Letters to Editor
used mannitol infusions to treat PDPH successfully for years with much success. If post‑operative patient complains of headache that is characteristic of PDPH, 20% mannitol (100 ml) is given over ½ h intravenously and followed by 100 ml on a 12 hourly basis. The first dose of mannitol usually settles the PDPH over 6–8 h and no analgesics are required thereafter. Intravenous fluids are given to the patient as per normal body requirement, and input/output chart is maintained. Frequent assessment is done and after 48 h it is unusual to need mannitol infusions. I had adopted this practice while I was employed there and continue to do so. I also extend this to patients who have had a dural puncture on attempting epidural technique with a Tuohy needle, to preempt the PDPH that develops in them. In another case, mannitol infusion was successfully used by the author to treat a patient who developed unilateral facial nerve palsy after caesarean section under spinal anaesthesia, 4 days after discharge. At the time of readmission, unilateral facial palsy was well established, and patient was greatly stressed. After institution of mannitol therapy, it vanished by the 3rd day, and she was discharged with no neurological deficit. The postulation and possibly the reason for improvement in the PDPH status is mannitol draws fluid from inside the neurons and glia, by osmotic diuresis, thereby the actual effective weight of the brain is reduced and it “refloats” in an improved cerebrospinal fluid volume. This relieves the pressure or traction on the meninges and vessels at the base of the brain that causes PDPH and thus mitigates it.[6] I have not found any side effects of mannitol therapy in patients who were given this therapy. Can this be the best non‑invasive option to reduce PDPH in patients? This management method has not been described before in any scientific journal or text. Studies can be carried out to establish/refute this claim and to know the risks associated with this approach.
MM Rizvi, Raj Bahadur Singh, RK Tripathi, Sister Immaculate1 Department of Anaesthesiology and Critical Care, Era’s Lucknow Medical College and Hospital, 1Department of OB and G, BCM Hospital, Khairabad, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Raj Bahadur Singh, Department of Anaesthesiology and Critical Care, Era’s Lucknow Medical College and Hospital, Lucknow ‑ 226 003, Uttar Pradesh, India. E‑mail: [email protected]
REFERENCES 1.
Bier A. Experiments on the cocainization of the spinal cord. Deutsch Z Chir 1899;51:361-9.
Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
2. Lee JA. Arthur Edward James Barker 1850‑1916. British pioneer of regional analgesia. Anaesthesia 1979;34:885‑91. 3. Chadwick HS. An analysis of obstetric anesthesia cases from the American society of anesthesiologists closed claims project database. Int J Obstet Anesth 1996;5:258‑63. 4. Vandam LD, Dripps RD. Long‑term follow‑up of patients who received 10,098 spinal anesthetics; syndrome of decreased intracranial pressure (headache and ocular and auditory difficulties). J Am Med Assoc 1956;161:586‑91. 5. Sechzer PH. Post‑spinal anesthesia headache treated with caffeine. Part II: Intracranial vascular distention, a key factor. Curr Ther Res 1979;26:440‑8. 6. Amini‑Saman J, Karbasfrushan A, Ahmadi A, Bazargan‑Hejazi S. Intravenous mannitol for treatment of abducens nerve paralysis after spinal anesthesia. Int J Obstet Anesth 2011;20:271‑2. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.155012
Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients Sir, During bariatric surgery procedures, the anaesthesiologists help facilitate proper placement of nasogastric tubes (NGTs) and bougies to size the gastric pouch. They help perform leak tests with saline, methylene blue or air to ensure staple‑line or anastomotic integrity. They ensure complete removal of all gastric tubes before gastric division to avoid unplanned stapling and transection of these tubes. After the surgery is performed, they re‑insert the NGT tube under vision watching the monitor carefully while the tube is advanced to avoid disruption of the anastomosis. NGT insertion in an anaesthetised patient is however a very cumbersome procedure for the anaesthesiologist with the need to burrow under sterile drapes to approach the oral cavity and the need to use a laryngoscope and Magill’s forceps to advance the tube 1–2 cms at a time to avoid coiling in the oropharynx because of the flexibility and slippery nature of a lubricated NGT through the compromised lumen of 261
