e4 Letter to the Editor / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) e1–e16

4 Van Dijk JF, van Wijck AJ, Kappen TH, et al. Postoperative pain Yonatan Y. Greenstein, MD
assessment based on numeric ratings is not the same for patients and Department of Medicine
professionals: A cross-sectional study. Int J Nurs Stud 2012;49:65–71. Division of Pulmonary & Critical Care Medicine and Allergic &
5 Ford DJ, Raj PP, Singh P, et al. Differential peripheral nerve block by local Immunologic Diseases
anesthetics in the cat. Anesthesiology 1984;60:28–33. Rutgers – New Jersey Medical School
6 Koplovitch P, Devor M. Dilute lidocaine suppresses ectopic neuropathic Newark, NJ
discharge in DRGs without blocking axonal propagation: A new approach
to selective pain control. Pain 2018.
7 Kunigo T, Murouchi T, Yamamoto S, et al. Injection volume and anesthetic
References
effect in serratus plane block. Reg Anesth Pain Med 2017;42:737–40.
1 Beaubien-Souligny W, Eljaiek R, Fortier A, et al. The association between
pulsatile portal flow and acute kidney injury after cardiac surgery: A
Felipe Muñoz-Leyva, MD* retrospective cohort study. J Cardiothorac Vasc Anesth 2017.
Wilman E. Mendiola, MD* 2 Mayo PH, Narasimhan M, Koenig S. Advanced critical care echocardio-
Antonio J. Bonilla, MD* graphy – The intensivist as the ACCE of hearts. CHEST 2017;152:4–5.
Javier Cubillos, MD*
https://doi.org/10.1053/j.jvca.2018.03.026
Diego A. Moreno, MD*
Ki Jinn Chin, FRCPC†
*
Department of Anesthesia, Javeriana University School of Medicine
Hospital Universitario San Ignacio Avoidance of Inadvertent Hypothermia With a
Bogotá, Colombia Fluid-Warming/Infusion System
†
Department of Anesthesia
University of Toronto, Toronto To the Editor:
ON, Canada

https://doi.org/10.1053/j.jvca.2018.03.033 Fluid-warming/infusion devices are sometimes used at low flow

