Letters to the Editor
Difficult Endotracheal Intubation To the Editor: I read with great interest the letter to the editor by Benson (1). The use of a gum-elastic bougie for difficult intubation seems to have been practiced in the United Kingdom since its introduction in 1949 (2) and as a first choice when the cords cannot easily be seen at laryngoscopy at Cardiff (3), but this is not so in the United States. We have developed an alternative device for difficult intubation when only the epiglottis is visible at laryngoscopy: a J-, hockey-stick-, or golf-club-shaped endotracheal tube (ETT) which is shaped by immersion in iced water (4). In practice, when the tip of the epiglottis comes into view on laryngoscopy, the epiglottis is lifted with the tip of the ETT which is then guided beneath the inferior surface until the glottis is passed. During this maneuver, an assistant maintains gentle backward pressure on the cricoid cartilage to prevent esophageal intubation. The assistant also presses on the area of the neck that provides the best view of the epiglottis. As the tip of the ETT gradually softens at room and body temperatures, the tube is advanced while the angle becomes less acute and more easily enters the trachea. Simultaneously, the assistant confirms passage through the glottis by tactile sensation. Insufflation of oxygen can be carried out as intubation proceeds. In an awake patient, elicitation of persistent cough indicates successful intubation. In an anesthetized patient, when the tip of the ETT is located at the glottis, ventilation can be accomplished by an assistant as intubation progresses. A stylet cannot be used with this method as it might not easily be removed owing to the angle of the ETT tip. Armored ETTs made of silicon rubber cannot be used for this technique, but a Mallinckrodt reinforced polyvinylchloride ETT (Glens Falls, N.Y.) can be used. For more than 25 yr, we have not been obliged to use fiberoptic bronchoscopy, a light wand, a stylet, or a gum-elastic bougie for endotracheal intubation when the epiglottis is visible at laryngosCOPY. Yukio Kubota, MD Yoshiro Toyoda, MD Hiroshi Kubota, MD Department of Anesthesia Osaka Kohseinekin Hospital 4-2-78, Fukushima, Fukushima-Ku Osaka, 553
Japan
Akira Asada,
MD, PhD
Department of Anesthesiology and lntensive Care Medicine Osaka City University, Medical School 1-5-7, Asahi-Machi, Abeno-Ku Osaka, 545 lapan
01992 by the International Anesthesia Research Society
References 1. Benson PF. The gum-elastic bougie: a life saver. Anesth Analg 1992;74: 318. 2. Macintosh RR. Anaid to oral intubation. Br Med J 1949;1:28. 3. Latto IP. Management of difficult intubation. In: Latto IP, Rosen M, eds. Difficulties in tracheal intubation. London: Bailliere Tindall, 1985;lll-2. 4. Kubota Y, Toyoda Y, Kubota H, Ueda Y. Shaping tracheal tubes. Anaesthesia 1987;42896.
Should the Anesthesiologist Estimate the Patient’s Weight? To the Editor: Anesthesiologists are frequently called upon to anesthetize a patient without an accurate measurement of the patient’s weight. Because the appropriate dose for many drugs administered during anesthesia is weight dependent, we frequently either ask the patient to estimate his or her own weight, or we estimate it ourselves. No information is available to tell us which estimate is most accurate, or indeed if either estimate is accurate. After obtaining institutional approval and patient consent, we studied the weights of patients presenting to our ambulatory surgery clinic. Four resident anesthesiologists and 174 patients participated in the study. The anesthesiologist first estimated the patient’s weight, then asked the patient for an estimation of weight, and then finally measured the patient’s weight. We found that the residents’ estimation deviated from the patient’s actual weight by an average of 8% 10% (standard deviation), and that the patients’ estimation deviated from their own weight by an average of 4% 4% (standard deviation). While it is probable that neither average deviation is clinically significant, the spread of the estimates may be clinically significant. The patient’s estimation of weight (range 16.7% under to 11.5%over) was more likely to be close to the actual weight than the anesthesiologist’s estimation (range 52.6% under to 18.6% over). We have concluded that, for any given patient, the anesthesiologist’s estimation and the patient’s estimation of patient weight may be significantly incorrect. However, the patient estimation is likely to be closer to the actual weight.
