Anaesthesia, 1975, Volume 30, pages 233-243
Correspondence
The Editor would be grateful ifcorrespondents would double-space their copy and use the format in which letters are customarily printed in Anaesthesia.
An anaesthetic technique for intracranial aneurysms W. Hart, MBE, FFARCS & Sheila Willatts, MRCP, FFARCS Long term security of internal jugular catheters W. R. Tingey, MB, FRCS & S. Farquharson, FFARCS Airway care in post-anaesthetic patients H. A. Buck, FFARCS The size of tracheal tube connectors R. J. Stout, MB, FFARCS 0.P. Dinnick, MB, FFARCS Magnetic adaptor for the Portex tracheostomy tube J. S. Thomas, MB, FFARCS & W. H. Morton, FFARCS Death in outpatient dental practice P. R. Bromage, MB, FFARCS P. J. Tomlin, MB, FFARCS The airway of the edentulous patient R. G. McGown, FFARCS Auditory guide to the extradural space C. J. Massey Dawkins, MD, FFARCS Macewen antedated? I. McLellan, FFARCS Arms and the Anaesthetist C. A. Gauchi, KHS, MD, FMHS Anaesthesia for coarctation Alan Gilston, MB, FFARCS F. Y. Dalal, MB, FFARCS
233 234 23 6 23 7
238 239 24 1
24 1 242 242 242
An anaesthetic technique for intracranial aneurysms Neurosurgical anaesthetists may be interested in a method which produces excellent operating conditions for intracranial aneurysms. In 1964 Epstein, Epstein & Surks' described a technique of controlled spinal drainage to facilitate neurosurgical operative exposures. In 1965 Mr John Gibbs, Consultant Neurosurgeon, Brook Hospital, used a method of lumbar puncture drainage of cerebrospinal fluid, and, by December 1973, had completed a series of over 100 cases. Mr Michael Briggs, who succeeded Mr Gibbs as Consultant Neurosurgeon in January 1974, has continued to use this technique. In his series of twenty two cases he has been impressed with the operating conditions and has confirmed the freedom from complications. We have participated personally in 117 of these cases and wish to describe briefly the combined lumbar puncture and anaesthetic technique used in this unit. Patients are premedicated in the theatre with atropine only and an intra-venous infusion
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Correspondence
of compound ringer lactate solution (BPC)-Hartmann’s solution is instituted. Induction is with methohexitone or Althesin and muscle relaxation is achieved with suxamethonium. After inflation of the lungs with oxygen, a cuffed flexometallic endotracheal tube, well lubricated with analgesic ointment, is passed. Ventilation is controlled with a high minute and high tidal volume using nitrous oxide, oxygen and halothane 0.5 per cent with intermittent doses of tubocurarine. Bronchial and pharyngeal secretions are removed, by suction if necessary, and the patient is transferred to the operating room. A lumbar puncture is performed in the lateral position using a disposable lumbar puncture needle ( 5 inch (12.5 cm) Steriseal 18 g). The needle is bent parallel with the skin and fixed securely with adhesive tape. A K 52 Novex tube with terminal stopcock (Pharmaseal) is attached to the needle to lead the cerebrospinal fluid away into a container, and the stopcock is closed. The patient is then positioned with sand-bags under the back to protect the lumbarpuncture needle and the operating table is tilted 30 degrees head up. Hypotension may be produced, if it is indicated; our agent of choice is hexamethonium bromide (Vegolysin) which is given intra-venously in 5 mg doses and this is supplemented, if necessary, by an increased halothane concentration. An indwelling arterial cannula may be used for continuous blood pressure monitoring, and blood samples may be taken from the arterial line for estimation of blood gases. The stopcock is opened after the bone flap has been removed, and the cerebro-spinal fluid allowed to drain freely. Shortly afterwards the brain is seen to become soft and contracted. Blood pressure is restored to the desired level after dealing with the aneurysm. This is done by increasing the rate of intra-venous infusion, levelling the table or withdrawing halothane. Cerebro-spinal fluid drainage is stopped after dural closure and the lumbar puncture needle removed. Ventilation is then reduced and the halothane turned off 10-15 minutes before completion of the operation and, finally, muscle paralysis is reversed with atropine and neostigmine, and the patient is extubated with pharyngeal suction. The patient is transferred directly to his bed in the lateral position and kept in the recovery room for at least 30 minutes. Recovery is usually rapid. There have been no complications attributable to drainage of the greater part of the cerebro-spinal fluid volume and, rather surprisingly, postoperative headache has not proved to be a problem. In the presence of a large clot lumbar puncture drainage is neither necessary nor advisable. The brain can be rendered less tense by removing the clot before treating the aneurysm. We have not found it necessary to use either urea or mannitol since the adoption of this technique; indeed operating conditions with this method are as good, if not better, than any produced by dehydrating agents, without the attendant disadvantages. Neuro-Surgical Unit, Brook Hospital, London SE 18
WALTER HART WILLATTS SHEILA
Reference 1. EPSTEIN, J.A., EPSTEIN, B.S. & SURKS, S . (1964) A new needle for controlled spinal drainage. Anesthesiology, 25, 99.
Long Term Security of Internal Jugular Catheters Cannulation of the internal jugular vein is a justifiably popular technique. It is particularly favoured, for instance, during cardiac surgery where it is used for monitoring right atrial pressure and for giving vital drugs such as heparin. The approach to the vein has been meticulously described by English et al. Fixation of the catheter over the short term presents little problem. However, when cannulation is
Correspondence
The Editor would be grateful ifcorrespondents would double-space their copy and use the format in which letters are customarily printed in Anaesthesia.
