Letters to Editor
Figure 1: Ultra sound image of the QL block with LA. EO = external oblique, IO = internal oblique, QL = Quadratus lumborum
regions without requiring multiple catheters. This could be due to spread of LA from QL and Psoas muscles to the paravertebral space covering more segments possibly from T4 to L2. Many case series or trials need to be conducted before confirming its efficacy.
Figure 2: Lateral tilt position QL block with secured catheter
4.
Visoiu M, Yakovleva N. Continuous postoperative analgesia via quadratus lumborum block — An alternative to transversus abdominis plane block. Paediatr Anaesth 2013;23:959-61. Access this article online Quick Response Code:
Website: www.joacp.org
In conclusion, ultrasound guided QL catheter infusion had low pain scores with minimal use of opioid analgesia without any complication.
DOI: 10.4103/0970-9185.150575
Acknowledgment I appreciate Martin Tyson for assisting in images. Dr T. Venkatesan for going through the manuscript.
Vasanth Rao Kadam Senior Clinical Lecturer, The University of Adelaide, The Queen Elizabeth Hospital, Woodville SA, Australia Address for correspondence: Dr. Vasanth Rao Kadam, Department of Anaesthesia, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville SA 5011, Australia. E-mail: [email protected]
References 1.
2.
3.
Rao Kadam V, Van Wijk RM, Moran JI, Miller D. Epidural versus continuous transversus abdominis plane catheter technique for postoperative analgesia after abdominal surgery. Anaesth Intensive Care 2013;41:476-81. Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia 2011;66:465-71. Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol 2013;29:550-2.
An unusual cause of electrocardiogram interference in the operation theater Sir, We report an electrocardiogram (ECG) malfunction in the operation theater (OT) during pediatric surgery. After induction of anesthesia, ECG leads of monitor (DatexOhmeda Division type f-CUB.09, S.N. -5161632) were connected to the patient. ECG tracing showed straight line on the monitor. We changed ECG electrodes and leads multiple times; however, there was no ECG trace on the monitor. Then another cardiac monitor was connected to a different electric board, and ECG leads were connected to the patient with different ECG electrodes. The new monitor also showed a flat line. Earthing wire connection of the monitor was also checked, which was adequately placed. A resident suddenly felt conducting current when he touched child and OT
Journal of Anaesthesiology Clinical Pharmacology | January-March 2015 | Vol 31 | Issue 1
131
Letters to Editor
Figure 1: Continuous disturbance in electrocardiogram (ECG) with warming mattress connected to the electrical circuit and normal ECG tracing after electrical cable of warming mattress removed
table. Immediately electrical connection of OT table was removed, which resulted in appearance of normal ECG tracing on both monitors. In another case, pediatric warming gel mattress was put on the OT table and connected to the electrical circuit. When ECG leads were connected to the child, it showed continuous disturbance [Figure 1]. Even with the change of ECG leads and monitor, the disturbances could not be corrected. Earth wire of the monitor was also checked and found to be well connected. Removal of electrical cable of the OT table did not help. Then electrical cable of warming mattress was removed, which resulted in normal ECG tracing.
Figure 2: Electrical plug (CEE 7/7) with only two pin and a hole at the place of earthing pin and electrical socket with earthing pin
different types of electrical power plugs and socket have been used, which may not be interchangeable. In our case, the electrical plug was compatible with socket having the earthing pin [Figure 2]. However, in India, electrical socket do not have earthing pin to accommodate the hole present in the CEE 7/7 plug. Secondly, the same electrical lead containing the CEE 7/7 plug can be connected to OT table, cardiac monitor and warming mattress machine. Therefore, it is essential that companies should provide those electrical lead with plugs, which are compatible to the existing system in the country to prevent unnecessary distress and disastrous consequences. OT personnel and staff should also be trained so that they will not connect plugs, which are not compatible to the existing pin system. Ankur Sharma, Renu Sinha
It was noticed that the connecting electrical cable of OT table (first case) and of warming mattress (in the second case) had a plug with only two pins, and there was a hole at the place of earthing pin [Figure 2]. Electrocardiogram tracing artifact can simulate serious arrhythmia, thus leading to unnecessary action in the OT and intensive care unit. The passage of current through a patient can also be potentially fatal. The patient under anesthesia or sedation will not report any symptoms of current passing through his body. Hence, any unexplained ECG abnormality under these circumstances should be immediately looked into to avoid disastrous consequences. Wills et al.[1] described a macroshock electrical injury to a nurse during plugging equipment to an extension cord. Selvan et al.[2] have reported intra-aortic balloon pump failure due to ECG artifact, which occurred on placement of the transthoracic echocardiography probe over the chest due to leakage of current from echocardiography machine secondary to earthing defect. Courtney et al.[3] have reported hazard resulting from compression of an electrical cable by OT table due to a live wire contact. In our case, the cause of electrical interference in ECG tracing was due to an electrical cable with different plug, which is not being used in India. In different countries, 132
Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Ankur Sharma, C/O Mr. Suneel Vyas, C 2/2287, Vasant Kunj, New Delhi, India. E-mail: [email protected]
References 1.
