In previously reported cases of subcutaneous emphysemaof the eyelid, the postulated mechanism was air transmissionthrough a lamina papyracea defect. In our case, themechanism of the emphysema is unclear. Our patient had aproperly placed ETT with an adequate seal, making itimprobable for the airway pressure to be transmitted to theeyelid area. Therefore, the previously described mechanismis unlikely in this case.

The most likely mechanism of eyelid subcutaneousemphysema in this patient was during the craniotomy; theperiosteum was elevated down to the orbital rim, creating adissection plane. After the operation, air almost certainlyremained intracranially, as pneumocephalus is a nearlyuniversal postoperative finding after craniotomy [8]. Whenthe patient coughed against the ETT prior to extubation,intrathoracic pressure increased. This action could havecaused an increase in arterial and central venous pressures,which resulted in an increased intracranial pressure (ICP).The change in ICP may have forced the intracranial air totravel into the previously created dissection plane in the scalpsoft tissue, over the orbital rim, and into the eyelid to causethe subcutaneous emphysema.

There is no consensus on management of subcutaneousemphysema of the eyelid. Most practitioners treat thecondition expectantly, allowing the air to reabsorb sponta-neously over the course of a few days to weeks. The use ofantibiotics is unclear. Some practitioners prefer to administerprophylactic antibiotics when there is a concomitant surgicalor dental procedure [5]. Although the condition is usuallybenign, it may have serious eye-threatening consequences,including optic nerve compression, which would manifest asdecreased visual acuity. In these cases, decompression isnecessary. Our patient had a normal cranial nerve examina-tion, and the swelling was localized to the eyelid. Therefore,no further treatment was necessary.

Andrea K. Girnius BS (Medical Student)Rafael Ortega MD (Professor)Department of Anesthesiology

Boston University Medical CenterBoston, MA 02118, USA

E-mail address: rortega@bu.edu

Lawrence S. Chin MD (Professor and Chair)Department of Neurosurgery

Boston University Medical CenterBoston, MA 02118, USA

doi:10.1016/j.jclinane.2009.10.009

References

[1] LeBlond RF, Brown DD, DeGowin RL. The chest: chest wall,pulmonary, and cardiovascular systems; The Breasts. In: LeBlond RF,Brown DD, DeGowin RL, editors. DeGowin's Diagnostic Examination.9th ed. Boston: McGraw-Hill Cos.; 2009. p. 302-433.

[2] Chiu W, Lih M, Huang TY, Ku WC, Wang W. Spontaneous orbitalsubcutaneous emphysema after sneezing. Am J Emerg Med 2008;26:382.e1-e2.

[3] Sharma M. Aerocele (subcutaneous emphysema) of the eyelid. Indian JOphthalmol 1978;30:180.

[4] Celebioğlu S, Keser A, Ortak T. An unusual complication ofrhinoplasty: subcutaneous emphysema. Br J Plast Surg 1998;51:266-7.

[5] Rosh AJ, Sharma R. Orbital emphysema after nose-blowing. J EmergMed 2008;34:327-9.

[6] Cavuslu S, Oncul O, Gungor A, Kizilkaya E, Candan H. A case ofrecurrent subcutaneous emphysema as a complication of endotrachealintubation. Ear Nose Throat J 2004;83:485-8.

[7] Toprak V, Keles GT, Kaygisiz Z, Tok D. Subcutaneous emphysemafollowing severe vomiting after emerging from general anesthesia. ActaAnaesthesiol Scand 2004;48:917-8.

[8] Reasoner DK, Todd MM, Scamman FL, Warner DS. The incidenceof pneumocephalus after supratentorial craniotomy. Observations onthe disappearance of intracranial air. Anesthesiology 1994;80:1008-12.

Passing a reinforced gastric tube behind a non-ProSealLaryngeal Mask Airway

To the Editor:Various instruments have been passed into the gastro-

intestinal tract behind the classic Laryngeal Mask Airway(LMA Classic; Intavent Direct, Maidenhead, UK). Al-though more difficult than the ProSeal LMA, the potentialspace behind the cuff allows insertion of larger instru-ments. Four studies in adults involving the LMA Classicshowed a low success rate for passage of a gastric tubebehind the LMA Classic cuff (40-55%) [1]. This findingwas attributed to the soft and flexible nature of the gastrictube [2]. Amitabh and colleagues reported nasal passage ofa cuffed red rubber tracheal tube (ETT) behind the LMAcuff into the upper esophagus, followed by railroading ofthe gastric tube through it to achieve nasogastric intubation[3]. The use of a reinforced gastric tube to assist insertionof a nasogastric tube behind a properly positioned LMAis presented.

