An unusual case of hysterical postoperative coma

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Correspondence Death in the dental chair

I read Dr Cartwright’s editorial on community dental anaesthesia (Anaesthesia 1999; 54: 105–7) with interest as I have been involved in giving paediatric dental anaesthesia on an isolated site for some years. However, I disagree with many of the points he made, and also with his vision of future dental anaesthesia in the UK. Death in the dental chair of a seemingly fit child is a rare but tragic event often highlighted by the press. The four deaths per year suggested by Dr Cartwright is the upper end of the mortality range. Between 1979 and 1987, the British Dental Association recorded 20 deaths, of which only seven were children under 16 years of age. Between 1988 and 1993, the incidence of death was between four and no deaths per year. Computerisation of records means that no data are available from 1994 onwards Contrary to the tone of Dr Cartwright’s editorial, most dentists already attempt to dissuade patients from having dental work under general anaesthesia. Indeed, the number of dental anaesthetics in the UK has fallen from 2 million in 1967 to an estimated 400 000 this year. The recent small rise in dental general anaesthesia is almost entirely due to commercial organisations having identified a health care need that the NHS had not addressed. Many patients cannot accept dental treatment whilst awake. These patients will neglect their dental care if not offered general anaesthesia and may present with serious conditions such as facial abscess, septicaemia or myocarditis.

Dr Cartwright underestimates the number of young children having multiple dental extractions especially with the growth of cosmetic orthodontics. Every week, I encounter children as young as four having almost complete dental clearances for dental caries. My workload involves, on average, six patients per week having four extractions each. There must continue to be local provision for these patients, many of whom are in lower social classes or of ethnic extraction. It is unrealistic to suggest that these patients can easily be dealt with in hospitals, where there are at present too few facilities to cope with this workload. Dr Cartwright’s own figures suggest that if community dental anaesthesia is abolished, the number of extra cases presenting to hospitals will be in the order of 400 000 per annum. Whilst it may be possible to reduce this number, patients denied general anaesthesia would still take up considerable NHS resource as their treatment under relative anaesthesia (local anaesthetic with sedation) would be slower and more difficult than under general anaesthesia. Nationally about £7.6 million per annum is spent on dental treatment under general anaesthesia. In South Buckinghamshire, the cost of dental extraction under general anaesthesia is £120 per patient in a stand-alone site run by the local NHS Trust, whilst the cost of an admission to the local hospital is in excess of £500. By extrapolation, bringing all the community dental operations into hospital could cost in excess of £100 000 locally or £160 million per year nationally. Even if this move abolished death in

the dental chair, each prevented death would cost at least £40 million. I agree that the facilities in some community dental clinics are below the standard that should be expected when general anaesthesia is used. Most importantly, the training of staff has been shown on occasions to be below the standard that should be expected and, as Dr Cartwright states, this is all too often highlighted at inquests. I feel that for some years the Royal College of Anaesthetists has failed in its charter obligations to protect the public in this area, but this is no reason to over-react now. Too many dental anaesthetics are delivered by doctors who do not reach the standard of training and ability commensurate with specialist status. This is largely driven by economic factors: an anaesthetist could expect to receive about £20 for giving a general anaesthetic for multiple dental extractions. Out of this fee, the cost of drugs and assistance has to be debited. With each anaesthetic taking 10 min with 30-min recovery time (local audit data), few consultant anaesthetists will find the time to do this type of work outside of their NHS contracts. The new guidelines laid down by the General Dental Council are appropriate. If a specialist anaesthetist assisted by trained anaesthetic assistance, trained recovery staff and a team of dentists cannot give high-quality advanced life support to a child, the anaesthetist should never have been given specialist status. It is by no means ‘self-evident’ as Dr Cartwright suggests that this highquality advanced life support cannot be given in a dental surgery. Indeed, British

All correspondence should be addressed to Professor M. Harmer, Editor of Anaesthesia, Department of Anaesthetics, University of Wales College of Medicine, Heath Park, Cardiff CF14 4XN, UK. Letters (two copies) must be typewritten on one side of the paper only and double spaced with wide margins. Copy should be prepared in the usual style and format of the Correspondence section. Authors must follow the advice about references and other matters contained in the Notice to Contributors to Anaesthesia printed at the back of each issue. The degree and diplomas of each author must be given in a covering letter personally signed by all the authors. Correspondence presented in any other style or format may be the subject of considerable delay and may be returned to the author for revision. If the letter comments on a published article in Anaesthesia, please send three copies; otherwise two copies of your letter will suffice.

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Dental Association data between 1979 and 1987 show the incidence of death during dental treatment was higher in hospital that in the community setting. The cost of employing and training appropriate staff, refurbishing clinics and regular College inspection of these clinics is a more appropriate and economically viable response than abandoning the clinic-based approach to dental treatment. These responses are far more likely to reduce the number of deaths in the dental chair than new drugs such as sevoflurane. The first step of appointing a Dental Anaesthesia Committee is appropriate. It is a shame, however, that the first news of the changes in dental anaesthesia were given on Radio 2 and that there seems to have been minimal consultation with doctors and dentists providing the service. Dental anaesthesia in the UK can be improved, it will cost money and it will cause some people to look for retraining or other employment. The changes must be led by the anaesthetic profession in co-operation with the General Dental Council and the Department of Health. With an estimated mortality rate of better than 1 in 100 000, dental anaesthesia is statistically already safe, and there is no good evidence on which to abandon a clinic-based approach. T. J. Dexter Wycombe General Hospital, High Wycombe HP11 2TT, UK I am extremely disturbed by Dr Cartwright’s February editorial. The attitude of the Royal College committee which he seems to convey is not, ‘How can we conduct dental anaesthesia in the surgery safely?’ but, ‘Prepare for abolition’. I agree there should be no anaesthetic deaths in the dental surgery – though, I believe, there are a few each year which are not associated with general anaesthesia. What I cannot agree about is that there is any need for the UK to be the same as other parts of the world. We do need to educate the British Public, but, please, not to be the same as the rest of the world! The difference between us and the rest of the world is why we still have the finest anaesthetic service.

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Dr Cartwright airily dismisses more than half my dental clientele – the physically and mentally handicapped, some children, etc. These really do need to be catered for, and I suspect far fewer general anaesthetics, conducted by consultants who do undergo peer review, will produce the dramatic improvement required. Already, I believe that the dental surgeries where I work are better than many places, for example, where ECTs, abortions, and some routine surgery are performed. The dental surgeries I work at are unlike some hospitals only because they do not have a mortuary attached, and do not keep patients lying on trolleys for hour after hour! Why not just leave the GDC regulations to settle down, pro tem? J. H. Williams Hove BN3 6QA, UK The title of your recent editorial (Anaesthesia 1999; 54: 105–7) was calculated to both shock and imply that dental chair anaesthesia is the main contributory factor in deaths associated with dentistry. This is plainly a too economical dealing of the truth since about half of the deaths [1, 2] occurred in hospital and involved anaesthetists of consultant grade: presumably, these are operating table deaths. The amended guidance on general anaesthesia issued by the General Dental Council (GDC) in November 1998 [3] applies to all dentists registered in the UK, including those in hospital practice, but the GDC puts the burden of responsibility on the dentist for ensuring that proper systems, equipment and processes are in place and that the anaesthetists and supporting staff are properly trained and accredited. There may be ambiguity in the field of oral and maxillofacial surgery where the surgeon is both medically and dentally qualified, who might not be necessarily registered with the GDC but with the General Medical Council, yet delegate dental operative procedures under general anaesthesia to junior staff who are singly qualified, registered with the GDC and would therefore need to fully comply with its guidance. The issue of whether general anaesthesia is always appropriate is an important

one. As a dentist with long-standing experience with children and adults with special needs, I see many patients for whom general anaesthesia is the only option. Many children have already experienced dentistry in general practice and are referred in for general anaesthesia as a last resort because of a history of poor co-operation and acute anxiety. Many children require multiple extractions which may not be achievable under local anaesthesia even with inhalation sedation: they may be cajoled to accept one treatment under local anaesthesia, but subsequently become impossible to manage. There is also a question of economics. In previous years, where dental payments were for each treatment item, there was a financial incentive for the general dental practitioner to carry out as much treatment as required in practice. Under the capitation arrangements for children introduced in 1990, this financial incentive was removed (apart from certain exceptions) and there was a tendency for dental caries in primary teeth to be left untreated until symptoms occur whereupon a referral for extractions is made. Fee per item has currently been reinstated so that more treatment of the primary dentitions is now being carried out in general dental practice. This change in funding obviously influences treatment and referral practices. The difficulties inherent in treating deciduous teeth inevitably means that many children will require multiple extractions and that general anaesthesia will remain as a appropriate option. If the referral is made to a centre or hospital where the only treatments available are extractions under general anaesthesia, then the decision becomes polarised towards exodontia under general anaesthesia. In the Community Dental Service, where resources and Service Specifications allow, patients can be given treatment which is most appropriate: this could include preventive treatment, conservation or extractions under local anaesthesia, sedation or general anaesthesia. In the General Dental Service, item of service payments remain for adults; however, the fee for general anaesthesia is likely to be removed shortly. There

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are, at present, far fewer general anaesthetics carried out in general dental practice funded from National Health Service monies. The majority of all anaesthetics are now administered either in hospitals or on Community Dental Service premises, where patients can be monitored. It is accepted that some premises, even hospitals, may not be ideal. Health Authorities need to work in partnership with provider Trusts to ensure that general anaesthetics are available, where appropriate, on premises which are entirely satisfactory in every respect for the safe administration of anaesthesia, as well as the delivery of operative dentistry, by accredited and trained staff. Equally high standards are de rigueur for recovery facilities. The General Dental Council’s intention was not to confine all general anaesthetics to the district general hospital but to highlight the responsibility of dentists in appropriate treatment decisions and for ensuring that appropriate facilities and staff are used. This was restated by Dame Margaret Seward, President of the General Dental Council, in answer to questions at the British Association for the Study of Community Dentistry conference in December 1998. General anaesthetics are generally safe but are never without risk, whether they are administered for dental surgery or general surgery. We need to ensure that, wherever the anaesthetic is given, risks are minimised, not only by close co-operation between anaesthetists and dentists, but by health service managers, planners and commissioners. J. A. Clewett Senior Dental Officer, Wrexham Dental Centre, Wrexham LL11 1DY, UK References 1 Coplans MP, Curson I. Deaths associated with dentistry. British Dental Journal 1982; 153: 357–62. 2 Coplans MP, Curson I. Deaths associated with dentistry and dental disease 1980–89. Anaesthesia 1993; 48: 435–8. 3 General Dental Council. Maintaining Standards: Guidance to Dentists on Personal and Professional Conduct.