2.
3.
Wills JH, Ehrenwerth J, Rogers D. Electrical injury to a nurse due to conductive fluid in an operating room designated as a dry location. Anesth Analg 2010;110:1647-9. Selvan RB, Rao PB, Ramachandran TR, Veliath DG. Earthing defect: A cause for unstable hemodynamics. Ann Card Anaesth 2012;15:47-9. Courtney NM, McCoy EP, Scolaro RJ, Watt PA. A serious and repeatable electrical hazard – compressed electrical cord and an operating table. Anaesth Intensive Care 2006;34:392-6.
Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.150576
Journal of Anaesthesiology Clinical Pharmacology | January-March 2015 | Vol 31 | Issue 1
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Figure 1: Ultra sound image of the QL block with LA. EO = external oblique, IO = internal oblique, QL = Quadratus lumborum
regions without requiring multiple catheters. This could be due to spread of LA from QL and Psoas muscles to the paravertebral space covering more segments possibly from T4 to L2. Many case series or trials need to be conducted before confirming its efficacy.
Figure 2: Lateral tilt position QL block with secured catheter
4.
Visoiu M, Yakovleva N. Continuous postoperative analgesia via quadratus lumborum block — An alternative to transversus abdominis plane block. Paediatr Anaesth 2013;23:959-61. Access this article online Quick Response Code:
Website: www.joacp.org
In conclusion, ultrasound guided QL catheter infusion had low pain scores with minimal use of opioid analgesia without any complication.
DOI: 10.4103/0970-9185.150575
Acknowledgment I appreciate Martin Tyson for assisting in images. Dr T. Venkatesan for going through the manuscript.
Vasanth Rao Kadam Senior Clinical Lecturer, The University of Adelaide, The Queen Elizabeth Hospital, Woodville SA, Australia Address for correspondence: Dr. Vasanth Rao Kadam, Department of Anaesthesia, The Queen Elizabeth Hospital, 28 Woodville Road, Woodville SA 5011, Australia. E-mail: [email protected]
References 1.
2.
3.
Rao Kadam V, Van Wijk RM, Moran JI, Miller D. Epidural versus continuous transversus abdominis plane catheter technique for postoperative analgesia after abdominal surgery. Anaesth Intensive Care 2013;41:476-81. Niraj G, Kelkar A, Jeyapalan I, Graff-Baker P, Williams O, Darbar A, et al. Comparison of analgesic efficacy of subcostal transversus abdominis plane blocks with epidural analgesia following upper abdominal surgery. Anaesthesia 2011;66:465-71. Kadam VR. Ultrasound-guided quadratus lumborum block as a postoperative analgesic technique for laparotomy. J Anaesthesiol Clin Pharmacol 2013;29:550-2.
