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Letters to the Editor

Two Other Simple Methods to Protect the Tracheal Cuff of a Double-Lumen Tube

To the Editor:

Coppa and Brodsky (1) described a method to protect the tracheal cuff of a double-lumen tube (DLT) from damage by teeth or by the laryngoscope blade during intubation of the airway. It probably works well, but it seems complicated. Erb (2) described a less difficult method to protect the cuff with a well lubricated teeth- guard and by lubricating the cuffs of the DLT. There are two other methods to protect the tracheal cuff of a DLT that are simple and require no additional material, help, or effort.

  • 1. Increase the curve of the endobronchial part of the DLT with the aid of the stylet included, such as a hockey stick, as for a difficult intubation. Thus, during the laryngoscopy, the DLT is placed in the airway, and the tracheal cuff is inserted inside the mouth without touching the teeth or the laryngoscope blade. All that remains is to intubate. It is easy and works well, without making intubation more difficult.

  • 2. Another method consists of first inserting the DLT until the tracheal cuff is placed inside the mouth, then visualizing the anatomy and intubating after the laryngoscope is inserted.

Ghislain Fortier, MD, Sophie St-Onge, MD, FRCP(C) Jean Bussie`res, MD, FRCP(C)

Department of Anesthesia University Heart and Lung Institute Laval Hospital Ste-Foy, Que´bec, Canada G1V-4G5

We failed to obtain a response from Dr. Brodsky.


  • 1. Coppa GP, Brodsky JB. A simple method to protect the tracheal cuff of a double-lumen tube [letter]. Anesth Analg 1998;86:675.

  • 2. Erb JM. A less difficult method to protect the tracheal cuff of a double-lumen tube [letter]. Anesth Analg 1998;87:1217.

The Cost-Effectiveness of Methohexital Versus Propofol: The Stability of Reconstituted Methohexital Should Eliminate Waste

To the Editor:

We read with interest the article by Sa Rego et al. (1) regarding the use of propofol versus methohexital for monitored anesthesia care. The authors state that, as a result of their institution’s policy of limiting the use of a reconstituted vial of methohexital to one patient, they found no overall cost savings in their study. They further state that drug costs associated with using methohexital could be significantly reduced by dividing the 500-mg vial into multiple dosage units. Barbiturates, such as methohexital and thiopental, are stable in solution beyond the period indicated in the product labeling. Beeman et al. (2) demonstrated that methohexital is chemically stable for at least 6 wk when stored at 4°C. We have similarly shown that thiopental is stable for at least 13 days when stored at 4°C (3). As a result of their high pH, solutions of these drugs also inhibit

  • 1064 Anesth Analg 1999;89:1064–70

microbial growth (2,4,5). Our operating room pharmacy has asep- tically manufactured unit-dose syringes from bulk packages for both of these drugs for several years without wastage of any unit- dose syringes so manufactured. Despite the limited expiration dating provided by manufacturers for many anesthetics, it is common for independent postmarketing drug stability data to be published. These data should be used by practitioners to avoid unnecessary waste of expensive medications.

Eric L. Chernin, RPh* Barry Smiler, MD†

Departments of *Pharmaceutical Care Services and †Anesthesia Sarasota Memorial Hospital Sarasota, Florida 34239



Sa Rego MM, Inagki Y, White PF. The cost-effectiveness of methohexital versus propofol for sedation during monitored anesthesia care. Anesth Analg 1999;88:723–8.


Beeman CS, Dembo J, Bogardus A. Stability of reconstituted methohexital sodium. J Oral Maxillofac Surg 1994;52:393–6.


Chernin EL, Stewart JT, Smiler B. Stability of thiopental sodium and propofol in polypropylene syringes at 23 and 4 degrees C. Am J Health Syst Pharm 1996;53:1576–9.


Crowther J, Hrazdil J, Jolly DT, et al. Growth of microorganisms in propofol, thiopen- tal, and in a 1:1 mixture of propofol and thiopental. Anesth Analg 1996;82:475–8.


Sosis MB, Braverman B, Villaflor E. Propofol, but not thiopental, supports the growth of Candida albicans. Anesth Analg 1995;81:132–4.

In Response:

Chernin and Smiler have suggested that methohexital wastage can be eliminated by storing unit-doses at 4°C because the reconstituted drug is chemically stable for at least 6 wk (1). As suggested in our recent article (2), dividing the 500-mg vial into multiple unit-dose syringes would significantly reduce wastage. However, we question the validity of their statement that by utilizing unit doses (manu- factured by the operating room [OR] pharmacy from bulk packages of methohexital), no “wastage of any unit-dose syringes” has oc- curred for several years. Given the variability in methohexital dos- age requirements that exists among patients, it is virtually impos- sible to eliminate all wastage. Even when our OR pharmacy prepares individual syringes containing 100 mg of methohexital for patients undergoing electroconvulsive therapy procedures, there is inevitable wastage because most of these patients require only 60–80 mg of the anesthetic drug per treatment. The only way to effectively eliminate wastage of methohexital is to draw only what is needed for a given case from a reconstituted 500-mg multi-dose vial and then return all of the unused drug in the vial to the pharmacy for use at a later date. Unfortunately, we have had a very difficult time convincing our local OR pharmacists (and colleagues) that this is a reasonable practice because of their con- cerns regarding the possibility of cross-contamination. Neverthe- less, we strongly support the concept that practitioners should try to avoid unnecessary wastage of anesthetic drugs.

