Anju Sharma

Use of Schroeder directional stylet to enhance navigability during nasotracheal intubation

To the Editor: During nasotracheal intubation, the distal end of the tracheal tube is introduced from the nares into the oropharynx and can impinge on the posterior wall of the nasopharynx, where the nasal passage curves perpendicularly. Posterior pharyngeal wall laceration can occur as a result of anatomical abnormality and can result in dissection of retropharyngeal mucosa. Retropharyngeal laceration is a serious complication of nasotracheal intubation [1]. Henceforth, a number of methods have been described to enhance the navigability of the tracheal tube, which include use of the nasopharyngeal airway, a nasogastric tube or gum elastic bougie, or using a digitally assisted technique [2–5]. We describe here the use of the Schroeder directional stylet (SteBar Instrument Corp., Grand Rapids, MI, USA) to enhance navigability through the nasopharyngeal passage. A 19-year-old girl was scheduled for bilateral genioplasty for temporomandibular joint ankylosis. Physical examination revealed a 45-kg girl with micrognathia and retrognathia with mouth opening of 1.5 cm. Mentohyoid and mentothyroid distances were 2 and 4 cm, respectively. Patient was premedicated with oral midazolam 7.5 mg, ranitidine 150 mg, and intramuscular glycopyrrolate 0.2 mg. After applying routine monitoring, inhalation induction was carried out with sevoflurane in oxygen. Blind nasotracheal intubation was planned. The right nares was found to be more patent and xylometazoline 0.05% nasal drops were instilled into the nares. A well-lubricated 6.5-mm ID Portex Blue line cuffed tracheal tube could be smoothly passed via the right nares. However, resistance was felt to its passage after 5–6 cm was negotiated via the nasal passage, which was attributed to impaction of the tube against the posterior pharyngeal wall. The tracheal tube was pulled back for a short distance and the patient’s head was extended to facilitate passage beyond this point. However, three attempts at this maneuver failed. Anticlockwise rotation of the tube and tilting the patient’s head to the side of intubation also failed to disimpact the tube [5]. The digital maneuver described by us earlier was not feasible because of the restricted mouth opening [4]. It was decided to use the Schroeder directional stylet (Fig. 1) to disimpact the tracheal tube from the posterior nasopharyngeal wall. The nasotracheal tube was withdrawn for a short distance and a well-lubricated Schroeder directional stylet was passed into the tube. The lever on the proximal end of the device was depressed, which led to alteration of the curvature of the stylet with consequent anterior flexion of the tube leading to its smooth

Detecting distal cuff fold over position of proseal laryngeal mask airway

in use at our institution (Mallinkrodt, Hazelwood, USA) are the same size as those found on the larger tubes. While the tracheal tube may pass through the cLMA, the pilot balloon of will not pass through a cLMA smaller than size 21⁄2. Therefore, we commonly place an uncuffed tube in smaller children when using this technique, followed by a tube exchange if necessary. Newer SGAs, such as the Air-Q (Mercury Medical, USA) or the Ambu AuraOnce (Ambu, USA) have larger diameter barrels, which accommodate larger endotracheal tubes and allow for the passage of the pilot balloon through smaller sized models. 3. When resistance is encountered as the tube is advanced over the endoscope into the trachea during intubation through a cLMA, it is difficult to discern whether the resistance is due to the aperture bars or from impingement of a glottic structure such as the arytenoids. The absence of glottic aperture bars in newer SGAs eliminates this potential obstacle to advancement. Paul A. Stricker John E. Fiadjoe John J . McCloskey Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, PA, USA (email: strickerp@email.chop.edu)

Beneficial effects of statin therapy on infection related mortality in patients with atherosclerotic and cardiovascular disease.

1. Escolar G, Bozzo J, Maragall S, Argatroban: a direct thrombin inhibitor with reliable and predictable anticoagulant actions. Drugs Today 2006;42:223 2. Nielsen VG, Steenwyk BL, Gurley WQ, Lell WA, Kirklin JK. Argatroban, bivalirudin, and lepirudin do not decrease clot propagation and strength as effectively as heparin-activated antithrombin in vitro. J Heart Lung Transplant 2006;25:653–63 3. Young G, Yonekawa KE, Nakagawa PA, Blain RC, Lovejoy AE, Nugent DJ. Differential effects of direct thrombin inhibitors and antithrombin-dependent anticoagulants on the dynamics of clot formation. Blood Coagul Fibrinolysis 2007;18:97–103

Tube design for nasotracheal intubation.

1. Sluga M, Ummenhofer W, Studer W, et al. Rocuronium versus succinylcholine for rapid sequence induction of anesthesia and endotracheal intubation: a prospective, randomized trial in emergent cases. Anesth Analg 2005;101:1356–61. 2. Pardo C, Chamorro C, Romera MA, et al. Succinil-colina ¿bloqueante neuromuscular de elección para la intubación de pacientes crı́ticos? Med Intensiva 2001;25(Suppl 1):89. 3. Tryba M, Zhorn A, Thole H, Zenz M. Rapid-sequence oro-tracheal intubation with rocuronium: a randomized doubleblind comparison with suxamethonium, preliminary communication. Eur J Anaesthesiol 1994;11(suppl 9):44–8. 4. Chamorro C, Martinez-Melgar JL, Romera MA, et al. Uso de rocuronio en la secuencia rápida de inducción-intubación de los pacientes crı́ticos. Med Intensiva 2000;24:253–6. 5. Booij LH. Is succinylcholine appropriate or obsolete in the intensive care unit? Crit Care 2001;5:245–6.

Capnography and oxygenation via single-use bougie

1. Annamaneni R, Hodzovic I, Wilkes AR, Latto IP. A comparison of simulated diffi cult intubation with multiple-use and single use bougies in a manikin. Anaesthesia. 2003;58:45–9. 2. Al-Shaikh B. Capnography through the lumen of tracheal tube guide. Anaesthesia. 2003;58:809–10. 3. Sellers WFS. Finding the use for a tracheal tube guide. Anaesthesia. 2003;58:190. 4. Al-Shaikh B, Philips M. Tracheal tube introducer and capnography in diffi cult intubation. CPD Anaesthesia. 1999;1:153. 5. Miller FA, Hutchison GL, Glavin R. Gum elastic bougie, capnography and apnoeic oxygenation. Eur J Anaesthesiol. 2001;18: 51–3.

Intra‐arterial access in pediatric patients

To the Editor, We were interested in the recent case report by Joshi and Tobias regarding intentional use of intra-arterial medications when venous access is not available (1). It comes as a milestone article at the time when we are still groping to secure difficult venous access in pediatric patients. This case report is likely to change anesthetic management of pediatric patients in whom securing i.v. line may be virtually impossible and at a time when literature is gathering which commends tracheal tube intubation in pediatric patients without i.v. access (2–5). We report a case in which tracheal intubation without i.v. access proved to be highly eventful.