Correspondence 619

the glottic. This avoids an inadvertent misdirection of thetube tip that is liable to occur when the tube contacts thewalls ofthe narrow oropharyngcal passaj^e created usingleft molar laryngoscopy. Further, when introduced fromthe right corner of the niouch. the tip of the tube facestowards the right and this results in a better \Ícw ofthelarynx |.^|. In some cases, one may need ti) bend the styletlike a hockey stick to aehieve the goal [3,4).

Alternatively or if use of the stylet does not succeed, useof a gum elastic bougie increases the success rate ofnegotiating the trachea! tube into the trachea. The use(if a gum clastic bougie with an angled tip has been foundto be especially useful when the operator recognizessome anatomical landmarks, but cannot direct the tipof the trachea! tube into the laryngeal iniet |4,5]. Oncethe gum elastic bougie is negotiated into the glotticaperture, the laryngoscope is left in position and thedesired tube, preferably a flexometallic tube with ahemispherical bevel, is railroaded over the gum elasticbougie with a rotary motion. Use of a tube that minimizesthe gap between the leading edge and the gum elasticbougie is know n to facilitate insertion ofthe trachéal tubeinto the trachea [6]. Alternatively, after advancing thebougie in a left molar approach to a maximum of 4Scm[7], one can shift over to a conventional midlinc approachand negotiate the trachéal tube over the bougie in thisposition.

References1 Bozdogan N, Sener M, Bilen A, ei a!. Does left molar approach to

laryngoscopy make difficult intubation easier than the conventional midiineapproach? Eur J Anaesthesioi 2008; 25:681 -6B4,

2 Yamamoto K, Tsubokawa T, Ohmura S, ef a!. Left-molar approach improvesthe laryngeal view in patients with difficult laryngoscopy, Anesthesioiogy2000; 92:70-74.

3 Smith M, Buist RJ, Mansour NY, A simple method to facilitate difficultintubation. Can J Anaesth 1990; 37:144-145-

4 Dorsch JA, Dorsch SE, Trachéal tubes. In: Dorsch JA, Dorsch SE, editors.Understanding anesthesia equipment. Baltimore: Williams & Wilkins; 1 999,pp, 557-578.

5 Dogra S, Falconer R, Latlo IP. Successful difficult intubation. Trachéal tubeplacement over a gum-elastic bougie. Anaesthesia 1990; 45:774-776,

6 Makino H, Katoh T, Kobayashi S, et a!. The effects of trachéal tube tip designand tube thickness on laryngeal pass ability during oral tube exchange withan introducer. Anesth Anaig 2003; 97:285-288,

7 Henderson JJ, Popat MT, Latto IP, Pearce AC, Difficult Airway Society,Difficult Airway Society guidelines for management of the unanticipateddifficult intubation. Anaesthesia 2004; 59:675-694,

DOliI 0,1097/EJA.ObOI 3e328320a6af

Effective plexus anaesthesia in a patient withEhlers-Danlos syndrome type IIIJessica T. Wegener, Jan Fräßdorf and Markus F. StevensDepartment of Anesthesioiogy, Academic Medical Center, University ofAmsterdam, Amsterdam, The Netheriards

Coffeapondence to Dr Markus F, Stevens, MD, DEAA, DESRA, AssociateProfessor of Anesthesioiogy, Department of Anesthesioiogy, Academic Medical

Center, Meibergdreef 9, University of Amsterdam, 110ODD Amsterdam,The NetherlandsTel: -t-31 20 566 5815; fax: +31 20 6979441;e-mail: m,f.stevens@amc.uva.nl

