Anaesthesia 2014, 69, 928–938
Correspondence
posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
Reference 1. Stroud MA, Nolan J, Soni N. A defence of the NICE guidelines on intravenous fluids. Anaesthesia 2014; 69: 416–9. doi:10.1111/anae.12795
Infant Airtraq for adult bougie placement Rai’s recent editorial in Anaesthesia [1] acknowledges the utility of bougies for videolaryngoscopic intubations. We would like to describe a further method of introducing the bougie. During a recent training day on airway management, we noticed that the smallest available Airtraqâ (Infant Airtraq, Prodol Meditec S.A., Vizcaya, Spain) permitted good glottic views on the adult mannequin (AirSim Advance, Trucorp, Dublin, Ireland). Though too small to place a tube larger than 3.5 mm ID, it is possible to introduce an adult bougie (14 Fr Frova Intubating Introducer, Cook Medical, Bloomington, USA) into the glottic opening, remove the Infant Airtraq, and then railroad a normal adult sized tube into position. The narrow guiding channel aides anterior steering of the bougie toward the glottis when compared with the larger models (Fig. 2). It struck us that this technique could be very useful in adult patients with poor mouth opening and difficult direct laryngoscopy, as an alternative to fibreoptic intubation. As measured with a transluscent millimetre-marked ruler (Helix, Kingswinford, UK), the antero-posterior thickness of the 936
Figure 2 From left to right: Infant Airtraq with gum elastic bougie; Adult Airtraq with gum-elastic bougie; Pentax AWS blade; King Vision #3 channelled blade; C-MAC D blade. Infant Airtraq blade is 11 mm. This compares favourably with adult videolaryngoscopes: Adult Airtraq blade 17 mm; Pentax-AWS blade (Pentax, Hamburg, Germany) 18 mm; King Vision #3 channeled blade (King Systems, Noblesville, USA) 18 mm; CMAC D blade (Karl Storz, Tuttlingen, Germany) 17 mm (Fig. 2). Single-use plastic bougies are easier to pass through the channel of the Infant Airtraq than are gum-elastic bougies. The main drawback we foresee may be difficulty in advancing the ’scope due to the tighter curvature of the blade compared with adult videolaryngoscopes. S. T. J. Smith D. G. Maloney Ysbyty Gwynedd, Bangor, UK E-mail: [email protected] No external funding and no competing interests declared. Previously
posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com.
Reference
1. Rai MR. The humble bougie. . .forty years and still counting? Anaesthesia 2014; 69: 199–203. doi:10.1111/anae.12784
Common sense medicine and cerebrospinal lavage I read with great interest the case report by Dias et al. [1], describing the successful treatment of accidental spinal potassium chloride administration using a cerebrospinal fluid (CSF) lavage technique. I wish to commend the authors’ decisive action to dilute and remove the excess potassium chloride in exchange for saline, thereby avoiding major irreversible complications. As the authors discuss, accidental intra-
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
thecal administration of potassium chloride can have serious temporary or permanent sequelae, including death. The concept of CSF lavage to manage intrathecal injection of excess or wrong drugs is not a novel one; over the last 30 years, multiple authors, including myself, have reported the use of CSF lavage in both obstetric and non-obstetric patients [2–4]. In a recent obstetric case, we successfully used the same technique as Dias et al. to reverse accidental high spinal anaesthesia and prevent a total spinal [4]. Nevertheless, CSF lavage is rarely mentioned as a potential method of managing complications associated with accidental intrathecal injection, particularly in obstetric cases. The recent focus on evidencebased medicine has thrown support behind the randomised controlled trial (RCT) as the gold standard in evaluating new treatments. Given the lack of RCT evaluation, it is therefore understandable that CSF lavage is not considered as a standard treatment for accidental intrathecal injection or high/total spinal anaesthesia. Obviously, a proper RCT would address the effectiveness and safety of CSF lavage; however, since the method is usually only performed in emergency situations, such a trial would be difficult to perform and unlikely to be published in the near future. While one must exercise caution before accepting the benefits of a new treatment and applying it clinically based only on case reports [5], perhaps we should reconsider the risks and benefits of CSF lavage from a common sense perspective. Indeed, as
Anaesthesia 2014, 69, 928–938
in the ‘parachute’ argument [6], some believe that the benefits of certain treatments or interventions are obvious despite a lack of RCT evidence. The current literature has yet to report any major drawbacks when CSF lavage is used in a clinically indicated emergency situation. Indeed, the technique has shown efficacy in addressing a number of potentially dangerous clinical scenarios and preventing serious or permanent damage, and the presence of an intrathecal catheter provides a convenient means to remove and replace contaminated CSF. Thus, I urge clinicians to consider utilising this lavage technique, in addition to providing cardiopulmonary support as needed, at least on a case-by-case basis, rather than ignoring and overlooking its potential life-saving benefits simply because the procedure has yet to be supported by RCT evidence. B. C. Tsui University of Alberta, Edmonton, Canada E-mail: [email protected] Dr. Tsui is supported by a Clinical Scholar Award from the Alberta Heritage Foundation for Medical Research (AHFMR). No competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespon dence.com.
