Correspondence
Anaesthesia 2015, 70, 105–117
Figure 2 Bupivacaine packaging. The anaesthetist then read the levobupivacaine drug information leaflet provided in the multi-pack box, which mentions: “A sterile blister container should be chosen when a sterile ampoule surface is required. Ampoule surface is not sterile if sterile blister is pierced”. It is our opinion that the labelling of levobupivacaine ampoule blister packs is ambiguous, resulting in confusion about ampoule sterility. We therefore suggest the manufacturer consider modifying levobupivacaine ampoule/blister pack labels to state clearly that the ampoules are sterile. S. McCormick S. Kapur Russells Hall Hospital, Dudley, UK Email: [email protected]
when used in conjunction with videolaryngoscopy [1]. Although evidence shows improved intubating times with this combination, we wish to add balance to the discussion by highlighting a potential hazard. During an elective case, intubation was planned with a size-3 Airtraqâ (Prodol Meditec Ltd, Zhuhai, China) preloaded with a size-8.0 reinforced tracheal tube (Hudson RCIâ, Research Triangle Park, USA). Following induction and paralysis, the Airtraq was sited and a grade-2 view was obtained. Intubation was unsuccessful, so a 14-Ch bougie (P3 Medical Limited, Bristol, UK) was passed blindly through the tracheal tube, which was still loaded
on to the Airtraq. Mild resistance was felt before its appearance via the Airtraq’s eyepiece, and despite passing the bougie through the cords, we were unable to intubate as the tracheal tube would not railroad. We abandoned the procedure and instead intubated successfully with direct laryngoscopy. On closer inspection, we noticed that our bougie had traversed through the Murphy’s eye, which explains our difficulty in railroading (Fig. 3). Worryingly, despite this unusual path, the bougie appeared to be emerging normally from the tracheal tube lumen when viewed though the Airtraq’s eyepiece. The use of bougies through Airtraqs preloaded with tracheal tubes is a recognised practice and has been shown to be effective in a validating study of a difficult airway algorithm [2]. However, to avoid the problems we faced in railroading, we advocate that if a bougie is needed, it should always be preloaded within the tracheal tube before insertion into the Airtraq’s working channel.
No external funding and no competing interests declared. doi:10.1111/anae.12936
Preloading bougies during videolaryngoscopy We lent the the
read with interest the exceleditorial by Rai describing development and versatility of ‘humble bougie’, particularly
Figure 3 Bougie tip exiting Murphy’s eye of tracheal tube.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
111
Anaesthesia 2015, 70, 105–117
Correspondence
TAP block nomenclature
[2]. Unfortunately, the triangle was incorrectly illustrated in the lateral rather than posterior abdominal wall. The injection sites were also positioned laterally, particular for the subject in the CT image who received an injection centred anteriorly to the mid-axillary line. Jankovic et al. showed the anterior and middle parts of the triangle of Petit to be on average 5.8 cm and 9.3 cm posterior to the mid-axillary line, respectively [3]. As originally described, therefore, it is not possible to inject perpendicular to the triangle of Petit without rolling the patient onto his/her side. In many patients, the skin over the lumbar triangle of Petit is in contact with the mattress when positioned supine. I co-authored the first description of ultrasound-guided TAP block in 2007 [4], and was aware of McDonnell et al.’s detailed description of the triangle of Petit landmark technique at the time of
Børglum et al. propose a division of transversus abdominis plexus (TAP) block nomenclature into ‘upper’ and ‘lateral’ zones with ‘dual’ TAP blocks being injections into both zones [1]. The use of ‘posterior’ in this scheme is reserved for the injection through the triangle of Petit. Nomenclature involving the triangle of Petit in relation to abdominal wall blockade has been confused from the start. In their landmark 2007 paper, McDonnell et al. described a block via the triangle of Petit using illustrations, computed tomography (CT) and magnetic resonance images
Figure 4 Diagram of proposed TAP zones. USC, upper subcostal; LSC, lower subcostal; LAT, lateral; POST, posterior; II, ilio-inguinal.
M. John I. Ahmad Guys and St Thomas’ NHS Foundation Trust, London, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com.
