Anaesthesia
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We report the management of a patient requiring surgical laryngoscopy with a view to laser resection of an epiglottic recurrence of laryngeal cancer. Previous attempts at tracheal intubation and awake nasal fibreoptic intubation had failed. During a previous anaesthetic the patient had been both 'impossible to intubate and to ventilate'. ⋯ This was achieved using the Aintree intubation catheter as an aid to nasal fibreoptic intubation and as a tube exchanger. Novel roles of the Aintree intubation catheter and LMA Proseal in this case are discussed. Complications of transtracheal jet ventilation as well as possible methods for avoiding them are also reviewed.
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The use of epidurally administered opioids to control postoperative pain is a well established and widely accepted technique. However, despite this longstanding use, there is still an ongoing debate concerning the site of action of the opioids used. Some argue that analgesia is mediated by a spinal mechanism and others that a supraspinal mechanism is responsible. ⋯ A concentration of 10 microg x ml(-1) appears to be the threshold at which epidurally administered fentanyl can elicit segmental analgesia, a value which may have significant clinical applications. The evidence supporting a synergistic relationship between epidural opioids and local anaesthetics is weak and unsupported by a plausible physiological mechanism. Thus the 'threshold concentration' of approximately 10 microg x ml(-1) is unlikely to be lowered by co-administering opioids with local anaesthetics.
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Comparative Study
Learning and performance of tracheal intubation by novice personnel: a comparison of the Airtraq and Macintosh laryngoscope.
Direct laryngoscopic tracheal intubation is taught to many healthcare professionals as it is a potentially lifesaving procedure. However, it is a difficult skill to acquire and maintain, and, of concern, the consequences of poorly performed intubation attempts are potentially serious. The Airtraq Laryngoscope is a novel intubation device which may possess advantages over conventional direct laryngoscopes for use by novice personnel. ⋯ In both easy and simulated difficult laryngoscopy scenarios, the Airtraq decreased the duration of intubation attempts, reduced the number of optimisation manoeuvres required, and reduced the potential for dental trauma. The Airtraq device showed a rapid learning curve and the students found it significantly easier to use. The Airtraq appears to be a superior device for novice personnel to acquire the skills of tracheal intubation.
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Case Reports
Transoesophageal echocardiography: a useful tool to diagnose entrapment of pulmonary artery catheter.
Placement of a pulmonary artery catheter during cardiac surgery is associated with various complications, one of which is entrapment. On the day following surgery unusual resistance was encountered while attempting to remove a pulmonary artery catheter from a patient who had undergone coronary artery bypass grafting. ⋯ Surgical re-exploration and other potential complications related to catheter retrieval can be avoided if catheter entrapment is diagnosed intra-operatively. We suggest that a high index of clinical suspicion along with the use of intra-operative transoesophageal echocardiography is considered in situations where catheter entrapment is a possibility.