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Because the relative risks versus benefits of our approach were

unknown, our consent process was extensive and carried out in
several meetings. Careful planning and close cooperation between
the anesthesiologist and the operating surgeon permitted successful
multivisceral transplantation in this complex, compromised patient.
Charles D. Boucek, MD
Kareem Abu El Magd, MD
Department of Anesthesiology
University of Pittsburgh Medical Center
Pittsburgh, PA

1. Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal transplantation: a position paper of the American Society of Transplantation. Pediatr
Transplant 2001;5:80 7.
2. Harte FA, Chalmers PC, Walsh RF, et al. Intraosseous fluid administration: a parenteral
alternative in pediatric resuscitation. Anesth Analg 1987;66:6879.
3. Glaeser PW, Hellmich TR, Szewczuga D, et al. Five-year experience in prehospital
intraosseous infusions in children and adults. Ann Emerg Med 1993;22:1119 24.
4. Fiser DH. Intraosseous infusion. N Engl J Med 1990;322:1579 81.
5. Kohlstaedt KG, Page IH. Hemorrhagic hypotension and its treatment by intra-arterial
and intravenous infusion of blood. Arch Surg 1943;47:178 91.
6. Negovsky V. Treatment of the agonal state of clinical death. JAMA 1945;129:1226.
7. Brown AS. Transfusion by the intra-arterial route. Lancet 1953;265:745 8.

Positioning for Intubation in Morbidly

Obese Patients
To the Editor:
Patient positioning in the obese patient is of critical importance
when performing laryngoscopy. Brodsky et al. (1) report a series of
100 patients in which 99 were successfully tracheally intubated
using an elevated head-up position (Fig. 1) (2). In this position, the
shoulders are elevated with several pads, the head and neck are
extended, and the external auditory meatus is in line with the
sternal notch. We propose a modification of this position that
achieves the same goals without application of the rolls under the
patients shoulders (Fig. 2). This modified position is commonly
used in our hospital. Our positioning technique achieves the same
relative patient orientation without the burden of placing the extra
pads under the shoulders. This positioning is effective and saves the

Figure 2. Whelan-Calicott position.

health care provider from the additional strain of moving the
weight of these large patients.
David A. Zvara, MD
Randy W. Calicott, MD
Deborah M. Whelan, MD
Department of Anesthesiology
Wake Forest University School of Medicine
Winston-Salem, NC

1. Brodsky JB, Lemmens HJM, Brock-Utne JG, et al. Morbid obesity and tracheal intubation. Anesth Analg 2002;94:732 6.
2. Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Anesthetic considerations for bariatric
surgery: proper positioning is important for laryngoscopy. Anesth Analg 2003;96:

Desfluranes Effect on QTc Interval:

Electrophysiological Mechanisms Need to
Be Explored
To the Editor:
Owczuk et al. (1) incorrectly state that their report is the first to
describe the influence of desflurane on the QT interval. The influence of desflurane on the QT interval was reported by Yildirim et al.
(2) several months earlier. Although the study by Owczuk et al.
focuses only on QT correction for heart rate (QTc), the study by
Yildirim et al. explores the effects of sevoflurane, isoflurane, and
desflurane on various aspects of QT interval (2), including QT
dispersion (QTD), heart rate corrected QT interval (QTc), and QTc
dispersion of the electrocardiogram (QTcD). The effects of desflurane on QTc interval are comparable in both studies. One MAC of
inhaled anesthetic causes a significant increase in QTc, QTD, and
QTcD (2). Further electrophysiological studies are needed to determine whether the effects of desflurane on the QT interval are
mediated by an increase in transmural dispersion of repolarization
(e.g., halothane (3)) or a reduction in Ik current (e.g., sevoflurane)
Thiruvenkatarajan Venkatesan, MD, DA, DNB
Christian Medical College Hospital
Tamilnadu, India

Figure 1. Elevated head-up position. Reproduced with permission

from Airway Cam Video Series, Volume 3: Advanced Airway Imaging and Laryngoscopy Techniques. Courtesy of Richard Levitan,
MD, Airway Cam Technologies, Inc., Wayne, PA.

1. Owczuk R, Wujtewicz MA, Sawicka W, et al. The influence of desflurane on QTc
interval. Anesth Analg 2005;101:419 22.
2. Yildirim H, Adanir T, Atay A, et al. The effects of sevoflurane, isoflurane and desflurane on QT interval of the ECG. Eur J Anaesthesiol 2004;21:566 70.