References
1. Rai MR. The humble bougie. . .forty years and still counting? Anaesthesia 2014; 69: 199–203. 2. Amathieu R, Combes X, Abdi W, et al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrachTM): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology 2011; 114: 25–33. doi:10.1111/anae.12947
112
writing. When it became apparent that posterior block did not spread well above the umbilicus, I described a ‘subcostal’ approach to improve spread [5], the term being used in the surgical sense as in subcostal (Kocher’s) incision, rather than in reference to the subcostal nerve. ‘Subcostal oblique’ was used to define the passage of the needle along the costal margin, enabling a catheter to be placed, producing a more extensive block across the line of the nerves. Børglum and colleagues propose that we should drop the use of ‘subcostal’ to avoid confusion with the subcostal nerve, but I do not think this a strong argument as the term has been in use in the literature for six years and correlates with the surgical anatomy. ‘Intercostal’ has also been used to refer to the subcostal location, which makes less sense since intercostal block already exists, and almost all blocks into the TAP block the inter-
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2015, 70, 105–117
Figure 2 Bupivacaine packaging. The anaesthetist then read the levobupivacaine drug information leaflet provided in the multi-pack box, which mentions: “A sterile blister container should be chosen when a sterile ampoule surface is required. Ampoule surface is not sterile if sterile blister is pierced”. It is our opinion that the labelling of levobupivacaine ampoule blister packs is ambiguous, resulting in confusion about ampoule sterility. We therefore suggest the manufacturer consider modifying levobupivacaine ampoule/blister pack labels to state clearly that the ampoules are sterile. S. McCormick S. Kapur Russells Hall Hospital, Dudley, UK Email: [email protected]
when used in conjunction with videolaryngoscopy [1]. Although evidence shows improved intubating times with this combination, we wish to add balance to the discussion by highlighting a potential hazard. During an elective case, intubation was planned with a size-3 Airtraqâ (Prodol Meditec Ltd, Zhuhai, China) preloaded with a size-8.0 reinforced tracheal tube (Hudson RCIâ, Research Triangle Park, USA). Following induction and paralysis, the Airtraq was sited and a grade-2 view was obtained. Intubation was unsuccessful, so a 14-Ch bougie (P3 Medical Limited, Bristol, UK) was passed blindly through the tracheal tube, which was still loaded
on to the Airtraq. Mild resistance was felt before its appearance via the Airtraq’s eyepiece, and despite passing the bougie through the cords, we were unable to intubate as the tracheal tube would not railroad. We abandoned the procedure and instead intubated successfully with direct laryngoscopy. On closer inspection, we noticed that our bougie had traversed through the Murphy’s eye, which explains our difficulty in railroading (Fig. 3). Worryingly, despite this unusual path, the bougie appeared to be emerging normally from the tracheal tube lumen when viewed though the Airtraq’s eyepiece. The use of bougies through Airtraqs preloaded with tracheal tubes is a recognised practice and has been shown to be effective in a validating study of a difficult airway algorithm [2]. However, to avoid the problems we faced in railroading, we advocate that if a bougie is needed, it should always be preloaded within the tracheal tube before insertion into the Airtraq’s working channel.
No external funding and no competing interests declared. doi:10.1111/anae.12936
Preloading bougies during videolaryngoscopy We lent the the
read with interest the exceleditorial by Rai describing development and versatility of ‘humble bougie’, particularly
Figure 3 Bougie tip exiting Murphy’s eye of tracheal tube.
© 2014 The Association of Anaesthetists of Great Britain and Ireland
111
Anaesthesia 2015, 70, 105–117
Correspondence
TAP block nomenclature
[2]. Unfortunately, the triangle was incorrectly illustrated in the lateral rather than posterior abdominal wall. The injection sites were also positioned laterally, particular for the subject in the CT image who received an injection centred anteriorly to the mid-axillary line. Jankovic et al. showed the anterior and middle parts of the triangle of Petit to be on average 5.8 cm and 9.3 cm posterior to the mid-axillary line, respectively [3]. As originally described, therefore, it is not possible to inject perpendicular to the triangle of Petit without rolling the patient onto his/her side. In many patients, the skin over the lumbar triangle of Petit is in contact with the mattress when positioned supine. I co-authored the first description of ultrasound-guided TAP block in 2007 [4], and was aware of McDonnell et al.’s detailed description of the triangle of Petit landmark technique at the time of
Børglum et al. propose a division of transversus abdominis plexus (TAP) block nomenclature into ‘upper’ and ‘lateral’ zones with ‘dual’ TAP blocks being injections into both zones [1]. The use of ‘posterior’ in this scheme is reserved for the injection through the triangle of Petit. Nomenclature involving the triangle of Petit in relation to abdominal wall blockade has been confused from the start. In their landmark 2007 paper, McDonnell et al. described a block via the triangle of Petit using illustrations, computed tomography (CT) and magnetic resonance images
Figure 4 Diagram of proposed TAP zones. USC, upper subcostal; LSC, lower subcostal; LAT, lateral; POST, posterior; II, ilio-inguinal.
M. John I. Ahmad Guys and St Thomas’ NHS Foundation Trust, London, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesiacorrespondence.com.
References
1. Rai MR. The humble bougie. . .forty years and still counting? Anaesthesia 2014; 69: 199–203. 2. Amathieu R, Combes X, Abdi W, et al. An algorithm for difficult airway management, modified for modern optical devices (Airtraq laryngoscope; LMA CTrachTM): a 2-year prospective validation in patients for elective abdominal, gynecologic, and thyroid surgery. Anesthesiology 2011; 114: 25–33. doi:10.1111/anae.12947
112
writing. When it became apparent that posterior block did not spread well above the umbilicus, I described a ‘subcostal’ approach to improve spread [5], the term being used in the surgical sense as in subcostal (Kocher’s) incision, rather than in reference to the subcostal nerve. ‘Subcostal oblique’ was used to define the passage of the needle along the costal margin, enabling a catheter to be placed, producing a more extensive block across the line of the nerves. Børglum and colleagues propose that we should drop the use of ‘subcostal’ to avoid confusion with the subcostal nerve, but I do not think this a strong argument as the term has been in use in the literature for six years and correlates with the surgical anatomy. ‘Intercostal’ has also been used to refer to the subcostal location, which makes less sense since intercostal block already exists, and almost all blocks into the TAP block the inter-
© 2014 The Association of Anaesthetists of Great Britain and Ireland
