Epidural anaesthesia in the anaesthetised patient

Correspondence

Clinical Governance ± what's itall about?

In their Editorial on Clinical Govern-ance (Anaesthesia 1999; 54: 311±12),Drs Morris and Johnson allude to the

use of drugs outside of the conditionsdelineated by Product Licence. Anaes-thetists, particularly those involved in

obstetric or paediatric subspecialties,commonly administer drugs in this unli-censed manner, and much of current(evidence-based) anaesthetic practice

falls into this category. A recently pub-lished poll of obstetric anaesthetistsdemonstrates the extent and complexity

of the practice, and highlights some ofthe inherent dif®culties [1]. Whilst thereis widespread awareness of the preva-

lence of unlicensed drug administration,precise knowledge of what is, or is not,licensed is limited, even amongst super-specialist clinicians. However, the solu-

tion to this problem, if indeed it is aproblem, may not be as simple as theauthors suggest. The creation of local or

national unlicensed prescribing guide-lines or formularies is fraught with dif®-culties, and may not, in the end, be

helpful to either patients or clinicians.With many drugs and mixtures (com-

monly used but rarely licensed), Product

Licence lags far behind actual clinicalpractice, even to the point of absurdity(see the entry under thiopentone whichmakes it incompatible with the technique

of rapid sequence induction). In addition,many important drugs have no ProductLicence at all, falling into the categories

of unlicensed Specials (e.g. magnesiumsulphate, physostigmine) or PreparedMedicines (e.g. total parenteral nutrition).

Like previous authors [2], Drs Morris& Johnson have suggested that nationalbodies such as the Royal College of

Anaesthetists or the Association of Anaes-thetists may have a role in `formalisingthe status quo' with respect to drug

administration. However, in view ofthe complexity of the subject, and thevast number of drugs, routes of adminis-

tration and indications to be considered,I suggest that this would be dif®cult toachieve. In addition, development ofsuch a list of àcceptable' drug uses

would ultimately create an unacceptablerestriction on clinical practice, since themedicolegal constraints this might pro-

duce would effectively halt progressiveand innovative medicine.

Many of the current contradictions

evident in the licensing process arisefrom the fact that commercial interestalone drives the application for a Pro-duct Licence. Whilst development of an

Òrphan Drug Program' as operated inthe USA and Australia might form partof a solution, perhaps it is now time to

review the whole concept and value ofthe current licensing system.

As clinicians aspiring to best practice

we should continue to enjoy our clinicalfreedom in drug prescribing. However,with that freedom goes personal respon-

sibility, and the knowledge that we mustalways be able to justify our actions toourselves, our peers and our patients.

P. R. HowellSt Bartholomew's Hospital,

London EC1A 7BE, UK

References

1 Howell PR, Madej TH.

Administration of drugs outside of

Product Licence: awareness and

current practice. International Journal of

Obstetric Anesthesia 1999; 8: 30±6.

2 Mather CNW, O'Kelly SW.

Unlicensed drug administration.

Anaesthesia 1995; 50: 189±90.

Use of a cuffed oropharyngealairway and Aintree catheter ina dif®cult airway

The cuffed oropharyngeal airway

(COPATM, Mallinkrodt) is similar to aGuedel airway but has a pharyngeal cuff,a standard 15-mm connector and larger

internal dimensions. It can be placedin the oropharynx and connected to abreathing system, allowing the patient to

breathe spontaneously through it. A®breoptic laryngoscope can be passedthrough the device, and a previouspaper has described the use of this tech-

nique to intubate the trachea with thehelp of the Aintree catheter [1], a venti-lation-exchange bougie that makes a

snug ®t over a ®breoptic laryngoscope.In that report, the feasibility of using theCOPA as a conduit for the ®breoptic

laryngoscope and Aintree catheter wasdemonstrated in patients with normalairways. We wish to report the use of

the COPA and Aintree catheter to assisttracheal intubation in a patient with adif®cult airway, due to tumour involvingthe posterior tongue and extending onto

the epiglottis and surrounding pharyn-geal wall.

A 57-year-old man presented on an

elective oral surgery operating list forexamination under anaesthesia andbiopsy of an extensive oropharyngeal

Anaesthesia, 1999, 54, pages 909±920................................................................................................................................................................................................................................................

909Q 1999 Blackwell Science Ltd

All correspondence should be addressed to Professor M. Harmer, Editor of Anaesthesia, Department of Anaesthetics, University of Wales College of

Medicine, Heath Park, Cardiff CF14 4XN, UK.

Letters (two copies) must be typewritten on one side of the paper only and double spaced with wide margins. Copy should be prepared in the usual

style and format of the Correspondence section. Authors must follow the advice about references and other matters contained in the Notice to

Contributors to Anaesthesia printed at the back of each issue. The degree and diplomas of each author must be given in a covering letter personally signed

by all the authors.

Correspondence presented in any other style or format may be the subject of considerable delay and may be returned to the author for revision. If the

letter comments on a published article in Anaesthesia, please send three copies; otherwise two copies of your letter will suf®ce.

tumour. On examination of his airway

during a pre-operative assessment, hewas found to be edentulous with goodmouth opening; Mallampati grade 3;thyromental distance greater than four

®ngerbreadths and a full range of neckmovements. He denied any stridor.

It was felt that the safest option would

be an awake ®breoptic laryngoscopy andintubation, but despite a full explanationby the Consultant in charge of his care,

the patient refused any kind of awakeprocedure. Although it was likely thatsome dif®culty would be encountered

intubating the trachea, we felt thathis airway would otherwise be easy tomaintain. In view of this he was giventhe option of an inhalational induction,

with the proviso that if at any stage wefelt his safety was compromised, hewould be woken and an awake ®bre-

optic intubation performed.After antisialagogue premedication,

he arrived in the anaesthetic room,

where routine monitoring was institutedand intravenous access secured. Anaes-thesia was induced with sevo¯urane in

oxygen with the patient breathing spon-taneously throughout. At no time washis airway dif®cult to maintain. Afterinduction of anaesthesia, direct laryngo-

scopy was performed and a Cormackand Lehane grade 4 view obtained. Allthat could be seen was a friable, necrotic

area over the oropharynx. The tonguecould not be displaced anteriorly, andany attempt to do so caused bleeding

from the tumour.A size 10 COPA was inserted and

connected to the breathing system afterin¯ation of the cuff with just 20 ml of

air. The patient continued to breathesevo¯urane and oxygen through anunobstructed airway. The Aintree cathe-

ter was mounted onto the ®breopticlaryngoscope and they were bothpassed through the COPA via a RuÈsch

self-sealing angle piece. Initially, norecognizable anatomy was seen, butafter jaw thrust and a downward rotation

movement of the COPA [1], the glottiswas visualised with a small amount ofblood around the posterior pharyngealwall. The scope was passed through the

cords and then removed along with theCOPA, leaving the Aintree catheter inthe trachea. After ensuring that the

patient could be ventilated by hand

through the Aintree catheter, suxa-methonium (1.0 mg.kgÿ1) was adminis-tered. A size 7.0-mm tracheal tube wasrailroaded over the catheter into the

trachea, the Aintree catheter removedand the tracheal tube secured in place.Surgery then progressed uneventfully,

with a tracheostomy being performedprior to wakening. The patient was ableto breathe spontaneously with a clear

airway during all manoeuvres prior to theaction of suxamethonium. He remainedhaemodynamically stable and his oxygen

saturation on pulse oximetry was 100%throughout.