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London: General Dental Council, 1998.

Sometime after those of us directly involved in chair dental anaesthesia have given up wondering if anyone in the anaesthetic hierarchy cares, you have printed an editorial on the subject. The writer does not state his involvement but is obviously anxious about the subject judging by the use of bold type. Unfortunately, he has merely followed the hype and not looked at reality. The time for action was years ago. The reality is that chair general anaesthetics have been treated as a purely dental matter for far too long. We hear regularly about lack of recognition of anaesthetic skills by the private insurers yet not a word about the dire situation in the NHS dental chair. On taking up my consultant post, I found myself with a community dental session where the numbers of anaesthetics were limited by the supply of anaesthetists. I discovered that my colleagues were as frightened of dental general anaesthetics as the patients were. Financial rewards from the Dental Estimates Board (DEB) ensured no competition between dental general anaesthetics and the attractions of private general surgical practice conducted in similarly isolated surroundings. They also ensured a hurried and often insensitive anaesthetic that induced a fear of anaesthesia itself. Those few consultants involved in chair anaesthetics are more concerned with providing a service than making money. The result is that doctors unlinked to the hospital service (with its requirements for audit and CME) were, and are, left to provide what is a much-needed service to the dental patient in many parts of the country. Despite this, mortality, although unacceptable, is measured on the fingers of one hand unlike that of hospital patients. When I enquired of the defence union why GP/anaesthetists were not required to pay the grossly inflated subscription of the professional anaesthetist despite a case number load possibly higher than the latter, I was told that the risk in dental general anaesthetics was ‘not significant’ [Medical Protection Society, personal communication]. Concern is expressed about where we

anaesthetise. Having, like many of my generation, been brought up to work in small isolated hospitals, I learned the need for case, procedure and technique selection. As few anaesthetists have taken an active role in the development of the service it is not surprising that many premises are anaesthetically unsuitable. The editorial talks of general anaesthetic extraction as the ‘easy option’. This may well be the case in the hospital oral surgery department but comments that I received when surveying local dentists implied that this was anything but the case. ‘I was very much relieved when (due to retirement of the anaesthetist) we had to stop’ [1] was typical. Having paused after Poswillo, some practices did not restart, ‘my coronaries felt so much better’ was one comment. I would be not surprised if many of the individual practices halted in reaction to the GDC ruling did not restart. We should be asking why health authorities continued ‘farming out’ GA to GDPs instead of building up hospitallinked community services. Why did the building of integrated services on DGH sites fall at the first hurdle? General anaesthesia should be just one part of a continuum of psychological input; from soft words and patience, through local anaesthesia and sedation, to the intubated GA. We have audited our GA conservation cases and discovered that with this approach we achieve a significant degree of clinical effectiveness with only a handful of handicapped patients not progressing to ‘awake’ treatment [2]. The dental hierarchy appears to decry a technique that is needed and will continue to be needed for many years. Dental phobia is embedded firmly in human culture throughout the world, as the orally observant traveller will observe. It is suffered by all classes irrespective of wealth or education. In comic books, the dentist is the object of fear, ‘Happy Families’ games have ‘Mr Pain the Dentist’. Dental anaesthesia had its own notoriety. In the clinic we see fear being taught by parents and grandparents to naive children; previously compliant patients become phobic following inappropriately prolonged attempts at extraction or inappropriate treatment techniques.

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Professor Vermulen-Cranch quotes the statistics from the Netherlands of 45% of conscripts to the army being in serious need of dental treatment [3]. Of course, the Dutch are a hardy lot not needing analgesia, according to some of their medical hierarchy. Apparently there is a firm in Rotterdam who will give a general anaesthetic, remove all of your teeth and provide a set of plastic ones. Pre NHS, as a wedding present, a girl would undergo the same procedure. Are we to revert to that situation again? It is no coincidence that the first general anaesthetic in England given by Francis Boote was for the extraction of Miss Lonsdale’s tooth. As anaesthetists, not the technicians of the surgeons, it our function to make sure that procedures can be performed with the minimum of distress and maximum of safety. If that involves a general anaesthetic then we must make sure that conditions are optimal. We do not insist on local anaesthesia for the frightened patient in the main operating theatres, why therefore in the dental environment? We must not join a panic-driven bandwagon which if unstopped will leave our patients terrified, rotten toothed, only appearing when with a fat face and trismus. There is no more evidence that there is no ‘defined clinical need’ for general anaesthesia in dentistry [4] than for cosmetic surgery yet I do not hear any call to limit that. When I reviewed the DEB figures for dental general anaesthetics in Clwyd, the graph followed a steady downward trend which, extrapolated, passed through zero some time in 1991. At the time, I thought that this was a demand effect but further review implies a supply effect as the GPs and dentists giving general anaesthetics retired. Community numbers were showing a gentle rise but demand rose dramatically, even after filtering out those treatable by a different approach, and continues to be unmet and awaits further anaesthetic input. Criticism has been levelled at a chain of commercial dental centres, funded from DEB item-of-service payments, whose case numbers form a significant proportion of all recorded anaesthetics. I neither praise nor condemn them but must ask why departments of anaesthesia

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around the country have not been involved in the development of such services, preferably session based, and thus have control over standards, in particular over the staffing. The option of sedation has been raised; however, Poswillo effectively stopped many of the practices in this area from providing this. It must be also remembered that one of the five reported deaths in the last year was under ‘sedation’. There should be no excuses for second-rate anaesthetics; with sevoflurane available there is no excuse for the use of halothane, and even the minimal risk it presents is, in these days, not acceptable [5]. Perhaps the Editorial should have been asking why the Dental Estimates Board was not insisting on its use and providing appropriate funding for it? Why have anaesthetists put up with being formally regarded as being in the same position re professional responsibility as the dental nurse for all these years [6]? Perhaps such questions are too political but if we do not ask them the press will ask why we did not. T. B. Webb Ysbty Glan Clwyd, Rhyl, UK References 1 Local dental practitioner in response to a survey of practices asking about Anaesthesia and resuscitation. Results presented to Association of Dental Anaesthetists 1991, Further similar responses in follow up survey presented to European Society for Anaesthesia and Dentistry in Handicapped as Changes in attitudes to general anaesthesia and resuscitation. Trier Sept., 1993. 2 Webb TB, Sandham JS. Is general anaesthesia for dental conservation worth while? A view through the retrospectoscope. Proceedings of Association of Dental Anaesthetists 1998; 7: in press. 3 Vermeulen-Cranch DM. Pain control in dentistry in the Netherlands. Proceedings of Association of Dental Anaesthetists 1998; 6: 16. 4 Royal College of Anaesthetists.

Standards and Guidelines for General Anaesthesia for Dentistry. February 1999; 5. 5 Worthington LM, Flynn PJ, Strunin L. Death in the dental Chair: an avoidable catastrophe? British Journal of Anaesthesia 1998; 80: 131–2. 6 Greenan J. Am I my brother’s keeper? Paper to Association of Dental Anaesthetists. June 1995.

A reply Thank you for the opportunity to reply to these letters. As I indicated in my editorial, strong emotions are roused by discussions on this topic. I stand by my views – and lest anyone think otherwise, let me make it clear that I am not speaking from some ‘ivory tower’. I single handedly provided the general anaesthetic service to our community dental service for some 12 years and practised in dental surgeries as well. I have never doubted that there will always be a residual need for general anaesthesia to be provided. At issue is the setting and personnel and these are the critical areas which we need to address. I am well aware of the public health issues, the numbers involved and the needs of children, but this sort of emotional blackmail is always employed when change is envisaged. Comment is focused very largely on children, but I do not underestimate the needs of adults. I acknowledge the skills, commitment and safety record of many practitioners who have provided an excellent service for many years in this difficult area, often in inadequate premises. I am also sure that many dental surgeons do indeed dissuade patients from seeking general anaesthesia and I also know perfectly well the problem of young children with grossly carious dentition. That is precisely the point that needs to be made. General anaesthesia needs to be restricted to those cases where it is genuinely indicated, and the total number required should then fall to a level at which alternative provision can be made, rather than working in a multitude of isolated sites. That there are many conscientious and skilled practitioners working successfully in this field is not in doubt,

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but every tragedy brings disrepute to the profession. The mantle of paternalism is gone forever, and it is sad but true that the majority is tarred with the same brush as the minority. The ramifications of recent high-profile cases are part of this process, which we cannot avoid or evade. It is my view that it is better to lead change than have change imposed upon us. I do not underestimate the difficulties or the costs involved in such a change in practice, but someone somewhere has to say ‘enough’. Unless this is done, the situation will persist. We must have the courage to say that the time for action is now. The decision to make the change is essentially political, since that is the source of funding. Should the political will not be there, we should at least make our professional views clear. I have made mine clear, as has the Royal College of Anaesthetists via its Dental Committee. The Royal College of Anaesthetists’ Dental Committee is in favour of safe dental anaesthesia, wherever it is conducted, but in our view it should not be conducted on isolated sites. It is also our view, and that of the General Dental Council, that anaesthesia should be conducted by trained specialists who are on the Specialist Register of the General Medical Council. Is this unreasonable? I must on behalf of the Royal College of Anaesthetists refute the question that it has failed in its charter obligation to protect the public. The College has control only over training and consultant appointments, and not over individual practice in dental surgeries. The service is indeed underfunded and that has been pointed out on many occasions; the available fees are so low that it is unlikely to attract skilled consultant anaesthetists. The College can only advise but has no actual power. The power to limit the activities of individual practitioners lies with the General Medical Council, which has never addressed this area of practice. The General Dental Council has now acted and its advice is plain: only specialists should provide anaesthesia in dental surgeries. It is indeed a pity that the first news of the changes in dental anaesthesia came via the media, but this followed the General Dental Council’s decision and

