0Sir,
We read with interest the review article regarding difficult airway and positioning of obese parturient for intubation.111 We would like to add a comment with reference to position, which would benefit the readers. Ramp position is widely accepted for intubating obese patients. Obtaining optimal ramp position using blankets folded under the chest and head would be tedious as it is a trial-and-error method involving adding or removing blankets.[2] Also, it would be troublesome to remove those blankets after the patient has been anaesthetized as it may cause inadvertent disconnection of monitors and breathing circuits, as well as injury to the patient or the operating room personnel. Also, the "head up" position may cause haemodynamic instability after induction of anaesthesia, which might be undesirable in the setting of obstetric emergency. To avoid this, supine position should be achieved as soon as possible after endotracheal intubation, which might take a few moments. To overcome these problems, alternative methods have been described in the literature to achieve ramp position, which include Rapid Airway Management Positioner [RAMP] system and 25-degree 'back up" position [TABLE RAMP].[3-4] In both these techniques, one can position and reposition the patient comfortably in less time.
Chitra Rajeswari Thangaswamy, Lenin Babu Elakkumanan
Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and
Research, Puducherry, India
Address for correspondence:
Dr. Lenin Babu Elakkumanan, Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research,
Puducherry, India.
E-mail: dr.lenin@gmail.com
REFERENCES
1. Rao DP, Rao VA. Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new? Indian J Anaesth 2010;54:508-21.
2. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: A comparison of the "sniff' and "ramped" positions. Obes Surg 2004;14:1171-5.
3. Cattano D, Melnikov V, Khalil Y, Sridhar S, Hagberg CA. An evaluation of the rapid airway management positioner in obese patients undergoing gastric bypass or laparoscopic gastric banding surgery. Obes Surg 2010;20:1436-41.
4. Rao SL, Kunselman AR, Schuler HG, DesHarnais S. Laryngoscopy and tracheal intubation in the head-elevated position in obese patients: a randomized, controlled, equivalence trial. Anesth Analg 2008;107:1912-8.
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Rapid Airway Management Positioner (RAMP) system is a new positioning system, which has been evaluated in morbidly obese patients for bariatric surgery and found to be effective.131 This contains specially designed inflatable chambers, which would be filled with compressed air or nitrogen. Because of the need for compressed air or nitrogen, it may not be available in all hospitals. Another alternative would be TABLE RAMP, which is made using the electronic table; it controls and flexes the table at trunk-thigh hinge and raises the trunk portion of the table to optimal position.[4] The head piece of the table may or may not be removed depending upon the patient's height. This technique has been compared with classical positioning with blankets, and it has been found that both are equivalent. But we believe that the TABLE RAMP has the advantage of making the patient assume supine position immediately; unlike with the blankets, which takes longer time. Operating room table with electronic control would be available in majority of the hospitals. So whenever feasible, TABLE RAMP should be used to achieve ramp position for intubating an obese parturient.
Use of LMA as ventilatory device for PCT: Our experience
This is to highlight the difficulties experienced and the solutions reached while doing percutaneous tracheostomy (PCT) in our critical care setup. We have done 67 PCTs between March 2008 and Sept 2010. In our neurosurgical ICU, these PCTs were done for patients requiring prolonged ventilation to facilitate better pulmonary toileting and expedite weaning from ventilator. PCT is commonly performed by either Griggs or Ciaglia (multiple/single dilator) techniques.111 At our institute, we use the Griggs technique. The problems encountered were essentially of airway management during the procedure.
Initially, we used to withdraw the endotracheal tube
(ETT) so as to keep the cuff just distal to the glottis, as described in the original technique. While 39 cases were done using ETT cuff distal to the glottis, we faced complications in 6 of the cases. In four of our cases, cuff/ETT wall was punctured by the introducer needle. In one case, there was difficulty in introduction of dilator, while in another one case there was entanglement of guide wire in ETT.
To overcome these problems, we modified the technique and the ETT was withdrawn further, so as to keep the cuff just proximal to the glottis (in 18 cases) and cuff was inflated with 20 ml air and pressed onto glottis to maintain tight seal during IPPV. However, in 3 out of these 18 cases, the ETT got displaced during the crucial steps of the procedure, leading to desaturation which was managed by reintubation.
So, keeping these problems in mind, we used LMA in our last 10 cases without encountering any of the above mentioned complications as seen with ETT with cuff proximal or distal to glottis.[2]
The patients requiring PCT are usually on ventilator for more than 10 days and are having thick / copious secretions. To decrease the risk of aspiration patients are kept NPO for 6 h and, LMA placed after thorough oral suction. The LMA is used for airway management for minimum time (10-15 min, only procedure time). So, aspiration of secretions and inability to maintain PEEP do not pose much of a problem.
We can use fibreoptic bronchoscope also, through LMA,[3] which allows direct step-by-step visualization of procedure and significantly reduces incidence of complications such as posterior tracheal wall tear, false passage, pneumothorax and subcutaneous emphysema thus, making the procedure very safe. In our set up, we could not use fibreoptic endoscope, as it was not readily available. We never encountered any of the above complications in our series. In view of potential advantages of low risk of accidental tube puncture, extubation and no need for an additional assistant, we suggest that LMA, be used, wherever possible as a ventilatory device during PCT.
Sneh Lata, Amit Kumar, Adarsh C Swami, Sunny Rupal,
Ashwini Sharma
Department of Anaesthesiologists', Fortis Hospital, Mohali, Punjab, India
Address for correspondence:
Dr. Sneh Lata,
B 142, Kendriya Vihar, Sector 48 B, Chandigarh 160 047, India.
E-mail: drsneh@rediffmail.com
REFERENCES
1. Kost KM. Percutaneous tracheostomy: Comparison of Ciaglia and Griggs techniques. Crit Care 2000;4:143-6
2. Linstedt U, Möller F, Grote N, Zenz M, Prengel A. Intubating laryngeal mask as a ventilatory device during percutaneous dilatational tracheostomy: A descriptive study. Br J Anaesth 2007;99:912-5.
3. Linstedt U, Zenz M, Krull K, Häger D, Prengel AW. Laryngeal mask airway or endotracheal tube for percutaneous dilatational tracheostomy: A comparison of visibility of intratracheal structures. Anesth Analg 2010;110: 1076-82.
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lili 111
DOI: 10.4103/0019-5049.79882
Patient with post infective demyelinating disease for dynamic hip screw repair under epidural anaesthesia
We report a case of a 47-year-old female weighing 35 kg, height - 150 cm, of Post Infective Chronic Demyelinating Disease, for a Dynamic Hip Screw of right intertrochanteric fracture femur. She was diagnosed with chronic demyelinating disease 3 years ago following Falciparum malaria. Magnetic resonance imaging showed tiny nodular, hyperintense lesion in right corpus callosum, possibly lacunar infarct/focal demyelination. After injection artesunate, dopamine infusion for 48 hours, injection Methylprednisolone 500 mg BD, she improved, with residual lower limb weakness, ptosis and dysarthria. She walked minimally until 2 weeks ago when she sustained a right-sided intertrochanteric fracture, following a fall. She was conscious, oriented, speech suggestive of spastic dysarthria, right eye ptosis with bilateral restricted extraocular movements. Other cranial nerves were normal.
All limbs had hyperreflexia, spasticity, muscle wasting, motor power 3/5, equivocal Babinski's sign and ill-
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