Letters to Editor
the oesophagus secondary to the inflated endotracheal bulb.[1] Several techniques to simplify this procedure have been recommended in the literature.[2‑7] Of these a quick and easy way often adopted intra‑operatively by many anaesthesiologists is to pass a paediatric endotracheal tube (ETT) nasally and a NGT is passed down this tube directly to the oesophagus without coiling or trauma.[2‑4] The ETT can be then be removed from around the NGT without displacement of the tube. Correct position of NGT is confirmed by injection of air and auscultation over the epigastrium, aspiration of gastric contents or direct visualisation/palpation at surgery. An ETT is preferred over a nasopharyngeal airway as guide for NGT insertion because of its length. We would like to share our experience of a possible undesired event associated with this manoeuvre to create awareness and for adoption of necessary precautions. We recently encountered three patients undergoing bariatric procedures for treatment of their morbid obesity spread over three different centres that were complicated by intra‑operative migration of the guiding nasal ETT into the oesophagus after dislodgement of the tube from its connector by this manoeuvre [Figure 1a and b]. In all three cases unaware of tube dislodgment (as the connector was the only visible portion), the NGT was threaded pushing the tube further downwards. In all three cases, the tube could not be readily accessed for removal through the mouth and were managed by endoscopic retrieval in two and retrieval through a gastrostomy in one [Figure 2a and b]. Portex® ETT connectors easily get separated from the tube if attached shallowly resulting in dislodgement of the tube. The simplest precaution to prevent dislodgement is to encircle a 1‑cm wide tape at the proximal end of tube and secure it to the connector or use a one‑size larger tracheal tube connector, which can be easily and snugly fit into the proximal end of the tube.[8] Furthermore, the Portex® ETTs used should be larger than the NGT as a snugly fitting NGT can easily carry the ETT also with it. Precautionary measures should always be implemented to avoid this unnecessary intra‑operative complication.
Rachel Maria Gomes, Praveen P Raj, Saravana S Kumar, Chinnusamy Palanivelu Department of Minimal Access Surgery, Gem Hospital and Research Centre, Coimbatore, Tamil Nadu, India Address for correspondence: Dr. Rachel Maria Gomes, C/O Dr. Praveen P Raj, Department of Minimal Access Surgery, Gem
262
a
b
Figure 1: (a) Endoscopic image of the proximal end of migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector, (b) Endoscopic image of the body of the migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector
a
b
Figure 2: (a) Endoscopic image of the visualization and grasping of the migrated nasal endotracheal tube in the oesophagus , (b) Endoscopic image of the retrieval of the migrated nasal endotracheal tube from the oesophagus Hospital and Research Centre, Coimbatore ‑ 641 045, Tamil Nadu, India. E‑mail: [email protected]
REFERENCES 1.
Kamat RD. Use of Magill tube for passing nasogastric tube in anesthetized or comatose patients. Anesth Analg 1975;54:156. 2. Tahir AH, Adriani J. A method of inserting a nasogastric tube in the anesthetized or comatose patient. Anesth Analg 1971;50:179‑80. 3. Singh N, Rao PB, Ambesh SP, Gupta D. Letter to editor: Endotracheal tube aided nasogastric tube placement with classic laryngeal mask airway in situ. Anaesth Pain Intensive Care 2013;17:308. 4. Yadav G, Das SK, Jain G, Choupoo S. Letter to editor: A modified technique for difficult nasogastric tube insertion. Anaesth Pain Intensive Care 2013;17:304‑5. 5. Reid S, Falconer R. A novel method of nasogastric tube insertion. Anaesthesia 2005;60:1154‑5. 6. Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconscious intubated patient. N Am J Med Sci 2013;5:68‑70. 7. Tsai YF, Luo CF, Illias A, Lin CC, Yu HP. Nasogastric tube insertion in anesthetized and intubated patients: A new and reliable method. BMC Gastroenterol 2012;12:99. 8. Mahajan R, Kumar S, Gupta R. Prevention of aspiration of nasopharyngeal airway. Anesth Analg 2007;104:1313. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.155013
Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
Copyright of Indian Journal of Anaesthesia 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.