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was not in the control of the College or the Association. There had been extensive consultation among the profession and a consensus view emerged, which I support. If we can reduce the number of general anaesthetics given to those clinically indicated, we would have the staff and facilities to cope. Since the General Dental Council’s ruling, the number of dental general anaesthetics is reported to have fallen steeply. I have not heard of a corresponding leap in hospital waiting lists, so presumably alternative treatment is now taking place. Dr Williams misunderstands me. I do not ‘airily dismiss’ any group of patients, but we have to be realistic. I am in favour of safe dental anaesthesia wherever it is conducted. Death after dental anaesthesia is indeed rare; the public expectation is that it should be avoidable and that the provision of anaesthesia on isolated sites is no longer acceptable. Dental anaesthesia has a long history but it is time for change. Dr Clewett makes some valid points, but I refute the suggestion that my editorial was economical with the truth. I was careful not to allude to the publications by Coplans and Curson, as both of these relate to conditions before the Poswillo report. It is a sad fact that deaths continue to occur – indeed I have heard of a death in a dental surgery which has occurred since the editorial was published. I agree with much of what Dr Webb writes, but would assure him that we are not ‘joining a bandwagon’, nor just ‘following hype’. He is right in his assertion that the time for action was years ago, but the fact that nothing has happened is largely the fault of the specialty. For too long, anaesthetists have been willing to preserve the status quo and continue to provide a service, with only occasional mutterings. Few have been prepared to stand up and say ‘Enough – we cannot continue like this’. We have continued to provide the service, in the interests of patients, and our own incomes. Funding is at the heart of the problem. Adequate funding and a proper financial return would (I hope) result in a better quality of service. The present system is cheap for the NHS, and relies on goodwill for little

financial reward, but so long as we do it why should the government increase funding? This may be unpalatable, but it is true. It is not the function of the DEB to insist on the use of particular anaesthetic agents; they simply pay out for procedures performed. They have no interest in safety, merely in keeping costs down. They are more likely to insist on halothane, which I do not think many would find acceptable. The real answer, as I wrote in my editorial, is for anaesthetists to force change. I have heard and understand the special pleadings for various groups. I sympathise with them and agree that we must provide a service for them, but in safety. Redirection of resources would enable this service to be provided, but we have to force the issue. I echo Dr Clewett’s sentiments regarding the need for partnership between Health Authorities, Trusts and the professions. If we can achieve this we really will take a huge stride in improving safety, but so long as we continue to work in the present system there is no incentive for change. I used to provide general anaesthetics for the community dental service. Following Poswillo, I indicated that I would resign if improvements were not forthcoming. They were not. I resigned, and could not be replaced until the service was located on a hospital site, where we now provide an anaesthetic service under the auspices of the local Department of Anaesthesia, including training for junior anaesthetists. So long as we soldier on, the present system will persist. Persuasion has failed. It is time for action. D. P. Cartwright Derbyshire Royal Infirmary, Derby DE1 2QY, UK

An unexpected complication of the intubating laryngeal mask

The case report submitted by Dr Branthwaite (Anaesthesia 1999; 54: 166–7), the barrister acting for the relatives of this patient, raises some questions, which require answers. The case as

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presented invites the reader to draw the following conclusions: (a) the accident occurred during the course of a clinical trial, (b) the protocol of this ‘trial’ was not followed, (c) there was no predisposing pathology, (d) the device probably caused the injury by virtue of its rigidity, (e) the use of the device in elective anaesthetised patients in hospitals is inappropriate. None of these conclusions is justified by the facts. No trial had been started in this hospital, so no protocol was in place. The use of the intubating laryngeal mask (ILMA) on this occasion was purely for demonstration purposes. Three consultant radiologists independently confirmed the presence of a high oesophageal pouch. The coroner’s pathologist admitted at the inquest that he might well have missed this abnormality. Had the accident been due to the nature of the device, other cases would now surely have come to light. This has not occurred and the concluding advice offered, namely that the ILMA should not be used in elective hospitalised patients undergoing general anaesthesia, is unsupported by the evidence reported in a number of trials involving a substantial number of patients [1–4]. A more considered conclusion might have been to advocate great care when instrumenting the pharynx especially in the elderly, for, as Dr Branthwaite points out, tracheal intubation, however performed, is not without hazard, albeit rarely. A. I. J. Brain Royal Berkshire Hospital, Reading RG1 5AN, UK References 1 Baskett PJF, Parr MJA, Nolan NP. The intubating laryngeal mask: results of a multicentre trial with experience of 500 cases. Anaesthesia 1998; 53: 1174–9. 2 Chan YW, Kong CF, Kong CS, Hwang NC, Ip-Yam PC. The intubating laryngeal mask airway (ILMA): initial experience in Singapore. British Journal of Anaesthesia 1998; 81: 610–1. 3 Shung J, Avidan MS, Ing R, Klein

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DC, Pott L. Awake intubation of the difficult airway with the intubating laryngeal mask airway. Anaesthesia 1998; 53: 645–9. 4 Joo H, Rose K. Fastrach – A new intubating laryngeal mask: successful in patients with difficult airways. Canadian Journal of Anaesthesia 1998; 45: 253–6.

Having been closely involved with the preliminary trials on the intubating laryngeal mask (ILMA), which was developed in our Institution between 1994 and 1997, we wish to comment on the case report submitted by Dr Branthwaite, regarding an unexpected complication following the use of this device (Anaesthesia 1999; 54: 166–7). This case was presented at a symposium on the ILMA held at the Glasgow Meeting of the Association of Anaesthetists on 23 September 1998, when Dr Brain cautioned those present on the possibility of damaging the elderly oesophagus when attempting blind intubation through the ILMA. The initial trial with a prototype ILMA in this hospital involved 100 patients, who were intubated ‘blindly’ without complications [1]. This prototype was further modified to become the ILMA and using a dedicated soft silicone tracheal tube, a further 100 patients were ‘blindly’ intubated uneventfully [2]. Since then the ILMA has been continuously in use both for training and demonstration purposes without encountering any serious complications [3]. The ILMA is, in our experience, an extremely useful tool for securing the airway in awake and fasted patients undergoing anaesthesia, particularly with patients known to have difficult airways [4]. Other investigators have reported similar experiences [5, 6]. The ILMA is designed to be more versatile than the LMA for overcoming the difficult airway and the soft-tipped tracheal tube designed for use with the ILMA makes trauma very unlikely in the presence of a normal oesophagus. The tragic case reported by Dr Branthwaite appears to be an extremely rare complication of accidental oesophageal intubation and/or nasogastric tube insertion into a diseased oesophagus. Clearly, the case described illustrates a

rare but real hazard which might well have made any form of oesophageal intubation hazardous. It would be inappropriate to remove such a valuable intubating tool from the anaesthetist’s armamentarium. Experience with the ILMA should be gained by its use during elective surgery before attempting use in the difficult airway. Hence, we strongly disagree with Dr Branthwaite’s concluding remarks on the use of the ILMA during elective surgery in hospitals. M. Srivastava A. Kapila C. Verghese Royal Berkshire Hospital, Reading RG1 5AN, UK References 1 Kapila A, Addy EV, Verghese C, Brain AIJ. The intubating laryngeal mask airway: an initial assessment of performance. British Journal of Anaesthesia 1997; 79: 710–3. 2 Brain AIJ, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask. II. A preliminary clinical report of a new means of intubating the trachea. British Journal of Anaesthesia 1997; 79: 704–9. 3 Brain AIJ, Verghese C. The Intubating Laryngeal Mask Airway: Instruction Manual (1st edn). Intavent Ltd, 1998. 4 Cros AM, Colombani S. Preliminary study of intubation with a new laryngeal mask for difficult intubation. Abstract from ASA Meeting. 18–22 October 1997, San Diego. Anesthesiology 1997; 86: A482. 5 Baskett PJF, Parr MJA, Nolan JP. The intubating laryngeal mask; results of a multicentre trial with experience of 500 cases. Anaesthesia 1998; 53: 1174–9. 6 Rosenblatt WH, Murphy M. The intubating laryngeal mask: use of a new ventilating-intubating device in the Emergency Department. Annals of Emergency Medicine 1999; 33: 234–8.

I write in connection with the case report written by Dr Branthwaite (Anaesthesia 1999; 54: 166–7). As the co-ordinator of the Multicentre Trial of the

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Intubating Laryngeal Mask referred to in the third paragraph of the case report, I should like to make some comments. A number of centres were approached inviting them to take part in the multicentre trial. A draft protocol was produced and sent to all participants for comment. All comments were assimilated into a final version which was then submitted for ethical approval at each participating centre. Part of the protocol stipulated that a representative from each centre should take part in a demonstration of the correct technique of insertion of the device and subsequent tracheal intubation. As is the way of things, some centres obtained ethical approval and took part in demonstrations before others and progress was made at different rates in different centres. The centre involving the patient whose case is reported by Dr Branthwaite did not take part in the trial which was well underway when the case was reported by Dr Brain at the Association of Anaesthetists meeting in September 1998. When the very unfortunate event in this case was made known to me, I sent a note to all participants in the trial reemphasizing that the device should not be used in patients with detected pathology or abnormality in the pharynx, larynx or oesophagus. The aim of the trial was to collect experience of this new and promising [1, 2] device in 500 patients in a variety of centres using a common protocol. Our results have been reported in Anaesthesia after peer review and show that the experience has been very favourable with no untoward sequelae [3]. Tracheal intubation, performed by any technique, is not without hazard. Failure to intubate is also a source of morbidity and mortality. The intubating laryngeal mask offers a method of overcoming difficulty in intubation [4] but should only be employed by those with experience in its use. The stressful situation of an emergency such as a difficult intubation is not the time to use the device, or indeed any other device, for the first time. The principle object of our trial was to determine the learning curve for using the intubating laryngeal mask by experienced anaesthetists in

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carefully restricted conditions designed to be as safe as possible. The intubating laryngeal mask has the potential to overcome the rare, but very serious, situation of failure to intubate and thus I believe justifies investigation. Clearly all trials of new devices must be undertaken with a carefully designed protocol and with full ethical approval and informed consent. I believe that this was done in this trial. Only by trying to improve our practice, can we make progress. P. J. F. Baskett Frenchay Hospital, Bristol BS16 1LE, UK. References 1 Kapila A, Addy EV, Verghese C, Brain AIJ. The intubating laryngeal mask airway: an initial assessment of performance. British Journal of Anaesthesia 1997; 79: 710–3. 2 Brain AIJ, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask. II. A preliminary clinical report of a new means of intubating the trachea. British Journal of Anaesthesia 1997; 79: 704–9. 3 Baskett PJF, Parr MJA, Nolan NP. The intubating laryngeal mask: results of a multicentre trial with experience of 500 cases. Anaesthesia 1998; 53: 1174–9. 4 Parr MJA, Gregory M, Baskett PJF. The intubating laryngeal mask. Anaesthesia 1998; 53: 343–8.