Received 6 November 2008 Revised 19 November 2008Accepted 26 November 200B

Editor.Ehlers-Danlos syndrome type III (also called hypcrmo-bility type) is an autosomal dominant-inherited disease ofthe connective tissue with an incidence of 1: 150000 [1].Although defects in the genes encoding for procollagenIII (COL3A1) or tenascin-X (TNXB) have beensuggested as possible candidates, up to now the precisedefect for this genetic disease remains unknown [2].From an anaesthcsiologist's point of view, the mostimportant features in patients with Khiers-Danlos syn-drome are vessel fragility, poor skin healing, excessivebleeding, spontaneous pneumothorax, joint dislocationincluding vertebral instability, valvular prolapse and - intype IV - spontaneous dissections and ruptures of majorvessels. Thus, the vessel fragility and successive bleedingas well as scoliosis may be a relative contraindicationagainst regional anaesthesia in favour of general anaes-thesia, whereas cervical spine joint laxity, skin fragility,an increased risk of temporomandibtilar joint dislocation,laryngeal trauma and pneumothorax may push the pen-dulum back in the direction of regional anaesthesia.Furthermore, there have been studies showing that sub-cutaneous infiltration of lidocaine has a reduced time ofaction and that transcutaneous application of a cutccticmixture of lidocaine 2.5% and prilocaine 2.5% (EMLA,AstraZeneca, Södertälje, Sweden) did not produce suffi-cient analgesia [3]. Additionally, patients with benignjoint hypermotility syndrome (incidence 1:10000), asyndrome with clinical features overlapping with thoseof Ehlers-Danlos syndrome type III, and a possiblysimilar genetic background [2] report an increased ratioof local anaesthesia failure compared with controls 141. Incontrast to these observations, there have been casereports of successful epidural and spinal anaesthesia inpatients with Ehlers-Danlos syndrome 15-7].

To our knowledge, there are no reports on peripheralnerve blocks in patients with Ehlers-Danlos syndrome.This would be interesting, especially in patients withEhlers-Danlos syndrome type III, as, in these patients,the 'possibility of a resistance to local anaesthetics' hasbeen stated [4]. Furthermore, these patients undergorepeated operations for their unstable joints,, and it wouldbe valuable to have knowledge about the possibility ofperipheral nerve blockades in these patients.

Case reportA 56-year-()ld female patient was scheduled to undergo arepeated arthroplasty of her left carpometacarpal joint.She was known to have a mitral valve prolapse, had

620 European Journal of Anaesthesiology 2009, Vol 26 No 7

undergone an anterior cervical hernia operation C5/6 andC6/7 and was treated for arterial hypertension. She hadbeen diagnosed with Ehlers-Danlos syndrome type IIIon clinical grounds several years earlier and had under-gone several orthopaedie, traumatologie and plasticsurgeries in the past. She had undergone surgery onher wrists four times under brachial plexus blockadeanaesthesia. On detailed questioning, she reported thatall regional blocks were sufficient and did v\ear off w itliinreasonable time. Review of the anaesthesia ñles re\ ealedthat she had had an axillary block twice and a \crticalinfraclavicular block twice: al! of them had been donewithin the previous 2 years with the help of a ner\cstimulator. On three occasions she had received 40 nilmepivacaine 1.5% with epinephrine 1:200000 and OEIthe fourth occasion 30 ml levobupivacaine ().,Í75% for anaxillary block. One axillary block had to be supple-mented by a distal radial nerve block at the level ofthe elbow with 10 ml lidocaine 1%. Furthermtire. allblockades were successful, and the operations hadbeen performed without additional sedation or analgesia.The blockades with mepivacaine wore off 4-5 h afterthe injection while the patient was still in the reeoveryunit, whereas the blockade with levobupivacaine lasted6-Hh. Thus, she had a completely normal history ofperipheral nerve bloekades with a typical duration ofblocks.

In contrast, she admitted that, duting several dentalprocedures, the local anaesthetic effect (atticaine) wasof rather unusual short duration of approximately l.Sminaccording to hct dentist. It was her explicit wish toundergo a further hand operation under regional anaes-thesia, because she had had a bad experience with urinaryretention after an earlier general anaesthesia. Therefore,she gave informed consent for a supraelavicular blockadewith a peripheral nerve catheter for postoperative paintherapy and publication of the case.

Thus, we performed a braehial plexus blockade underultrasound guidance {12 MHz linear probe, LOGIQ e,(ÍE Medical Systems, (^hina) \ia a supraelavicularapproach using an in-plane technique. The braehialplexus could be identified above the subcUnian arter\'and above the first rib. With an in-plane techni(]ue, thecannula was visualized the whole time and the spread ofloeal anaesthetic checked and accordingly adjusted.Twenty millilitres of niepi\acaine 2% was injectedthrough the needle and then catheter advanced 3 cmabove the tip of the needle (Contiplex D; B. Braun,Melsungen, Germany). Finally, the correct positioningof the catheter was checked by a test injection of aminuscule air bubble to visualize the end of the catheterand 1 ml lidocaine 1% in order to check adequate spreadof the htcal anaesthetic around the plexus. Althoughcontact with all visible vessels was avoided, there wassome bleeding ftom the puncture site necessitating a

local compression for a couple of minutes. Thereafter, nofurther bleeding or swelling was seen.

