SummaryAn attempt was made toplace apercutaneous catheter between thefirst and second cartilaginous rings of the trachea in 20 cadavers presenting for postmortem examination. Only nine of the catheters entered the trachea in the intended space. All catheters which were noted to be dificult toplace entered the trachea higher than intended. One third of all catheterspunctured the thyroid isthmus. Key wordsTracheostomy , percutaneous; placement.Most percutaneous techniques suffer a failure rate associated with inability to locate the desired structure accurately within the body. Fortunately, it is easy to confirm that a catheter is within the lumen of the trachea (but not that it remains there). However, it is more difficult to ascertain the exact point of entry of the catheter into the trachea. This information is important if complications such as vocal change, tracheal stenosis and tracheo-innominate fistula are to be avoided. This study was performed to assess the accuracy of blind percutaneous catheterisation of the trachea as is routinely carried out as the first part of a formal percutaneous dilational tracheostomy. MethodTwenty patients requiring a postmortem examination for clinical reasons or at the request of the coroner were entered into the study. After the removal of the cranial contents, the neck was extended to achieve a position appropriate for a percutaneous tracheostomy to be performed. The neck and trachea were palpated and a 14G or 16G catheter was placed with the intention of entering the trachea between the first and second tracheal cartilages. All catheters were placed by the same operator. A consultant pathologist then performed the postmortem examination with the catheter still in situ. The pathologist assessed the course of the catheter through the neck. The trachea was split down the posterior aspect and the entry site of the catheter sought. The site of entry into the trachea was noted as were any major structures that had been punctured on the catheter's course through the neck. A record was kept of age, height and neck circumference of each patient; a comment was entered on the study document as to any technical difficulty in palpating the trachea or placing the catheter. ResultsAll 20 catheters entered the trachea. Nine catheters entered at the intended position; of the rest, seven were higher than the intended space and four lower (Table 1). One catheter pierced the cricothyroid membrane, none entered below the fourth tracheal ring. Four placements were considered difficult; all these were found to have been placed higher than intended and they included the cricothyroid puncture. It was not possible to trace the course of two catheters through the neck, but of the remaining 18, six had pierced the thyroid isthmus (Figs 1 and 2). Only three catheters were judged to have entered the centre of the trachea, of the remaining 17, 11 were to the left with one of the placements considered difficult being significantly to the left and through the cricothyroid membrane resulting in damage to ...
SummaryA randomised, prospective trial was conducted to assess the efficacy of various means of alleviating the pain of subcutaneous lidocaine infiltration. One hundred and twenty-two patients were randomly allocated to different groups to receive buffered lidocaine 1%, warmed lidocaine 1% or infiltration by the counter-irritation technique. A visual analogue pain score was recorded at different stages of cannulation and results showed that pain scores were significantly lower in the group receiving buffered lidocaine 1% (p`0.02) and in the counter-irritation group (p`0.05). Thus buffering lidocaine 1% and administration of lidocaine 1% by the counter-irritation technique is effective in relieving the pain of lidocaine infiltration.Keywords Anaesthetic, local; lidocaine. Procedures, venepuncture. ...................................................................................... Correspondence to: Dr E. L. Ong Accepted: 27 February 1999 It is common practice for anaesthetists to use a subcutaneous infiltration of lidocaine to alleviate the pain of venepuncture with a cannula. While previous studies have shown this to be less painful than insertion of a cannula, even one as small as 22-gauge [1], the pain associated with lidocaine infiltration has at times led to debate about this procedure. It was, therefore, the need to alleviate the 'lidocaine sting' that prompted this study, which compares various means of reducing this pain. Well-tested methods include alkalinisation of lidocaine with sodium bicarbonate solution and warming the lidocaine to body temperature. A less well-known method, counter-irritation, has been suggested to be effective [2]. Previous studies with volunteers have performed testing on the forearm [3, 4], this study aims to test the efficacy of these pain-reducing methods on the dorsum of the hand of patients, which is the common site of venous cannulation. A previous study has shown that the skin sensitivity of different parts of the arm vary with the dorsum of the hand being less sensitive than the volar aspect of the arm. If this is the case it may not be necessary to go to lengths to alleviate lidocaine sting [5]. MethodsAfter approval by the hospital ethics committee and informed consent, 122 unpremedicated ASA grade I and II patients were enrolled into the study. Exclusion criteria included allergy to local anaesthetics and pregnancy. The patients were randomly assigned to one of four treatment groups. Groups A and D received 1% lidocaine at room temperature (20 ЊC) as was the standard practice. Group B received 1% lidocaine buffered by adding 8.4% sodium bicarbonate in the ratio of 1-10 of lidocaine. Group C received 1% lidocaine warmed to 37 ЊC by means of a thermostatically controlled water bath available in all operating theatres.The dorsum of the nondominant hand was cleansed with an alcohol swab and allowed to dry. A quantity (0.5 ml) of the prepared solution in a 2.5-ml syringe was infiltrated subcutaneously via a 27-gauge needle over 5 s. In group D, counter-irritation ...
SummaryIn a randomised, double-blinded, two-centre trial we evaluated the effect of a microbiological filter (SuporÒ, Pall Life Sciences) on propofol injection pain. We studied 336 unpremedicated adult patients, who graded pain experienced during induction of anaesthesia with propofol on a 4-point verbal rating scale. Use of the microfilter reduced both the incidence and severity of propofol injection pain (p < 0.001). Incidence of severe pain in the filter group was 2.4% compared with 16.6% in the control group. Overall, 33.7% in the filter group experienced pain compared with 62.1% in the control group. A microbiological filter may provide a non-pharmacological alternative to a lidocaine ⁄ propofol mixture for reducing injection pain. It would also reduce the risk of any glass and bacterial contamination.
A modification of the Ciaglia multiple-dilator method for percutaneous tracheostomy using both a fibreoptic bronchoscope and laryngeal mask airway to visualise the upper airway, so as to aid in safer placement, is described.
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