References 1. Dias J, Lages N, Marinho A, et al. Accidental spinal potassium chloride injection successfully treated with spinal lavage. Anaesthesia 2014; 69: 72–6. 2. Kaiser KG, Bainton CR. Treatment of intrathecal morphine overdose by aspi-
© 2014 The Association of Anaesthetists of Great Britain and Ireland
3.
4.
5.
6.
ration of cerebrospinal fluid. Anesthesia and Analgesia 1987; 66: 475–7. Southorn P, Vasdev GM, Chantigian RC, Lawson GM. Reducing the potential morbidity of an unintentional spinal anaesthetic by aspirating cerebrospinal fluid. British Journal of Anaesthesia 1996; 76: 467–9. Tsui BC, Malherbe S, Koller J, Aronyk K. Reversal of an unintentional spinal anesthetic by cerebrospinal lavage. Anesthesia and Analgesia 2004; 98: 434–6. Chambers WA, Smith WC. Case reports of novel treatments - proper evaluation before clinical use. Anaesthesia 2011; 66: 539–40. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. British Medical Journal 2003; 327: 1459–61. doi:10.1111/anae.12796
Opening Portex EpifuseTM connectors I read with interest your correspondence relating to problems encountered with the Portex EpifuseTM epidural catheter connector [1–6]. I would like to share with readers a potential solution to the difficulties encountered with opening the device. The manufacturer supplies a blue, T-shaped guide to aid threading the catheter into the needle. This also doubles as a ‘key’ that will fit into the port on the front of the device that facilitates its opening (Fig. 3). Since switching away from using syringes to open the device [7] I have never had a problem opening the Epifuse device, and it has the added benefit of incurring no additional cost. B. D. Rippin Leeds General Infirmary, Leeds, UK E-mail: [email protected] 937
Correspondence
posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
Reference 1. Stroud MA, Nolan J, Soni N. A defence of the NICE guidelines on intravenous fluids. Anaesthesia 2014; 69: 416–9. doi:10.1111/anae.12795
Infant Airtraq for adult bougie placement Rai’s recent editorial in Anaesthesia [1] acknowledges the utility of bougies for videolaryngoscopic intubations. We would like to describe a further method of introducing the bougie. During a recent training day on airway management, we noticed that the smallest available Airtraqâ (Infant Airtraq, Prodol Meditec S.A., Vizcaya, Spain) permitted good glottic views on the adult mannequin (AirSim Advance, Trucorp, Dublin, Ireland). Though too small to place a tube larger than 3.5 mm ID, it is possible to introduce an adult bougie (14 Fr Frova Intubating Introducer, Cook Medical, Bloomington, USA) into the glottic opening, remove the Infant Airtraq, and then railroad a normal adult sized tube into position. The narrow guiding channel aides anterior steering of the bougie toward the glottis when compared with the larger models (Fig. 2). It struck us that this technique could be very useful in adult patients with poor mouth opening and difficult direct laryngoscopy, as an alternative to fibreoptic intubation. As measured with a transluscent millimetre-marked ruler (Helix, Kingswinford, UK), the antero-posterior thickness of the 936
Figure 2 From left to right: Infant Airtraq with gum elastic bougie; Adult Airtraq with gum-elastic bougie; Pentax AWS blade; King Vision #3 channelled blade; C-MAC D blade. Infant Airtraq blade is 11 mm. This compares favourably with adult videolaryngoscopes: Adult Airtraq blade 17 mm; Pentax-AWS blade (Pentax, Hamburg, Germany) 18 mm; King Vision #3 channeled blade (King Systems, Noblesville, USA) 18 mm; CMAC D blade (Karl Storz, Tuttlingen, Germany) 17 mm (Fig. 2). Single-use plastic bougies are easier to pass through the channel of the Infant Airtraq than are gum-elastic bougies. The main drawback we foresee may be difficulty in advancing the ’scope due to the tighter curvature of the blade compared with adult videolaryngoscopes. S. T. J. Smith D. G. Maloney Ysbyty Gwynedd, Bangor, UK E-mail: [email protected] No external funding and no competing interests declared. Previously
posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com.
