1124

LETTERS TO THE EDITOR

I am raising this alert because it is a preventable, iatrogenic

danger and suggest:
1. Careful collection of the removed staples away from the surgical field and subsequent safe disposal into sharps-disposal
devices.
2. Sticking to the good, old habit of keeping a vigilant watch on
the surgical field and the patient under anaesthesia (rather
than relaxing away in the high-tech, sophisticated anesthesia
environment).
3. Being aware of such a possibility when some airway complication occurs in a similar situation.
I hope this warning letter may help prevent any such complication in future.
Prasad V. Akole, DNB (Anaesthesiology)
Department of Anaesthesiology
Critical Care and Pain
Tata Memorial Hospital and Cancer Research Centre
Mumbai, India

Reference
1. Finkelstein DM, Noyek AM, Friedberg J, Goldberg M. Inhalation of a safety pin by a
laryngectomized patient: a case report. J Otolaryngol 1989;18:189 92.
DOI: 10.1213/01.ANE.0000025157.75597.15

Per Oral Removal of Tapeworm Following

Vomiting After Surgery
To the Editor:
A 20-yr-old patient with ASA physical status I underwent an uneventful lower segment cesarean section for cephalopelvic disproportion under subarachnoid block. While the dressing was being
applied, the patient started complaining of nausea and vomited out
a small volume of fluid. Following this, she felt a burning sensation
in the throat. Her heart rate, arterial blood pressure, and oxygen
saturation were 82 bpm, 124/76 mm Hg and 99%, respectively.
Metoclopramide was administered slowly IV. The burning sensation continued and in addition, she now felt some fullness in the
throat. She became restless and while being transferred on the
trolley, she put her hand in the mouth and took out a curled up
tape-like structure from her mouth. On closer examination, it was
noted to be a 128-cm long tapeworm. She appeared comfortable
after this but about 5 min after transfer to the recovery area, she
vomited once again and pulled out another tapeworm (64 cm) from
her throat. Her vitals through the two episodes remained stable. The
burning sensation disappeared after she pulled out the second
tapeworm. On questioning, she gave a history of eating pork once in
a while over the last few years. She was referred to the attending
physician who treated her with niclosamide. The postoperative
period was uneventful and she was discharged on the 7th postoperative day.
Man is the final host in the life cycle of tapeworm that grows
mainly in the upper jejunum. Infection in man occurs generally by
eating raw or undercooked meat containing the cysticercus stage. In
the stomach, proteolytic enzymes dissolve the capsule of the cyst
and the parasite attaches itself to the intestinal mucosa. Infection can
also be acquired by ingestion of mature eggs or egg-laden segments
(proglottides) that are passed out with stools from time to time (1).
Intestinal tapeworms are considered to be minimally pathogenic
causing little or no symptoms, but they do utilize some of the food
consumed by the host and some of the species are known to cause
pernicious anemia. Clinical manifestations of tapeworm infestation
are often mild and infections may remain unrecognized or inadequately treated for many years (2). However, the problems frequently occur when man develops cysticercosis.
We wish to create awareness that a tapeworm can pass out orally
with vomit in the immediate postoperative period. As the terminal
segments of the tape worm (proglottides) are laden with mature
eggs, the possibility of the anesthetist contaminating his hands with
eggs and thereby getting infected while handling such a patient

ANESTH ANALG
2002;95:1119 28

cannot be ruled out. We suggest that an anesthetist wear gloves

while dealing with a patient who is vomiting.
Vandana Chugh, MD
Baljit Singh, MD
Department of Anesthesiology
Lady Hardinge Medical College and Associated Hospitals
New Delhi, India

References
1. Andreassen J. Intestinal tapeworms. In: Collier L, Balows A, Sussman M, eds. Topley
& Wilsons Microbioloy and microbial infections. Vol 5, Parasitology, 9th ed. London:
Arnold, 1998:52137.
2. Wright EP, Jain S. Human infestation by Taenia saginata lasting over 20 years.
Postgrad Med J 1984;60:495 6.
DOI: 10.1213/01.ANE.0000022684.46533.67