rates or intermittently. Unless the efferent tubing is actively
warmed (as it is in some devices), the warmed fluid again loses
Clarification of Critical Care Ultrasonography heat as it slowly flows down, or stagnates in the tubing. Infusing
Certification this cooled fluid can contribute to hypothermia.1–3 This was
confirmed using a temperature probe in the distal end of our
To the Editor: warmer/infuser device extension tubing (Belmont Instrument
Corporation, Billerica, MA), which showed that warmed fluid in
I read with great interest the article by Beaubien-Souligny the tubing cooled to room temperature (161C) within 5 minutes of
et al.1 on pulsatile portal flow and acute kidney injury after flow cessation. To maintain infusate temperature of 371C, a
cardiac surgery. I commend the authors on their work, however, minimum flow rate of 80 mL/min was needed.
it is important to bring to light an incorrect statement about In an attempt to mitigate this cooling, we added passive
certification in critical care ultrasonography (CCUS) as the field insulation by wrapping a 3/8” foam pipe sleeve (M-D Building
is rapidly changing. The authors indicated that screening was Products, Oklahoma City, OK) around the tubing (Fig 1).
done by an experienced intensive care physician with “National
Board Certification in critical care ultrasound from the Amer-
ican College of Chest Physicians (CHEST).” Currently CHEST
offers a Certificate of Completion program for CCUS; this is not
a National Board Certification. At the time this article was
written experience in CCUS in North America could be
established by becoming a testamur of the National Board of
Echocardiography Examination of Special Competence in Adult
Echocardiography, by participating in the CHEST Certificate of
Completion program, or by fellowship training in CCUS. The
field of CCUS is gaining steam and physicians wishing to
have national-level certification in CCUS will have a formal
opportunity for board certification as the National Board of
Echocardiography will be offering an Advanced Critical Care
Echocardiography certification beginning January 2019.2 This
has been made possible by the work of members of the CHEST
Ultrasonography Working Group, the American Thoracic
Society, the Society of Critical Care Medicine, the Society of
Cardiovascular Anesthesiologists, the American Society of
Echocardiography, and the American College of Emergency Fig 1. (A) Fluid warmer extension tubing with intraluminal temperature probe.
Physicians. Those interested should stay tuned as the details will (B) Tubing with polyethylene foam pipe wrap for passive insulation that helps
be available in the coming months. maintain infusate temperature at lower flow rates.
 Letter to the Editor / Journal of Cardiothoracic and Vascular Anesthesia 32 (2018) e1–e16
Fig 2. Three-way stopcock and return line at distal end of rapid infuser
extension tubing allows stagnant/cooled fluid in tubing to be diverted back to
infuser reservoir until inflow line is primed with warmed fluid before flow is
then redirected to patient.
This slowed down the cooling of the stagnant fluid to room
temperature from 5 minutes to 15 minutes, and reduced the
minimum flow required to maintain normothermic infusate
from 80 mL/min to 20 mL/min.
Once the fluid in the tubing reaches ambient temperature, this
cold volume of fluid will be infused into the patient
with the next fluid challenge. To prevent this, we created a setup
that would allow flushing of the stagnant/cold fluid
from the efferent tubing (returning it to the reservoir without
waste) immediately before a fluid bolus while priming the tubing
with warmed fluid for subsequent infusion into the patient (Fig 2).
References
1 Faries G, Johnston C, Pruitt KM, et al. Temperature relationship to distance
and flow rate of warmed IV fluids. Ann Emerg Med 1991;20:1198–200.
2 Presson RG Jr., Bezruczko AP, Hillier SC, et al. Evaluation of a new fluid
warmer effective at low to moderate flow rates. Anesthesiology 1993;78:
974–80.
3 Kim GS, Ko JS, Yu JM, et al. The intermittent bolus infusions of rapid
infusion system caused hypothermia during liver transplantation. Korean J
Anesthesiol 2013;65:363–4.
David B. Wax, MD
William Tyson, MD
Natalie Smith, MD
Department of Anesthesiology
Mount Sinai School of Medicine
New York, NY
https://doi.org/10.1053/j.jvca.2018.04.030
Preintubation Adult Fiberoptic Bronchoscope
Assessment—An Effective Way to Know Depth
of Insertion of Double-Lumen Tube
To the Editor:
We read with great interest the study “Chest computed
tomography image for accurately predicting the optimal insertion
depth of left-sided double-lumen tube” by Liu et al.1 and an
editorial, “Double lumen endotracheal tube placement—knowing
depth of insertion firsthand may make a difference,” by Essandoh
et al.2 Authors of the study measured distance from vocal cords to
e5
carina using computed tomography (CT) scan, which was used to
guide double-lumen tube (DLT) insertion. With this method, they
could achieve satisfactory position of the DLT in 90% of patients
within a significantly shorter time as compared to blind insertion of
the DLT. We congratulate the authors for their success. We wish
to share few comments regarding use of predetermined depth of
insertion in securing the DLT.
We agree with the authors that the pediatric fiberoptic broncho-
scope (PFOB) is an expensive instrument with a high cost of
maintenance. Also, because of limited perioperative indications for
its use, the PFOB is not commonly available in many institutes,
especially in developing and underdeveloped countries. In centers
with high volumes of thoracic surgeries, a PFOB may not be
available if it is being used simultaneously in other operating
rooms. A PFOB of more than 2.2-mm external diameter cannot be
passed through 26F, 28F, or 32F DLTs. In such conditions,
methods that allow anesthesiologists to know the depth of insertion
of the DLT are of immense help. CT scan-guided measurement of
length of the trachea is one of the methods to know depth of
insertion of the DLT. However, this method carries certain
limitations. Firstly, CT scans of the chest often do not include
images at the level of the vocal cords. Secondly, if the trachea is
deviated, then the standard 2-dimensional CT scan cannot measure
accurately its length. On the same principle, 2-dimensional CT
scans cannot measure distance from the vocal cords to secondary
carina of either bronchus. Three-dimensional reconstruction of CT
scan helps in these measurements.
Another method to assess depth of insertion of the DLT is to
measure the distance from the incisors to secondary carina by
means of an adult fiberoptic bronchoscope (AFOB). Amin et
al. conducted a randomized controlled double-blind study in
84 patients, where distance from incisor to secondary carina
was measured prior to intubation by using an AFOB.3 This
distance guided insertion of lung isolation devices in the study
group, whereas in the control group, lung isolation devices
were inserted blindly. In both groups, a PFOB was used to
categorize the position of the lung isolation device as
optimum, suboptimum, or malpositioned. Preintubation airway
measurements by an AFOB significantly improved the success
rate of optimal placement of the lung isolation device from
25% (11/44) to 50% (18/36) (p ¼ 0.04). The incidence of
suboptimal placement was lower in the study group at 38.9%
(14/36) versus 65.9% (29/44). Thus, preintubation assessment
of dimensions of airways with an AFOB improved the success
rate of optimal placement of the lung isolation device. An
AFOB is commonly available in most of the institutes.
Preintubation airway measurements by an AFOB have the
added advantage of detecting variations in airway anatomy,
helping to choose the type of lung isolation device. Also, as
bronchoscopy often is performed by surgeons prior to thoracic
surgery to assess endobronchial disease, the depth measure-
ments can be done without an added procedure. Broncho-
scopes have markings on the surface to indicate distance from
the tip. Hence, it becomes quite easy to measure distance from
incisor to secondary carina using an AFOB. Considering that
the tip of the left DLT should be sited 0.5 to 1 cm above left
secondary carina, 1 cm is deducted from the distance recorded