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[Downloaded free from on Saturday, December 12, 2015, IP: 181.112.82.


Letters to Editor

Smita Prakash
Department of Anaesthesia and Intensive Care, Vardhman Mahavir
Medical College and Safdarjang Hospital, New Delhi, India
Address for correspondence:
Dr. Smita Prakash,
C 17 HUDCO Place,
New Delhi - 110 049, India.


Ramkumar V. Preparation of the patient and the airway for
awake intubation. Indian J Anaesth 2011;55:442-7.
2. Williams KA, Barker GL, Harwood RJ, Woodall NM. Combined
nebulization and spray-as-you-go topical local anaesthesia of
the airway. Br J Anaesth 2005;95:549-53.
3. British Thoracic Society Bronchoscopy Guidelines
Committee, a Subcommittee of Standards of Care Committee
of British Thoracic Society. British Thoracic Society
guidelines on diagnostic flexible bronchoscopy. Thorax
2001;56(suppl 1):i1-21.
4. Langmarc EL, Martin RJ, Pak J, Kraft M. Serum lidocaine
bronchoscopy. Chest 2000;117:1055–60.
5. DiFazio CA. Local anesthetics: Action, metabolism, and
toxicology. Otolaryngol Clin North Am 1981;14:515–51.
6. Ackerman S, Kleinman W, Nitti GJ, Nitti JT. Airway
Management, In: Morgan GE Jr, Mikhail MS, Murray MJ,
editors. Clinical Anesthesiology. 3rd ed. New York City, U.S.
McGraw-Hill; 2001. p. 59-85.
Access this article online
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Management of difficult airway.
Awake and under anaesthesia
We read with great interest the review article by
Dr. Ramkumar on airway for awake intubation[1] and
had few additions and suggestions to be made on the
content published.
The title of the article is about awake intubation for
difficult airway (DA); however, the author mentions in
great detail about intubation under anaesthesia, preoxygenation with 100% oxygen and muscle relaxants.
The title could probably have been, “Management of
DA: Awake and under anaesthesia”. The author seems

preoccupied with fibreoptic intubation (FOI) for
management of DA. FOI no doubt is the best available
modality for awake DA, but not a panacea for DA
management.[2] Retrograde intubation, blind nasal
intubation, laryngeal mask and direct laryngoscopy
under airway blocks can be performed under expert
hands to secure awake DA, and could have been
mentioned in detail in the article. We would have
liked to read on DA in an emergency situation too.
Psychological preparation of the patient mentions that
consent for surgical airway or cricothyridotomy is
always preferred. A surgical patent and secure airway
still remains as the last resort in DA management
in spite of latest airway “gadgets”, and remains the
ultimate rescue measure in emergency DA.
We would like to add on ketamine as an alternate drug
for sedation for FOI. Low-dose ketamine is frequently
used for paediatric bronchoscopies as well as for
conscious sedation DA intubations, either alone or in
combination with hypnotics, opiods and sedatives.[3]
The author mentions about fibreoptic bronchoscopy
(FOB) under general anaesthesia with muscle relaxants.
We feel that if it is easy to mask ventilate the patient,
it is preferable to use a non-depolarizing relaxant
rather than succinylcholine. It gives enough time
for the endoscopist for controlled laryngoscopy and
fibrescopy as well as for training students. Moreover,
we usually perform a check direct laryngoscopy
after FOB to visualize the Cormack Lehane grade. It
gives us confidence during extubation of the DA and
determines whether reintubation is possible with or
without fibreoscopy.
The discussion on airway blocks does not mention
the complications of the techniques. They are either
common (haematoma, inadvertent arterial injection) or
specific to a block, e.g. vascular, posterior tracheal wall
and vocal cords damage, subcutaneous emphysema
with trans-tracheal block and upper airway obstruction
due to relaxation of musculature around the base of
the tongue following glossopharyngeal nerve block.

Ashish Bangaari, Trevor Nair
Department of Anaesthesiology, MIOT Hospitals, Manapakkam,
Chennai, Tamil Nadu, India
Address for correspondence:
Dr. Ashish Bangaari,
Department of Anaesthesiology, MIOT Hospitals, 4/112,
Mount Poonamallee Road, Manapakkam, Chennai,
Tamil Nadu-600089, India.