Paul F. White, PhD, MD, FANZCA

Department of Anesthesiology and Pain Management University of Texas Southwestern Medical Center at Dallas Dallas, TX 75235-9068

Monica Sa Rego, MD

Resident in Anesthesia Harvard Medical School Boston, MA 02115




Beeman CS, Dembo J, Bogardus A. Stability of reconstituted methohexital sodium. J Oral Maxillofac Surg 1994;52:393–6.


Sa Rego MM, Inagaki Y, White PF. The cost-effectiveness of methohexital versus propofol for sedation during monitored anesthesia care. Anesth Analg 1999;88:723–8.

©1999 by the International Anesthesia Research Society





Percutaneous Electrical Nerve Stimulation or Acupuncture

To the Editor:

As a pain specialist who has used acupuncture for 15 yr, I was happy to read about the use of this technique in a prestigious journal (1). Based on my reading of this article, a similar article by the same group published earlier (2), and a television news flash about the earlier article, I can not see a difference between electro- acupuncture and percutaneous electrical nerve stimulation. I see no difference between acupuncture needles and “acupuncture-like nee- dle probes.” I believe that the brand of needles specified in the second article are sold as acupuncture needles. I wish that we were not afraid of the word acupuncture or electroacupuncture. I see no advantage in using the term percutaneous electrical nerve stimulation.

M. Craig Pinsker, MD, PhD

Pathways Medical Center Richmond, VA 23235


  • 1. Ghoname EA, Craig WF, White PF, et al. Percutaneous electrical nerve stimulation for low back pain. JAMA 1999;281:818–23.

  • 2. Ghoname EA, Craig WF, White PF, et al. The effect of stimulus frequency on the analgesic response to percutaneous electrical nerve stimulation in patients with chronic low back pain. Anesth Analg 1999;88:841–6.

In Response:

In suggesting that classical acupuncture and percutaneous electrical nerve stimulation (PENS) are the same because both techniques involve insertion of similar appearing needles, Dr. Pinsker has failed to understand the two fundamentally important differences between these two nonpharmacologic analgesic techniques.

1) PENS involves stimulation of dermatomes, myotomes,


and/or sclerotomes, which correspond to the specific sen- sory nerves originating at the site(s) of the painful stimuli (1–5). In contrast, acupuncture involves stimulation at spe- cific acupoints based on classical Chinese medical teachings. PENS involves application of electrical current to the needle probes in differing patterns and frequencies of stimulation from a low-output electrical generator. Without the addition of electrical stimulation, “sham” (or inactive) PENS therapy is no more effective than a placebo treatment (3,4).

Although we have no objection to the use of the term acupuncture (or electroacupuncture), it would be inaccurate to describe PENS therapy by either of these terms (1–5). We would encourage pain specialists like Dr. Pinsker to compare PENS to classical Chinese acupuncture. In a study involving transcutaneous electrical nerve stimulation, we found that dermatomal stimulation was as effective as acupoint stimulation in producing an analgesic-sparing effect (6). It is possible that simultaneous percutaneous electrical stimulation at both acupoints and dermatomes would produce an even more pro- found and longer-lasting analgesic effect in patients with acute and chronic pain syndromes. Finally, we would encourage our colleagues in pain management to consider the use of these complementary pain-relieving therapies as adjuvants to conventional pharmacologic and nonpharmacologic modalities rather than as alternatives. In describing a “new” type of pain therapy, it is important to use precise terminology in defining the treatment. Insertion of the thin “needles” per se is not the critically important feature of either acupuncture or PENS. We would hope that the use of more precise terminology will minimize confusion regarding these nonpharma- cologic therapeutic modalities in the future.

Paul F. White, PhD, MD, FANZCA

Department of Anesthesiology & Pain Management University of Texas Southwestern Medical Center at Dallas Dallas, TX 75325-9068

William F. Craig, MD

Forest Park Institute for Pain Management Ft. Worth, TX 76102


  • 1. Ahmed HE, Craig WF, White PF, et al. Percutaneous electrical nerve stimulation: an alternative to antiviral drugs for acute herpes zoster. Anesth Analg 1998;87:911–4.

  • 2. Ahmed HE, Craig WF, White PF. Percutaneous electrical nerve stimulation (PENS): a complementary therapy for the management of pain secondary to bony metastasis. Clin J Pain 1998;14:320–3.