The COPA has been shown to be easyto use giving good airway control [2],

and is particularly easy to insert afterinduction of anaesthesia with sevo¯urane[3]. A recent publication has described a

technique using the COPA to assist ®bre-optic tracheal intubation with the scopeand tracheal tube passing outside the

COPA, between the cuff and the phar-yngeal wall [4]. In our patient this wouldhave caused bleeding from the friable

lesion, thus compromising the airwayand resulting in loss of view throughthe ®breoptic scope. By using the Ain-tree catheter, and remaining within the

COPA, the scope did not come intocontact with any blood, and all mani-pulations could occur under direct vision

until the best view of the glottis wasobtained. Importantly, a clear airway wasmaintained throughout, with the COPA

acting as a `dedicated airway' [5]. Thus,all manoeuvres could take place in anunhurried and controlled manner, whichhas obvious advantages. The laryngeal

mask airway has also been used in thismanner [6], but because of the friablenature of the lesion in this patient, inser-

tion of this device could have causedexcessive bleeding in the oropharynx.

Further evaluation of this device is

needed, but in conjunction with theAintree catheter it may prove to be auseful aid for managing the dif®cult

airway, as this case demonstrates.

M. Hawkins

E. A. RobertsUniversity Hospital,Aintree, Fazakerley,

Liverpool L9 7AL, UK

References

1 Hawkins M, O'Sullivan E, Charters P.

Fibreoptic intubation using the cuffed

oropharyngeal airway and Aintree

catheter. Anaesthesia 1998; 53: 891±4.

2 Asai T, Koga K, Jones RM, Stacey M,

Latto IP, Vaughan RS. The cuffed

oropharyngeal airway. It's clinical use

in 100 patients. Anaesthesia 1998; 53:

810±22.

3 Nakata Y, Goto T, Saito H, Ichinose F,

Uezono S, Morita S. The placement of

the cuffed oropharyngeal airway with

sevo¯urane in adults: a comparison

with the laryngeal mask airway.

Anesthesia and Analgesia 1998; 87:

143±6.

4 Greenberg RS, Kay NH. Cuffed

oropharyngeal airway (COPA) as an

adjunct to ®breoptic tracheal

intubation. British Journal of Anaesthesia

1999; 82: 395±8.

5 Ralston SJ, Charters P. Cuffed

nasopharyngeal tube as a `dedicated

airway' in dif®cult intubation.

Anaesthesia 1994; 49: 133±6.

6 Atherton DPL, O'Sullivan E, Lowe D,

Charters P. A ventilation-exchange

bougie for ®breoptic intubations with

the laryngeal mask airway. Anaesthesia

1996; 51: 1123±6.

Neck ¯exion and the intubatinglaryngeal mask

We should like to comment on thearticle by Asai and Shingu (Anaesthesia1998; 53: 1199±201) describing the

successful use of the intubating laryngealmask (ILM) in a patient with a ®xed¯exed neck and deviated trachea.

Firstly, we disagree with the authors'

statement that laryngeal mask airway(LMA) insertion `may be dif®cult orimpossible with the neck ¯exed'. We

suspect that the authors intended to saythat it `may be dif®cult or impossiblewith the neck extended' since they

recently showed that neck ¯exionfacilitates placement [1]. In our experi-ence, misconceptions about head and

neck position are a common cause forfailed and/or traumatic LMA place-ment. The manufacturer recommendsthat neck ¯exion and head extension is

best for LMA insertion [2]. Ishimura and

Correspondence Anaesthesia, 1999, 54, pages 909±920................................................................................................................................................................................................................................................

910 Q 1999 Blackwell Science Ltd

colleagues [3] attempted to quantify this

using a curved aluminium plate modeland showed that if the angle between theoral (determined mostly by head posi-tion) and pharyngeal axes (determined

mostly by neck position) was greaterthan 908, LMA insertion would be easysince the LMA tip would not impact at

the junction of the two axes. Headextension and neck ¯exion increasethis angle, the converse being true for

head ¯exion and neck extension. Ishi-mura's hypothesis has not been directlytested in patients, but appears to be a

valuable, if somewhat oversimpli®ed,concept for the optimal path taken bythe LMA during insertion.

Second, a limiting factor to ILM

placement, not mentioned by the authors,is that the guiding handle must beapplied close to and parallel with the

chest wall to allow the user to ¯atten thecuff against the hard palate before rotat-ing it into position. If this gap is reduced

by head and neck positional deformity,the recommended start position cannotbe adopted and ILM placement may be

dif®cult or impossible. In this respect,the LMA has advantages over the ILM.

Finally, we would like to commendthe authors on their use of a ®breoptic

scope to facilitate intubation via theILM. Although the blind technique hasa high success rate within a few attempts

[4], and is an important skill to acquire,®breoptic guidance should be usedwhenever available to minimise the risk

of trauma and oesophageal intubation.

J. BrimacombeCairns Base Hospital,Cairns, Australia

C. KellerLeopold-Franzens University,

Innsbruck, Austria

References

1 Asai T, Neil J, Stacey M. Ease of

placement of the laryngeal mask

during manual inline neck

stabilization. British Journal of

Anaesthesia 1998; 80: 617±20.

2 Brimacombe JR, Brain AIJ, Berry AM.

The Laryngeal Mask Instruction Manual

for Anaesthesia. Henley-on-Thames:

Intavent Research Ltd, 1999.

3 Ishimura H, Minaini K, Sata T,

Shigematsu A, Kadoya T. Impossible

insertion of the laryngeal mask airway

and oropharyngeal axes. Anesthesiology

1995; 83: 867±9.

4 Brain AIJ, Verghese C, Addy EV,

Kapila A, Brimacombe J. The

intubating laryngeal mask. II. a

preliminary clinical report of a new

means of intubating the trachea. British

Journal of Anaesthesia 1997; 79: 704±9.

A reply

Our expression of the neck position

should have been more unambiguous.This ambiguity was due to a commonpractice of not distinguishing explicitlythe position of the upper from lower

cervical spine. We stated that ìnsertionof the conventional laryngeal mask isbest achieved when the patient's neck

is ¯exed and the head extended asdescribed by Magill (`snif®ng' position)'[1]. This is the most commonly used

expression of the head and neck positionthat Drs Brimacombe and Keller alsoadopt. A more accurate expression isextension of the occipitoatlantoaxial

complex (i.e. extension of the head onthe neck and of the upper cervical spine)and ¯exion of the lower cervical spine [2].

We also stated that ìn fact, its inser-tion becomes more dif®cult or imposs-ible when the patient's head and neck are

in either the neutral or ¯exed position'[1] and cited three articles [3±5]. In the®rst study [3], insertion of the laryngeal

mask was more dif®cult when the occi-put was placed directly on the trolleyand the head and neck were stabilised(manual in-line position) than when the

head and neck were placed in the Magillposition. In retrospect, we should nothave used the term `neutral position',

since it can be regarded as the position ofthe head and neck when the occiput isplaced either directly on the trolley or on

one pillow (or a pad). In the secondstudy [4], it was suggested that ¯exionof both the occipitoatlantoaxial complex

and lower cervical spine by cricoid pres-sure made insertion more dif®cult. Inthe third report [5], insertion of themask was impossible when the occipito-

atlantoaxial complex was ¯exed and thelower cervical spine extended.

