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ANESTH         ANALG                                                                                                      ...
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Difficult extubation a new management


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Difficult extubation a new management

  1. 1. ANESTH ANALG LETTERS TO THE EDITOR 4331995:81:424-35anesthetics (EMLA@ cream; Astra Pharmaceutical Products Inc., Difficult Extubation: A New ManagementWestborough, MA). In addition to the uses pointed out, our expe-rience has shown that the application of EMLA@ cream can be a very To the Editor:useful measure to facilitate venipuncture in patients with reflex We describe a new method to deal with difficult extubation duesympathetic dystrophy (RSD; Sudeck’s atrophy). to failed cuff deflation. A 28.yr-old patient about to undergo Intravenous regional blocks with guanethidine are a safe and herniorrhaphy was intubated with an 8.5-mm cuffed PVC tubeeffective treatment in these patients. Venous cannulation, however, (Portex, UK) without difficulty after induction of anesthesia.can be a very painful procedure due to the fact that most patients After the surgery, neuromuscular block was reversed and thewith RSD experience hyperalgesia and allodynia. Because edema is resident pulled the inflating tube off its attachment to deflate thea major symptom, venipuncture in the affected limb can often be cuff rapidly. It stretched before snapping off near its attachment,very difficult. After a first unsuccessful attempt, patients will fre- but the tracheal tube could not be removed. The patient, who wasquently not allow any further manipulation of the affected limb due now struggling, was given a small dose of thiopental, and laryn-to pain and frustration. Furthermore, there is also a pathophysio- goscopy revealed an inflated cuff preventing extubation. Thelogic reason to avoid painful procedures such as venipuncture in tube was firmly held, and a small V-shaped cut was madepatients with RSD. Any nociceptive input can contribute to central through the wall of the tracheal tube across the inflating lumensensitization, a mechanism instrumental in the development of just beyond the attachment of the inflating tube (Fig. 1) The cutchronic pain syndromes (3). Additional pain can result in increased segment was lifted to allow air to escape, and the tracheal tubeactivity of the sympathetic efferents with deterioration of the was then easily removed. We believe that this method is easy,symptoms. With the use of EMLA@ cream, venipuncture for intra- quick, and safer than the methods described in literature. How-venous blocks is no longer a distressing procedure. The confidence ever, before using this method, one should confirm that difficultyin painless venous cannulation decreases the patients’ fears and in extubation is due to failed cuff deflation only and that a freshencourages them to continue with a series of blocks. From the patho- tube is available if remtubation becomes necessaryphysiologic point of view, painless venipuncture with EMLAB creamprevents iatrogenic nociceptive impulses. This might help to achievebetter results with sympatholytic blocks. We did not perform a pro-spective, randomized, double-blind study regarding the use of EMLA@cream in patients with RSD because we considered it to be unethical in Ruchi Gupta, MD*this particular patient population. However, based on our experience, Sham L. Singla, Mstwe strongly recommend the application of EMLAB cream before ve- Dqmtments of “Anaesthesiology and iSi*rpynipuncture for intravenous blocks in patients with RSD. Medzcal College and Hospztnl Rohfak 124001, IndiaNorbert GrieBinger, MDReinhard Sittl, MDDepartment of AnesthesiologyUniversity of Erlanp-Ntirnberg91054 Erlangen, GemanyReferences Effects of Pentastarch on Global Cerebral 1. Gajraj NM, Pennant JH, Watcha MF. Eutectic mixture of local anesthetics (EMLA”) cream. An&h Analg 1994;78:574&83. Ischemia and Reperfusion 2. Nerad JL, O’Connor CJ. Further applications for EMLA” cream [letterl. An&h Analg 1994;79:814. To the Editor: 3. Coderre TJ, Katz J, Vaccarino AL, Melzack R. Contribution of central neuroplasticity to pathological pain: review of clinical and experimental evidence. Pain 1993;52:259-85. With great interest I read the report by Goulin et al. (1) on the effect of pentastarch in experimental global cerebral ischemiaFigure 1. Tracheal tube wth the detached mflat-mg tube and the “cut” (arrow)