An anaesthetic technique for intracranial aneurysms W. Hart, MBE, FFARCS & Sheila Willatts, MRCP, FFARCS Long term security of internal jugular catheters W. R. Tingey, MB, FRCS & S. Farquharson, FFARCS Airway care in post-anaesthetic patients H. A. Buck, FFARCS The size of tracheal tube connectors R. J. Stout, MB, FFARCS 0.P. Dinnick, MB, FFARCS Magnetic adaptor for the Portex tracheostomy tube J. S. Thomas, MB, FFARCS & W. H. Morton, FFARCS Death in outpatient dental practice P. R. Bromage, MB, FFARCS P. J. Tomlin, MB, FFARCS The airway of the edentulous patient R. G. McGown, FFARCS Auditory guide to the extradural space C. J. Massey Dawkins, MD, FFARCS Macewen antedated? I. McLellan, FFARCS Arms and the Anaesthetist C. A. Gauchi, KHS, MD, FMHS Anaesthesia for coarctation Alan Gilston, MB, FFARCS F. Y. Dalal, MB, FFARCS
233 234 23 6 23 7
238 239 24 1
24 1 242 242 242
An anaesthetic technique for intracranial aneurysms Neurosurgical anaesthetists may be interested in a method which produces excellent operating conditions for intracranial aneurysms. In 1964 Epstein, Epstein & Surks' described a technique of controlled spinal drainage to facilitate neurosurgical operative exposures. In 1965 Mr John Gibbs, Consultant Neurosurgeon, Brook Hospital, used a method of lumbar puncture drainage of cerebrospinal fluid, and, by December 1973, had completed a series of over 100 cases. Mr Michael Briggs, who succeeded Mr Gibbs as Consultant Neurosurgeon in January 1974, has continued to use this technique. In his series of twenty two cases he has been impressed with the operating conditions and has confirmed the freedom from complications. We have participated personally in 117 of these cases and wish to describe briefly the combined lumbar puncture and anaesthetic technique used in this unit. Patients are premedicated in the theatre with atropine only and an intra-venous infusion
233
234
Correspondence
of compound ringer lactate solution (BPC)-Hartmann’s solution is instituted. Induction is with methohexitone or Althesin and muscle relaxation is achieved with suxamethonium. After inflation of the lungs with oxygen, a cuffed flexometallic endotracheal tube, well lubricated with analgesic ointment, is passed. Ventilation is controlled with a high minute and high tidal volume using nitrous oxide, oxygen and halothane 0.5 per cent with intermittent doses of tubocurarine. Bronchial and pharyngeal secretions are removed, by suction if necessary, and the patient is transferred to the operating room. A lumbar puncture is performed in the lateral position using a disposable lumbar puncture needle ( 5 inch (12.5 cm) Steriseal 18 g). The needle is bent parallel with the skin and fixed securely with adhesive tape. A K 52 Novex tube with terminal stopcock (Pharmaseal) is attached to the needle to lead the cerebrospinal fluid away into a container, and the stopcock is closed. The patient is then positioned with sand-bags under the back to protect the lumbarpuncture needle and the operating table is tilted 30 degrees head up. Hypotension may be produced, if it is indicated; our agent of choice is hexamethonium bromide (Vegolysin) which is given intra-venously in 5 mg doses and this is supplemented, if necessary, by an increased halothane concentration. An indwelling arterial cannula may be used for continuous blood pressure monitoring, and blood samples may be taken from the arterial line for estimation of blood gases. The stopcock is opened after the bone flap has been removed, and the cerebro-spinal fluid allowed to drain freely. Shortly afterwards the brain is seen to become soft and contracted. Blood pressure is restored to the desired level after dealing with the aneurysm. This is done by increasing the rate of intra-venous infusion, levelling the table or withdrawing halothane. Cerebro-spinal fluid drainage is stopped after dural closure and the lumbar puncture needle removed. Ventilation is then reduced and the halothane turned off 10-15 minutes before completion of the operation and, finally, muscle paralysis is reversed with atropine and neostigmine, and the patient is extubated with pharyngeal suction. The patient is transferred directly to his bed in the lateral position and kept in the recovery room for at least 30 minutes. Recovery is usually rapid. There have been no complications attributable to drainage of the greater part of the cerebro-spinal fluid volume and, rather surprisingly, postoperative headache has not proved to be a problem. In the presence of a large clot lumbar puncture drainage is neither necessary nor advisable. The brain can be rendered less tense by removing the clot before treating the aneurysm. We have not found it necessary to use either urea or mannitol since the adoption of this technique; indeed operating conditions with this method are as good, if not better, than any produced by dehydrating agents, without the attendant disadvantages. Neuro-Surgical Unit, Brook Hospital, London SE 18
WALTER HART WILLATTS SHEILA
Reference 1. EPSTEIN, J.A., EPSTEIN, B.S. & SURKS, S . (1964) A new needle for controlled spinal drainage. Anesthesiology, 25, 99.
Long Term Security of Internal Jugular Catheters Cannulation of the internal jugular vein is a justifiably popular technique. It is particularly favoured, for instance, during cardiac surgery where it is used for monitoring right atrial pressure and for giving vital drugs such as heparin. The approach to the vein has been meticulously described by English et al. Fixation of the catheter over the short term presents little problem. However, when cannulation is
