Download - Tied up in knots
fistula and a lung tear [2,3]. Our case
demonstrates that in doubtful situations
attaching an air-tight plastic bag or
ETCO2 monitoring line to the external
end of the feeding tube can be used to
diagnose tracheal placement, provided
the tube is not kinked or obstructed.
We also suggest that in addition to the
usual precautions recommended while
inserting feeding tubes, cleaning and
draping of the chest and abdomen
should not occur until correct place-
ment has been confirmed.
V. Datt
D. K.Tempe
S. Virmani
A. Banerjee
G. B. Pant Hospital,
New Delhi )110002, India
E-mail: [email protected]
References1 Stark P. Inadvertent nasogastric tube
insertion into the tracheobronchial tree.
A hazard of new high-residual
volume cuffs. Radiology 1982; 142:
239–40.
2 Miller KS, Tomlinson JR, Sahn SA.
Pleuropulmonary complication of ent-
eral tube feeding. Two reports, review
of the literature, and recommendations.
Chest 1985; 88: 230–3.
3 McDanal JT, Wheeler DM, Ebert J. A
complication of nasogastric intubation:
pulmonary hemorrhage. Anesthesiology
1983; 59: 356–8.
Tied up in knots
We wish to report a case of tracheal
tube pilot balloon failure which has not
previously been reported in the litera-
ture. A middle-aged man required pro-
longed ventilatory support following
coronary artery bypass grafting. A large
air leak was detected at the patient’s
mouth which was presumed to be
coming from around the tracheal tube.
The pilot balloon of the tracheal tube
was noted to be partially inflated and air
was gradually injected through the pilot
balloon valve until it became maximally
inflated. Despite this measure the air
leak continued and mechanical ventila-
tion became inadequate. A decision was
made to extubate and re-intubate the
patient’s trachea. The tracheal tube was
secured at the patient’s lips with a
cotton tie which was cut and the air
withdrawn from the pilot balloon valve
to deflate the pilot balloon. The
patient’s trachea was extubated and
immediately re-intubated with a new
tracheal tube. The original tracheal tube
was examined and the pilot balloon
tubing was seen to be kinked at the site
of the knot of the cotton tie around the
tube (Fig .6). The kink had completely
obstructed the pilot balloon tubing.
Lewer et al. have previously reported
a large air leak due to kinking of the
pilot balloon tubing at the junction with
the tracheal tube due to a manufactur-
ing defect [1]. Chua et al. have recently
described a large air leak due to a defect
in the tracheal tube itself [2]. In this case
the pilot balloon failed to indicate the
state of the tracheal tube cuff. Careful
tying to avoid the pilot balloon tubing
or the use of adhesive tape to secure the
tracheal tube should prevent this com-
plication with the attendant risks of
inadequate ventilation and aspiration of
gastric contents.
J. S. D. Allen
S. T. Webb
Royal Victoria Hospital,
Belfast BT12 6BA, UK
E-mail: [email protected]
References1 Lewer BM, Karim Z, Henderson RS.
Large air leak from an endotracheal
tube due to a manufacturing defect.
Anesthesia and Analgesia 1997;
85: 944–5.
2 Chua WL, Ng AS. A defective
endotracheal tube. Singapore Medical
Journal 2002; 43: 476–8.
An unusual first presentationof myasthenia gravis
A 20 year-old Caucasian woman pre-
sented with a one-day history of
abdominal pain of increasing severity
and a presumptive diagnosis of acute
appendicitis was made. She had no
significant past medical history and
two previous general anaesthetics had
been uneventful. She was extremely
anxious and her main concern was of
not waking up from the anaesthetic.
Clinical examination findings included
a pulse rate of 94 bpm and a blood
pressure of 124 ⁄ 68 mmHg. There
were no signs of dehydration. Follow-
ing pre-oxygenation, she was given
midazolam 1 mg and fentanyl 100 lg.
Cricoid pressure was applied and
anaesthesia induced with propofol
100 mg and succinylcholine 100 mg.
When the succinylcholine had worn
off, vecuronium 6 mg was given.
Anaesthesia was maintained with
nitrous oxide, oxygen and sevoflurane
1.3%. No additional vecuronium was
given. She was also given morphine
8 mg, cefuroxime 750 mg and metro-
nidazole 500 mg. Intravenous fluids
consisted of 1 l of Hartman’s solution.
The operation to remove the appen-
dix lasted 30 min and at the end of
the procedure her neuromuscular
function was assessed using a periph-
eral nerve stimulator. There were no
twitches.
The patient was kept anaesthetised
and blood sent for urea and electrolyte
estimation. These were normal as was
the blood glucose. She was normother-
mic (36.4 �C) and succinylcholine
apnoea was excluded as the patient
had recovered from the succinylcholine
prior to administration of the vecuro-
nium. One and a half hours following
the administration of the vecuronium,
her first twitch appeared and the neuro-
muscular blockade was reversed with
glycopyrrolate 500 lg and neostigmine
2.5 mg. She then had a train of four
ratio of about 25%. At two and a half
hours, she was given a repeat dose of
glycopyrrolate and neostigmine. At this
point, because of the possibility of
sensitivity to opioids or benzodiazepines
or both she was also given naloxone
Figure 6 Cotton tie kinking pilot balloon
tubing.
Anaesthesia, 2004, 59, pages 505–517 Correspondence......................................................................................................................................................................................................................
� 2004 Blackwell Publishing Ltd 515