Indian Journal of Anaesthesia | Vol. 56| Issue 2 | Mar-Apr 2012

  Different patient positions during insertion or removal of the catheter may increase the resistance. then injecting some radiopaque dye may make it possible to visualize it on the X-ray. The catheter could entangle the bony structures or even a nerve. 56| Issue 2 | Mar-Apr 2012 attempts). etc.ijaweb. surgeons and anaesthesiologists as well. A new approach. may uncoil the catheter and thus avoid knotting. 2015.4] Although the authors have not mentioned how much the length of the catheter increased with stretching.  flexion of spine in lateral decubitus position may ease the removal of catheter. it will always be advisable to evaluate the status of the catheter before removing a struck catheter in multiple attempts without the use of any adjunct.[1] Such cases are more common on obstetric patients.[Downloaded free from http://www. An injection of sterile saline may help determine whether the catheter is knotted. but excessive stretching could increase the chances of catheter breakage.[10] In the era of evidence medicine and presence of radiological investigations. there is evidence indicating that the withdrawal force is reduced in the lateral decubitus position.[3] Patient’s position manipulations are the most frequently attempted [4] The initial methods to free entrapped catheters. Ramkumar V.[11] 211 .[5] If it is suspected that a knot has formed.96323 Removing a trapped epidural catheter: Concerns Sir. The authors took four attempts without any modification. excessive force might be applied if the catheter is placed while the patient’s back is arched but is removed with the patient in a different position (e.[2] The authors managed a knotted epidural catheter by slow.[5] It becomes prudent that if resistance is encountered then each repeat attempt should be with some manoeuvres as we usually advocate for repeat laryngoscopy in difficult airway. and various manoeuvres have been described to ease the removal of catheter without undue force.4103/ DOI: 10. the characteristics inherent to the materials (not mentioned by the authors) of the epidural catheters could also predict the risk of breakage.82. Goel S.112. at times.55:442-7.12:801-5. Although position during removal has not been described by the authors. this technique may not be advocated as the technique as concluded by the authors. and status of the catheter can be visualized. The force applied during removal of the trapped catheter should be the least. BMC Anesthesiology 2011. Difficult paediatric intuabation when fibreoptic laryngoscopy fails. IP: on Saturday. Subcutaneous dissociative conscious sedation (sDCS) an alternative method for airway regional blocks. Also. any broken catheter is always a concern for the patient. if injected in initial attempts. The tensile strength of various epidural catheters was evaluated.[1. Paediatr Anesth 2002. steady and gentle traction. recommend that the patient be placed in the same position for insertion and withdrawal of the catheter. like change on patient position or injection of saline.11. kinked or entangled. The X-ray may reveal the status of the catheter if it is radioopaque and.250] Letters to Editor REFERENCES 1. Access this article online Quick response code Website: www. We read with interest the article titled “A rare complication of epidural anaesthesia a case report with brief review of literature”..[3. [9] Morris et al. to remove the catheter. Javid MJ.. and the authors concluded that nylon or polyurethane catheters were more resistant than Teflon or polyethylene catheters. 2. the same position as on insertion. For example. to stop pulling if the catheter begins to stretch too much (not reported by the authors in this case report). and the force required to remove an epidural catheter was 2. if non‑radioopaque. Although the catheter is inert.ijaweb. therefore.5-times more with a patient in the sitting position [8] than in the lateral decubitus position.7] The injection of saline in the catheter could either make it stiff for its easy removal or. December 12. sitting position). some authors have suggested using a small and steady force for withdrawal (but not multiple Indian Journal of Anaesthesia | Vol.g.g. it may be non-biodegradable and. Vas L.19. the lateral decubitus position and a flexion or extension position) (again not described by the authors) and injecting normal saline through the catheter (not used by the authors). Ng A. 3. Preparation of the patient and the airway for awake intubation. It could be more informative if the author could mention the type of the epidural catheter and whether it has a radioopaque marker on it or not. placing the patient in various positions (e. Indian J Anaesth 2011.6. Although they were successful in getting the catheter intact.