Anticipated Difficult Airway: The Role

of Fiberoptics
To the Editor:
Sir, we read with great interest the article of Arya et al. (1) who
describe a modified retrograde intubation for the management of a
patient with bilateral ankylosis of the temporomandibular joint.
Although they mention the unavailability of a fiberscope, we want
to emphasize that this method should have been discussed. Today
it is generally accepted that the fiberoptic intubation in the awake
patient is a very important approach, if not even the method of
choice in the management of the anticipated difficult airway (2,3).
Surveys from the United States, France, and Denmark (4 6) have
shown that despite the availability of different airway tools, anesthesiologists prefer to use the fiberscope as the only additional
instrument for the management of the anticipated difficult airway.
Therefore the demand to learn this method is evident.
Thomas Heidegger, MD
Hansjo rg Gerig, MD
Department of Anesthesiology
Cantonal Hospital
St. Gallen, Switzerland

References
1. Arya VK, Dutta A, Chari P, Sharma RK. Difficult retrograde endotracheal intubation:
the role of a pharyngeal loop. Anesth Analg 2002;94:470 3.
2. Practice guidelines for management of the difficult airway: a report by the American
Society of Anesthesiologists Task Force on Management of the Difficult Airway.
Anesthesiology 1993;78:597 602.
3. Heidegger T, Gerig HJ, Ulrich B, Kreienbu hl G. Validation of a simple algorithm for
tracheal intubation: daily practice is the key to success in emergenciesan analysis of
13,248 intubations. Anesth Analg 2001;92:51722.
4. Rosenblatt WH, Wagner PJ, Ovassapian A, Kain ZN. Practice patterns in managing the
difficult airway by anesthesiologists in the United States. Anesth Analg 1998;87:1537.
5. Avargue`s P, Cros AM, Daucourt V, et al. Management of difficult intubation by French
anaesthetists and impact of the French experts conference. Ann Fr Anesth Re anim
1999;18:719 24.
6. Kristensen MS, Moller J. Airway behaviour, experience and knowledge among Danish
anaesthesiologists: room for improvement. Acta Anaesthesiol Scand 2001;45:11815.
DOI: 10.1213/01.ANE.0000025156.75597.5C

In Response:
We fully agree with Heidegger et al. (1) regarding the use of the
fiberscope as the primary additional instrument for management of
anticipated difficult airway, and every anesthesiologist should have
the skill to use the same. The flexible fiberscope is definitely safer,
effective, and a relatively atraumatic device in experienced hands.
However, in certain situations, although only a few have been
reported, the fiberscope-aided attempts have failed or proven very
difficult (2 4). Alternate techniques of difficult airway management, as described by us (5), may also prove useful in such scenarios
in addition to a situation when a fiberscope is not available.
Virendra K. Arya
Amitabh Dutta
Chandigarh, India

References
1. Heidegger T,Gerig HJ, Ulrich B, Kreienbuhl G. Validation of a simple algorithm for
tracheal intubation: daily practice is the key to success in emergenciesan analysis of
13,248 intubations. Anesth Analg 2001;92:51722.

ANESTH ANALG
2002;95:1119 28

LETTERS TO THE EDITOR

2. Mason RA. The obstructed airway in head and neck surgery. Anaesthesia 1999;54:
625 8.
3. Podder S, Dutta A, Chari P. Retrolaryngeal extension of goiter in a morbidly obese
patient leading to a difficult airway. Anaesthesia 2000;55:1219 21.
4. Kanaya N, Nakayama M, Seki S, Kawana S, Watanabe H, Namiki A. Two person
technique for fiberscope aided tracheal intubation in a patient with long and narrow
reteropharyngeal airspace. Anesth Analg 2001;92:16113.
5. Arya VK, Dutta A, Chari P, Sharma RK. Difficult reterograde endotracheal intubation:
the role of a pharyngeal loop. Anesth Analg 2002;94:470 3.