We read with a growing sense of unease the case reported by Dr Branthwaite concerning a death from apparent iatrogenic oesophageal trauma after elective use of the intubating laryngeal mask airway (ILMA). Dr Branthwaite suggests that tracheal intubation via the ILMA under elective general anaesthesia subjects the patient to unacceptable extra risk of damage to adjacent structures. If we accept this premise then what are the implications for other blind techniques commonly taught (and practised under elective general anaesthesia) to anaesthetic trainees? The anaesthetist or intensivist may cause trauma to the oesophagus. The

incidence of perforation is reported to be nearly equal for nasogastric intubation and difficult tracheal intubation [1]. That as experienced anaesthetists we can deal with both anticipated and unexpected cases of difficult intubation has relied upon our training in various airway manoeuvres in normal patients, some of which are blind techniques [2]. The gum elastic bougie is a useful aid to difficult intubation. Successful blind passage of the device towards the laryngeal inlet in an emergency is surely dependent on familiarity with the device gained under elective anaesthesia. Indeed, it has been suggested that simulated difficult intubation achieved by allowing a Grade 1 or 2 Cormack and Lehane view of the glottis [3] to become a grade 3 view will facilitate experience with this device [3, 4]. Blind nasal intubation remains an important technique in the management of the difficult airway [5]. The successful passage of the tube frequently relies on the anterior neck sign of the tube pressing into one or other vallecula. It is not immediately apparent how the ILMA can be any more traumatic because it is held in position by a rigid airway tube held firmly in place by its handle. No test is specific or sensitive enough to accurately predict all difficult intubations, so they will continue to occur in an unpredictable fashion [6]. Blind intubation through the standard laryngeal mask has been successfully demonstrated [7] and forms part of many anaesthetist’s difficult intubation armamentarium. The ILMA has recently been reported to be of use in difficult or failed intubations [8, 9] and to be a more reliable conduit for blind tracheal intubation than the standard laryngeal mask [9]. Furthermore, there appears to be a learning curve for this device [10]. Our group is currently undertaking a number of studies using the ILMA. We feel that it is a useful device alongside other equipment for management of the difficult airway. The successful use of the ILMA should rely on expert guidance and training in its correct handling. A. Choyce C. M. Timberlake N. J. D. McNeilis

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M. S. Avidan C. Patel King’s College Hospital, London SE4 9RS, UK References 1 Norman EA, Sosis M. Iatrogenic oesophageal perforation due to tracheal or nasogastric intubation. Canadian Anaesthetist’s Society Journal 1986; 33: 222–6. 2 Vaughan RS. Airways revisited. British Journal of Anaesthesia 1989; 62: 1–3. 3 Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105–11. 4 Gataure PS, Vaughan RS, Latto IP. Simulated difficult intubation. Anaesthesia 1996; 51: 935–8. 5 Harris RD, Gillett MJ, Joseph AP, Vinen JD. An aid to blind nasal intubation. Journal of Emergency Medicine 1998; 16: 93–5. 6 Wilson ME. Predicting difficult intubation. British Journal of Anaesthesia 1993; 71: 333–4. 7 Heath ML, Allagain J. Intubation through the laryngeal mask airway. A technique for unexpected difficult intubation. Anaesthesia 1991; 46: 545–8. 8 Parr MJA, Gregory M, Baskett PJF. The intubating laryngeal mask. Anaesthesia 1998; 53: 343–8. 9 Brain AIJ, Verghese C, Addy EV, Kapila A, Brimacombe J. The intubating laryngeal mask. II. A preliminary clinical report of a new means of intubating the trachea. British Journal of Anaesthesia 1997; 79: 704–9. 10 Kapila A, Addy EV, Verghese C, Brain AIJ. The intubating laryngeal mask airway: an initial assessment of performance. British Journal of Anaesthesia 1997; 79: 710–3.

A reply from Dr Branthwaite I do not wish to demur from the conclusion of those responsible for the design, development and promotion of the laryngeal mask and its variants that these are useful additions to the repertoire of techniques available to anaesthetists for airway management. Similarly, I

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concur with the advice of Dr Brain and the caution he expressed at the Glasgow meeting of the Association. Far more importantly, the case was reported because it drew attention to a number of moral and legal questions posed by research, development, demonstration and skill acquisition on patients who would not otherwise be exposed to the technique in question. At what point does a prototype become a routine instrument? Should patients be used for training and demonstration purposes if, for example, tracheal intubation would not otherwise be chosen? If there is or may be a greater risk, albeit only small, when intubation is carried out blindly rather than under direct vision, is it acceptable to employ this technique on patients anaesthetised electively in whom conventional methods of intubation would be feasible? For how long is it reasonable to persevere if the manoeuvre proves difficult? Are practitioners entitled to use patients to teach or maintain a professional skill, merely to ensure competence to employ that skill when treating some other patient for whom its use is essential? Kantian philosophers would utter a resounding ‘no’ and yet such practices undoubtedly have been, and perhaps still are, widespread. The practicalities of medicine throw these conflicts into sharp relief and have been the source of critical comment for several decades at least [1, 2]. The Royal College of Surgeons has responded by developing sophisticated simulators for practical training and research but some techniques are not amenable to this approach and can only be investigated in volunteers. The Trust where the reported incident occurred has already and laudably put in place revised procedures designed to avoid recurrence of any similar conflict of interest (vide infra). Protocols, Ethics Committees and written informed consent offer some protection to both patient and practitioner but do not negate the possibility of litigation or other adverse comment. Well publicised criticism and the investigation ordered subsequently by Government into the use of continuous negative extrathoracic pressure to treat respiratory distress in the newborn [3] illustrate

the hazards of today’s clinical research all too clearly. I can but conclude, I hope without contention, by endorsing the imperatives set out in Professor Harmer’s Editorial [4]. M. Branthwaite One Paper Buildings, London EC4Y 7EP, UK References 1 Pappworth ME. Human Guinea-Pigs: Experimentation in Man. London: Routledge and Kegan-Paul, 1967. 2 Kennedy I. The Unmasking of Medicine (the 1980 Reith Lectures). London: Allen & Unwin, 1981. 3 Jones J. Government sets up inquiry into ventilation trial. British Medical Journal 1999; 318: 553. 4 Harmer M. More ethical issues. Anaesthesia 1999; 54: 108–9.

The case described by Dr Branthwaite (Anaesthesia 1999; 54: 166–7), which took place in our hospital, raises several important issues, the most important of which is whether the patient gave proper informed consent. Current guidance on obtaining written consent requires that this is obtained by a person with a comprehensive understanding of the procedure or treatment and, in the main, relates to surgical operations [1]. We are unaware of any circumstance in which separate written consent is obtained by an anaesthetist. In most cases consent to anaesthesia is either implied or is obtained verbally. We question whether this practice should be reviewed? In our case, the patient was involved in a demonstration of a new device, the intubating laryngeal mask, prior to the start of a clinical trial. This had been previously approved by the Local Research Ethics Committee (LREC). Ethical Committee approval is not required if patients are being used for demonstration or teaching. We question whether it should be. At present, patients are not informed as to who is going to undertake a particular procedure, nor of the operator’s experience, nor who will be present during the procedure. We again question whether they have a right to know.

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The issues we have raised are not within the remit of the LREC and we are unaware of any hospital in the United Kingdom that has a body which can provide guidance on such matters. As a direct result of this case, we have set up a Trust Ethics Committee to advise on the matters raised. The committee’s membership includes clinicians, both medical and nursing, therapists and patient representatives and is chaired by a nonexecutive director of the Trust. Other issues that will be dealt with by the committee will include providing advice to clinicians as to when variation of a standard technique constitutes a new development requiring LREC approval and what information should be given to the patient in such circumstances. These are decisions that are acknowledged as being difficult [2, 3]. We commend our approach to you and, given the need for greater openness, feel that the issues we have raised merit wider debate. D. J. Scott Medical Director, Conquest Hospital, St Leonards-on-Sea TN37 7PT, UK References 1 General Medical Council. Seeking Patients’ Consent: the Ethical Considerations. London: General Medical Council, 1999. 2 McCullough L. Surgical Ethics. Oxford: Oxford University Press, 1998. 3 Lantos J. How can we distinguish clinical research from innovative therapy. American Journal of Pediatric Hematology/Oncology 1994; 16: 72–5.