The braehial plexus was blocked completely within15 min, and the patient underwent the operation withoutany additional sedation or analgesia. She received satis-factory postoperative pain therapy via the brachial plexuscatheter for 36h {bupivacaine 0.125% with an infusionrate of6mlh~' , visual analogue scale at all times <2()%)without any additional rescue medication and went homepain free on the second postoperative day.

DiscussionThis is the first description of peripheral nerve blocks in apatient with Ehlers-Danlos syndrome. The case shousthat peripheral regional anaesthesia is an option in thesepatients making the 'possibility of resistance to localanaesthesia' 14] in this patient group unlikely.

Ehlers-Danlos syndrome is a heterogeneous group ofinherited diseases characterized by abnormal connectivetissue. Because of the life-threatening fragility of thegreat vessels in type IV, this form has reeeived eonsider-able attention from anaesthesiologists [7,8]. In contrast,type III has received little interest, though a reducedefficacy of local anaesthetics could be demonstrated. Theinfiltration anaesthesia with lidocaine is shortened and,with a eutectic mixture of lidocaine and prilocaine. suffi-cient analgesia could not be reached. Furthermore, 58%of patients with benign joint hypermobility syndrome(which is regarded by some authorities as identieal toEhlers-Danlos type ill |2,9]) reported experiencing anineffective local anaesthesia in the past, whereas this wasreported by only 21% of the matched controls |4]. Thus,at least with transcutaneous and subcutaneous infiltrationof local anaesthetics, there is a redueed effieaey. This maybe due to the altered texture of the cutaneous andsubcutaneous connective tissue leading to a faster spreador systemic rcsorption or both of local anaesthetics. Incontrast, case reports have documented a normal effee-tiveness during spinal and epidural anaesthesia [5,71.To our knowledge, this is the first case report of foursuccessful plexus brachialis blockades of normal durationin a patient with Ehlers-Danlos syndrome type III.Possibly in ihese locations, the distribution and or résorp-tion of local anaesthetics are unaltered through theabnormal connective tisstie. Certainly, the nerves ofpatients with Ehlers-Dimlos type Til or benign jointhypermobility syndromes are not 'resistant' to localanaesthetics as stated by some authors [41. All voltage-gated sodium channels of eukaryotes have a highlyconserved region that binds to local anaesthetics |IOI.Beyond that, the genetic variations suggested to induceEhlers-Danlos syndrome type III (mutations in pro-collagen III or in tenascin-X) have no influence onthe sensitivity of the voltage-gated sodium ehannel.Thus, the reason for the deereased effeetiveness of

Correspondence 621

transcutaneous or subcutaneous loca! anaesthesia is likelyCO be an altered pharmacokinetics rather than a changein pharmacodynamics.

Another problem in patients with Ehlers-Danlos syn-drome is the fnifiility of blood vessels und the pleurae.Nowadays, injury to sensitive surrounding structuressuch as great vessels or the pleura may be avoided byrhe use of ultrasound-guided regional anaesthesia 111].Naturally, damage to small vessels cannot be avoidedand, therefore, our patient had a minor bleed next to theciirheter at the end of the procedure. We chose anultrasound-guided sLipradavicutar in-plane approach,because supraclavicularly the plexus brachialis is mostsuperficial to the skin and the cannula can be visualizedthe whole way with minimal tissue damage. Furthermore,the neural structures are very compact there, avoidingmultiple redirection of the needle as, for example, with:in axillary approach. However, with an ultrasoimd-giiided Technique, [he chance of injuring sensitive struc-tures can only be lower but may never be avoidedcompletely.

In conclusion, peripheral nerve blocks in a patient withKhlers-Danlos syndrome type III worked as effectivelyas in normal persons, whereas infiltration anaesthesia - asdescribed in the literature - is less effective. Ultrasound-guided regional anaesthesia may help to avoid injury tovessels or the pleurae, which are extremely fragile struc-tures in these patients.

