Download - Positioning for Intubation in Morbidly Obese Patient

Because the relative risks versus benefits of our approach wereunknown, our consent process was extensive and carried out inseveral meetings. Careful planning and close cooperation betweenthe anesthesiologist and the operating surgeon permitted successfulmultivisceral transplantation in this complex, compromised patient.Charles D. Boucek, MDKareem Abu El Magd, MDDepartment of AnesthesiologyUniversity of Pittsburgh Medical CenterPittsburgh, [email protected]

References1. Kaufman SS, Atkinson JB, Bianchi A, et al. Indications for pediatric intestinal trans-

plantation: a position paper of the American Society of Transplantation. PediatrTransplant 2001;5:80–7.

2. Harte FA, Chalmers PC, Walsh RF, et al. Intraosseous fluid administration: a parenteralalternative in pediatric resuscitation. Anesth Analg 1987;66:687–9.

3. Glaeser PW, Hellmich TR, Szewczuga D, et al. Five-year experience in prehospitalintraosseous infusions in children and adults. Ann Emerg Med 1993;22:1119–24.

4. Fiser DH. Intraosseous infusion. N Engl J Med 1990;322:1579–81.5. Kohlstaedt KG, Page IH. Hemorrhagic hypotension and its treatment by intra-arterial

and intravenous infusion of blood. Arch Surg 1943;47:178–91.6. Negovsky V. Treatment of the agonal state of clinical death. JAMA 1945;129:1226.7. Brown AS. Transfusion by the intra-arterial route. Lancet 1953;265:745–8.

Positioning for Intubation in MorbidlyObese PatientsTo the Editor:

Patient positioning in the obese patient is of critical importancewhen performing laryngoscopy. Brodsky et al. (1) report a series of100 patients in which 99 were successfully tracheally intubatedusing an elevated head-up position (Fig. 1) (2). In this position, theshoulders are elevated with several pads, the head and neck areextended, and the external auditory meatus is in line with thesternal notch. We propose a modification of this position thatachieves the same goals without application of the rolls under thepatient’s shoulders (Fig. 2). This modified position is commonlyused in our hospital. Our positioning technique achieves the samerelative patient orientation without the burden of placing the extrapads under the shoulders. This positioning is effective and saves the

health care provider from the additional strain of moving theweight of these large patients.David A. Zvara, MDRandy W. Calicott, MDDeborah M. Whelan, MDDepartment of AnesthesiologyWake Forest University School of MedicineWinston-Salem, [email protected]

References1. Brodsky JB, Lemmens HJM, Brock-Utne JG, et al. Morbid obesity and tracheal intuba-

tion. Anesth Analg 2002;94:732–6.2. Brodsky JB, Lemmens HJ, Brock-Utne JG, et al. Anesthetic considerations for bariatric

surgery: proper positioning is important for laryngoscopy. Anesth Analg 2003;96:1841a–2a.

Desflurane’s Effect on QTc Interval:Electrophysiological Mechanisms Need toBe ExploredTo the Editor:

Owczuk et al. (1) incorrectly state that their report is the first todescribe the influence of desflurane on the QT interval. The influ-ence of desflurane on the QT interval was reported by Yildirim et al.(2) several months earlier. Although the study by Owczuk et al.focuses only on QT correction for heart rate (QTc), the study byYildirim et al. explores the effects of sevoflurane, isoflurane, anddesflurane on various aspects of QT interval (2), including QTdispersion (QTD), heart rate corrected QT interval (QTc), and QTcdispersion of the electrocardiogram (QTcD). The effects of desflu-rane on QTc interval are comparable in both studies. One MAC ofinhaled anesthetic causes a significant increase in QTc, QTD, andQTcD (2). Further electrophysiological studies are needed to deter-mine whether the effects of desflurane on the QT interval aremediated by an increase in transmural dispersion of repolarization(e.g., halothane (3)) or a reduction in Ik current (e.g., sevoflurane)(4).Thiruvenkatarajan Venkatesan, MD, DA, DNBChristian Medical College HospitalTamilnadu, [email protected]

References1. Owczuk R, Wujtewicz MA, Sawicka W, et al. The influence of desflurane on QTc

interval. Anesth Analg 2005;101:419–22.2. Yildirim H, Adanir T, Atay A, et al. The effects of sevoflurane, isoflurane and desflu-

rane on QT interval of the ECG. Eur J Anaesthesiol 2004;21:566–70.

Figure 1. Elevated head-up position. Reproduced with permissionfrom Airway Cam Video Series, Volume 3: Advanced Airway Im-aging and Laryngoscopy Techniques. Courtesy of Richard Levitan,MD, Airway Cam Technologies, Inc., Wayne, PA.

Figure 2. Whelan-Calicott position.

1592 LETTERS TO THE EDITOR ANESTH ANALG2006;102:1585–98