Drs Brimacombe and Keller state that

we showed that neck ¯exion facilitated

placement, but what we showed was that

extension of the occipitoatlantoaxialcomplex (i.e. extension of the uppercervical spine) and ¯exion of the lowercervical spine facilitated placement [3].

Therefore, perhaps we should havestated that insertion may become moredif®cult when the occipitoatlantoaxial

complex (or the head and upper cervicalspine) is ¯exed. In our patient, both theoccipitoatlantoaxial complex and the

lower cervical spine were ¯exed due toburn contracture [1]. We expressed thisas a à ®xed ¯exed neck'.

T. Asai

K. ShinguKansai Medical University,Moriguchi, Osaka, 570±8507, Japan

References

1 Asai T, Shingu K. Tracheal intubation

through the intubating laryngeal mask

in a patient with a ®xed ¯exed neck

and deviated larynx. Anaesthesia 1998;

53: 1199±209.

2 Crosby ET, Lui A. The adult cervical

spine: implications for airway

management. Canadian Journal of

Anaesthesia 1990; 37: 77±93.

3 Asai T, Neil J, Stacey M. Ease of


during manual in-line neck

stabilisation. British Journal of

Anaesthesia 1998; 80: 617±20.

4 Asai T, Barclay K, Power I,

Vaughan RS. Cricoid pressure impedes


airway. British Journal of Anaesthesia

1995; 74: 521±5.

5 Ishimura H, Minami K, Sata T,

Shigematsu A, Kadoya T. Impossible

insertion of the laryngeal mask airway

and oropharyngeal axes. Anesthesiology

1995; 83: 867±9.

Laryngoscopy grades

May I respond to some interesting com-

ments made recently about the laryngo-scopy grades (Anaesthesia 1999; 54:

496±7). Our grading system was notaimed at the experienced anaesthetist;

it was intended for beginners. We mustnot forget that within a year or so ofstarting anaesthesia, trainees will be

expected to intubate emergency cases

Anaesthesia, 1999, 54, pages 909±920 Correspondence................................................................................................................................................................................................................................................


unsupervised and when intubation is

unexpectedly dif®cult this is a knowncause of disaster ± unless the trainee isproperly prepared. As part of the pre-paration, the use of descriptive grades of

laryngoscopy have proved effective, butas Dr Cook points out, there has beenconfusion over the grade 2 de®nition.

This came to light in a well-knownstudy [1], which has certainly advancedour understanding of the situation.

How then is the grade 2 confusion tobe dispelled? Several more elaboratesystems have been suggested, but will

that work ± arguably it would increaseconfusion. For experienced anaesthetistswho wish to re®ne their skills, an intri-cate system which identi®es all levels of

dif®culty may well be valuable ± but forthe beginner there is a case for keeping itsimple. The simplest system would have

just two grades, `green light' and `redlight'. `Green light' cases have varyingdegrees of dif®culty, but none should

cause failed intubation if the trainee isadequately trained, as de®ned, for exam-ple, by West et al. [2]. On the other

hand, the much smaller `red light' groupmay cause failure even for the expert. Itfollows that the critical factor is to beclear about this demarcation ± that is

what guided us in de®ning grade 2 andsome quite experienced anaesthetists,including Macintosh, took part in the

discussions. The paper reports just theconclusions, but some years later we sum-marised the underlying logic in a letter to

Anaesthesia [3]. Maybe Dr Yentis and DrCook missed it because at that time letterswere not listed in the Contents. The cur-rent format seems vastly better ± other

journals please copy. Probably it was Vol-taire who wrote: Ìt has all been saidbefore, but since no one listens we must

repeat ourselves'. Perhaps he did notforesee how hard it would be to keep up.

Thegathering storm inobstetricsmakes

depressing reading. However, there isone encouraging fact; the latest Con®-dential Enquiry is the ®rst to report no

deaths directly from general anaesthesia.It may be that, despite the confusion,some messages are being assimilated.

R. S. CormackNorthwick Park & St Mark's

Hospital,Harrow HA1 3UJ, UK

References

1 Cohen AM, Fleming BG, Wace JR.

Grading of direct laryngoscopy ± a

survey of current practice. Anaesthesia

1994; 49: 522±5.

2 West MRJ, Jonas MM, Adams AP,

Carli F. A new tracheal tube for

dif®cult intubation. British Journal of

Anaesthesia 1996; 76: 673±9.

3 Adams AP, Cormack RS, Lehane J.

Cricoid pressure ± one or two hands.

Anaesthesia 1996; 51: 986.

Airway problems in therecovery room

The audit of airway problems in therecovery room by Dr Abdy (Anaesthesia

1999; 54: 372±3) is both interesting andthought provoking. He reported that theincidence of airway problems was 2.8%(in 1000 patients) and has claimed that

`this incidence was in agreement withprevious studies and appears too low towarrant a full-time anaesthetic presence'

as suggested [1]. However, our study,which Abdy omitted to cite [2], showeda much higher incidence of 9.5% (in

1005 patients) occurring in the recoveryroom. The difference in the incidencesmay have been caused by several factors,

such as the de®nition of what constitutesan airway problem, patients' character-istics, anaesthetic peri-operative care, theduration of observation and the inci-

dence of under reporting. In fact, DrAbdy acknowledges that the low inci-dence of complications might have been

due to under reporting.Nevertheless, when one looks at the

Abdy audit, of the 28 patients who had

airway problems, 14 had severe problemsand needed urgent intervention by ananaesthetist. Taylor, writing in the Journalof the Medical Protection Society, refers to

four children who were badly braindamaged following airway complicationsduring the recovery period where there

was no anaesthetist available [3]. Whatwould have been the outcome in theAbdy audit if there had been no anaes-

thetist readily available?Abdy's suggestion of a `¯oating'

anaesthetist has merit as it is de®nitely

preferable to no anaesthetist available.However, like our American colleagues,

we would prefer an anaesthetist to ¯oat

out, and not into, the recovery area. TheAmerican anaesthesiology training pro-grammes include a period spent in therecovery room and the Post Anaesthetic

Care Unit (PACU) [4]. Furthermore,these areas are included in their ®nalexaminations.

The issue of recovery room problemswill need increasing attention given thegovernment's drive for clinical excel-

lence (NICE), clinical governance withpersonal and departmental portfolios allbeing constantly reviewed. If one were

to add an increasing litigation rate andthe GMC's plans for the future, the peri-operative care will be expected to beexcellent throughout. It would therefore

seem logical that time must be set asidefor training in this area. `The anaesthetistis responsible for his/her patient from

induction to full recovery' [3]. Is any-thing else acceptable?

R. S. VaughanUniversity Hospital of Wales,

Cardiff CF14 4XW, UK

T. AsaiKansai Medical University,Osaka 570±8507, Japan

References

1 Vaughan RS. Airway management in

the recovery room. Anaesthesia 1997;

52: 617±18.

2 Asai T, Koga K, Vaughan RS.

Respiratory complications associated

with tracheal intubation and

extubation. British Journal of Anaesthesia

1998; 80: 767±75.

3 Taylor T. Postoperative recovery.

Medical Protection Society Casebook no. 7.

1996, 4±7.

4 Frost EMA. Postoperative care:

organisation and complications. The

Intavent Lecture. Association of

Anaesthetists of Great Britain &

Ireland Annual Scienti®c Meeting,

Birmingham 1997.