Management of anaesthesia for Jehovah’s Witnesses

Whilst acknowledging that the recent Association publication on the Management of Anaesthesia for Jehovah’s Witnesses [1] represents a significant step forward in clarification of a vexed topic, certain aspects warrant comment. To give credence to, by consigning to print, the totally irrational and manipulative notion that administration of blood against a patient’s wishes is equivalent to

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‘forceful sexual interference’ (paragraph 2.4) is professionally unacceptable. However misguided and legally culpable a doctor is in instigating such a transfusion, to act with the intention of saving life cannot be compared with the forceful and traumatic abuse of a fellow human’s body solely for personal gratification Recent knowledge regarding the risks of transfusion reinforces the principle that all patients should give informed consent prior to transfusion [2] and that blood products should only be administered when it is clear that the benefits outweigh the risks. The issue of inherent risk cannot be construed, however, as support for the absolute refusal of blood products, despite the assertions of paragraph 2.5, since situations are clearly reached with gross anaemia whereby the benefits patently outweigh any such risk. The major deficiency of the publication, however, lies in the lack of specificity as to what death from uncorrected anaemia constitutes, this despite considerable emphasis on achieving informed consent. This process of dying has significant implications not only for the patient, but for other medical practitioners, for other patients and for the public purse. The patient should thus be aware that death is not some defining moment over which they maintain control, but constitutes a progressive decline, potentially over a very prolonged period, characterised by profound weakness and depression, cardiac failure with palpitations, extreme dyspnoea, gross oedema, wound breakdown, recurrent and multisource infections, and diarrhoea from gastrointestinal failure. The patient should also be aware that controlled ventilation and inotropic support are clearly not an answer to the underlying problem and in the presence of the above merely serve to delay the inevitable. This issue clearly impacts on intensive care and generates an otherwise unnecessary burden of care not only directly medical, but also in problematic discussion with patient, relatives and liaison groups and ethically disturbing decision making during that process. The impact on other patients is one of

denial of access to intensive care beds for those more capable of benefiting and this is clearly contrary to principles of social justice. The further cost to society is that of the expense of prolonged hospitalisation, including intensive care, and all the secondary supportive care such as erythropoietin, TPN in the presence of gut failure, antibiotics for the inevitable infections, oxygen therapy and the return to the operating theatre for wound or anastomotic breakdown, all of which may prove ineffective and therefore futile. The process of informed consent should therefore extend beyond discussion on the use of blood products and should ideally involve intensive care practitioners who are well placed to discuss the implications of a refusal of blood products and ensure that decision making with regard to intensive care takes place at a sufficiently early time. The religious group should certainly be made aware of the implications of their choices, not only for the individual patient, but on scarce resources and overall costs. Any document that emphasises the rights of a religious minority should be balanced by discussion of the responsibilities of that group within a wider society, particularly when their beliefs have such significant impact. M. D. D. Bell The General Infirmary at Leeds, Leeds LS1 3EX, UK References 1 Association of Anaesthetists of Great Britain and Ireland. Management of Anaesthesia for Jehovah’s Witnesses. March 1999. 2 Williams FG. Consent for transfusion. British Medical Journal 1997; 315: 380–1.

A reply Thank you for the opportunity to comment upon Dr Bell’s letter. Firstly, I am disappointed in his misinterpretation of the comparison to sexual interference. I do not believe the document states that giving blood to a Jehovah’s Witness is the same as rape, but we did suggest that the insult would be perceived by the Witness recipient with as much disgust! As far as the remainder of the letter is

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concerned, I think Dr Bell has a valid point. The question of the economics of the unilateral decision not to accept blood was raised at the Working Party but a decision was taken that the purpose of the ‘glossy’ was to collect in one handy place the relevant medical and legal information and background necessary to deal with the care of these patients. The morality was touched on, certainly, in order to explain the background but a judgemental view, such as the writer’s, was felt to be inappropriate in the booklet. Similar economic concerns have been voiced elsewhere [1] but the ‘glossy’ was designed to cover medical and legal aspects as outlined above. I believe that it would have been inappropriate for the Association to have expressed a view on the economics of such care. M. E. Ward Chairman of Working Party, Association of Anaesthetists of Great Britain and Ireland References 1 Wooding N. Costs incurred by one severely ill Jehovah’s Witness could run one unit in Africa for one year (Letter). British Medical Journal 1999; 318: 873. Rigid bronchoscopy during percutaneous tracheostomy

Dr Cooper’s recent survey of the use of percutaneous tracheostomy in intensive care units confirms that the procedure is now well established (Anaesthesia 1998; 53: 1209–12). The survey also reveals that there is no consensus on the use of fibreoscopy, with only 31.3% of units using it routinely. In addition, though not mentioned in the survey, the method of maintaining the airway during the procedure remains a subject of debate, with the tracheal tube, laryngeal mask [1], intubating laryngeal mask [2] and the Combitube [3] all having been described for this purpose. We would like to describe the use of a rigid bronchoscope during percutaneous tracheostomy, which allowed both ventilation and continuous observation of the stages of the procedure.

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A female patient had been intubated orally for a prolonged period following an intracerebral bleed. Following a failed trial of extubation, it was decided to proceed to an examination of the airway under anaesthesia (EUA) and a percutaneous tracheostomy. Following induction of anaesthesia, the orotracheal tube was removed and replaced by a rigid bronchoscope and the EUA performed. The bronchoscope was then left in the trachea and the lungs ventilated using an injector system. Each stage of the percutaneous tracheostomy was then observed under direct vision via the bronchoscope, allowing continuous confirmation of correct intratracheal placement of needle, guidewire, dilators and, finally, tracheal tube. Continuous observation via a rigid bronchoscope helps avoid potential complications, and is also of benefit when teaching the procedure as it allows constant feedback and reassurance of correct positioning. Intermittent and continuous observation are possible with a flexible bronchoscope, but one advantage of the rigid bronchoscope is that it avoids the potential risk of damage to an expensive flexible bronchoscope. The rigid bronchoscope provided an adequate method of maintaining the airway and ventilating the lungs in this case. However, its use for this purpose is obviously limited to situations where poor lung compliance or impaired gastric emptying are not a concern. P. Jefferson V. Addison A. J. Taylor Sunderland Royal Hospital, Sunderland, UK References 1 Lyons BJ, Flynn CGM. The laryngeal mask simplifies airway management during percutaneous dilational tracheostomy. Acta Anaesthesiologica Scandanavica 1995; 39: 414–15. 2 Jones DA, Ball AJ. Ventilation during percutaneous tracheostomy. Anaesthesia 1998; 53: 931. 3 Mallick A, Quinn AC, Bodenham AR, Vucevic M. Use of the Combitube airway for airway maintainance during percutaneous tracheostomy. Anaesthesia 1998; 53: 249–55.

Defect in the wiring of reinforced laryngeal mask leading to airway obstruction

The use of the reinforced laryngeal mask (RLMA) has a well-established role in airway management during adenotonsillectomy [1]. The nonkinkable wire within the silicone tubing allows for greater flexibility. It resists compression and can be fixed in any direction without causing airway obstruction while allowing acceptable surgical access. We describe an unusual problem encountered with the RLMA during a routine tonsillectomy in a 16-year-old female weighing 55 kg. A size 3 RLMA was used during this procedure and the patient was breathing spontaneously. Following insertion of the Boyle-Davis gag, complete airway obstruction occurred. This was initially assumed to be due to compression of the RLMA by the Boyle-Davis gag. However, it was unrelieved by repositioning and eventual removal of the gag. The RLMA was removed and the patient’s trachea intabated with a 7.0-mm cuffed tracheal tube and the procedure was completed uneventfully. On examination of the RLMA, a defect in the wire within the tubing was noted (Fig. 1). When manipulated into the position adapted during tonsillectomy, kinking and obstruction of the tubing was seen to occur (Fig. 2). This particular RLMA had been used on 26 previous occasions, well within the manufacturer’s recommended 40 uses of each RLMA. We reported this incident to the Defect and Investigation Centre and to the manufacturer, Intavent Orthofix, which is normal procedure for any encountered equipment defects. Following investigation by the above authorities, the failure of this device was declared as a ‘user fault’, stating that it ‘may have been bitten down on or accidentally crushed by methods unknown’. This is the only recorded incident of this type involving the RLMA. A previous report describes an oral reinforced tracheal tube crushed and perforated from biting [2]. The manufacturer asked if the reinforced laryngeal masks are being used with a bite-block as recommended. It has not been routine

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and perforated from biting. Anesthesia and Analgesia 1989; 69: 552–3. Unilateral lung hyperinflation following tracheal tube change

Figure 1

practice in our department to use a biteblock with the RLMA. Obviously it is not possible to use such a device during a tonsillectomy, but it may be inserted at the end of surgery after removal of the BoyleDavis gag to prevent biting on the tube by the patient during the recovery phase. Such a defect in the wire may pass unnoticed when returned for sterilisation and preparation for further use. We suggest that each RLMA should be thoroughly examined before and after use by the anaesthetist to detect any defects and therefore hopefully avoiding this problem. Perhaps it should be

named the ‘flexible’ laryngeal mask airway rather than ‘reinforced’. M. E. Molloy I. Orr Craigavon Area Hospital, Co. Amagh BT63 5QQ, UK References 1 Williams PJ, Bailey PM. Comparison of the reinforced laryngeal mask airway and tracheal intubation for adenotonsillectomy. British Journal of Anaesthesia 1993; 70: 30–3. 2 Hoffmann CO, Swanson GA. Oral reinforced endotracheal tube crushed

I was surprised to see the conclusions that Dr deBeer et al. arrived at in their case report (Anaesthesia 1998; 53: 1131). The mediastinum is undoubtedly shifted to the left but the question is whether it is pulled or pushed. If it were due to hyperinflation of the right lung with a mucus plug acting as a ballvalve, as suggested, then the signs of tension would include depression or even eversion of the right hemidiaphragm and equal compression of the left upper and lower lobes. The pressure to cause that degree of mediastinal shift would cause compression of the major veins and the patient would be unlikely to be haemodynamically stable. The radiological interpretation of the chest radiograph is of left lower lobe collapse with loss of the silhouettes of the descending aorta and left hemidiaphragm but relative preservation of the left upper lobe volume. The commonest cause for this in an intubated patient is a mucus plug in the left lower lobe bronchus and that would be expected to respond to physiotherapy and suction as in this case. In my experience in the ITU setting, such films are very common M. J. Charig Department of Clinical Radiology, Wexham Park Hospital, Slough SL2 4HL, UK

Figure 2

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A reply Thank you for giving us the opportunity of replying to Dr Charig’s letter. We agree that left lower lobe collapse is commonly seen within the ITU setting, and that this can produce similar radiological signs to those reported. While there is undoubtedly some collapse of the left lower lobe, our suggestion that hyperinflation of the right lung could have resulted in part from a mucus plug acting as a ball valve was based on the following: a rapid clinical deterioration that followed a procedure which was most likely to have created obstruction in the right-sided bronchial tree, and a 713