  • 3. Ghoname EA, Craig WF, White PF, et al. Percutaneous electrical nerve stimulation for low back pain. JAMA 1999;281:818–23.

  • 4. Ghoname EA, Craig WF, White PF, et al. Effect of stimulus frequency on the analgesic response to electrical stimulation in patients with low back pain. Anesth Analg 1999;88:841–6.

  • 5. Ghoname EA, Craig WF, White PF. Use of percutaneous electrical nerve stimulation (PENS) for treating ECT-induced headaches. Headache. In press.

  • 6. Chen L, Tang J, White PF, et al. The effect of the location of transcutaneous electrical nerve stimulation on postoperative analgesic requirement: acupoint versus nonacu- point stimulation. Anesth Analg 1998;87:1129–34.

Formulas for Temperature Pao 2 Correction

To the Editor:

I have read with interest the report of Hansen et al. (1) on the effect of moderate hypothermia in alveolar-arterial oxygen difference. As stated in the article, the solubility of gases such as oxygen increases during hypothermia. If the oxygen content remains constant, this results in a decrease of its partial pressure. The inverse effect is observed with hyperthermia: solubility decreases and partial pres- sure increases. The blood gas apparatus analyzed the sample at 37°C, and the values displayed are those at 37°C. If desired, the patient’s temper- ature can be introduced, and the value at that temperature will be calculated. There are several formulas for temperature correction, and the one used in the ABL 235 blood gas analyzer (Radiometer, Copenhagen, Denmark) is reproduced in Appendix 1:

logcPa o 2 logPa o 2 [ 37-T] /2.303) f (1)

where f 0.058/(0.243[Pao 2 /100] 3.88 1) 0.013. I have applied the Equation 1 using Microsoft Excel 97 software (Microsoft Ibe´rica SRL, Madrid, Spain) (Table 1). The values show a decrease in Pao 2 with hyperthermia and an increase with hypother- mia, the opposite of what might be expected. If [37-T] is changed for [T-37] as follows:

logcPa o 2

logPa o 2

[T-37] /2.303) f


the values obtained are as shown in Table 1. In this case, the values follow the expected changes: Pao 2 in- creases with hyperthermia and decreases with hypothermia. So, I wonder if there is an error in the formula as appears it in Appendix 1 of the article by Hansen et al. (1).

Carlos Merino, MD

Servicio de Anestesia Hospital Nuestra Sen˜ora de Aranzazu 20080 - San Sebastian, Spain


  • 1. Hansen D, Syben R, Vargas O, et al. The alveolar-arterial difference in oxygen tension increases with temperature-corrected determination during moderate hypothermia. Anesth Analg 1999;88:538–42.

Table 1. Corrected Pao 2

Temperature (°C)

Pao 2 a

Pao 2


  • 40 70


  • 39 73


  • 38 76


  • 37 80


  • 36 84


  • 35 88


  • 34 92


Value calculated using Equation 1. b Value calculated using Equation 2.







Glycerol Trinitrate Plus Epidural Sympathetic Block in the Ischemia of Glans Penis

To the Editor:

Circumcision, the oldest and most prevalent surgical procedure in

boys, is performed throughout the world for ritual, traditional, or

medical reasons. Although circumcision is a minor procedure, the

incidence of complications ranges from 1.5% to 5% (1). An 11-yr-old

boy who had circumcision 3 days ago was admitted to our hospital

complaining of color change and tenderness in his glans penis.

Pediatric surgeons determined penile edema and a necrotic appear-

ance and removed surgical sutures to rule out technical problems.

Then, the patient was transported to the operating room, and gen-

eral anesthesia was administered for further examination and pain

management. Dorsal penile nerve block was performed with 3 mL

of 0.25% bupivacaine solution. Simultaneously, glycerol trinitrate

(3 mg/kg, 2 mL) was administered to the cavernous body of the

penis to improve postarteriolar smooth muscle relaxation (2). Be-

cause little improvement in the necrotic area was observed, contin-

uous epidural sympathetic block was performed with the aim of

improving the circulation of the glans.

Bupivacaine 0.0625% was administered epidurally for 5 days, and

Rheomacrodex infusion 0.3 mL kg 1 h 1 was administered for

6 days. Healing started by the third day, and the patient was

discharged with full recovery on the seventh day.

Pediatric surgeons excluded surgical complications; therefore,

this event was considered to be an anesthetic complication. A gen-

eral practitioner performed the procedure in a private medical

center. He stated that for infiltration anesthesia he used a local

anesthetic prepared by a nurse, and he thought it was free from

vasoconstrictor. However, in all probability, a local anesthetic con-

taining vasoconstrictor was used. In this case, the possibility of

glans amputation caused aggressive therapeutic management. Be-

rens and Pontus (3) reported a case that was successfully treated

with caudal sympathetic block. Obviously, the local anesthetics

used for circumcision should not contain vasoconstrictor.