Epidural protocol audit

I read with interest the letter by Wigfull

and Welchew concerning the results ofa recent audit of the postoperative epi-dural service at their hospital (Anaesthesia



1999; 54: 299). A recent audit of the

epidural protocol at our hospital hasemphasised a signi®cant failure in themedical and nursing staff to appreciatethe importance of protocols and to use

the guidelines appropriately. Ten consul-tant anaesthetists, of whom ®ve specialisein cardiothoracic anaesthesia, along with

10 trainee anaesthetists and eight special-ist nurses from each of the cardiothor-acic, orthopaedic, vascular and recovery

wards were interviewed. The question-naire was based on the Trust epiduralprotocol.

Only 30% of the consultant anaesthe-tists (and 40% of the cardiothoracicconsultant anaesthetists) had any knowl-edge of the ESSAM scale [1]. This is a

locally established monitoring techniquedesigned to enable easy and safe moni-toring of patients with thoracic epidurals

in situ. It occupies one-third of an A4 sideof the epidural protocol. At a time whenContinuing Professional Development

and Revalidation are in vogue, this mustbe a cause for concern. Interestingly,recovery nurses (75%) and thoracic

nurses (63%) faired signi®cantly better.The Bromage scale is a simple guide

for recording and managing the effect ofepidurals on the lower limb power [2].

The ®ndings from questions relating tothis scale were alarming. Nurses fromthe recovery, vascular and orthopaedic

wards considered it acceptable practice,with patients who were not mobilising,to infuse lumbar epidural analgesia to a

point at which the patient was pain-freebut unable to move his/her legs. Theywould frequently fail to apply the Brom-age scoring system and consequently

there would be no attempt to reducethe infusion rate. Clearly this compro-mises the patient's safety. Epidural analge-

sia carries major risks in a ward settingand the protocol is designed to reducemorbidity and provide a higher standard

of care.The recommendations from our audit

are that the nursing staff undergo a re-

education programme and that the Trustraises staff awareness of the existence oflocal and national protocols.

J. M. CupittBooth Hall Children's Hospital,Manchester M9 7AA, UK

References

1 Razek E, Vohra A. An epidural

scoring system for arm movements

(ESSAM). British Journal of Anaesthesia

1999; 82: 466±7P.

2 Bromage PR. Epidural Analgesia.

Philadelphia: WB Saunders, 1978;

458±60

Nausea and vomiting duringCaesarean section under spinalanaesthesia

We read with interest the paper byAbouleish and colleagues (Anaesthesia

1999; 54: 479±82) evaluating ondanse-tron for control of nausea and vomitingduring Caesarean section under spinalanaesthesia. Although the authors have

good reason for only giving the studydrug following clamping of the umbili-cal cord, we feel that by this stage they

may have metaphorically missed thenausea train, or at best caught up withit a long way from the station, as most

emetic episodes in this group of patientsoccur prior to delivery of the baby. Wefound glycopyrronium to be an effective

anti-emetic compared with placebo in asimilar group of patients [1], with theadvantage that it can be given beforedelivery as its quaternary amine structure

prevents passage across the placenta insigni®cant amounts [2, 3]. Reviewingour data, we found that approximately

two-thirds of nausea or vomiting epi-sodes occurred prior to delivery of thebaby, in both treatment and placebo

groups, although the absolute numberswere lower in the treatment group. Wethink that this early nausea is mainlycaused by haemodynamic instability as

a consequence of subarachnoid block.After delivery, when the subarachnoidblock height has stabilised and measures

have been taken to treat hypotension,traction on the pelvic structures andvisceral peritoneum is probably more

important. While the incidence ofnausea before injection is included inthe data in this paper, the frequency and

severity prior to injection is not men-tioned. Although ondansetron appearsto have a place in the management ofthis dif®cult problem, we suspect that

the data on nausea and vomiting given in

the study may tell less than half the story

in these patients.

D. UreK. S. JamesM. McNeillGlasgow Royal In®rmary,

Glasgow G4 0SF, UK

References

1 Ure D, James KS, McNeill M,

Booth JV. Glycopyrrolate reduces

nausea during spinal anaesthesia for

Caesarean section without affecting

neonatal outcome. British Journal of

Anaesthesia 1999; 82: 277±9.

2 Ali-Melkkila T, Kaila T, Kanto J,

Iisalo E. Pharmacokinetics of

glycopyrronium in parturients.

Anaesthesia 1990; 45: 634±7.

3 Abboud TK, Read J, Miller F,

Chen T, Valle R, Hearken E. Use of

glycopyrrolate in the parturient: effect

on the fetal and maternal heart rate

and uterine activity. Obstetrics and

Gynecology 1981; 57: 224±7.

Labelling of obstetric patients

Recently in our hospital a patient wasanaesthetised soon after the normal deliv-

ery of a live, healthy baby for the man-agement of a postpartum haemorrhage.When cross-matched blood arrived, the

patient was found not to be wearing anidentity band. The only identi®cationpossible was the assurance of a midwifethat the patient's name was the same as

that on the notes in the operating theatre.As signi®cant blood loss had occurred,transfusion was commenced with the

available blood, which was group O.The patient was given in total 12 unitsof blood without ill effect, for haemor-

rhage from her ruptured uterus.In the subsequent investigation as to

how a patient without an identity bandcame to be anaesthetised, it was discov-

ered that it was the midwives' policy notto label patients in the maternity unitantenatally unless they need to go to the

operating theatre because they are not illand are able to identify themselves. Post-natal patients wear identity bands which

match those worn by the baby. Discus-sions with consultant obstetric colleagues



revealed that they were unaware of this

policy, which has been reviewed atdirectorate level. All obstetric patientsnow wear name bands from the time ofadmission.

In an informal telephone survey ofother obstetric units in the Wessexregion, we discovered that in six units

all patients routinely wear name bandsfrom the time of admission, but in threeother units, name bands are only worn

by patients going to the operating theatre.One unit felt unable to disclose theinformation. In one case, a consultant

obstetric anaesthetist was unaware ofwhat their policy was and followingour telephone call discovered thatwomen in that unit were not wearing

name bands routinely.Although obstetric patients are gen-

erally ®t and well, there are many poten-

tial situations in which identi®cation ofan unconscious patient may be necessary(e.g. after an eclamptic ®t, inadvertent

total spinal or prior to blood transfusionduring anaesthesia). We would advise allthose involved in the care of this group

of patients to ensure that their unitpolicy is not dependent on patientsbeing labelled at times of crisis, which,as the above case demonstrates, may not

ensure that all unconscious patients canbe identi®ed.

S. HughesK. D. Thomson

North Hampshire Hospital,Basingstoke, UK

Epidural catheter clamp ®xestoo ®rmly?

Like Drs Coupe and Al-Shaikh (Anaes-thesia 1999; 54: 98) and Dr Bellamy(Anaesthesia 1999; 54: 510±1), we have

been impressed by the new epidural®xation device (Sims Portex 16G Epi-dural catheter clamp, 100/33/016).There is nothing more soul-destroying

for a labouring woman or her anaesthe-tist than to have an effective epiduralcease to function due to catheter migra-

tion and any advance which reduces thelikelihood of this is to be welcomed.However, Dr Bellamy reports a potential

problem with the catheter becoming

wedged in the clamp and blocking. We

would add a further note of caution withthis device.

