Occasionally during the perioperative period a spontaneous or iatrogenic pneumothorax may occur with serious consequences, particularly if the diagnosis is made late and insertion of an effective underwater seal is delayed. The object of this letter is to present a simple apparatus that may be used in an emergency, while awaiting more definitive treatment. The supplies that are needed are al1 readily available in any operating room (Fig 1). These include a 14-gauge 2%-in intravenous (IV) catheter, a 250-mL glass bottle or plastic IV solution container (the glass bottle is preferred), a straight hemostat clamp, plastic pressure tubing, an Wgauge or larger needle, and a scissors. The 250-mL container is first prepared by removing either the metal tap and the metal diaphragm of the glass bottle or the white stopper of the plastic container. A sterile, straight hemostat clamp is then introduced into the bottle through the rubber at the top of the bottle or the outlet of the plastic container. The female end of the pressure tubing is cut off with the scissors, and that end is introduced into the fluid (wel1 below the fluid level) with the help of the hemostat clamp. After the skin is appropriately cleaned, the 1Cgauge IV catheter is inserted into the pleura1 cavity on the affected side.
196
LETTERS TO THE EDITOR
Fig 1. The equipment necessary for the rapid construction of an underwater seal apparatus includes a Iarge-bore (Wgauge) IV catheter, a 250.mL glass bottle of IV fluid, plastic pressure tubing, an 18.gauge or larger needle, a straight sterile hemostat clamp, and a scissors.
This is usually done through the second intercostal space in the midclavicular line, taking care not to injure the intercostal bundle. The proximate end of the needle is then attached to the male adapter of the pressure tubing, which in turn is attached to the underwater seal bottle. The large-bore needle (> Wgauge) is inserted through the rubber on the top of the bottle or through the drip injection port of the plastic container. The 14-gauge catheter can now be secured into position on the chest with a silk suture. The glass bottle or plastic container is placed on the floor or taped into place on the operating table or drip stand. Lastly, al1 connections are secured with tape (Fig 2). This method is a modification of the technique described by Holmes and Mark, which was used in the treatment of pneumothorax in the newborn.’ They used a 250-mL glass bottle that had glass tubing attached to the rubber outlet, extending inside the bottle almost to the bottom. These bottles are no longer manufactured. Therefore, we present this modification of their technique, which can be used with materials now available.
197
LETTERS TO THE EDITOR
This technique is a simple, safe, and dependable means of producing underwater seal drainage for patients of any age with spontaneous pneumothorax. Al1 the equipment needed is readily available in the operating room. Therefore, a workable underwater seal apparatus can be functioning within minutes in the event of a life-threatening pneumothorax. John G. Broek-Utne, FFASA Jay B. Brodsky, MD Gordon Haddow, MB
Department
of Anesthesia
James B.D. Mark, MD
Department of Surgery Stanford University Medical Center Stanford, CA REFERENCE 1. Holmes
SL, Mark JBD: A simple apparatus
for underwater
Vancomycin
seal in pneumothorax
and the Red-Man
of the newborn.
J Pediatr
Surg 3:87-88, 1968
Syndrome
To the Editor:
In a recent case report, “Cardiovascular Collapse and Refractory Bronchospasm Following Administration of Vancomycin, Esmolol, and Heparin,” Bloom et al state in the Discussion that “Vancomycin is an aminoglycoside antibiotic; thus, it shares the potential toxicity that this group possesses as a whole.“’ In fact, vancomycin is not an aminoglycoside antibiotic, but is a glycopolypeptide that is unrelated to al1 other antibiotics.*.3 Moreover, the quoted side effects of “fever, nausea, pain on injection with or without phlebitis . . .” are relatively rare adverse effects of the aminoglycoside antibiotics.4 Nephrotoxicity, although a complication encountered with both classes of antibiotics, is now infrequent with the newer, more pure preparations of vancomycin.3.5 Finally, one wonders whether the rarity with which the “red-man syndrome” has been reported in the cardiac anesthesia literature is related to the not uncommon practice of giving both H,- and H,-blockers prior to the induction of anesthesia and the administration of vancomycin. As correctly noted by the authors, pretreatment with histamine antagonists may prevent the occurrence of this syndrome. Christopher O’Connor, MD
Department of Anesthesia Massachusetts Genera1 Hospita1 Boston. MA REFERENCES 1. Bloom B, Chalmers PC, Danker PR, et al: Cardiovascular collapse and refractory bronchospasm following administration of vancomycin, esmolol, and heparin. J Cardiothorac Anesth 3:748749,1989 2. Lietman PS: Aminoglycosides and spectinomycin: Aminocyclitols, in Mandell G, Douglas R, Bennett J (eds): Principles and Practice of Infectieus Diseases (ed 2). New York, NY, Wiley, 1985, pp 192-206 3. Fekety R: Vancomycin, in Mandell G, Douglas R, Bennett J
(eds): Principles and Practice of Infectieus York, NY, Wiley, 1985, pp 232-235
Diseases
(ed 2). New
4. Sande M, Mandell G: Antimicrobial agents: The aminoglycosides, in Goodman L, Gilman A, Rall T, Murad F (eds): The Pharmacological Basis of Therapeutics (ed 7). New York, NY, MacMillian, 1985, pp 1160-1170 5. Hermans PE, Wilhelm 62:901-905, 1987
MP: Vancomycin.
Mayo Clin Proc
