Yasuhiko Imashuku

The “jaw thrust” maneuver rather than the “BURP” maneuver improves the glottic view for Pentax-AWS assisted tracheal intubation in a patient with a laryngeal aperture

Visualizing the glottic opening aids inachieving successful tracheal intubation; however, occa-sionally we have experienced difficulty in visualizing theglottic opening because the epiglottis could not be elevateddue to its close proximity to the posterior wall of thepharynx. Using the Macintosh laryngoscopy, the BURP(backward, upward, and right-sided pressure on the thyroidand cricoid cartilages)

Nasotracheal intubation using the Airway Scope and an Endotrol tracheal tube

The Airway Scope (AWS; Hoya-Pentax, Tokyo, Japan) videolaryngoscope, designed for orotracheal intubation, has been shown to be useful in patients with a difficult airway [1]. The AWS has been reported as a useful and safe device for nasotracheal intubation [2]. During conventional nasotracheal intubation using the Macintosh laryngoscope, Magill’s forceps are often required to introduce the tracheal tube through the glottis. However, when the AWS is used for nasotracheal intubation, the AWS blade may obstruct Magill’s forceps. We have previously reported a method for combining the use of the AWS with the fibreoptic bronchoscope [3], and a gum-elastic bougie may also be used to introduce the tracheal tube into the glottis [2, 4]. Herein, we report a new method in which the Endotrol tracheal tube (Mallinckrodt Medical, Athlone, Co Westmeath, Ireland) is used for nasotracheal intubation with the AWS. The Endotrol tracheal tube has a wire hook that can be used to control the curve of the tube, and has been used successfully in blind intubation [5]. The combination of the Endotrol tracheal tube and a lightwand has been used successfully for nasotracheal intubation [6]. We report the use of this tube with the AWS for nasotracheal intubation. After induction of anaesthesia and establishing mask ventilation, we insert the Endotrol tracheal tube into the patient’s nostril, and the AWS into the patient’s mouth. When the glottis is seen on the monitor, the tube is advanced to the glottis. The tube’s tip may then be directed upward by pulling the wire hook. In our experience with seven cases of nasotracheal intubation using the AWS, the tube can be successfully advanced through the glottis in this manner. We believe the combination of the Endotrol tracheal tube and the AWS is effective for nasotracheal intubation.

Pediatric airway scope is available for gastric tube insertion in adult patients.

To the Editor: In our anesthetic management of coronary artery surgery, gastric tube (GT) insertion is a routine practice after intubation. Occasionally, a small mucosal injury caused by the blind insertion of a GT (including postcricoid ulceration and vocal cord paralysis 1 ) may induce massive hemorrhage because of the systemic administration of heparin during cardiac surgery. To avoid this complication, the GT insertion preferably should be performed under visual control during the GT advancement. Until recently, most visualization devices, including the Airway Scope (AWS; Pentax-AWS, Hoya, Tokyo, Japan), limited the oropharyngeal manipulations because narrowing of the oropharyngeal space by the endotracheal tube interferes with the advancement of the laryngoscope and decreases visibility of the posterior larynx. Recently, a new AWS blade for children, which is smaller than that for adults, has been made available for pediatric endotracheal intubation. This blade also can pass through a narrow upper airway and visualize the hypopharynx in adult anesthetized, endotracheally intubated patients. We report the use of this new pediatric blade for the insertion of the GT in an endotracheally intubated adult patient. A 73-year old woman (height, 1.71 m; weight, 53.1 kg) was scheduled to undergo cardiac surgery. After anesthesia induction and paralysis, the trachea was intubated with an 8.0-mm internal diameter orotracheal tube. For oral insertion of the GT, a 16 F, 122 cm, Argyle Salem Sump tube (Coviden, Dublin, Ireland) was attached to the main channel of the pediatric blade of the AWS (Fig 1). The pediatric blade was placed smoothly into the oral cavity and advanced to the hypopharynx. When a good view of the hypopharynx was obtained, the GT was advanced under the arytenoid cartilage through the inlet of the esophagus and introduced into the stomach. No mucosal injury or bleeding was noted during withdrawal of the blade. Successful placement of the GT was checked by aspiration of the gastric juice using vacuum suction. Ikeno et al 2 reported that the AWS facilitated GT placement in anesthetized patients. The AWS blade for adults might be placed between the endotracheal tube and the epiglottis. In such cases, a view of the hypopharynx, including the inlet of the esophagus, cannot always be obtained. Therefore, a small and compact pediatric blade is more suitable for oropharyngeal manipulations and viewing of the hypopharynx.