On two occasions, one of the authorshas used the device to secure a Portex

16G epidural catheter sited in obesewomen in early labour. In both cases,the catheter was sited with the patient in

the sitting position, leaving 5 cm withinthe epidural space. In both cases, theepidural worked well throughout the

®rst stage of labour. Both women weredelivered by Caesarean section for fetaldistress after prolonged labour. Both had

received epidural bolus doses from theirmidwives to good effect in the hourpreceding their Caesarean section. Inboth cases, an epidural bolus of 15 ml

lignocaine 2% was given incrementallyto prepare for the Caesarean section.However, in both cases this bolus failed

to produce any extension of the existingblock whatsoever. Satisfactory anaesthe-sia for Caesarean section was not obtained

and both women required general anaes-thesia which proved uneventful. Subse-quent inspection of the catheters revealed

them both to be apparently undisturbed atthe skin. On removal, both were patentand intact. The wedging phenomenondescribed by Dr Bellamy had not

occurred in either case.In both cases, the top-up for Caesar-

ean section was administered with the

patient on the operating table with rou-tine monitoring in situ. Thus the top-upswere given after the patient had been

transferred from bed to trolley and thentrolley to table. Whilst siting epidurals,but prior to securing them, in obesepatients we have often been struck by

the extent to which the patient's skin atthe site of insertion moves relative to thecatheter with the vigorous respiratory

excursion typical of labour. This`travel' can often be more than a centi-metre along the length of the catheter.

We therefore wonder whether such ®rm®xation of the catheter to our patients'skin led to its migration during the

¯exion and extension of the vertebralcolumn caused by transferring thesepatients. Many anaesthetists wouldargue against the administration of an

epidural bolus for Caesarean sectionimmediately prior to transfer from thedelivery room to the operating theatre as

the patient is then unmonitored during

the time she is most likely to experiencehaemodynamic instability. Thus it maybe that the epidural catheter clampshould be used with caution in obese

women in labour.

C. J. T. TackaberryNorth Manchester General Hospital,Manchester M8 5RB, UK

R. Wadsworth

Central Manchester Healthcare NHSTrust, Manchester M13 9WL, UK

Pulsating mass in the neckfollowing attempted internaljugular vein catheterisation

A 64-year-old female was admitted tothe Intensive Care Unit due to respira-

tory failure requiring ventilatory support.Tracheostomy had been performed toassist weaning from the ventilatory sup-

port. An attempt was made to perform apercutaneous catheterisation of the rightinternal jugular vein for central venous

access and monitoring. After multipleunsuccessful attempts, the procedure wasabandoned. Neither venous nor arterialblood was aspirated during these attempts

and consequently no further action wastaken at the site. A few days later, thepatient was found to have a pulsatile mass

with a bruit in the right neck region.While angiography revealed whatappeared to be an extracranial pseudo-

aneurysm (Figure overleaf), the de®nitivediagnosis of a right vertebral arterysource was not made until the time ofsurgical exploration. This pseudoaneur-

ysm was surgically excised with repair tothe artery.Fig. 1

Pseudoaneurysms and arteriovenous

®stulae can follow internal jugularvenous cannulation with an incidenceof 0.2% [1]. However, the incidence of

this complication is probably underesti-mated [2]. Pseudoaneurysms frequentlyremain asymptomatic and may resolve

spontaneously [2]. Signs and symptomsinclude neck pain, swelling, tinnitis,dyspnoea (airway compromise), heartfailure, and cerebral and spinal cord

ischaemia [3, 4]. Angiography is neededfor diagnosis, localisation of the feedingartery and vein, and to assess blood ¯ow



through the contralateral vertebral arteryin case surgical ligation is necessary [3, 4].

This is vital, as the affected vertebralvessel may be the dominant supply tothe vertebrobasilar neural system [2]. In

such cases, every effort should be madeto preserve the blood ¯ow to avoidspinal cord or cerebral ischaemic events

[2]. Once localised, treatment includessurgical ligation, transarterial embolisa-tion or both. All interventions can cause

neurological complications [5].The vertebral artery is the ®rst branch

of the subclavian artery and has anapproximately 4 cm extraspinous course

adjacent to the internal jugular veinprior to its cephalic ascent. While thisportion of the vertebral artery is more

medial and deeper to the internal jugularvein, its proximity can lead to injuryduring attempts at internal jugular vein

catheterisation when approached in thewrong direction or at the wrong depth[5]. As noted by Aoki et al. [5], to avoid

this complication care must be taken notto insert the needle too deeply or pene-trate the internal jugular vein. Also, eventhough haemostasis by manual compres-

sion is anatomically dif®cult due to the

depth of the vertebral artery, suf®cientmanual compression at the puncture site

must be performed after suspectedinjury to prevent complications at anearly stage [5].

M. Elias

Medical College of Wisconsin,9200 W. Wisconsin Ave.,Milwaukee, WI-53226, USA

References

1 Hayward R, Swanton H, Treasure T.

Acquired arterio-venous

communication: complication of

cannulation of the internal jugular

vein. British Medical Journal 1984; 288:

1195.

2 Ricol® F, Valiente E, Bodson F,

Poquet E, Charas J, Gaston A.

Arteriovenous ®stula complicating

central venous catheterization; value of

endovascular treatment based on a

series of seven cases. Intensive Care

Medicine 1995; 21: 1043±7.

3 VanHalbach V, Hiagashida RJ,

Hieshima GB. Treatment of vertebral

arterio-venous ®stula. American Journal

of Radiology 1988; 150: 405±12.

4 Nagashima C, Iwasaki T, Kawanuma S,

Sakaguchi A, Kamisasa A, Suzuki K.

Traumatic A-V ®stula of vertebral artery

with spinal cord symptoms. Journal of

Neurosurgery 1977; 46: 681±7.

5 Aoki H, Mizobe T, Nozuchi S,

Hatanaka T, Tanaka Y. Vertebral artery

pseudoaneurysm: a rare complication of

internal jugular vein catheterisation.

Anesthesia and Analgesia 1992; 75: 296±8.

Painful ear sign

A 67-year-old man with an underlyingurological problem required centralvenous access. The right subclavian

vein was punctured using the Seldingertechnique. Upon advancement of theguidewire, the patient complained of a

sharp, intense pain in his right ear, whichdisappeared following withdrawal by afew centimetres. The pain was repro-duced again twice on advancement of

the wire, and relieved after withdrawal.The catheter was introduced and achest radiograph con®rmed that the

catheter was malpositioned, probablywithin the internal jugular vein (Figureoverleaf).

This pain may represent referred painsecondary to irritation of the jugularbulb which is innervated by the vagusnerve. We have not encountered the

`painful ear sign' in the literature as anindication of central line malposition.