Deniz O ¨ zzeybek, MD*

Ug˘ur Koca, MD*

Zahide Elar, MD*

Mustafa Olguner, MD†

Gu¨ lce Hakgu¨ der, MD†

Departments of *Anesthesiology and †Pediatric Surgery Dokuz Eylu¨l University Medical School Izmir, Turkey


  • 1. Sathaye UV, Goswami AK, Sharma SK. Skin bridge: a complication of paediatric circumcision. Br J Urol 1990;662:214.

  • 2. Owen JA, Saunders F, Harris C, et al. Topical nitroglycerin: a potential treatment for impotence. J Urol 1989;1413:546–8.

  • 3. Berens R, Pontus SP Jr. A complication associated with dorsal penile nerve block. Reg Anesth 1990;156:309–10.

Capnography Via the LTA: Friend or Foe?

To the Editor:

This article (1) gave me an uneasy feeling. The choice of title by the

editor and conclusions by the authors are not supported by the

contents of the article.

The title suggested that the laryngotracheal topical anesthesia kit

(LTA) facilitates placement of an endotracheal tube into the trachea

of a patient with a difficult airway. The authors neither examined

patients with difficult airways nor used the LTA to aid intubation.

A more appropriate title might be “Is a modified LTA able to detect

esophageal intubation by an intubating stylet?”

In the results section, the authors attribute to investigator error

results from one patient with an esophageal Pco 2 greater than

tracheal Pco 2 . This supposition would be best presented in the

discussion rather than results section. Additionally, a reader might

conclude, based on the authors’ discussion, that gas sampling from

the LTA might produce seemingly inverted results without postu-

lating experimental error.

The authors suggest this technique can be used during difficult

intubation to determine accurate placement of the stylet before

passing an endotracheal tube. The most favorable interpretation by

the authors of their results produces a one in eight chance of a

clinician’s conclusion from this technique being wrong. Whereas

such a mistake in a patient with a normal airway may be benign, a

12% chance of removing an endotracheal tube from the trachea or

encouraging esophageal intubation exacerbates the risk of catastro-

phe in a patient with a difficult airway. The more valid and valuable

conclusion, in contrast to those published, is that clinicians should

not use gas sampling as described in this study to influence judg-

ment in a patient with a difficult airway.

I suspect that many readers might agree that more evidence must

be presented before the authors or editors can justify either the title

or conclusions of this study.

Samuel Metz, MD

Department of Anesthesiology MCP Hahnemann School of Medicine Philadelphia, PA 19129



Bourke DL, Biehl J. The laryngotracheal topical anesthesia kit with capnography for difficult endotracheal intubation. Anesth Analg 1999;88:943–5.

In Response:

We thank Dr. Metz for his interest in our article (1) and are sorry he

did not like our title or presentation of data. With regard to the third

issue, we wish he had read more carefully. We make it absolutely

clear in the summary paragraph that this technique should be used

only when conditions permit further safe attempts to intubate the

trachea. Additionally, we emphasize the capnographic data are only

an aid to be used with “other clues, experience, and judgment” and

should never be the sole determinant of stylet placement. Further, it

should be obvious that the 12% error rate occurs when Pco 2 values

near 12 mm Hg are observed. A Pco 2 20 mm Hg ensures intra-

tracheal stylet placement with 96% accuracy. Likewise, a Pco 2

6 mm Hg indicates almost certain esophageal stylet placement.

We do expect anyone who uses the information in our article to use

his or her head as well.

Denis L. Bourke, MD

Jerry Biehl, CRNA

Anesthesiology Service Baltimore Veterans Affairs Medical Center Baltimore, MD 21201-1566




Bourke DL, Biehl J. The laryngotracheal topical anesthesia kit with capnography for difficult endotracheal intubation. Anesth Analg 1999;88:943–5.

Respiratory Complications Associated with Tracheal Extubation in Adults

To the Editor:

I read with interest the article of Webster et al. (1) who compared the

efficacy of the flexible reinforced laryngeal mask with a tracheal

tube during intranasal surgery. They also compared the incidence of

complications associated with removal of the laryngeal mask,

tracheal extubation when the patient was deeply anesthetized

with tracheal extubation when the patient had regained


They claim that “[e]valuation of tracheal extubation in awake and

anesthetized patients has been examined in children but not in

adults” (1). However, we studied this factor in adults, and the study

was published (2,3) well before the date of acceptance of Webster et

al.’s article (1).





Webster et al. (1) report that coughing occurred in 19 of 32

patients (59%) when the trachea was extubated during deep anes-

thesia, defined as “at a depth of anesthesia [after cessation of inha-

lational anesthetics] sufficient to suppress the cough reflex response

to movement to the lateral position and cuff deflation.” I suggest

that if the trachea is extubated before isoflurane is turned off, the

incidence of coughing could be minimized, although supporting the

jaw may often be required to maintain a patent airway (2).