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marked mediastinal, and in particular tracheal, shift to the left. However, the main reason for reporting this case was to highlight the potential danger of misinterpreting such gross chest X-ray findings as a tension pneumothorax, particularly within the clinical context of acute respiratory distress and rapid arterial desaturation. This would have exposed the patient to the risk of needle or chest drain insertion into a hyperinflated right lung. D. A. H. deBeer A. J. Mellor P. Razis St George’s Hospital, London SW17 0QT, UK

Cannon oximetry

An 83-year-old woman suffering from cardiac failure rapidly desaturated despite full ventilatory support and 100% oxygen. The pulse oximeter, attached to her earlobe, read 40% with a good plethysmographic signal. Her heart rate, blood pressure, tidal volumes and airway pressures had not significantly changed and she did not appear clinically cyanosed. Her electrocardiogram showed an idioventricular rhythm of 60 beat.minÿ1 and ‘cannon waves’ appeared regularly on her jugular venous pressure trace. Urgent arterial blood gas analysis showed no arterial hypoxaemia. It seemed likely that the pulse oximeter was mistakenly interpreting her ‘cannon’ venous waveform. She had recently been medically cardioverted from atrial fibrillation with amiodarone. Amiodarone can cause bradycardia and conduction disturbances and was temporarily stopped. Her electrocardiogram reverted to sinus rhythm and the pulse oximeter read 98%. Idioventricular rhythms can develop during anaesthesia and after myocardial infarction. The atria either contract after ventricular systole or simultaneously with the ventricle producing regular ‘cannon’ waves, visible in the jugular pressure waveform [1]. Pulse oximetry estimates arterial haemoglobin saturation by differentiating between pulsatile and constant absorption of light. All pulsatile absorption is assumed to be 714

due to arterial flow [2]. In the case of patients with prominent venous pulsation, this assumption may lead to gross inaccuracy, particularly if an ear probe is used [3]. The oximeter reading was considered an artefact and rapidly disregarded because it was very low, representing low mixed venous saturation classically seen in low cardiac output states and there were no corroborating clinical signs. If the mixed venous saturation had been normal (75–80%), the oximeter reading may not have been disregarded as quickly. Idioventricular rhythm is not a well recognised cause for pulse oximetry error This case reiterates the importance of interpreting pulse oximetry in the context of information from other monitors and clinical signs. M. Schuster-Bruce Royal United Hospital, Bath BA1 3NG, UK References 1 O’Rourke RA, Braunwald E. Physical examination of the cardiovascular system. In: Fauci AS, Braunwald E, Isselbacher KJ, et al. eds. Harrison’s Principles of Internal Medicine, 14th edn. McGraw-Hill, 1998: 1231–7. 2 Tremper KK, Barker SJ. Pulse oximetry. Anesthesiology 1989; 70: 98–108. 3 Stewart KG, Rowbottom SJ. Inaccuracy of pulse oximetry in patients with severe tricuspid regurgitation. Anaesthesia 1991; 46: 668–70.

An unusual site for a PA catheter

A 56-year-old female was admitted to hospital with a 2-day history of increasing dyspnoea. She became increasingly unwell requiring sedation, mechanical ventilation, pulmonary artery catheterisation and cardiovascular support with a noradrenaline infusion. After 8 days on the intensive care unit, the central venous catheters were resited. A triple-lumen central venous catheter was inserted into the left internal jugular vein followed by a pulmonary artery catheter; the latter was quoted as being difficult to insert. The chest X-ray film is shown in Fig. 1.

The central venous catheter is seen to curl on itself in the superior vena cava. The pulmonary artery catheter performs a double loop in the region of the left subclavian vein-brachiocephalic vein junction. The final position of the catheter tip is thought to lie within the left internal mammary vein. The other resting place could be within the pleural space resulting from perforation of the subclavian or brachiocephalic vein. The subsequent progress of the patient did not suggest that this was the case. Catheter misplacement or malposition is not uncommon, and numerous investigations have shown that if the catheter tip is placed blindly it may settle in an unsatisfactory and often alarming position, irrespective of the route of insertion [1, 2]. It was as far back as 1972 that Johnston & Clark [1] suggested that the position of a central venous catheter could not be predicted accurately on clinical criteria alone and that an X-ray was mandatory if the risk of complications was to be reduced. Our case may argue for the value of X-raying after each individual catheter has been placed, rather than the current practice of inserting two adjacent catheters at a single sitting. It could be postulated that the less than satisfactory position of the first catheter subsequently led to the problem with the second catheter. The patient later developed a grossly swollen face, neck, upper limbs and upper torso. A clinical diagnosis of superior vena cava obstruction due to intraluminal clot was confirmed radiologically (Fig. 2). Following injection of radiopaque dye through the distal lumen, the X-ray demonstrates retrograde flow alongside the left internal jugular catheter and into the internal jugular vein. No dye is seen to flow forwards. This raises the question as to whether the thrombosis was the cause or the result of the problems with venous cannulation. Subsequent flotation of a pulmonary artery catheter was uneventful, implying that catheter-related trauma to the intimal lining of the great veins in the neck most probably contributed to the development of the superior vena cava thrombosis. J. M. Cupitt Manchester Royal Infirmary, Manchester M13 9WL, UK Q 1999 Blackwell Science Ltd

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A safe, simple and effective technique for securing nasojejunal tubes in the intensive care unit

Figure 1

References 1 Johnston AOB, Clark RG. Malpositioning of central venous catheters. Lancet 1972; 2: 1395–7.

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2 Langston CS. The aberrant central venous catheter and its complications. Radiology 1971; 100: 55–9.

In critically ill patients, nutrition delivered by the enteral rather than parenteral route is now the preferred method [1]. Use of the gut is said to prevent deterioration of intestinal mucosal integrity and stop translocation of gut bacteria, limiting the gut’s ability to act as the motor of the sepsis syndrome. Nutrition can be delivered via a nasogastric (NG) tube, but loss of gastric motility is usual in the critically ill. This leads to pooling of feed and the risk of regurgitation and pulmonary aspiration. Feeding is pointless if nutrients fail to reach the jejunum. Despite small bowel villous atrophy, absorptive capacity is maintained. Delivering nutrients beyond the pylorus to the jejunum, e.g. by nasojejunal (NJ) feeding, leads to significantly greater delivery of energy requirements, greater rises in albumin levels and a lower incidence of nosocomial pneumonia [2]. Therefore, maintenance of enteral feeding in the short term is best achieved by the jejunal route using a nasojejunal tube. All methods of positioning of NJ tubes have problems. Spontaneous transpyloric passage of tubes is slow with a low success rate. Fluoroscopic techniques require radiographic facilities, trained staff and time, taking up to 43 min for correct tube placement in one report [3]. Placement involves significant radiation dosage, equivalent to more than 650 chest X-rays [3]. For those patients receiving intensive care, transfer to the imaging facility may be necessary, a hazard in itself. Endoscopic methods are also time-consuming, need a skilled endoscopist and a sedated patient. Although fluoroscopic and endoscopic techniques have a high success rate, misplacement still occurs, leading to complications such as lethal arrhythmias [4] and fatal tension pneumothorax [5]. Expense is another factor, with triple lumen NJ tubes costing up to £130. Unfortunately, nasogastric and nasojejunal tubes tend to be dislodged or removed by disorientated patients. One large American series showed that dislodgement occurred in up to 50% of all 715

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patients and accounted for 60% of NJ tube insertions (i.e. more than once in some and as many as 12 times in one patient) [4]. Preventing accidental removal of these difficult-to-place tubes would be clinically and managerially desirable. A better means of securing tubes is necessary. We have achieved this by securing NJ tubes to a separate loop of NG tubing that has been passed around the nasal septum (Figs 1 and 2). Following insertion of the NJ tube using an endoscopic technique, a size 12 NG tube is fed up one nostril and out through the mouth. The process is repeated with another NG tube through the other nostril. A guidewire is then passed down one NG tube, out the mouth and sufficient length pulled through to feed into the end of the other NG tube protruding from the mouth and so out of the opposite nostril. An artery clamp is placed around one NG tube to hold the guidewire firm. The other tube is manipulated out of the opposite nostril. The two ends of this tube are then tied (or superglued) together and trimmed to length. The NJ tube can then be secured to this loop, so that when the patient tugs on it, pain will be felt in the nose, discouraging further attempts at dislodgement. Considerable force is needed to cause tissue trauma. A silastic tube, rather than a nasogastric tube, can be used to improve long-term comfort. Tubes secured in this way are difficult to remove, providing the loop of NJ/NG tube does not hang too far below the nares. We claim no originality, but we feel that given the expense, complexity and risks of NJ tube insertion, it is worth reporting our own experience. The method has clear advantages over other methods of securing nasal feeding tubes such as suturing the tube to the nasal septum, a method which can result in serious tissue damage. One case report describes the use of an American football helmet to prevent a demented patient from removing an NG tube [6]. Whilst effective, this has obvious practical disadvantages in the intensive care unit. In our hands, we believe the use of a nasal loop or halter has prevented many untoward dislodgements. S. Chay P. N. Board

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Figure 1 Diagrammatic representation of

the anatomical position of halter (NG tube) lying alongside the nasojejunal tube below the inferior concha.

P. G. Lawler South Cleveland Hospital, Middlesborough TS4 3BW, UK. References 1 American Gastroenterological Association. American Gastroenterological Association Medical Position Statement: Guidelines for the Use of Enteral Nutrition. Gastroenterology 1995; 108: 1280–301.

2 Montecalvo MA, Steger KA, Farber HW, et al. Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. Critical Care Medicine 1992; 20: 1377–87. 3 Grathwohl KW, Gibbons RV, Dillard TA, et al. Bedside videoscopic placement of feeding tubes: Development of fibreoptics through the tube. Critical Care Medicine 1997; 25: 629–34. 4 Gutierrez ED, Balfe DM. Fluoroscopically guided nasoenteric feeding tube placement: Results of a 1-year study. Radiology 1991; 178: 759–62. 5 Zeiss J, Woldenberg LS. Inadvertent tracheobronchial placement of feeding tubes (letter). Radiology 1988; 169: 874–5. 6 Levine JA, Morris JC. The use of a football helmet to secure a nasogastric tube. Nutrition 1995; 11: 285.

