Sir,The insertion of a nasogastric tube (NGT), in an anaesthetized, paralyzed and intubated patient, as easy as it may seem, can be a tiresome and an challenging exercise for even the most experienced anaesthesiologist.Fibreoptically it has been determined that NGTs usually encounter greatest resistance to insertion at the arytenoid cartilages and the piriform sinuses (1). Over the years, many techniques have been proposed to aid in the process of NGT insertion including forward displacement of the larynx (2), use of split endotracheal tubes placed via the nasoesophageal route (3), use of a nasopharyngeal airway to serve as an obturator (4), immersion of the NGT in ice-cold water (5), forward neck flexion (6) and insufflation of air in the oropharnyx to open the upper oesophageal sphincter (7).A recently described innovative technique proposes to use the flexible fibreoptic bronchoscope to guide the NGT through the nasal cavity under vision and subsequently direct it down the oesophagus using the laryngoscope and Magill's forceps in a standard manner (8). However, the justification of using a flexible fibreoptic bronchoscope as a means to guide a NGT needs questioning especially when there are problems with universal availability and the inherent possibility of damage to the expensive fibreoptic system.We have developed a simple technique of NGT insertion under direct vision involving minimal laryngoscopy and airway instrumentation. This involves the standard passage of a generously lubricated 18/16-G NGT through the appropriate nasal passage. A gentle laryngoscopy is then performed and the NGT is retrieved via the oral cavity by grasping its tip with a Magill's forceps and nearly the entire length is pulled out through the oral cavity leaving only about 3-4 inches outside the nares. Next, the tip of the tube is guided into the oesophagus by grasping it 2-3 inches proximal to its distal end with a Magill's forceps. This step does not need any operation in the depth of the oropharynx thus allowing better manoeuvrability. Once a sufficient length of NGT is introduced inside, the proximal end is pulled out until the desired mark is reached at the level of nares whereupon it is secured with the adhesive tape.Our method has distinct benefits, which include a decreased time period of laryngoscopic stimulation and its consequences therein, a greater range of manoeuvrability by not having to work in the depths of the oropharynx thus avoiding trauma to delicate structures such as uvula and the soft mucosa of the posterior pharyngeal wall. Moreover, the technique is 100% successful even in patients where other methods have failed.The use of laryngoscopy with the Magill's forceps to aid insertion of the GT is not new but our modification of this technique has allowed us a safe, easy and atraumatic means to accomplish the same result.

Context:A wire-reinforced silicone tube (LMA-Fastrach™ endotracheal tube) is specially designed for tracheal intubation using intubating laryngeal mask airway (ILMA). However, conventional polyvinyl chloride (PVC) tracheal tubes have also been used with ILMA to achieve tracheal intubation successfully.Aim:To evaluate the success of tracheal intubation using the LMA-Fastrach™ tracheal tube versus conventional PVC tracheal tube through ILMA.Settings and Design:Two hundred adult ASA physical status I/II patients, scheduled to undergo elective surgery under general anaesthesia requiring intubation, were randomly allocated into two groups.Methods:The number of attempts, time taken, and manoeuvres employed to accomplish tracheal intubation were compared using conventional PVC tubes (group I) and LMA-Fastrach™ wire-reinforced silicone tubes (group II). Intraoperative haemodynamic changes and evidence of trauma and postoperative incidence of sore throat and hoarseness, were compared between the groups.Statistical Analysis:The data was analyzed using two Student's t test and Chi-square test for demographics and haemodynamic parameters. Mann Whitney U test was used for comparison of time taken for endotracheal tube insertion. Fisher's exact test was used to compare postoperative complications.Results:Rate of successful tracheal intubation and haemodynamic variables were comparable between the groups. Time taken for tracheal intubation and manoeuvres required to accomplish successful endotracheal intubation, however, were significantly greater in group I than group II (14.71±6.21 s and 10.04±4.49 s, respectively (P<0.001), and 28% in group I and 3% in group II, respectively (P<0.05)).Conclusion:Conventional PVC tube can be safely used for tracheal intubation through the ILMA.

The prophylactic granisetron-dexamethasone combination was more effective than granisetron alone in the prevention of post-operative emesis during the first 24 h after anaesthesia in children undergoing middle ear surgery.

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This case report highlights problems during right internal jugular vein cannulation resulting from high back pressure and flow from superior vena cava obstruction in steroid-induced mediastinal lipomatosis. Other anesthetic considerations in mediastinal lipomatosis are also discussed.

: The mean pre-ECT BIS values correlate significantly with the durations of both the motor and electrical seizure activity and awakening time under propofol anesthesia. Before extrapolation to daily clinical practice, further large controlled clinical trials need to be done to establish the role of BIS monitoring in predicting seizure duration and awakening time during MECT.

References1 Baldelli R, Battista C, Leonetti F et al. Glucose homeostasis in acromegaly: effects of long-acting somatostatin analogues treatment. Clin Endocrinol (Oxf) 2003; 59: 492-499. 2 Dilger JA, Rho EH, Que FG et al. Octreotide-induced bradycardia and heart block during surgical resection of a carcinoid tumor.