Takashi Asai, MD, PhD

Department of Anesthesiology Kansai Medical University Moriguchi City, Osaka, Japan


  • 1. Webster AC, Morley-Forster PK, Janzen V, et al. Anesthesia for intranasal surgery: a comparison between tracheal intubation and the flexible reinforced laryngeal mask airway. Anesth Analg 1999;88:421–5.

  • 2. Koga K, Asai T, Vaughan RS, Latto IP. Respiratory complications associated with tracheal extubation: timing of tracheal extubation and use of the laryngeal mask during emergence from anaesthesia. Anaesthesia 1998;53:540–4.

  • 3. Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth 1998;80:767–75.

In Response:

We appreciate the interest shown by Dr. Asai in our article describ-

ing the use of the flexible reinforced laryngeal mask airway for

intranasal surgery. Our study was originally submitted to Anesthesia

& Analgesia in May, 1998, just before the two articles on the topic of

tracheal extubation in adults by Dr. Asai et al. were published. Our

article required revision, was resubmitted in September, 1998, and

was accepted for publication in November, 1998. Dr. Asai’s articles

were published in June, 1998 while we were revising the manu-

script. The findings of Dr. Asai et al. support the conclusion of our

paper, i.e., the use of the laryngeal mask compared with endotra-

cheal intubation decreases the incidence of respiratory complica-

tions on emergence.

Dr. Asai suggests that coughing could be minimized by extubat-

ing the trachea before the isoflurane is discontinued. In fact, this was

the method we followed in Group III, the patients were extubated

while they were deeply anesthetized. The wording is somewhat

misleading and should be clarified. As stated in the article, the

isoflurane was discontinued in all groups after lateral positioning.

However, Group III patients were extubated immediately after lat-

eral positioning, while isoflurane was still being administered. If

they coughed in response to being turned, the isoflurane concen-

tration was increased until they were breathing regularly. After

deep extubation, the inhaled anesthetic was discontinued, and these

patients breathed air/oxygen while a patent airway was maintained

by jaw thrust. The coughing that occurred in 59% of Group III

patients as they emerged from the anesthetic was probably attrib-

utable to blood trickling onto their vocal cords.

We hope these explanations clarify the points raised by Dr. Asai

et al.

Pat Morley-Forster, MD, FRCPC

James Watson, MD, FRCPC

Victor Janzen, MD, FRCPC

Anthony Webster, MB, FRCPC

Steve Dain, MD, FRCPC

St. Joseph’s Health Center University of Western Ontario London, Ontario, Canada

Prevention of Airborne Exposure During Endotracheal Intubation

To the Editor:

Anesthesiologists are often called for airway management in critical

care units and patient floors. Occasionally, patients cough during

passage of the endotracheal tube into the trachea or with the move-

ment of the tube within the airway after intubation. Often, this

results in expectorated secretions contacting the skin and mucous

ANESTH ANALG LETTERS TO THE EDITOR 1067 1999;89:1064–70 Webster et al. (1) report that coughing occurred

Figure 1. Stylette passed through the swivel adapter attached to an elbow.

ANESTH ANALG LETTERS TO THE EDITOR 1067 1999;89:1064–70 Webster et al. (1) report that coughing occurred

Figure 2. An elbow connector replaces the swivel adapter.

membranes of the anesthesiologist or other ancillary health care

providers near the patient. During coughing, exhaled air can attain

velocities of up to 965 km/hr (600 mph) (1), endangering people

even at more distant locations. Exposed personnel are at risk of

bacterial and viral infections, such as tuberculosis, hepatitis B or C,

and human immunodeficiency virus, because these secretions often

contain blood or serum secondary to infection or trauma to the






airways. Even if the mucosal membranes are spared, contamination

of skin on the face, neck, or arms is unpleasant and may shift

attention away from patient. We use a simple system to obviate the

risk of exposure during tracheal intubation of awake and/or un-

paralyzed patients. The endotracheal tube is attached to a Portex

Fibroptic Bronchoscope Swivel Adapter (Concord/Portex, Keene,

NH) which in turn is attached to an elbow adapter. If necessary, a

stylette can be passed through the swivel adapter to facilitate intu-

bation (Fig. 1). If a stylette is not needed, an elbow connector may

replace the swivel adapter (Fig. 2). This arrangement will direct the

exhaled air and secretions toward the bed of patient, minimizing the

risk of exposure.

Despite the aggressive dissemination of universal precaution in-

formation by the Center for Disease Control and regulatory actions

by the Occupational Safety and Health Administration, the compli-

ance of universal precautions remains less than satisfactory (2). The

universal precautions are not observed by 11%–99% of personnel in

different series in literature (3–8). Complete muscle relaxation of the

patient can prevent this type of contamination, but it is not possible

in all settings. We have found that this simple measure is effective

in preventing unnecessary exposure of personnel to patients’


NavParkash S. Sandhu, MD

Shirl Schaffer, MD

Levon M. Capan, MD

Department of Anesthesiology New York University Medical Center New York, NY 10016

Jatinder S. Gill, MD

Department of Anesthesiology Massachusetts General Hospital Boston, MA 02114


  • 1. Ganong WF. Regulation of respiration. Review of medical physiology. Norwalk, CT: Appleton & Lange, 1997;626–35.