Homogenous mixing of propofol emulsion into an infusion solution

Target-controlled infusion [1, 2] often requires the mixing of solutions with different densities. Propofol emulsion normally has a lower density than

Figure 2 The photograph shows a triple lumen nasojejunal tube emerging from the

right nostril. The halter is seen tightly secured to the NJ tube. Through and through sutures unite the two ends of the NG tube halter.

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infusing solutions, including electrolyte/ dextrose. Our normal practice is to add propofol emulsion from a side valve into the infusion solution. We noticed that when mixed in this way, the emulsion and the solution are separated by laminar flow in the tube, resulting in stagnation of the emulsion at the tube curvature (Fig. 1A). We have made a simple device that can produce a homogenous mixture of propofol emulsion and electrolyte/ dextrose solution. By adding an additional valve to the standard apparatus, we made a narrowing in the tube. This narrowing produces turbulent flow, and the propofol and infusion mix evenly. The handle on the valve is turned approximately 15–308 (Fig. 1B). This results in maximum turbulence with a minimum obstruction of flow. Mixing can be made even more effective by using a greater number of valves with the flow set at a faster rate. Using this device, we were able to achieve a smooth mixture of the solution without any laminar flow or stagnation (Fig. 1C). This device should make target-controlled infusion more accurate. Figure 1

S. Aida K. Shimoji Niigata University School of Medicine, Niigata 951–8510, Japan References 1 Struys M, Versichelen L, Thas O, Herregods L, Rolly G. Comparison of computer-controlled administration of propofol with two manually controlled infusion techniques. Anaesthesia 1997; 52: 41–50. 2 Struys M, Versichelen L, Byttebier G, Mortier E, Moerman A, Rolly G. Clinical usefulness of the bispectral index for titrating propofol target effect-site concentration. Anaesthesia 1998; 53: 4–12.

An unusual case of hysterical postoperative coma

We wish to report an unusual case of hysterical postoperative coma. A 36year-old fit 72-kg male presented for routine nasal septum surgery as a day

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case. He was being treated for depression with citalopram, a selective serotonin re-uptake inhibitor, and his previous medical history included several episodes of deliberate self harm. The patient was unpremedicated. General anaesthesia was induced with fentanyl 100 mg and thiopentone 450 mg. Tracheal intubation was facilitated by atracurium 40 mg and anaesthesia was maintained with nitrous oxide in oxygen and isoflurane 1.3%. Ketorolac 30 mg and fentanyl 50 mg were given 10 min after induction. At the end of surgery, residual neuromuscular block was reversed with neostigmine 2.5 mg and glycopyrronium 0.5 mg. Following the resumption of spontaneous respiration, the patient’s trachea was extubated and he was transferred to recovery Although all physiological variables were normal, the patient failed to regain consciousness and therefore after 30 min a thorough neurological examination was performed. The findings were unremarkable except for persistent flickering of his closed eyelids and a

fixed upward gaze when examining the pupils. There was a normal train-of-four response to peripheral nerve stimulation. Painful stimuli were vigorously applied to the supra-orbital nerves, behind the jaw, over the sternum and onto the nailbeds. In addition, sustained tetany at 50 Hz was applied to the facial and ulnar nerves. None of these manoeuvres elicited a response. A full blood count, urea and electrolytes, glucose, liver enzymes and arterial blood gases were all unremarkable. After another 2 h with no improvement in his neurological status, the diagnosis of coma secondary to hysterical conversion syndrome was considered. In view of the complete absence of any response to pain, the dramatic step of occluding the patient’s airway was taken. This was achieved by holding the patient’s head whilst applying a Waters circuit firmly to the patient’s face with the outlets obstructed. The patient was unable to tolerate this for longer than 60 s before he made a purposeful grab for the face mask, after which he 717

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immediately resumed his previous state. The diagnosis of hysterical postoperative coma was made and he was admitted for further observation. He remained unresponsive for another 6 h when a nurse noticed his eyes were open. He appeared to be fully alert and orientated and denied any recollection of postoperative events. He was discharged home the next morning. Postoperative coma due to hysterical conversion is rare and we believe that this is the first such case to be described in a male patient. In a previous report, a 22-year-old female who had been otherwise unresponsive to painful stimuli applied to her sternum and nailbeds awoke dramatically after tetanic stimulation of her ulnar nerve [1]. The authors stated that this reaction was both irresistible and unsurprising. However, our patient tolerated even this degree of pain with no obvious alteration in his conscious level, heart rate, arterial blood pressure or respiratory pattern. Forced downward deviation of the eyes has been described as a useful diagnostic sign in patients with hysterical coma [2, 3]. However, the gaze of our patient was persistently upward. Presumably, abnormal deviation of the eyes is simply an attempt to avoid eye contact and we would suggest that the direction of the gaze itself may be unimportant. Although cortical somatosensory evoked responses have been used to differentiate hysterical from organic coma [4], this method is not widely available. In the event, the urge to breathe following occlusion of the airway proved irresistible to our patient, permitting the diagnosis of hysterical conversion to be made. H. Maddock S. Carley A. McCluskey Stepping Hill Hospital, Stockport SK2 7JE, UK References 1 Adams AP, Goroszeniuk T. Hysteria: a cause of failure to recover after anaesthesia. Anaesthesia 1991; 46: 932–4. 2 Henry JA, Woodruff GHA. A diagnostic sign in states of apparent unconsciousness. Lancet 1978; 2: 920. 3 Rosenberg ML. The eyes in hysterical

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states of unconsciousness. Journal of Clinical Neuro-Ophthalmology 1982; 2: 259–60. 4 Levy R, Behrman J. The somatosensory evoked response in patients with hysterical anaesthesia. Journal of Psychosomatic Research 1973; 17: 81–4.

Poor anaesthetist hygienic practices – a problem across all grades of anaesthetist

The recent article by El Mikatti and colleagues regarding anaesthetic hygienic practices highlighted poor compliance of consultant anaesthetists with Association of Anaesthetists’ guidelines (Anaesthesia 1998; 54: 13–18). This is not unique to the consultant grade, but applies across all grades of anaesthetist. The guidelines published by the Association of Anaesthetists in 1992 and updated in 1996 are widely available and include the routine use of gloves, eye protection and mask and gown wearing [1]. These have been emphasised in the light of a growing rate of undiagnosed HIV infection and hepatitis C infection in the population. The incidence of HIV in a high-risk population has been reported as high as 9.9% with lower rates in a young, general-risk population of 0.18–0.23% (The Unlinked Anonymous HIV Prevalence Monitoring Programme in England and Wales, 1995). An incidence as high as 1.79% has been reported in patients attending an inner London Accident and Emergency department [2]. A survey of anaesthetists’ working practices and attitudes to HIV infection was carried out in 1992 and demonstrated a low rate of routine universal precautions among anaesthetists of all grades [3]. In particular, only 16% routinely wore gloves during invasive vascular procedures and 35% resheathed needles that had been in contact with a patient’s bodily fluids. El Mikatti and colleagues report a similar low rate of 14.5% always wearing gloves. During 1997 and 1998, we carried out a five hospital-wide audit to assess anaesthetic practice in line with recommendations. This involved three teaching hospitals and two large district

general hospitals in the south-east of England. Eighty anaesthetists of all grades were questioned about their knowledge of the Association guidelines and their current practice. This represented a random selection across all grades who were available to be questioned. The sample included 34 consultants, 29 specialist registrars and 13 senior house officers, with four of other grades. In total, only 49% knew the published guidelines. According to grade, this represented 67% of consultants and 30% of trainees. Routine glove wearing was still low at 29%. Again this was across all grades, with a trainee rate of 35%. The most frequently cited reason was a loss of ‘feel’ (86%), with 9% claiming that they were not easily available and 10% unconcerned. Few anaesthetists routinely wore eye protection for vascular procedures (4% – allowing for spectacle wearers) or masks and gowns (7.5%). Most would not resheath used needles (74%). Despite these figures, 77% would change their practice with a known HIV-positive patient: most notably and universally wearing gloves. In addition, 32% were in favour of routine screening for HIV infection in all surgical patients. This compares with 50% of respondents in the survey in 1992. It would seem that practice has not altered considerably since guidelines have been introduced and this applies equally across grades. The value of simple precautions has been well documented. Of those advised, routine glove wearing is simple and perhaps of most documented benefit. Their regular use reduces the incidence of needlestick injury and overall percutaneous injury [4]. This is widely accepted, judging by the number of anaesthetists who would change their practice with a known HIV-positive patient. It is disappointing that all grades are equally at fault. It might be argued that established behaviour is more difficult to change, but it would seem that trainees are learning similar patterns of practice. In the light of these findings it is perhaps timely and prudent to once again raise this issue and re-emphasise the value of simple precautions in every day practice.

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J. T. McNamara Bedford Hospital, Bedford MK42 9DJ, UK S. G. Stacey Great Ormond Street Hospital, London WC1N 3GH, UK References 1 Association of Anaesthetists of Great Britain and Ireland. A report received by Council of The Association of Anaesthetists on Blood Borne Viruses and Anaesthesia. An Update. 1996. 2 Poznansky MC, Fothergill J, Parry JV, Weber J. The rising prevalence of HIV infection in Accident and Emergency. Journal of Accident and Emergency Medicine 1996; 13: 424. 3 O’Donnell NG, Asbury AJ. The occupational hazard of immunodeficiency virus and hepatitis B infection. Perceived risks and preventative measures adopted by anaesthetists. Anaesthesia 1992; 47: 923–8. 4 Ben-David B, Gaitini L. The routine wearing of gloves: impact on the frequency of needlestick and percutaneous injury and on surface contamination in the operating room. Anesthesia and Analgesia 1996; 83: 623–8. Prolonged bleeding from epidural catheterisation reconsidered

Persistent bleeding following insertion of an epidural catheter for labour is infrequent but its appearance is nonetheless problematic. We reported a prolonged bleeding from the skin puncture site which was treated successfully with adrenaline injected subcutaneously using a 25-gauge needle alongside the epidural catheter [1]. We wish to report a similar case in which this treatment using a 25-gauge needle was not successful. However, a repeated deeper injection of adrenaline up to 3 cm parallel to the epidural catheter via 21-gauge needle provided permanent haemostasis. This 24-year-old gravida 2, para 1 (height 136 cm, weight 70 kg) requested epidural analgesia for labour and delivery