New technique using an Airtraq optical laryngoscope in emergencies.

[1] Hanss R, Buttgereit B, Tonner PH, et al. Overlapping induction of anesthesia: an analysis of benefits and costs. Anesthesiology 2005;103: 391-400. [2] Lubarsky DA, Glass PS, Ginsberg B, et al. The successful implementation of pharmaceutical practice guidelines. Analysis of associated outcomes and cost savings. SWiPE Group. Systematic Withdrawal of Perioperative Expenses. Anesthesiology 1997;86: 1145-60. [3] Ross SA,Westerfield RW, JordanBD. Fundamentals of corporate finance. 8th edn. New York: McGraw Hill Irwin; 2008. p. 177, 303, 321-3. [4] Wiler JL, Gentle C, Halfpenny JM, et al. Optimizing emergency department front-end operations. Ann Emerg Med 2010;55: 142-60. [5] Lawrence D. Cashing in on check-in. As hospitals face steeper challenges in collecting fees for service, bringing the revenue cycle to the kiosk may be an answer. Healthc Inform 2010;27 (18):20. [6] Jones R. The role of health kiosks in 2009: literature and informant review. Int J Environ Res Public Health 2009;6:1818-55. [7] Sinclair DR. Capital budgeting decisions using the discounted cash flow method. Can J Anaesth 2010;57:704-5. New technique using an Airtraq optical laryngoscope in emergencies

Hyperkalemia caused by rapid red cell transfusion and the potassium absorption filter

We report a case of transient hyperkalemia during hysterectomy after cesarean section, due to preoperatively undiagnosed placenta accreta that caused unforeseen massive hemorrhage and required rapid red cell transfusion. Hyperkalemia-induced by rapid red cell transfusion is a well-known severe complication of transfusion; however, in patients with sudden massive hemorrhage, rapid red cell transfusion is necessary to save their life. In such cases, it is extremely important to monitor serum potassium levels. For an emergency situation, a system should be developed to ensure sufficient preparation for immediate transfusion and laboratory tests. Furthermore, sufficient stock of preparations to treat hyperkalemia, such as calcium preparations, diuretics, glucose, and insulin is required. Moreover, a transfusion filter that absorbs potassium has been developed and is now available for clinical use in Japan. The filter is easy to use and beneficial, and should be prepared when it is available.

Problematic use of a Pentax AWS-S200 in emergency and disaster medicine

ficulties in seeing the colour change of the soda lime in the re-usable canister when it has fully expired. We are currently looking at changing the colour and the material used in the re-usable canister. The CO2 re-usable canister handle acts as an integrated condenser, collecting water within the canister. The canister was designed to accept the maximum amount of water that could be generated within the life of the soda lime. Therefore, each time the user empties/replaces the CO2 absorbent, the excess water is also removed from the system. Whilst observing the colour change of soda lime is an accepted method of visually checking that the soda lime has expired, it is more likely that users would use the FICO2 reading from their gas module or patient monitor to check that the soda lime is fully exhausted. It is the anaesthetist’s decision to replace exhausted soda lime as they see appropriate, but in today’s cost-conscious and environmentally-friendly hospitals, it may be more accurate to use the FICO2 value as a trigger for changing soda lime rather than a visual inspection of the re-usable soda lime canister to see if it needs changing.

The importance of usage guidance from anesthesiologists when disseminating video laryngoscopes throughout emergency departments and intensive care units