used mannitol infusions to treat PDPH successfully for years with much success. If post‑operative patient complains of headache that is characteristic of PDPH, 20% mannitol (100 ml) is given over ½ h intravenously and followed by 100 ml on a 12 hourly basis. The first dose of mannitol usually settles the PDPH over 6–8 h and no analgesics are required thereafter. Intravenous fluids are given to the patient as per normal body requirement, and input/output chart is maintained. Frequent assessment is done and after 48 h it is unusual to need mannitol infusions. I had adopted this practice while I was employed there and continue to do so. I also extend this to patients who have had a dural puncture on attempting epidural technique with a Tuohy needle, to preempt the PDPH that develops in them. In another case, mannitol infusion was successfully used by the author to treat a patient who developed unilateral facial nerve palsy after caesarean section under spinal anaesthesia, 4 days after discharge. At the time of readmission, unilateral facial palsy was well established, and patient was greatly stressed. After institution of mannitol therapy, it vanished by the 3rd day, and she was discharged with no neurological deficit. The postulation and possibly the reason for improvement in the PDPH status is mannitol draws fluid from inside the neurons and glia, by osmotic diuresis, thereby the actual effective weight of the brain is reduced and it “refloats” in an improved cerebrospinal fluid volume. This relieves the pressure or traction on the meninges and vessels at the base of the brain that causes PDPH and thus mitigates it.[6] I have not found any side effects of mannitol therapy in patients who were given this therapy. Can this be the best non‑invasive option to reduce PDPH in patients? This management method has not been described before in any scientific journal or text. Studies can be carried out to establish/refute this claim and to know the risks associated with this approach.
MM Rizvi, Raj Bahadur Singh, RK Tripathi, Sister Immaculate1 Department of Anaesthesiology and Critical Care, Era’s Lucknow Medical College and Hospital, 1Department of OB and G, BCM Hospital, Khairabad, Lucknow, Uttar Pradesh, India Address for correspondence: Dr. Raj Bahadur Singh, Department of Anaesthesiology and Critical Care, Era’s Lucknow Medical College and Hospital, Lucknow ‑ 226 003, Uttar Pradesh, India. E‑mail: [email protected]
REFERENCES 1.
Bier A. Experiments on the cocainization of the spinal cord. Deutsch Z Chir 1899;51:361-9.
Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
2. Lee JA. Arthur Edward James Barker 1850‑1916. British pioneer of regional analgesia. Anaesthesia 1979;34:885‑91. 3. Chadwick HS. An analysis of obstetric anesthesia cases from the American society of anesthesiologists closed claims project database. Int J Obstet Anesth 1996;5:258‑63. 4. Vandam LD, Dripps RD. Long‑term follow‑up of patients who received 10,098 spinal anesthetics; syndrome of decreased intracranial pressure (headache and ocular and auditory difficulties). J Am Med Assoc 1956;161:586‑91. 5. Sechzer PH. Post‑spinal anesthesia headache treated with caffeine. Part II: Intracranial vascular distention, a key factor. Curr Ther Res 1979;26:440‑8. 6. Amini‑Saman J, Karbasfrushan A, Ahmadi A, Bazargan‑Hejazi S. Intravenous mannitol for treatment of abducens nerve paralysis after spinal anesthesia. Int J Obstet Anesth 2011;20:271‑2. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.155012
Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients Sir, During bariatric surgery procedures, the anaesthesiologists help facilitate proper placement of nasogastric tubes (NGTs) and bougies to size the gastric pouch. They help perform leak tests with saline, methylene blue or air to ensure staple‑line or anastomotic integrity. They ensure complete removal of all gastric tubes before gastric division to avoid unplanned stapling and transection of these tubes. After the surgery is performed, they re‑insert the NGT tube under vision watching the monitor carefully while the tube is advanced to avoid disruption of the anastomosis. NGT insertion in an anaesthetised patient is however a very cumbersome procedure for the anaesthesiologist with the need to burrow under sterile drapes to approach the oral cavity and the need to use a laryngoscope and Magill’s forceps to advance the tube 1–2 cms at a time to avoid coiling in the oropharynx because of the flexibility and slippery nature of a lubricated NGT through the compromised lumen of 261
