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250]

Letters to Editor

Smita Prakash
Department of Anaesthesia and Intensive Care, Vardhman Mahavir
Medical College and Safdarjang Hospital, New Delhi, India
Address for correspondence:
Dr. Smita Prakash,
C 17 HUDCO Place,
New Delhi-110049, India.
E-mail: drsunilprakash@gmail.com

REFERENCES
1.

Ramkumar V. Preparation of the patient and the airway for

awake intubation. Indian J Anaesth 2011;55:442-7.
2. Williams KA, Barker GL, Harwood RJ, Woodall NM. Combined
nebulization and spray-as-you-go topical local anaesthesia of
the airway. Br J Anaesth 2005;95:549-53.
3. British Thoracic Society Bronchoscopy Guidelines
Committee, a Subcommittee of Standards of Care Committee
of British Thoracic Society. British Thoracic Society
guidelines on diagnostic flexible bronchoscopy. Thorax
2001;56(suppl 1):i1-21.
4. Langmarc EL, Martin RJ, Pak J, Kraft M. Serum lidocaine
concentrations
in
asthmatics
undergoing
research
bronchoscopy. Chest 2000;117:105560.
5. DiFazio CA. Local anesthetics: Action, metabolism, and
toxicology. Otolaryngol Clin North Am 1981;14:51551.
6. Ackerman S, Kleinman W, Nitti GJ, Nitti JT. Airway
Management, In: Morgan GE Jr, Mikhail MS, Murray MJ,
editors. Clinical Anesthesiology. 3rd ed. New York City, U.S.
McGraw-Hill; 2001. p. 59-85.
Access this article online
Quick response code
Website:
www.ijaweb.org

DOI:
10.4103/0019-5049.96322

Management of difficult airway.

Awake and under anaesthesia
Sir,
We read with great interest the review article by
Dr.Ramkumar on airway for awake intubation[1] and
had few additions and suggestions to be made on the
content published.
The title of the article is about awake intubation for
difficult airway (DA); however, the author mentions in
great detail about intubation under anaesthesia, preoxygenation with 100% oxygen and muscle relaxants.
The title could probably have been, Management of
DA: Awake and under anaesthesia. The author seems
210

preoccupied with fibreoptic intubation (FOI) for

management of DA. FOI no doubt is the best available
modality for awake DA, but not a panacea for DA
management.[2] Retrograde intubation, blind nasal
intubation, laryngeal mask and direct laryngoscopy
under airway blocks can be performed under expert
hands to secure awake DA, and could have been
mentioned in detail in the article. We would have
liked to read on DA in an emergency situation too.
Psychological preparation of the patient mentions that
consent for surgical airway or cricothyridotomy is
always preferred. Asurgical patent and secure airway
still remains as the last resort in DA management
in spite of latest airway gadgets, and remains the
ultimate rescue measure in emergency DA.
We would like to add on ketamine as an alternate drug
for sedation for FOI. Low-dose ketamine is frequently
used for paediatric bronchoscopies as well as for
conscious sedation DA intubations, either alone or in
combination with hypnotics, opiods and sedatives.[3]
The author mentions about fibreoptic bronchoscopy
(FOB) under general anaesthesia with muscle relaxants.
We feel that if it is easy to mask ventilate the patient,
it is preferable to use a non-depolarizing relaxant
rather than succinylcholine. It gives enough time
for the endoscopist for controlled laryngoscopy and
fibrescopy as well as for training students. Moreover,
we usually perform a check direct laryngoscopy
after FOB to visualize the Cormack Lehane grade. It
gives us confidence during extubation of the DA and
determines whether reintubation is possible with or
without fibreoscopy.
The discussion on airway blocks does not mention
the complications of the techniques. They are either
common (haematoma, inadvertent arterial injection) or
specific to a block, e.g. vascular, posterior tracheal wall
and vocal cords damage, subcutaneous emphysema
with trans-tracheal block and upper airway obstruction
due to relaxation of musculature around the base of
the tongue following glossopharyngeal nerve block.

Ashish Bangaari, Trevor Nair

Department of Anaesthesiology, MIOT Hospitals, Manapakkam,
Chennai, Tamil Nadu, India
Address for correspondence:
Dr. Ashish Bangaari,
Department of Anaesthesiology, MIOT Hospitals, 4/112,
Mount Poonamallee Road, Manapakkam, Chennai,
Tamil Nadu-600089, India.
E-mail: ashishbangaari@gmail.com

Indian Journal of Anaesthesia | Vol. 56| Issue 2 | Mar-Apr 2012

[Downloaded free from http://www.ijaweb.org on Saturday, December 12, 2015, IP: 181.112.82.250]

Letters to Editor

REFERENCES
1.