  • 2. DeJoy DM, Gershon RR, Murphy LR, Wilson MG. A work-system analysis of compli- ance with universal precautions among health care workers. Health Educ Q 1996;23:159–74.

  • 3. Baraf LJ, Talan DA. Compliance with universal precautions in a university hospital emergency department. Ann Emerg Med 1989;18:654–7.

  • 4. Hammond JS, Eckes JM, Gomez GA, Cunningham DN. HIV, trauma and infection control: universal precautions are universally ignored. J Trauma 1990;30:555–61.

  • 5. Berk WA, Todd K. Infection control for health care workers caring for critically injured patients: a national survey. Am J Emerg Med 1994;12:60–3.

  • 6. Yassi A, Mcgill M. Determinants of blood and body fluid exposure in a large teaching hospital: hazards of the intermittent intravenous procedure. Am J Infect Control 1991;19:129–35.

  • 7. Digiacompo JC, Hoff WS, Rotundo MF, et al. Barrier precautions in trauma resuscita- tion: real time analysis utilizing videotape review. Am J Emerg Med 1997;15:34–9.

  • 8. Willy ME, Dhillon GL, Lowen NL, et al. Adverse exposures and universal precautions practices among a group of highly exposed health professionals. Infect Control Hosp Epidemiol 1990;11:351–7.

Laparoscopic Resection of Unsuspected Pheochromocytoma

To the Editor:

I agree with Joris et al.’s (1) recommendation that laparoscopic

resection of pheochromocytoma must be performed by an experi-

enced surgeon and anesthesiologist. The following case indicates

that precise diagnosis and cautious preoperative preparation are

also prerequisites for this procedure.

A 55-yr-old patient was scheduled for laparoscopic resection of an

incidentally detected right adrenal tumor, which was diagnosed as

nonfunctioning as a result of the lack of apparent symptoms and the

negative results of urinary qualitative detection of vanillylmandelic

acid and I 131 -metaiodobenzylguanidine scintigraphy. Anesthesia

was induced uneventfully, but pneumoperitoneum and retroperi-

toneal dissection abruptly increased systolic blood pressure to

250 mm Hg. Aggressive use of nicardipine maintained the systolic

blood pressure at 200 mm Hg with difficulty. Histological inves-

tigation and analyses of plasma epinephrine and norepinephrine

levels during the surgery (2.83 and 15.07 ng/mL, respectively)

revealed that the tumor was pheochromocytoma.

Anesthesia and surgery for unsuspected pheochromocytoma are

extremely dangerous (2). An increased number of adrenal masses

were recently detected incidentally by imaging procedures (3), and

4%–11% of these masses were identified as pheochromocytoma,

which can be asymptomatic (4,5). Precise preoperative diagnosis

and cautious preoperative preparation are essential for safe anes-

thetic management of such cases (6).

Tokuya Harioka, MD

Koichiro Nomura, MD

Satoshi Hosoi, MD

Kumiko Mukaida, MD

Department of Anesthesia Shimada Municipal Hospital Shimada, Shizuoka 427, Japan



Joris JL, Hamoir EE, Hartstein GM, et al. Hemodynamic changes and catecholamine release during laparoscopic adrenalectomy for pheochromocytoma. Anesth Analg



Ambesh SP. Occult pheochromocytoma in association with hyperthyroidism present- ing under general anesthesia. Anesth Analg 1993;77:1074–6.


Mantero F, Masini AM, Opocher G, et al. Adrenal incidentaloma: an overview of hormonal data from the National Italian Study Group. Horm Res 1997;47:284–9.


Gagner M, Breton G, Pharand D, Pomp A. Is laparoscopic adrenalectomy indicated for pheochromocytoma? Surgery 1996;120:1076–80.


Linos DA, Stylopoulos N, Raptis SA. Adrenaloma: a call for more aggressive manage- ment. World J Surg 1996;20:788–93.


Russell WJ, Metcalfe IR, Tonkin AL, Frewin DB. The preoperative management of phaeochromocytoma. Anaesth Intensive Care 1998;26:196–200.

Percutaneous Tracheostomy Techniques


To the Editor:

We have read with interest the article by Drs. Ambesh and Kaushik

(1). They compared two percutaneous tracheostomy techniques, the

Ciaglia and the Griggs, but titled their study “Percutaneous Dila-

tional Tracheostomy: The Ciaglia Method Versus the Rapitrach

Method”. The Rapitrach kit (Surgitech Medical, Sydney, Australia)

(2,3) is used with the method developed by Schachner et al. (4). The

Portex kit (Hythe, Kent, UK) used in their study is designed for use

with the Griggs technique, which is a similar single dilational

method with a modified Howard Kelly forceps (5). Portex also

manufactures another kit, the SIMS kit, to be used with a modified

Ciaglia technique to perform progressive dilation of the trachea

with multiple straight dilators instead of forceps.