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at 38 weeks gestation. The patient was a nondrinker, nonsmoker with no significant past medical history and was taking no medications. She had a Caesarean section with successful epidural anaesthesia 4 years previously. On admission, her vital signs were BP 145/84 mmHg, heart rate 100 beat. minÿ1, respiratory rate 18 breath.minÿ1, temperature 36.8 8C. Laboratory investigations showed a haemoglobin of 11.3 g.dlÿ1, haematocrit of 33.4, prothrombin time (control) of 10.9 (11.4) s, partial thromboplastin time (control) of 30 (33) s, platelets 130 000. Following a field block with a 25-gauge needle, a midline epidural catheter was placed on the first attempt at the L3–4 interspace using a 17-gauge Hustead needle and the loss of resistance to air technique. The epidural space was 5 cm from the skin. Following a test dose, 15 ml of 0.1% ropivacaine with 2 mg.mlÿ1 of adrenaline was administered in three divided doses over 6 min. No CSF or blood was aspirated from the epidural catheter. Upon securing the catheter, bleeding was noted from the epidural insertion site. Constant pressure was applied with gauze intermittently for 10 min with an apparent improved haemostasis. A transparent sterile dressing (10 cm × 12 cm) was applied and the catheter was attached to an epidural PCA infusion pump. The patient was placed in a left lateral position and reported excellent pain relief with a sensory level, as measured by an application of ice, of T8 –S5 bilaterally and no evidence of motor block, as measured by a modified Bromage Scale. Two hours later, a nurse noticed a large blood clot 15 cm in diameter at the epidural site separating the dressing off the skin. The mattress was soaked with blood amounting to about 400 ml. Constant pressure with gauze and ice was applied to the patient’s back for over 10 min without successful haemeostasis. At this point, 0.1 mg adrenaline in 1 ml saline to a total of 30 mg was injected subcutaneously using a 26gauge Tuberculin needle alongside the epidural catheter. The epidural site bleeding continued and correlated to the patient’s pulse, suggesting arterial bleeding. A GELFOAM (Pharmacia & Upjohn Company, Kalamazoo, MI

49001) procoagulant was applied superficially without success. Suturing the site was contemplated but it was felt haematoma formation might ensue because the bleeding site was deeper. Twenty minutes later, a 4-cm 21-gauge needle was inserted and an additional 0.5 ml of adrenaline (50 mg) was injected parallel to the catheter up to a depth of 3 cm. The pulsating blood flow washed away some of the injected adrenaline. At this point, bleeding stopped almost immediately. Betadine and a new transparent dressing were applied over the catheter site. Haemostasis continued throughout labour and upon removal of the catheter. No further bleeding recurred for the following 48 h after which the patient was discharged home. Throughout this entire event, the patient’s vital signs remained relatively unchanged as did the fetal heart rate patterns. There was no deterioration of sensory and motor blocks, which would suggest epidural haemotoma. We recommend that in a case of persistent bleeding following an epidural insertion, a constant pressure be applied to the area. A GELFOAM procoagulant adjacent to the catheter site may be applied. If unsuccessful, adrenaline injections with a 21-gauge needle alongside the epidural catheter may be attempted. When a bleeding point is not superficial and is arterial, a superficial suture may not stop the bleeding and may create a subcutaneous haematoma. S. Cohen G. Kis E. Burley Robert Wood Johnson University Hospital, New Brunswick, New Jersey 08901–1977, USA Reference 1 Cohen S, Amar D. Prolonged bleeding from epidural catherization (letter). Canadian Journal of Anaesthesia 1989; 36: 482–7. Oral feeding after Caesarean section

I read with interest the article regarding attitudes to oral feeding after Caesarean section (Anaesthesia 1999; 54: 292–6).

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The overall results of that study do not come as too much of a surprise. Aside from general intra-abdominal/ bowel surgery (where general surgeons adhere to their own religious policies!), I am sure similar findings would be encountered if one was to examine the postoperative feeding practices in operation on other surgical wards. I can recall numerous instances whereby a fully alert and co-operative patient in the recovery ward has questioned me regarding their ability to eat and drink. My practical reply – ‘now’ – has brought both scorn and abuse from ward nurses. On one occasion I found myself personally brewing a cup of tea for an elderly man after he had had his knee arthroscopy performed under regional anaesthesia. Why do ward nurses still operate under an out-dated charter? What do they teach them during their Project 2000 years or, as now seems the case, during their 4 years reading for a Health Studies degree? I suspect it all boils down to the saying ‘if it’s not broken, don’t fix it’. The current system seems to work. Yet evidence suggests that we could do better, and in this age of evidenced-based medicine, we should do better. Someone should take the ‘bull by the horns’ and radically alter our current practice regarding postoperative oral feeding. I imagine the one major hurdle lies in deciding on whose shoulders the responsibility falls in governing postoperative feeding. It is frequently under the jurisdiction of the nursing staff but, as we have seen, wide variations in practice exist. Departmental policies are one solution. And as anaesthetists are involved in other aspects of the postoperative care of patients, should we not also include oral feeding as part of our overall assessment? There is some encouragement from the article in the fact that in only 17.2% of units were women routinely maintained ‘nil by mouth’ following Caesarean section under regional anaesthesia. In my opinion, if a woman is surgically and anaesthetically stable following Caesarean section under regional anaesthesia, there is no reason why she may not resume oral intake as soon as possible. Why should the situation be any different to that of a woman having had a

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vaginal delivery (with or without epidural analgesia) to whom the obstetric nursing staff are very enthusiastic in offering ‘tea and toast’ in the immediate postpartum period? An analogy could be drawn with our intensive care colleagues where there is mounting evidence for the benefit of early enteral feeding in the critically ill. Intensive care units have enteral feeding guidelines – surgical wards should have guidelines. I feel we should play a more active role in this aspect of patient care if we are to advance medicine beyond the more traditional ways. J. M. Cupitt Manchester Royal Infirmary, Manchester M13 9WL, UK

Multiple choice examinations

I read with interest the special communication by Hammond et al. on the issue of multiple choice examinations (MCQs) and the rationale of having negative marking for incorrect answers (Anaesthesia 1998; 53: 1105–8). Having sat many MCQs in the past, including the FRCA, I have always been convinced that guessing, even apparent ‘wild guessing’, tended to increase rather than decrease the final mark. As stated in the article, anaesthetic trainees are continually discouraged from guessing by their educators as the negative marking will result in the loss of marks. This misconception is held very strongly by a lot of MCQ candidates. I presume that the role of negative marking is to discourage guessing as guessing in clinical practice could be dangerous. In fact, negative marking simply prejudices against those candidates who fail to answer enough questions as a result of their fear of losing marks. The Royal College of General Practitioners discontinued negative marking a number of years ago when they demonstrated that it discriminated against female candidates, who tended to be more cautious with regards to guessing. In my opinion, negative marking is of no benefit whatsoever and does not improve the efficacy of the MCQ as a test of a candidate’s knowledge. I feel

that it is time for The Royal College of Anaesthetists to follow the lead of the MRCGP examination and drop negative marking from the Fellowship MCQ examinations. B. McGuire Ninewells Hospital, Dundee DD1 9SY, UK ‘Peanuts and Palacos’

Those of us who are prone to read the back of cereal packets at breakfast are also the sort of people who might read the label on the back of the Palacos bone cement liquid monomer container during an orthopaedic operation. Imagine our surprise when we found that the solution contains, amongst other things, E141 (otherwise known as peanut oil) [1]. The potential for cardiovascular and respiratory compromise at the time of insertion of acrylic bone cement used to anchor orthopaedic prostheses is widely recognised by orthopaedic surgeons and anaesthetists alike [2, 3]. The phenomenon of the ‘cement implantation syndrome’, which may include hypotension, bronchospasm, hypoxaemia, cardiac arrhythmias and sometimes fatal cardiovascular collapse, has usually been attributed to absorption of volatile acrylic monomer [3, 4]. Other theories have invoked embolisation by such substances as fat (from bone marrow), air (from the bone marrow cavity or from thermal damage to blood) or fibrinous debris induced by the release of procoagulant substances [5]. Peanuts and other nuts are now recognised as potent and potentially fatal allergens [6]. Although there have been no reports of anaphylactic reactions to bone cement in patients with known nut allergy, this may in large part be due to the fact that the manufacturers of Palacos have only recently started to list the presence of peanut oil in the liquid element of this product. We were unaware of this potential hazard, as were all the surgeons and anaesthetists to whom we have mentioned it. We felt that those of your readers who were also unaware might be grateful for this information.

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A. Sandison W. Harrop-Griffiths St Mary’s Hospital, London W2 INY, UK References 1 Palacos R-40 Datasheet. Belgium: Schering-Plough Europe, Year?. 2 Dahl OE. Cardiorespiratory and vascular dysfunction related to major reconstructive orthopaedic surgery. Acta Orthopaedica Scandinavica 1997; 68: 607–14. 3 Duncan JAT. Intra-operative collapse or death related to the use of acrylic cement in hip surgery. Anaesthesia 1989; 44: 149–53. 4 Nimmagadda U, Ramez Salem M. Acute bronchospasm associated with

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methylmethacrylate cement. Anesthesiology 1998; 89: 1290–1. 5 Enneking FK, Malawer MM. Cardiac arrest during total knee replacement using a long-stem prosthesis. Journal of Clinical Anesthesia 1995; 7: 253– 63. 6 O’B Hourihane J. Peanut allergy – current status and future challenges. Clinical and Experimental Allergy 1997; 27: 1240–6.

ways than one in getting a message across. I therefore found the Freudian use of colour, as a subliminal re-enforcer particularly interesting. Having, for obvious reasons, eschewed the use of blood red as a colour for the ‘glossy’s’ cover, it appears that the use of colloid yellow was the obvious alternative! R. P. R. Smith Royal Lancaster Infirmary, Lancaster LAI 4RP, UK

It’s all in the colour

Reference The Association is to be applauded for the publication of its recent ‘glossy’ entitled Management of Anaesthesia for Jehovah’s Witnesses [1]. There are more

1 The Association of Anaesthetists of Great Britain and Ireland. Management of Anaesthesia for Jehovah’s Witnesses; 1999 March.

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