Ramkumar V. Preparation of the patient and the airway for

awake intubation. Indian J Anaesth 2011;55:442-7.
2. Ng A, Vas L, Goel S. Difficult paediatric intuabation when
fibreoptic laryngoscopy fails. Paediatr Anesth 2002;12:801-5.
3. Javid MJ. Subcutaneous dissociative conscious sedation
(sDCS) an alternative method for airway regional blocks;
Anew approach. BMC Anesthesiology 2011;11;19.
Access this article online
Quick response code
Website:
www.ijaweb.org

DOI:
10.4103/0019-5049.96323

Removing a trapped epidural

catheter: Concerns
Sir,
We read with interest the article titled A rare
complication of epidural anaesthesia a case report
with brief review of literature.[1] Such cases are more
common on obstetric patients.[2] The authors managed
a knotted epidural catheter by slow, steady and gentle
traction. Although they were successful in getting the
catheter intact, this technique may not be advocated as
the technique as concluded by the authors. Although
the catheter is inert, it may be non-biodegradable and,
therefore, any broken catheter is always a concern for
the patient, surgeons and anaesthesiologists as well.
The authors took four attempts without any
modification, like change on patient position or
injection of saline, etc. to remove the catheter.[3,4]
Although the authors have not mentioned how much
the length of the catheter increased with stretching,
but excessive stretching could increase the chances of
catheter breakage. The force applied during removal
of the trapped catheter should be the least, and various
manoeuvres have been described to ease the removal
of catheter without undue force.[3] Patients position
manipulations are the most frequently attempted
[4]
The
initial methods to free entrapped catheters.
flexion of spine in lateral decubitus position may ease
the removal of catheter.[5] If it is suspected that a knot
has formed, some authors have suggested using a small
and steady force for withdrawal (but not multiple
Indian Journal of Anaesthesia | Vol. 56| Issue 2 | Mar-Apr 2012

attempts), to stop pulling if the catheter begins to

stretch too much (not reported by the authors in this
case report), placing the patient in various positions
(e.g., the same position as on insertion, the lateral
decubitus position and a flexion or extension position)
(again not described by the authors) and injecting
normal saline through the catheter (not used by the
authors).[1,6,7] The injection of saline in the catheter
could either make it stiff for its easy removal or, at
times, if injected in initial attempts, may uncoil the
catheter and thus avoid knotting. Although position
during removal has not been described by the authors,
there is evidence indicating that the withdrawal force
is reduced in the lateral decubitus position, and the
force required to remove an epidural catheter was
2.5-times more with a patient in the sitting position
[8]
than in the lateral decubitus position.
Different
patient positions during insertion or removal of the
catheter may increase the resistance. For example,
excessive force might be applied if the catheter
is placed while the patients back is arched but is
removed with the patient in a different position (e.g.,
sitting position).[9] Morris etal. recommend that the
patient be placed in the same position for insertion
and withdrawal of the catheter.[5] It becomes prudent
that if resistance is encountered then each repeat
attempt should be with some manoeuvres as we
usually advocate for repeat laryngoscopy in difficult
airway.
The catheter could entangle the bony structures
or even a nerve. An injection of sterile saline may
help determine whether the catheter is knotted,
kinked or entangled. It could be more informative
if the author could mention the type of the epidural
catheter and whether it has a radioopaque marker
on it or not. The X-ray may reveal the status of the
catheter if it is radioopaque and, if nonradioopaque,
then injecting some radiopaque dye may make it
possible to visualize it on the X-ray, and status of the
catheter can be visualized.[10] In the era of evidence
medicine and presence of radiological investigations,
it will always be advisable to evaluate the status of
the catheter before removing a struck catheter in
multiple attempts without the use of any adjunct.
Also, the characteristics inherent to the materials
(not mentioned by the authors) of the epidural
catheters could also predict the risk of breakage. The
tensile strength of various epidural catheters was
evaluated, and the authors concluded that nylon or
polyurethane catheters were more resistant than
Teflon or polyethylene catheters.[11]
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