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: tempedeepak@hotmail.com

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withdrawn from the pilot balloon valve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: stephentwebb@onetel.net.uk

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