A 43 year-old man was scheduled for laparoscopiccholecystectomy during general anesthesia. Following threefailed attempts to intubate the trachea, a size 4.0 LMAClassic was inserted to secure the airway successfully. Oninsertion of trochar, the surgeon noticed the patient'sdistended stomach and requested gastric decompression.An attempt to pass a well lubricated size 6.5 internal diameter(ID) polyvinyl chloride (PVC) ETT via the right nostril toachieve nasogastric tube placement, failed as the ETTbecame impacted against the posterior pharyngeal wall. Asecond attempt to pass the ETT into the pharynx led todislodgement of the LMA. The gastric tube (RomsonsSci&Surg, Ltd., Agra, India) was primed with a modifiedureteric guidewire [4]. This reinforced gastric tube waspassed through the right nostril with simultaneous deflationof the LMA cuff. This tube was easily negotiated into theesophagus. The ureteric guidewire was removed andpositioning was confirmed by auscultation over the epigas-trium; gastric decompression was achieved. Postoperative

386 Correspondence

examination of the patient showed injury to the posteriorpharyngeal wall, which was managed conservatively.

The second case was a 50 year-old woman undergoinglaparoscopic cholecystectomy. After failed intubationattempts, her airway was secured with a size 3 LMA Classic.The surgeon requested evacuation of gastric contents. A welllubricated size 6.5 ID PVC ETT was passed through the rightnostril into the nasopharynx, then into the hypopharynx withsimultaneous deflation of the LMA cuff. The gastric tubewas passed through the nasotracheal tube. However, despiteall efforts, we failed to advance the gastric tube beyond adistance of 30 cm, which was equal to the ETT length. TheETT was removed and the gastric tube was primed with amodified ureteric guidewire and passed via the right nostril;it was easily negotiated into the esophagus. The position wasconfirmed by auscultation over the epigastrium and gastricdecompression was achieved.

Nasal passage of an ETT is associated with nasal andpharyngeal mucosal trauma and bleeding [5]. In the firstcase, pushing the ETT led to dislodgement of the LMA. Inthe second case, the bevel of the ETT probably got lodgedagainst the LMA/pharyngeal mucosa, leading to failure tonegotiate the gastric tube. The literature is replete with casesof severe injury when PVC tubes are passed blindly [6]. Useof a reinforced nasogastric tube is safe and avoids injuriesassociated with ETT passage through the nose. Deflating theLMA cuff creates a channel behind the cuff through whichany instrument inserted nasally must traverse to reach thestomach. The gastric tube is of smaller diameter; hence evena small channel would suffice to allow passage of this thinyet firm and flexible gastric tube, in contrast to the need for achannel of a larger diameter for ETT passage. We have usedthis technique in 10 patients and were successful in all butone patient, in whom it was successful on the second attemptfrom the opposite nostril.

Rajesh Mahajan MD (Associate Professor)Amit Manhas MD (Senior Resident)

Department of AnesthesiaASCOMS, Jammu, J&K, India

E-mail address: drmahajanr@rediffmail.com

Rahul Gupta MD Senior ResidentDepartment of Hepatology

PGIMER, Chandigarh, India

doi:10.1016/j.jclinane.2009.10.010

References

[1] Brimacombe AJ. Conduit to respiratory and gastrointestinal tracts. In:Brimacombe JR, editor. Laryngeal Mask Anesthesia: Principles andPractice. 2nd ed. London: W.B. Saunders Co., Ltd.; 2005. p. 153-76.

[2] Ozer S, Benumof JL. Oro- and nasogastric tube passage in intubatedpatients: fiberoptic description of where they go at the laryngeal level

and how to make them enter the esophagus. Anesthesiology 1999;91:137-43.

[3] Dutta A, Ganguly N, Sood J, Kumra V. Intraoperative nasogastric tubeinsertion with non-ProSeal laryngeal mask in place. Anesth Analg2006;102:1294-5.

[4] Mahajan R, Gupta R, Sharma A. Insertion of a nasogastric tube using amodified ureteric guide. J Clin Anesth 2009;21:387-8.

[5] Hall CE, Shutt LE. Nasotracheal intubation for head and neck surgery.Anaesthesia 2003;58:249-56.

[6] Bartlett DS, Grace R, Newell S. Perforation of and intubation throughthe palatoglossal fold. Anaesth Intensive Care 2009;37:481-3.

Reproducible peaked T wave due to transfusion viacentral venous catheter in an infant

To the Editor:Cardiac arrest associated with hyperkalemia during

transfusion has been reported [1]. Transfusion-relatedhyperkalemia depends not only on the potassium concentra-tion in the blood product, but also on volume and rate oftransfusion [1]. It has also been suggested that transfusion viathe central venous catheter contributes to a more concen-trated potassium load to the heart, especially in pediatricpatients [1,2]. Compared with stored blood units, fresh bloodunits, which have a lower potassium concentration, seem tobe rarely related to hyperkalemia during transfusion [2,3].However, we report a reproducible peaked T wave that wasprobably due to transfusion of fresh umbilical cord blood.

A one day-old, 1,400 gram baby girl (gestational age = 25wks), delivered by Cesarean section, was scheduled for leftpneumonectomy for a giant congenital cystic adenomatoidmalformation (CCAM). Prenatal ultrasonographic assess-ment had already shown several anomalies, including thegiant CCAM. At delivery, umbilical cord blood wascollected for autologous transfusion. Immediately afterdelivery, the infant's trachea was intubated and controlled

Fig. 1 Central venous (CV) and arterial blood (A) access usingumbilical vein and artery. CCAM = congenital cystic adenomatoidmalformation.

387Correspondence