P. KoÈnigSt James's University Hospital,

Leeds LS9 7TF, UK

S. RoscoeLeeds General In®rmary,Leeds LS1 3EX, UK

Treating Guillain±BarreÂSyndrome by ®ltration ofcerebrospinal ¯uid

Guillain±BarreÂ Syndrome (GBS) is anacute polyneuropathy of unknown, butpresumed autoimmune, cause. Anaes-

thetists are often involved in the man-agement of such patients. We came tohear of cerebrospinal ¯uid (CSF) ®ltra-tion as treatment when one of us

attended a talk on the subject. Onfurther enquiries, we learnt that CSF



®ltration was originally developed in thelate 1980s in Germany [1±3]. Its useoutside Germany is relatively new and

we would like to report our experience.The reason for ®ltration is to remove (as

yet unknown) substances from the CSFthat cause the syndrome. Although not

aimed at any speci®c constituent, electronmicrographs of the ®lters following ®ltra-tion show cells, cellular debris, immune

complexes and other proteins attached tothe ®bres [2]. There is experimentalevidence that when CSF from GBS

patients is applied to nerve preparations,GBS-like changes are produced. Pro-duction of these changes can be negatedby prior ®ltration of the CSF [4±6].

However, there are no publishedrandomised clinical trials. In one study[2], 12 patients aged 12±75 years, who

had little or no response to plasmaphar-esis, underwent CSF ®ltration. Follow-ing treatment, measurement of CSF

protein showed a marked decrease inonly six patients but the authors claimedsome clinical improvement in all 12.

There was no correlation between clini-cal improvement and measurements ofimmune system activity, such as CSFproteins or serum immunoglobulins. A

randomised controlled trial was reportedto be underway in 1994 but, to date,does not appear to have been published

[3]. The idea of ®ltering the CSF toremove harmful constituents seemsattractive and has led to its use in other

conditions such as bacterial meningitis[7, 8] and other autoimmune diseases [9].

Our patient, a 59-year-old woman,was admitted with a 3-week history of

increasing weakness and paraesthesiae;GBS was diagnosed. Electrophysiologi-cal studies showed motor and sensory

involvement with signi®cant axonal loss.Initial therapy included immunoglo-bulins and plasmapharesis. After 3 weeks,

arti®cial ventilation was commenced.Following 15 months without improve-ment, we decided to try CSF ®ltration.

To do this, a Touhy needle is used to

introduce a 16-g epidural catheter intothe lumbar subarachnoid space. Thecatheter is attached to a CSF ®ltration

system made by Pall Biomedical. Thisconsists of a 0.2-mm polyester matrix®lter speci®cally made for CSF ®ltration

and a bypass with ¯ow controlledby means of one-way valves. A 50-mlsyringe is connected distal to the ®lter

and is placed into a bidirectional syringepump which withdraws 20±50 ml ofCSF at 1.5±2 ml.minÿ1 via the bypassbefore re-infusing the CSF through

the ®lter and back into the patient at2±4 ml.minÿ1. The course consisted of10 such cycles per day for 5 days. The

catheter was left in place throughout the

course which was then repeated via a freshcatheter at weekly intervals for 3 weeks.

Unfortunately, our patient did notappear to show any signs of improve-

ment after CSF ®ltration. This may havebeen due to the long delay in startingtreatment from the onset of the disease

(over a year) or it may be related to theelectrophysiology report of `signi®cantaxonal loss'. Six months later, she began

to show signs of recovery and 22 monthsfrom the start of arti®cial ventilation, thepatient was well enough to be discharged

from the intensive care unit and wenthome a month later.

We believe that this is the ®rst reportof this procedure in the UK and in the

anaesthetic literature. Anaesthetists maybe asked to carry it out, given their skillswith epidural catheters or may have

patients in their care in whom this treat-ment is carried out.

Y. TzabarM. White

Cumberland In®rmary,Carlisle CA2 7HY, UK

References

1 Wollinsky KH, Weindler M, HuÈlser PJ,

et al. Liquorpheresis (CSF-®ltration):

an effective treatment in acute and

chronic severe autoimmune

polyradiculoneuritis (Guillain±BarreÂ

syndrome). European Archives of

Psychiatry and Clinical Neuroscience

1991; 241: 73±6.

2 Wollinsky KH, HuÈlser PJ, Westarp ME,

Mehrkens HH, Kornhuber HH.

Cerebrospinal ¯uid pheresis in Guillain

BarreÂ syndrome. Medical Hypotheses

1992; 38: 155±65.

3 Wollinsky KH, HuÈlser PJ,

Mehrkens HH, Kornhuber HH,

RuÈdel R. Filtration of cerebrospinal

¯uid in acute demyelinating

polyneuropathy (Guillain±BarreÂ

syndrome). Annales de Medecine Interne

1994; 145: 451±8.

4 HuÈlser PJ, Weitholter H,

Wollinsky KH. Liquorpheresis

eliminates blocking factors from

cerebrospinal ¯uid in

polyradiculoneuritis (Guillain±BarreÂ

syndrome). European Archives of

Psychiatry and Clinical Neuroscience

1991; 241: 69±72.



5 Brinkmeier H, Wollinsky KH,

HuÈlser PJ, et al. The acute paralysis in

Guillain±BarreÂ syndrome is related to

a Na� channel blocking factor in the

cerebrospinal ¯uid. P¯ugers Archiv:

European Journal of Physiology 1992;

421: 552±7.

6 WuÈrz A, Brinkmeier H, Wollinsky KH,

Mehrkens HH, Kornhuber HH,

RuÈdel R. Cerebrospinal ¯uid and

serum from patients with in¯ammatory

polyradiculoneuropathy have opposite

effects on sodium channels. Muscle and

Nerve 1995; 18: 772±81.

7 Plauser B, Grubwieser G, BoÈsch S,

Vollert H, Herold M, Schmutzhard E.

Cerebrospinal ¯uid ®ltration reduces

TNF alpha in bacterial meningitis-

CSF. European Journal of Neurology

1995; 2: 570±2.

8 Brizzi M, ThoreÂn A, Hindfelt B.

Cerebrospinal ¯uid ®ltration in a case

of severe pneumococcal meningitis.

Scandinavian Journal of Infectious Diseases

1996; 28: 455±8.

9 Plauser B, BoÈsch S, Grubwieser G,

et al. Multimodal therapy in life-

threatening cerebral lupus

erythematosus: the bene®t of

cerebrospinal ¯uid pheresis.

International Archives of Allergy and

Immunology 1995; 107: 592±4.

Problems involved withanaesthetising patients withDHPR de®ciency

We read with interest the letter from DrsGill and Wyatt entitled Àn absolutecontraindication to nitrous oxide' (Anaes-

thesia 1999; 54: 307) in which the pro-blems involved with anaesthetisingpatients with dihydropteridine reductase(DHPR) de®ciency are discussed. There

are a number of situations in whichnitrous oxide must be used with caution.These include prolonged anaesthesia in

susceptible or debilitated patients, thosewith a pre-existing folate de®ciency andthe use of nitrous oxide for repeated

anaesthetics [1, 2]. The degree of haema-tological impairment has been assessed byquantifying both the changes in themorphology of bone marrow aspirates

and by the culture of haematopoieticstem cells from the peripheral blood.

However, we must remember that it

has been clearly shown that pretreatmentwith folinic acid can prevent theseadverse effects [3±5]. Furthermore, thereis also evidence to suggest that folinic acid

therapy prevents the undesirable meta-bolic effects of DHPR de®ciency itself[6]. It would therefore seem prudent to

consider pre-operative administration offolinic acid in patients with DHPR asan alternative to rejecting out of hand

a well-proven agent, which has clearclinical advantages.

D. J. DalgleishB. Sweeney

Poole Hospital,Dorset BH15 2JB, UK

References

1 Amos RJ, Amess JA, Hinds CJ,

Mollin DL. Incidence and pathogenesis

of acute megaloblastic bone marrow

change in patients receiving intensive

care. Lancet 1982; 2: 835±8.