The authors state that there was no difference between the tech-

niques. However, they have reported that the Griggs method re-

quired considerably less time, which may be a sign that either the

surgeons had more experience with the technique or that the tech-

nique was inherently easier and/or faster.

Joseph L. Nates, MD*

Mathew Joseph, MD†

Departments of *Anesthesia and Critical Care and †Neurosurgery University of Texas—Houston Houston, Texas 77030




Ambesh SP, Kaushik S. Percutaneous dilational tracheostomy: the Ciaglia method versus the Rapitrach method. Anesth Analg 1998;87:556–61.


Fisher EW, Howard DJ. Percutaneous tracheostomy in a head and neck surgery. J Laryngol Otol 1992;106:625–7.


Leinhardt DJ, Mughal M, Bowles B, et al. Appraisal of percutaneous tracheostomy. Br J Surg 1992;79:255–8.


Schachner A, Ovil Y, Sidi J, et al. Percutaneous tracheostomy: a new method. Crit Care Med 1989;17:1052–6.


Caldicott LD, Olroyd GJ, Bodenham AR. An evaluation of a new percutaneous tracheostomy kit. Anaesthesia 1995;50:49–51.

In Response:

We would like to thank Drs. Nates and Joseph for showing the

interest in our article (1) and pointing out the ambiguity in our title.





The Rapitrach kit (Surgitech Medical, Sydney, Australia) was intro-

duced in clinical practice for the rapid formation of a percutaneous

dilational tracheostomy (PDT), and the method was known as Rapi-

trach method (2), but as a result of some life threatening complica-

tions (3), the Rapitrach kit is no longer used. The Portex kit (Hythe,

Kent, UK) used in our study is based on the Griggs technique (4),

which uses modified tracheal stoma dilating forceps (similar to

modified Howard Kelly forceps) with a rounded end. As a matter of

old practice, the method used with the Portex kit is still known as

the Rapitrach method, but the terminology of Rapitrach method has

now been changed to Griggs method. We are not aware of another

kit manufactured by Portex 4 for the modified Ciaglia technique, and

we have yet to see a publication with this new kit.

Ours is a tertiary-care, super-specialty hospital, and formation of

a PDT is almost routine in patients who require prolonged ventila-

tory support or isolation of the airway. We have performed more

than 300 PDTs; hence, there is no paucity of experience. The forma-

tion of a PDT with Rapitrach method (Griggs technique) is defi-

nitely faster, but, in terms of ease, the Ciaglia technique is better and

preferred because it produces a gradual, progressive dilation of the

tracheal stoma with a temponade effect on the stoma vessels and

minimal bleeding. However, the two techniques are comparable,

and there is no statistically significant difference in complication

rates. There is no doubt that experience is the key factor in making

any technique easy.

Sushil P. Ambesh, MD

Soma Kaushik, MD, DA

Department of Anesthesiology and Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, India


  • 1. Ambesh SP, Kaushik S. Percutaneous dilational tracheostomy: the Ciaglia method versus the Rapitrach method. Anesth Analg 1998;87:556–61.

  • 2. Bodenham A, Cohen A, Webster N. A clinical evaluation of the ‘Rapitrach’: a bedside percutaneous tracheostomy technique. Anaesthesia 1992;47:332–4.

  • 3. Hutchinson RC, Mitchell RD. Life threatening complications from percutaneous dila- tional tracheostomy. Crit Care Med 1991;19:118–20.

  • 4. Griggs WM, Worthley LIG, Gilligan JE, et al. A simple percutaneous tracheostomy technique. Surg Gynecol Obstet 1990;170:543–5.

Unintentional Recirculation with the Rapid Infusion System

To the Editor:

We would like to make others aware of a potential problem with the

use of the Haemonetics Rapid Infusion System (RIS) (Braintree,

MA), which we routinely use during orthotopic liver transplanta-

tion (OLT). We attached the two ports of the RIS to 8.5F catheters in

the right antecubital vein and right internal jugular vein. This al-

lowed delivery of a mixture of normal saline, packed red blood cells,

and fresh frozen plasma at 1500 mL/min, which is sometimes

necessary at various times during OLT. There was an exceptional

amount of blood loss during the case. At one point, we noted the RIS

recorded that we gave 45,000 mL, although we only loaded the RIS

with approximately 20,000 mL of the mixture.

Figure 1 shows the proper positioning of the recirculation line,

which runs from the filter through a clamp to the reservoir. The

recirculation line warms the mixture before infusion. When an

infusion is given, the clamp engages and prevents recirculation of

the fluid mixture. In our case, the recirculation line was not properly

seated in the clamp (Figure 2), and engagement of the clamp during

infusion only partially occluded the recirculation line. This allowed

approximately half of the mixture to be recirculated rather than

infused, although the recirculated mixture was counted on the

“total volume infused” readout.