*
*
Richard J. Sperry, MD Christopher P. Harkin,
MD
Department of Anesthesiology University of Utah 50 North Medical Drive Salt Lake City, UT 84132
Anesth Analg 1992;75:46-71
461
Difficult Endotracheal Intubation To the Editor: I read with great interest the letter to the editor by Benson (1). The use of a gum-elastic bougie for difficult intubation seems to have been practiced in the United Kingdom since its introduction in 1949 (2) and as a first choice when the cords cannot easily be seen at laryngoscopy at Cardiff (3), but this is not so in the United States. We have developed an alternative device for difficult intubation when only the epiglottis is visible at laryngoscopy: a J-, hockey-stick-, or golf-club-shaped endotracheal tube (ETT) which is shaped by immersion in iced water (4). In practice, when the tip of the epiglottis comes into view on laryngoscopy, the epiglottis is lifted with the tip of the ETT which is then guided beneath the inferior surface until the glottis is passed. During this maneuver, an assistant maintains gentle backward pressure on the cricoid cartilage to prevent esophageal intubation. The assistant also presses on the area of the neck that provides the best view of the epiglottis. As the tip of the ETT gradually softens at room and body temperatures, the tube is advanced while the angle becomes less acute and more easily enters the trachea. Simultaneously, the assistant confirms passage through the glottis by tactile sensation. Insufflation of oxygen can be carried out as intubation proceeds. In an awake patient, elicitation of persistent cough indicates successful intubation. In an anesthetized patient, when the tip of the ETT is located at the glottis, ventilation can be accomplished by an assistant as intubation progresses. A stylet cannot be used with this method as it might not easily be removed owing to the angle of the ETT tip. Armored ETTs made of silicon rubber cannot be used for this technique, but a Mallinckrodt reinforced polyvinylchloride ETT (Glens Falls, N.Y.) can be used. For more than 25 yr, we have not been obliged to use fiberoptic bronchoscopy, a light wand, a stylet, or a gum-elastic bougie for endotracheal intubation when the epiglottis is visible at laryngosCOPY. Yukio Kubota, MD Yoshiro Toyoda, MD Hiroshi Kubota, MD Department of Anesthesia Osaka Kohseinekin Hospital 4-2-78, Fukushima, Fukushima-Ku Osaka, 553
Japan
Akira Asada,
MD, PhD
Department of Anesthesiology and lntensive Care Medicine Osaka City University, Medical School 1-5-7, Asahi-Machi, Abeno-Ku Osaka, 545 lapan
01992 by the International Anesthesia Research Society
References 1. Benson PF. The gum-elastic bougie: a life saver. Anesth Analg 1992;74: 318. 2. Macintosh RR. Anaid to oral intubation. Br Med J 1949;1:28. 3. Latto IP. Management of difficult intubation. In: Latto IP, Rosen M, eds. Difficulties in tracheal intubation. London: Bailliere Tindall, 1985;lll-2. 4. Kubota Y, Toyoda Y, Kubota H, Ueda Y. Shaping tracheal tubes. Anaesthesia 1987;42896.
Should the Anesthesiologist Estimate the Patient’s Weight? To the Editor: Anesthesiologists are frequently called upon to anesthetize a patient without an accurate measurement of the patient’s weight. Because the appropriate dose for many drugs administered during anesthesia is weight dependent, we frequently either ask the patient to estimate his or her own weight, or we estimate it ourselves. No information is available to tell us which estimate is most accurate, or indeed if either estimate is accurate. After obtaining institutional approval and patient consent, we studied the weights of patients presenting to our ambulatory surgery clinic. Four resident anesthesiologists and 174 patients participated in the study. The anesthesiologist first estimated the patient’s weight, then asked the patient for an estimation of weight, and then finally measured the patient’s weight. We found that the residents’ estimation deviated from the patient’s actual weight by an average of 8% 10% (standard deviation), and that the patients’ estimation deviated from their own weight by an average of 4% 4% (standard deviation). While it is probable that neither average deviation is clinically significant, the spread of the estimates may be clinically significant. The patient’s estimation of weight (range 16.7% under to 11.5%over) was more likely to be close to the actual weight than the anesthesiologist’s estimation (range 52.6% under to 18.6% over). We have concluded that, for any given patient, the anesthesiologist’s estimation and the patient’s estimation of patient weight may be significantly incorrect. However, the patient estimation is likely to be closer to the actual weight.
*
*
Richard J. Sperry, MD Christopher P. Harkin,
MD
Department of Anesthesiology University of Utah 50 North Medical Drive Salt Lake City, UT 84132
Anesth Analg 1992;75:46-71
461
