Download - Labelling of obstetric patients
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 `acceptable' 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
`Orphan 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 `insertionof 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 `in 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 `a ®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
placement of the laryngeal mask
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
placement of the laryngeal mask
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................................................................................................................................................................................................................................................
911Q 1999 Blackwell Science Ltd
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: `It 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
Correspondence Anaesthesia, 1999, 54, pages 909±920................................................................................................................................................................................................................................................
912 Q 1999 Blackwell Science Ltd
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
Anaesthesia, 1999, 54, pages 909±920 Correspondence................................................................................................................................................................................................................................................
913Q 1999 Blackwell Science Ltd
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
Correspondence Anaesthesia, 1999, 54, pages 909±920................................................................................................................................................................................................................................................
914 Q 1999 Blackwell Science Ltd
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±Barre 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
Anaesthesia, 1999, 54, pages 909±920 Correspondence................................................................................................................................................................................................................................................
915Q 1999 Blackwell Science Ltd
®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
Barre 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.
Correspondence Anaesthesia, 1999, 54, pages 909±920................................................................................................................................................................................................................................................
916 Q 1999 Blackwell Science Ltd
5 Brinkmeier H, Wollinsky KH,
HuÈlser PJ, et al. The acute paralysis in
Guillain±Barre 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 `An 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
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917Q 1999 Blackwell Science Ltd
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 `agonising 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.
Correspondence Anaesthesia, 1999, 54, pages 909±920................................................................................................................................................................................................................................................
918 Q 1999 Blackwell Science Ltd
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),
Anaesthesia, 1999, 54, pages 909±920 Correspondence................................................................................................................................................................................................................................................
919Q 1999 Blackwell Science Ltd
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
Correspondence Anaesthesia, 1999, 54, pages 909±920................................................................................................................................................................................................................................................
920 Q 1999 Blackwell Science Ltd
Figure 2
Figure 1
Figure 2