There are multiple safety devices built into the RIS to prevent

complications, but there is no alarm to detect an improperly posi-

tioned recirculation line. When the RIS infusion dial was turned to

1500 mL/min, the infusate flow rate readout falsely confirmed

ANESTH ANALG LETTERS TO THE EDITOR 1069 1999;89:1064–70 The Rapitrach kit (Surgitech Medical, Sydney, Australia) was

Figure 1. Proper seating of the recirculation line in the clamp.

ANESTH ANALG LETTERS TO THE EDITOR 1069 1999;89:1064–70 The Rapitrach kit (Surgitech Medical, Sydney, Australia) was

Figure 2. Improper positioning of the recirculation line prevents

full obstruction of recirculation flow during clamping.

  • 1500 mL/min, although we were only delivering about 700 mL/

min. It is not unusual to need to give 1500 mL/min intermittently

during OLT, and the inability to do this resulted in a more labile

course than usual.

There were several indications that we were not delivering

  • 1500 mL/min despite the RIS readout. First, the infusate pressure

was 120 mm Hg when 1500 mL/min was dialed in. In our expe-

rience, the line pressure is usually 200 mm Hg when the RIS is

attached to two 8.5F catheters in two large veins. Second, the

mixture was visible when it was entering the top of the reservoir

during infusion; this should only happen during recirculation.

Third, administering a fluid bolus by pressing the 500-mL or

100-mL buttons did not result in a corresponding decrease in the

reservoir level.

Thus, improper positioning of the recirculation line through the

clamp may result in recirculation of the mixture during attempted

infusion. The RIS will be limited in maximum infusion rate, and the

RIS will overstate the amount of mixture infused.

Stewart J. Lustik, MD

Ashwani K. Chhibber, MD

Department of Anesthesiology University of Rochester Medical Center Rochester, NY 14642






Transesophageal Atrial Pacing Can Facilitate -Adrenergic Blockade and Heart Rate Control

To the Editor:

Dr. Raby et al.’s article (1), and its associated editorial (2), add to the

growing body of evidence that the administration of -adrenergic

blockers and the control of heart rate perioperatively reduce mor-

bidity and mortality. However, many patients who might benefit

from perioperative -adrenergic blockade still do not receive such

treatment. Reluctance of anesthesia personnel to use -blockade

intraoperatively may, in part, arise from the concern of causing

bradycardia and its consequences, hypotension, and/or low cardiac


I have been conducting research on and clinically using trans-

esophageal atrial pacing (TEAP) for several years. TEAP appears to

be a safe, effective, and easy technique for treating sinus bradycar-

dia or junctional rhythms. In my practice, I am now more willing to

aggressively administer -blockers to at-risk patients, knowing that

a nodal rhythm or sinus bradycardia can be immediately treated

and that heart rate can be more precisely controlled. Having TEAP

available involves inserting a pacing esophageal stethoscope, which

differs from the standard 18F esophageal stethoscopes now com-

monly used only in that there are pacing electrodes attached that

Dr. Roth is on the Medical Advisory Board of CardioCommand, Inc., Tampa, Florida, a producer of TEAP systems. CardioCommand, Inc. has also supported his research.

can be used for both atrial pacing and electrogram recording for

arrhythmia diagnosis. Pharmacologic treatment of bradycardia may

have a delayed onset of action, may be partly or totally ineffective,

may produce excess tachycardia or a new dysrhythmia, may not be

easily or quickly reversed, has an unpredictable duration of action,

and may cause other unwanted side effects (central nervous system,

gastrointestinal, genitourinary) (3).

Although there is no outcome study to prove the effectiveness of

this technique, the combination of -blockade with TEAP backup

provides a means of precise heart rate control, with the anticipation

that morbidity and mortality will be reduced. If atrial pacing is

needed postoperatively, there is a 10F pacing catheter that can be

inserted nasally and is tolerated in the awake, extubated patient. In

this era of cost containment, a cost-benefit analysis may be needed

to justify its use. My personal bias is that, for at-risk patients, the

incremental cost of having TEAP available is small compared with

the cost of investigating the possibility of or treating a suspected or

actual adverse myocardial event. For those readers not familiar with

TEAP, I recommend a review article as an introduction to the

technique (3).

Jonathan V. Roth, MD

Department of Anesthesiology Albert Einstein Medical Center Philadelphia, PA 19141


  • 1. Raby KE, Brull SJ, Timimi F, et al. The Effect of heart rate control on myocardial ischemia among high-risk patients after vascular surgery. Anesth Analg 1999;88:477–82.

  • 2. Tuman KJ, McCarthy RJ. Individualizing -adrenergic blocker therapy: patient-specific target-based heart rate control. Anesth Analg 1999;88:475–6.

  • 3. Roth JV. Transesophageal pacing and recording: an update. Prog Anesthesiol 1996;22: 431–48.