Many anesthesiologists use the video laryngoscopes (Airway scope (Pentax Co., Tokyo, Japan) or McGRATH MAC (Aircraft Medical Lt., Edinburgh, UK)) as their first choice during intubation in Japan. On the other hand, video laryngoscopes are not as widely used among emergency and intensive care physicians other than anesthesiologists at our hospital. We therefore distributed a questionnaire on video laryngoscopes to 12 physicians not including anesthesiologists from the emergency department and intensive care unit at our hospital. When we asked which intubation device was used as the first choice during endotracheal intubation, all 12 physicians responded that they used the Macintosh laryngoscope, and none used video laryngoscopes. We then asked these physicians whether they were aware of any studies on the usefulness of video laryngoscopy (Airway scope) in cases where intubation is difficult [1] or in cases of restricted cervical spine mobility [2], and found that all 12 physicians knew of such research. The most common reasons for not using video laryngoscopes as the first choice were lack of skill and insufficient experience. When asked whether they would be more tempted to use video laryngoscopes if they received guidance on their use from anesthesiologists, all 12 physicians responded that they would indeed be more tempted to use them. Now that the usefulness of video laryngoscopes has been revealed and the dissemination of these devices has been achieved throughout the field of anaesthesiology, we believe that it is important for anesthesiologists to provide guidance on the use of video laryngoscopes in order to next disseminate these devices throughout the field of emergency and intensive care.

Washing out potassium absorption filters with normal saline after use

The potassium concentration of irradiated red cell bags generally increases during the storage period. When blood products with increased potassium concentrations are administered to patients with renal dysfunctions, there is a high risk of causing hyperkalemia. In these cases, a filter (KPF-4, Kawasumi Laboratories, Tokyo, Japan) to adsorb the potassium in the red cell bags is useful [1, 2]. It has been reported that the filter is effective for use during surgery as large volume blood transfusions are required [3, 4], but it is also useful to patients of renal dysfunctions. The potassium-adsorption filter contains cation exchange resins that exchange sodium and potassium, and thus is able to adsorb and eliminate potassium from the blood products. The filter is extremely convenient and effective, but care is needed after use. When normal saline is used to wash out the filter after the administration of blood products, there is a risk of high administration of potassium to the patient owing to reprecipitation of the adsorbed potassium. We rinsed a filter with approximately 100 ml of normal saline after using 4 units of blood products and disconnect from a patient; when a part of the saline solution was examined, a high concentration of potassium (approximately 9–17 mmol/l) was detected. This danger is listed in the warning section of product information, but many physicians are unaware of this information. Blood transfusion products are precious and limited resources; thus, it is necessary to use them as efficiently as possible. For this reason, after the completion of blood transfusions, normal saline is sometimes added to the blood product remaining in the standard blood transfusion filters and administration lines and administered to the patients. However, when using the potassium-adsorption filter, washing out the filter with normal saline is dangerous. We suggest that care is especially needed not only in the operating room but also in the unit where many patients with severe renal dysfunction are treated.

An Indwelling Nasogastric Tube Interferes With Intubation Assisted by the Pentax Airway Scope

1. Stevenson J, Ural N, LeVan P, et al: Use of a transesophageal chocardiographic probe as a surface probe for evaluating the size, osition, and patency of the internal jugular veins. J Cardiothorac Vasc nesth 24:119-120, 2010 2. Kihara C, Murata K, Wada Y, et al: Impact of intraoperative ranesophageal echocardiography in cardiac and thoracic aortic surery: Experience in 1011 cases. J Cardiol 54:282-288, 2009 3. Taillefer J, Couture P, Sherdian P, et al: A comprehensive stratgy to avoid transesophageal echocardiography probe damage. Can J naesth 49:500-502, 2002 4. Karakistos D, Labropoulos N, De Groot E, et al: Real-time ltrasound guided catheterisation of the internal jugular vein: A propective comparison to the landmark technique in critical care patients. rit Care 10:R162, 2006 5. Leung J, Duffy M, Finckh A: Real-time ultrasonographicallyuided internal jugular vein catheterization in the emergency departent increases success rates and reduces complications: A randomized, rospective study. Ann Emerg Med 48:540-547, 2006 6. Stone MB, Moon C, Sutijono D, et al: Needle tip visualization uring ultrasound-guided vascular access: Short-axis vs. long-axis aproach. Am J Emerg Med 28:343-347, 2010 7. Bevilacqua S, Romagnoli S, Ciappi F, et al: Transpharyngeal ltrasonography for cannulation of the internal jugular vein. Anestheiology 102:873-874, 2005 8. Ender J, Erdoes G, Krohmer E, et al: Tranesophageal echocardiogaphy for verification of the position of the electrocardiographically-placed entral venous catheter. J Cardiothorac Vasc Anesth 23:457-461, 2009