An unusual cause of electrocardiogram interference in the operation theater Sir, We report an electrocardiogram (ECG) malfunction in the operation theater (OT) during pediatric surgery. After induction of anesthesia, ECG leads of monitor (DatexOhmeda Division type f-CUB.09, S.N. -5161632) were connected to the patient. ECG tracing showed straight line on the monitor. We changed ECG electrodes and leads multiple times; however, there was no ECG trace on the monitor. Then another cardiac monitor was connected to a different electric board, and ECG leads were connected to the patient with different ECG electrodes. The new monitor also showed a flat line. Earthing wire connection of the monitor was also checked, which was adequately placed. A resident suddenly felt conducting current when he touched child and OT
Journal of Anaesthesiology Clinical Pharmacology | January-March 2015 | Vol 31 | Issue 1
131
Letters to Editor
Figure 1: Continuous disturbance in electrocardiogram (ECG) with warming mattress connected to the electrical circuit and normal ECG tracing after electrical cable of warming mattress removed
table. Immediately electrical connection of OT table was removed, which resulted in appearance of normal ECG tracing on both monitors. In another case, pediatric warming gel mattress was put on the OT table and connected to the electrical circuit. When ECG leads were connected to the child, it showed continuous disturbance [Figure 1]. Even with the change of ECG leads and monitor, the disturbances could not be corrected. Earth wire of the monitor was also checked and found to be well connected. Removal of electrical cable of the OT table did not help. Then electrical cable of warming mattress was removed, which resulted in normal ECG tracing.
Figure 2: Electrical plug (CEE 7/7) with only two pin and a hole at the place of earthing pin and electrical socket with earthing pin
different types of electrical power plugs and socket have been used, which may not be interchangeable. In our case, the electrical plug was compatible with socket having the earthing pin [Figure 2]. However, in India, electrical socket do not have earthing pin to accommodate the hole present in the CEE 7/7 plug. Secondly, the same electrical lead containing the CEE 7/7 plug can be connected to OT table, cardiac monitor and warming mattress machine. Therefore, it is essential that companies should provide those electrical lead with plugs, which are compatible to the existing system in the country to prevent unnecessary distress and disastrous consequences. OT personnel and staff should also be trained so that they will not connect plugs, which are not compatible to the existing pin system. Ankur Sharma, Renu Sinha
It was noticed that the connecting electrical cable of OT table (first case) and of warming mattress (in the second case) had a plug with only two pins, and there was a hole at the place of earthing pin [Figure 2]. Electrocardiogram tracing artifact can simulate serious arrhythmia, thus leading to unnecessary action in the OT and intensive care unit. The passage of current through a patient can also be potentially fatal. The patient under anesthesia or sedation will not report any symptoms of current passing through his body. Hence, any unexplained ECG abnormality under these circumstances should be immediately looked into to avoid disastrous consequences. Wills et al.[1] described a macroshock electrical injury to a nurse during plugging equipment to an extension cord. Selvan et al.[2] have reported intra-aortic balloon pump failure due to ECG artifact, which occurred on placement of the transthoracic echocardiography probe over the chest due to leakage of current from echocardiography machine secondary to earthing defect. Courtney et al.[3] have reported hazard resulting from compression of an electrical cable by OT table due to a live wire contact. In our case, the cause of electrical interference in ECG tracing was due to an electrical cable with different plug, which is not being used in India. In different countries, 132
Department of Anesthesiology, All India Institute of Medical Sciences, New Delhi, India Address for correspondence: Dr. Ankur Sharma, C/O Mr. Suneel Vyas, C 2/2287, Vasant Kunj, New Delhi, India. E-mail: [email protected]
References 1.
2.
3.
Wills JH, Ehrenwerth J, Rogers D. Electrical injury to a nurse due to conductive fluid in an operating room designated as a dry location. Anesth Analg 2010;110:1647-9. Selvan RB, Rao PB, Ramachandran TR, Veliath DG. Earthing defect: A cause for unstable hemodynamics. Ann Card Anaesth 2012;15:47-9. Courtney NM, McCoy EP, Scolaro RJ, Watt PA. A serious and repeatable electrical hazard – compressed electrical cord and an operating table. Anaesth Intensive Care 2006;34:392-6.
Access this article online Quick Response Code:
Website: www.joacp.org
DOI: 10.4103/0970-9185.150576
Journal of Anaesthesiology Clinical Pharmacology | January-March 2015 | Vol 31 | Issue 1
Copyright of Journal of Anaesthesiology Clinical Pharmacology is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