References1 Baum VC, O'Flaherty JE, Ehlers-Dantos syndrome. In: Bauni VC,

O'Flatierty JE, editors. Anesthesia lor genetic, metabolic, £ dysmorphicsyndromes of childhood. Philadelphia, Pennsylvania: Lippincott Williams &Wilkins; 2007, pp, 115-118.

2 Zweers MC, Kucharekova M, Schalkwijk J. Tenascin-X: a candidate genefor benign jotnt hypermobility syndrome and hypermobility type Ehlers-Danlos syndrome? Ann Rheum D!s 2005: 64:504-505.

3 Arendt-Mielsen L, Kaalund S, Bjerring P, Hogsaa B. Insufficient effect oflocal analgesics in Ehlers Danlos type III patients (connective tissuedisorder). Acta Anaesthesiol Scand 1990: 34:358-361,

4 Hakim AJ, Grahame R, Norris P, Hopper C. Local anaesthetic failure in jointhypermobility syndrome, J R Soc Med 2005: 98:84-85.

5 Kuczkowski KM, Benumof JL Cesarean section and Ehlers-Danlossyndrome: choice of anesthesia. !nt J Obstet Anesth 2002: 11:222-224.

B Dill-Russell P, Jones LS, Anaesthesia for caesarean section in a patient withEhlers-Danios syndrome and mitral valve prolapse, !nt J Obstet Anesth2001: 10:192-197,

7 Campbell H. Rosaeg OP. Anesthetic management of a parturient withEhlers Danlos syndrome type IV. Can J Anaesth 2002: 49:493-496.

B Solan K, Davies P. Anaesthelic and intensive care management of a patientwith Ehlers-Danlos type IV syndrome after laparotomy. j4naesi>iesia 2004;59:1224-1227.

9 Buckingham RB, Braun T, HannsEein DA, ei a!. Te m poro mandibular jointdysfunction syndrome: a close association with systemic joint laxity (thehypermobile joint syndrome). Ora! Surg Oral Med Oral Patho! 1991;72:514-519.

10 Nau C, Wang GK. Interactions of local anesthetics with voltage-gated Na4-cfianneis. J Membr Biol 2004: 201:1 -8 .

11 Gray AT. Ultrasound-guided regional anesthesia: current state of the art.Anesthes!o!ogy 2006; 104:388-373.

DOI:10.1097/EJA.ObOI 3e328324044e

A useful device for difficult nasal traehealintubation in ChinaHong Jiang, Yu Sun and Yesen ZhuDepartment of Anesthesiology, Shanghai Ninth People's Hospital affiliated toShanghai Jiao Tong University School of Medicine, Shanghai, China

Correspondence to Hong Jiang, PhD. MD, Department of Anesthesiology,Shanghai Ninth People's Hospital affiliated to Shanghai Jiao Tong UniversitySchool of Medicine, Zhizaoju Road 639, Shanghai 200011, ChinaTel: +8621 63138341: fax: -1-8621 63163572:e-mail: dr,jianghong@yahoo.com.cn

Received 30 November 2006 Accepted 2 December 200B

Editor,There are a wide variety of options for anticipated difficultinttibation, and the fihreoptic bntnchoscopes and intuba-tion lar\ngeal mask ain\ay have been advocated as effec-tive tools for difficult intubation [1,2]. At times, when noneof the instruments is available, alternatives need t« beconsidered. The blind intubation device (BID), manufac-tured by Anhui Xiaoshan Hygienic Material Co Ltd, JixiCounty, China, is a new single-use intubation device andseems to be one such alternative in our institute.

The BID (Fig. 1 ) consists of a battery cell, a light-guidedcatheter and an oesophageal tube. The light-guidedcatheter is a 7()cm long flexible wire, with an externaldiameter of 3.5 mm and a fixed anterior curvature of 30" atthe tip. At the anterior tip, there is also a small light bulb.The oesophagcal tube is a graduated, single-lumen poly-vinyl chloride (PVC) tube, with an inner diameter of6.0 mm and a round dead end. At a distance of 6 cm fromthe dead end, there is an ellipse gap with a 30 ramp at itsbottom. Over the ellipse gap is a cuff which can beintiated. ^^he intubation technique (Fig. 2) is easy.

. 1

The blind intubation device, the battery cell (B), the light-guidedcatheter (L) and the oesophageal tube (E).