Reference
1. Rai MR. The humble bougie. . .forty years and still counting? Anaesthesia 2014; 69: 199–203. doi:10.1111/anae.12784
Common sense medicine and cerebrospinal lavage I read with great interest the case report by Dias et al. [1], describing the successful treatment of accidental spinal potassium chloride administration using a cerebrospinal fluid (CSF) lavage technique. I wish to commend the authors’ decisive action to dilute and remove the excess potassium chloride in exchange for saline, thereby avoiding major irreversible complications. As the authors discuss, accidental intra-
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
thecal administration of potassium chloride can have serious temporary or permanent sequelae, including death. The concept of CSF lavage to manage intrathecal injection of excess or wrong drugs is not a novel one; over the last 30 years, multiple authors, including myself, have reported the use of CSF lavage in both obstetric and non-obstetric patients [2–4]. In a recent obstetric case, we successfully used the same technique as Dias et al. to reverse accidental high spinal anaesthesia and prevent a total spinal [4]. Nevertheless, CSF lavage is rarely mentioned as a potential method of managing complications associated with accidental intrathecal injection, particularly in obstetric cases. The recent focus on evidencebased medicine has thrown support behind the randomised controlled trial (RCT) as the gold standard in evaluating new treatments. Given the lack of RCT evaluation, it is therefore understandable that CSF lavage is not considered as a standard treatment for accidental intrathecal injection or high/total spinal anaesthesia. Obviously, a proper RCT would address the effectiveness and safety of CSF lavage; however, since the method is usually only performed in emergency situations, such a trial would be difficult to perform and unlikely to be published in the near future. While one must exercise caution before accepting the benefits of a new treatment and applying it clinically based only on case reports [5], perhaps we should reconsider the risks and benefits of CSF lavage from a common sense perspective. Indeed, as
Anaesthesia 2014, 69, 928–938
in the ‘parachute’ argument [6], some believe that the benefits of certain treatments or interventions are obvious despite a lack of RCT evidence. The current literature has yet to report any major drawbacks when CSF lavage is used in a clinically indicated emergency situation. Indeed, the technique has shown efficacy in addressing a number of potentially dangerous clinical scenarios and preventing serious or permanent damage, and the presence of an intrathecal catheter provides a convenient means to remove and replace contaminated CSF. Thus, I urge clinicians to consider utilising this lavage technique, in addition to providing cardiopulmonary support as needed, at least on a case-by-case basis, rather than ignoring and overlooking its potential life-saving benefits simply because the procedure has yet to be supported by RCT evidence. B. C. Tsui University of Alberta, Edmonton, Canada E-mail: [email protected] Dr. Tsui is supported by a Clinical Scholar Award from the Alberta Heritage Foundation for Medical Research (AHFMR). No competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespon dence.com.
References 1. Dias J, Lages N, Marinho A, et al. Accidental spinal potassium chloride injection successfully treated with spinal lavage. Anaesthesia 2014; 69: 72–6. 2. Kaiser KG, Bainton CR. Treatment of intrathecal morphine overdose by aspi-
© 2014 The Association of Anaesthetists of Great Britain and Ireland
3.
4.
5.
6.
ration of cerebrospinal fluid. Anesthesia and Analgesia 1987; 66: 475–7. Southorn P, Vasdev GM, Chantigian RC, Lawson GM. Reducing the potential morbidity of an unintentional spinal anaesthetic by aspirating cerebrospinal fluid. British Journal of Anaesthesia 1996; 76: 467–9. Tsui BC, Malherbe S, Koller J, Aronyk K. Reversal of an unintentional spinal anesthetic by cerebrospinal lavage. Anesthesia and Analgesia 2004; 98: 434–6. Chambers WA, Smith WC. Case reports of novel treatments - proper evaluation before clinical use. Anaesthesia 2011; 66: 539–40. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. British Medical Journal 2003; 327: 1459–61. doi:10.1111/anae.12796
Opening Portex EpifuseTM connectors I read with interest your correspondence relating to problems encountered with the Portex EpifuseTM epidural catheter connector [1–6]. I would like to share with readers a potential solution to the difficulties encountered with opening the device. The manufacturer supplies a blue, T-shaped guide to aid threading the catheter into the needle. This also doubles as a ‘key’ that will fit into the port on the front of the device that facilitates its opening (Fig. 3). Since switching away from using syringes to open the device [7] I have never had a problem opening the Epifuse device, and it has the added benefit of incurring no additional cost. B. D. Rippin Leeds General Infirmary, Leeds, UK E-mail: [email protected] 937