2 O'Leary PW, Combs MJ, Schilling RF.

Synergistic deleterious effects of

nitrous oxide exposure and vitamin

B12 de®ciency. Journal of Laboratory and

Clinical Medicine 1985; 105: 428±31.

3 Skacel PO, Hewlett AM, Lewis JD,

Lumb M, Nunn JF, Chanarin I.

Studies on the haemopoietic toxicity

of nitrous oxide in man. British Journal

of Haematology 1983; 53: 189±200.

4 Nunn JF, Chanarin I, Tanner AG,

Owen ER. Megaloblastic bone

marrow changes after repeated nitrous

oxide anaesthesia. Reversal with folinic

acid. British Journal of Anaesthesia 1986;

58: 1469±70.

5 Amos RJ, Amess JA, Nancekievill DG,

Rees GM. Prevention of nitrous oxide

induced megaloblastic changes in bone

marrow using folinic acid. British

Journal of Anaesthesia 1984; 56: 103±7.

6 Irons M, Levy HL, O'Flynn ME, et al.

Folinic acid therapy in treatment of

dihydropteridine reductase de®ciency.

Journal of Pediatrics 1987; 110: 61±7.

Forearm venous pressures andblood back ¯ow

To prevent back ¯ow of blood down

an intravenous infusion line duringautomatic blood pressure cycling onthe same arm, we lightly pressurise the

infusion bag and adjust the infusion

clamp to the desired ¯ow. A more com-plicated method has been described [1].

To discover the infusion bag pressureneeded, we have measured forearm

venous pressures in a normotensive(120/80) volunteer (W.F.S.S.) and ontwo patients during major surgery. A

16G intravenous cannula was attachedto a three-way tap and pressure trans-ducer in the supine volunteer and a

resting venous pressure of 10 mmHgrose to a maximum of 60 mmHg as theautomatic blood pressure cuff de¯ated.

Forearm pressures in two anaesthetisedpatients rose to about two-thirds of thediastolic pressure. Maximum pressuresoccur as the diastolic pressure is being

measured and we now in¯ate our bags tothe patient's diastolic pressure.

K. VeaseyJ. Nelson

W. F. S. SellersKettering General Hospital NHSTrust,

Kettering NN16 8UZ, UK

Reference

1 Kondo M, Nomura R, Enoki T. A

simple device to prevent back ¯ow of

blood into the intravenous line.

Anesthesiology 1998; 88: 1693.

An unfortunate cause of death

A 62-year-old woman was admitted tothe Accident and Emergency department

following a cardiac arrest at home. Shehad a background history of noninsulin-dependant diabetes and epilepsy, both of

which were well controlled. On the dayof admission, she appeared to have a smallepisode of coughing followed by a col-lapse. The ambulance arrived within

10 min of being called and cardiopul-monary resuscitation was commenced.The patient was intubated by the para-

medic. In the Accident and Emergencydepartment, she had a Glasgow ComaScale of 3 out of 15, her pupils were

®xed and she required inotropic andrespiratory support. No other historywas available at this stage. The paramedic

who intubated her had reported seeing alarge mass in her mouth which on closerexamination seemed to be bleeding. An



ENT surgeon was called who diagnosed

a pharyngeal `tumour' and suggestedfurther investigation when the patientwas more stable.

The patient's family then arrived and

some additional information was obtained.Ten days previously she had had a similarcoughing episode and on that occasion she

had swallowed her dentures. Her G.P. hadbeen informed and an abdominal and chestX-ray were performed. The dentures

were not seen on either of these ®lms.Nothing else was done.

In the intensive care, the `tumour'

began to bleed and the ENT surgeonswere recalled. After an hour, they recov-ered her partial dentures, which had beenstuck in her nasopharynx for the previous

10 days and had presumably caused arespiratory obstruction leading to her car-diac arrest. She was eventually declared

brain dead and treatment was withdrawn.Metallic dentures are radio-opaque,

but acrylic dentures may not be visible

because of the surrounding tissue; this isan advantage of metallic dentures [1].Acrylic dentures would often not be

visible behind the mediastinum on achest X-ray and loops of bowel maymake it dif®cult to see on an abdominal®lm. It may be easier to see if a lateral

cervical spine or barium swallow [2] isperformed. Abdullah et al. [3] reported aseries of 200 patients with impacted

foreign bodies, 21 (11.5%) of whichwere dentures. They state that ®vewere detected by indirect laryngoscopy

and only seven were seen on plain radio-graphy. Sixteen of these patientsrequired endoscopic removal of the den-tures, two could not be removed and

were allowed to pass through the gastro-intestinal tract under close monitoringand the remaining three were only

detected when they were in fact passed.It is possible that a peripheral neuro-

pathy secondary to her diabetes had

allowed the patient to tolerate the den-tures in her mouth for so long. Nopharyngeal pouch was found at autopsy.

Abdullah et al. [3] suggest that in thepresence of a positive history and/orsymptoms, endoscopic examination andremoval should be performed.

G. D. Baigel

Kettering General Hospital,Kettering NN16 8UZ, UK

References

1 Davenport JC, Basker RM,

Heath JR, Ralph JP. Colour Atlas of

Removable Partial Dentures. Ipswich:

Wolfe Medical Publications, 1988, 109.

2 Sutton D. Textbook of Radiology and

Imaging, 5th edn. London: Churchill

Livingstone, 1993, 1241.

3 Abdullah BJ, Teong LK, Mahadevan J,

Jalaludin A. Dental prosthesis ingested

and impacted in the esophagus and

orolaryngopharynx. Journal of

Otolaryngology 1998; 27: 190±4.

Why not just ask the parent?

It is often said that medicine is an art,not a science. There are often no rightanswers. Our own practice is part evi-dence-based and part personal choice.

This is as apparent in anaesthesia as it isin the other medical specialities. Yetwe painfully try to ®nd the solution to

problems that, certainly in my lifetime,will not be resolved. Debate after debatecontinues over such controversial issues

as `regional anaesthesia ± awake or asleep'and `the CSE technique ± needlethrough needle or separate punctures'.

The `parents at induction' (Anaesthesia1999; 54: 507±8) highlights anotherexample about which I have a particularbugbear. At the end of the day and if

circumstances permit, we simply ask theparent whether they wish to escort thechild into the anaesthetic room (preferably

before they appear at the operating theatredoors). If they refuse ± ®ne. If they accept± ®ne. We cannot and should not force

parents to attend against their own wishes.And if it is felt that their presence in theanaesthetic room would place the child,parent or member of staff at risk, then this

should be clearly explained to them well inadvance. Isn't life straightforward?

I cannot see why we have to get on our

high horse about some things that, to me,just need a little bit of common sense.

J. M. CupittBooth Hall Children's Hospital,

Manchester M9 7AA, UK

Raynauld's phenomenon andpropofol

We should like to comment on a letter

written by Dr Gilston on pain andpropofol injection (Anaesthesia 1999;54: 307). Raynauld's phenomenon is a

well-recognised entity, characterised byspasm of the arterial supply of the ®ngersand toes. Injection of intravenous pro-pofol is therefore of little consequence,

irrelevant of injection site. There are, ofcourse, many alternative explanationsfor this patient's àgonising pain'.