Letters to Editor
the oesophagus secondary to the inflated endotracheal bulb.[1] Several techniques to simplify this procedure have been recommended in the literature.[2‑7] Of these a quick and easy way often adopted intra‑operatively by many anaesthesiologists is to pass a paediatric endotracheal tube (ETT) nasally and a NGT is passed down this tube directly to the oesophagus without coiling or trauma.[2‑4] The ETT can be then be removed from around the NGT without displacement of the tube. Correct position of NGT is confirmed by injection of air and auscultation over the epigastrium, aspiration of gastric contents or direct visualisation/palpation at surgery. An ETT is preferred over a nasopharyngeal airway as guide for NGT insertion because of its length. We would like to share our experience of a possible undesired event associated with this manoeuvre to create awareness and for adoption of necessary precautions. We recently encountered three patients undergoing bariatric procedures for treatment of their morbid obesity spread over three different centres that were complicated by intra‑operative migration of the guiding nasal ETT into the oesophagus after dislodgement of the tube from its connector by this manoeuvre [Figure 1a and b]. In all three cases unaware of tube dislodgment (as the connector was the only visible portion), the NGT was threaded pushing the tube further downwards. In all three cases, the tube could not be readily accessed for removal through the mouth and were managed by endoscopic retrieval in two and retrieval through a gastrostomy in one [Figure 2a and b]. Portex® ETT connectors easily get separated from the tube if attached shallowly resulting in dislodgement of the tube. The simplest precaution to prevent dislodgement is to encircle a 1‑cm wide tape at the proximal end of tube and secure it to the connector or use a one‑size larger tracheal tube connector, which can be easily and snugly fit into the proximal end of the tube.[8] Furthermore, the Portex® ETTs used should be larger than the NGT as a snugly fitting NGT can easily carry the ETT also with it. Precautionary measures should always be implemented to avoid this unnecessary intra‑operative complication.
Rachel Maria Gomes, Praveen P Raj, Saravana S Kumar, Chinnusamy Palanivelu Department of Minimal Access Surgery, Gem Hospital and Research Centre, Coimbatore, Tamil Nadu, India Address for correspondence: Dr. Rachel Maria Gomes, C/O Dr. Praveen P Raj, Department of Minimal Access Surgery, Gem
262
a
b
Figure 1: (a) Endoscopic image of the proximal end of migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector, (b) Endoscopic image of the body of the migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector
a
b
Figure 2: (a) Endoscopic image of the visualization and grasping of the migrated nasal endotracheal tube in the oesophagus , (b) Endoscopic image of the retrieval of the migrated nasal endotracheal tube from the oesophagus Hospital and Research Centre, Coimbatore ‑ 641 045, Tamil Nadu, India. E‑mail: [email protected]
REFERENCES 1.
Kamat RD. Use of Magill tube for passing nasogastric tube in anesthetized or comatose patients. Anesth Analg 1975;54:156. 2. Tahir AH, Adriani J. A method of inserting a nasogastric tube in the anesthetized or comatose patient. Anesth Analg 1971;50:179‑80. 3. Singh N, Rao PB, Ambesh SP, Gupta D. Letter to editor: Endotracheal tube aided nasogastric tube placement with classic laryngeal mask airway in situ. Anaesth Pain Intensive Care 2013;17:308. 4. Yadav G, Das SK, Jain G, Choupoo S. Letter to editor: A modified technique for difficult nasogastric tube insertion. Anaesth Pain Intensive Care 2013;17:304‑5. 5. Reid S, Falconer R. A novel method of nasogastric tube insertion. Anaesthesia 2005;60:1154‑5. 6. Ghatak T, Samanta S, Baronia AK. A new technique to insert nasogastric tube in an unconscious intubated patient. N Am J Med Sci 2013;5:68‑70. 7. Tsai YF, Luo CF, Illias A, Lin CC, Yu HP. Nasogastric tube insertion in anesthetized and intubated patients: A new and reliable method. BMC Gastroenterol 2012;12:99. 8. Mahajan R, Kumar S, Gupta R. Prevention of aspiration of nasopharyngeal airway. Anesth Analg 2007;104:1313. Access this article online Quick response code Website: www.ijaweb.org
DOI: 10.4103/0019-5049.155013
Indian Journal of Anaesthesia | Vol. 59 | Issue 4 | Apr 2015
Copyright of Indian Journal of Anaesthesia 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.