1125

amount of flow through the catheter, and that all the standards
should be revised to offer less variability in the ID and OD of
needles and catheters.
Wonsik Ahn, MD
Jae-Hyon Bahk, MD
Young-Jin Lim, MD
Department of Anesthesiology and Clinical Research Institute
Seoul National University Hospital
Seoul, Republic of Korea

References

The Gauge System for the Medical Use

To the Editor:
The size of needles and catheters is categorized by the gauge
system. Medical references about the definition of gauge are not
available. In the early 19th century, Peter Stubs invented the socalled gauge system but a definition was not included, and only
an arbitrary conversion table for the iron wire existed (1). Recently,
the International Organization for Standardization (ISO) published
some guidelines for the dimensions of needles and catheters (Tables
1 and 2) (2 4). For the needles, ISO standards for inner and outer
diameters (ID and OD) are available, but for the catheters, only OD
standards are available. In addition, the needles and catheters of the
same gauge appear to have different IDs and ODs. Thus, whenever
we want to know the exact ID or OD of needles or catheters, e.g.,
combined spinal-epidural techniques, spinal needle insertion
through an introducer, comparison with French system or guidewire insertion during the retrograde intubation etc., we have to
refer to the manufacturers catalog or contact the customer representatives. We suggest that ISO should set some guidelines for
IDs of catheters because it is ID that mainly determines the

1. Iserson KV. The origins of the gauge system for medical equipment. J Emerg Med
1987;5:45 8.
2. ISO 9626: Stainless steel needle tubing for the manufacture of medical devices, 1st ed.
Geneva: International Organization for Standardization, 1991:12.
3. ISO 9626: Stainless steel needle tubing for the manufacture of medical devices, Amendment 1. Geneva: International Organization for Standardization, 2001:12.
4. ISO 10555-5: Sterile, single-use intravascular cathetersPart 5: Over-needle peripheral
catheters, 1st ed. Geneva: International Organization for Standardization, 1996:13.
DOI: 10.1213/01.ANE.0000025152.75597.49

Pharmacological Prevention of
Postanesthetic Shivering
To the Editor:
We question why in their study investigating drugs for preventing
postanesthetic shivering Piper et al compared placebo with dolasetron and clonidine (1). We also wonder why they state that a
dose-response study would be scientifically important and economically justified only if its side-effect profile were significantly superior to that of established drugs.

Table 1. Dimensions of Medical Needles

Range of outside diameters
(mm)

Minimum inside diameter of tubing (mm)

Gauge*

Minimum

Maximum

Normal-walled

Thinwalled

Extra-thinwalled

29
27
26
25
22
20
19
18
17
16
14

0.324
0.400
0.440
0.500
0.698
0.860
1.030
1.200
1.400
1.600
1.950

0.351
0.420
0.470
0.530
0.730
0.920
1.100
1.300
1.510
1.690
2.150

0.133
0.184
0.232
0.232
0.390
0.560
0.648
0.790
0.950
1.100
1.500

0.190
0.241
0.292
0.292
0.440
0.635
0.750
0.910
1.156
1.283
1.600

0.522
0.687
0.850
1.041
1.244
1.390
1.727

* Needle gauge selection is based on the commonly used medical products of large market share.
(This table was modified from ISO 9626:1991/Amd.1:2001 and is reproduced with the permission of the International Organization for Standardization [ISO].
These standards can be obtained from any ISO member and from the Web site of the ISO Central Secretariat at the following address: http://www.iso.org.
Copyright remains with ISO.)

Table 2. Gauge and Corresponding Sizes of Intravascular Catheters

Gauge*

Range of actual outside diameter

(mm)

24
22
20
18
16
14

0.6500.749
0.7500.949
0.9501.149
1.1501.349
1.5501.849
1.8502.249

Nominal outside diameter

of catheter tube (mm)
0.7
0.8;
1.0;
1.2;
1.6;
1.9;

0.9
1.1
1.3
1.7; 1.8
2.0; 2.1; 2.2

* Catheter gauge selection is based on the commonly used medical products of large market share.
(This table was modified from ISO 10555-5:1996 and is reproduced with the permission of the International Organization for Standardization [ISO]. These
standards can be obtained from any ISO member and from the Web site of the ISO Central Secretariat at the following address: http://www.iso.org. Copyright
remains with ISO.)