Pain on injection of propofol is adistressing symptom with a high inci-dence [1], and many methods to avoid

this have been investigated including theuse of an anticubital vein [2]. Individualpain thresholds can vary 10-fold, and the

patient describing `the worst pain of mylife' was simply at one end of a descrip-tive spectrum in response to a recognisedside-effect. Despite the lack of support-

ing trials, the use of propofol 2% wouldmean a greater concentration of the drugin the aqueous phase (manufacturer's

information) which would lead to ahigher incidence and increased severityof pain on injection [3]. Perhaps these

factors are more relevant in explainingthe severity of the patient's symptoms.

P. H. DoddG. BiswasWycombe General Hospital,

High Wycombe HP11 2TT, UK

References

1 Stark RD, Binks SM, Dutka VN,

O'Connor KM, Arnstein MJA,

Glen JB. A review of the safety and

tolerance of propofol (`Diprivan').

Postgraduate Medical Journal 1985; 61

(Suppl. 3): 152±6.

2 Briggs LP, Clarke RSJ, Dundee JW,

Moore J, Bahar M, Wright PJ. Use of

di-isopropyl phenol as main agent for

short procedures. British Journal of

Anaesthesia 1981; 53: 1197±201.

3 Doenicke AW, Roizen MF, Rau J,

Kellerman W, Babl J. Reducing pain

during propofol injection: the role of

the solvent. Anesthesia and Analgesia

1996; 82: 472±4.



Epidural anaesthesia in theanaesthetised patient

Professor Rosen's letter (Anaesthesia

1999; 54: 510) prompts me to reporta similar case, as such cases are probablyunder-reported. Some years ago, a

patient in her late 30s produced aletter describing a complication ofanaesthesia. She had been anaesthetisedby an experienced consultant anaesthe-

tist in another hospital. The letterstated that the consultant had discussedher case with colleagues, and that none

was aware of a similar case, and nonecould explain the complication.According to the letter, after induction

of anaesthesia, an epidural had beenperformed for a gynaecological opera-tion. She was left with a permanent

foot-drop. She walked with dif®culty,wearing a device which helped toelevate the front of her shoe. Herquality of life had been seriously

impaired.Serious complications as a result of

performing spinal or epidural anaes-

thetics in anaesthetised patients are rare.However, it is our responsibility (Dutiesof a Doctor ± General Medical Council)

and our patients' expectation that weminimise the risk of serious complica-tions. We cannot achieve this by per-forming spinal or epidural anaesthesia in

the unconscious patient

J. J. HendersonWestern In®rmary,Glasgow G11 6NT, UK

Experts in our ®eld?

Dr P. W. Doyle (Anaesthesia 1999; 54:

510) is kind enough to consider me anexpert, but I fear that he did not read my

earlier letter (Anaesthesia 1999; 54: 86)closely enough. I did not say that I am`just an anaesthetist', but I made thepoint that, just like the author of an

earlier editorial (Anaesthesia 1998; 53:

727±9), I am an anaesthetist. In thateditorial, Dr Barrie Fischer had referred

to people who take a different view tohimself somewhat pejoratively as `medi-cal experts'. Thus I consider Dr Doyle's

comments irrelevant. I have no dif®cultyin standing up to be counted, but I

would be grateful if he would read

more carefully what I write. He mightalso usefully look at the letter from DrHelen Wise in the May issue of Anaes-thesia News on `status' of anaesthetists.

J. A. W. Wildsmith

Ninewells Hospital & MedicalSchool,Dundee DDI 9SY, UK

A plan for the NHS for the 21stcentury

I found the special article by ProfessorRosen valuable food for thought. I was,however, left disheartened by the state-

ment in his conclusion relating to publicwants and expectations that `there is along way to go to achieve these aims'.

While I agree with the statement, I feelthat the NHS already goes furthertowards meeting these aims than anycomparable healthcare system while the

cost is a fraction of similar systems. TheNHS is excellent value for money.While the expectations of the public,

the Royal Colleges, the General MedicalCouncil and the Department of Healthare of a superlative expert service, fund-

ing is of a bargain-basement level. If weare to make further progress, should wenot demand appropriate funding and

remuneration?Another point of interest for me was

the lack of representation of Cornish

towns in Table 1. Is Cornwall to be

abolished in the 21st Century?

Y. M. FishTreliske Hospital, Truro,Cornwall TRI 3LJ, UK

Editor's note

I understand that Table 1 was suppliedby the Of®ce for National Statistics in

Fareham, Hampshire, based on townswith a population in excess of 50 000.They have no plans to abolish Cornwall.

Scissors as a propofol ampoule`snapper'?

Injury associated with opening a propo-fol ampoule is a concern for anaesthetists

[1, 2]. The problem is the sharpenedvertical spike produced despite havingopened the ampoule in the manner

described on the packaging [2]. Severalideas have been reported to prevent thespike on the ampoule [3, 4], though any

where the ®ngers are close to the cuttingedge may be dangerous.

We have found a safer method for

opening a propofol ampoule. We graspthe ampoule with one hand with theblue spot facing upwards. Then we snapthe middle of the neck of the ampoule

using scissors held in the other hand.Amazingly, the cut edge is alwayssmooth without any spike (Fig. 1),



Figure 1

compared with a sharpened spike produced

by the recommended method (Fig. 2)

K. Koga

M. HiroseUniversity of Occupational andEnvironmental Health,

Kitakyushu, 807±8555, Japan

References

1 Stewart PC. A persistent problem with

glass ampoules. Anaesthesia 1997; 52:

509±10.

2 Ali PB. Persistent problem with propofol

ampoules. Anaesthesia 1997; 52: 1020.

3 Palmer J, Ball D. Opening propofol

ampoules. Anaesthesia 1998; 53:

416±17.

4 Morrison WJ. Another cracking idea.

Anaesthesia 1999; 54: 307±8.

Undecipherable abbreviations

Accepting the contents of a EuropeanMeeting to be published in Anaesthesia is

a laudable initiative of the Editors. Thesame standards in quality should, how-ever, be kept by the guest editors. In the

supplement to Anaesthesia, May issue, anarticle is published on `Haemodynamicchanges during surgery in the knee-elbow position' (Anaesthesia 1998; 53:

Suppl. 2, 12±14). This highly technicalpaper allows calculations of systolic timeintervals, resolutions, ratios, etc. We are

kindly informed that heart rate is thusabbreviated (HR), but are not informedwhat PEPi would mean or how valuable

intra-operative reduction of ABF couldbe in pre-existing cardiac disease.

It took Champollion about 15 years todecipher the hieroglyphs of the Rosetta

stone.I fear clinical anaesthetists don't have

the same opportunities.

G. Verheecke

St. Lueaskliniek (Klina),B-2180 Antwerp ± Ekeren, Belgium

Precordial stethoscopes inchildren

We use Nikomed ECG electrodes tohelp secure precordial stethoscopes inchildren (Fig. 1). They are ideal for this

purpose, given the limited space on achild's chest. In order to avoid extra-neous noises we also tape a face mask

over the stethoscope (Fig. 2). The ECGsignal is acceptable as long as theelectrode gel pads are not actually incontact with the metal plate of the

stethoscope.

W. F. S. SellersG. BaigelKettering General Hospital NHS

Trust,Kettering NN16 8UZ, UK



Figure 2

Figure 1

Figure 2

Documents

Epidural anaesthesia in the anaesthetised patient