Khan, Maha

Khan, Robyna

Rashid, Saima

Shamim,, Faisal

English

eCommons@AKU

eCommons@AKUDepartment of Anaesthesia Medical College, PakistanApril 2018Palliative surgical gastrostomy underultrasound‑guided bilateral rectus sheath blocks ina head and neck cancer patientSaima RashidAga Khan University, saima.rashid@aku.eduFaisal Shamim,Aga Khan University, faisal.shamim@aku.eduMaha KhanAga Khan UniversityRobyna KhanAga Khan University, robyna.khan@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesiology CommonsRecommended CitationRashid, S., Shamim,, F., Khan, M., Khan, R. (2018). Palliative surgical gastrostomy under ultrasound‑guided bilateral rectus sheathblocks in a head and neck cancer patient. Saudi Journal of Anesthesia, 12(2), 371-373.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesth/143371Saudi Journal of Anesthesia / Volume 12 / Issue 2 / April-June 2018Letters to Editorendotracheal versus bronchial intubation: A Diagnostic accuracy study. Anesthesiology 2016;124:1012-20.2. Dubey PK, Dubey P, Kumar N, Bhardwaj G, Kumar N. Blind nasal intubation revisited: No longer a blind technique? J Emerg Med 2017;52:231-4.3. Nakamura S, Watanabe T, Hiroi E, Sasaki T, Matsumoto N, Hori T, et al. Cuff damage during naso-tracheal intubation for general anesthesia in oral surgery. Masui 1997;46:1508-14.Access this article onlineWebsite:www.saudija.orgQuick Response CodeDOI:10.4103/sja.SJA_706_17How to cite this article: Dubey PK, Dubey P. Point‑of‑care ultrasonography for detection of tracheal tube cuff rupture following nasal intubation?. Saudi J Anaesth 2018;12:369‑71.© 2018 Saudi Journal of Anesthesia | Published by Wolters Kluwer ‑ MedknowThis is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms.Palliative surgical gastrostomy under ultrasound‑guided bilateral rectus sheath blocks in a head and neck cancer patientthat tracheostomy will be performed only in case of loss of airway.In the preoperative assessment, there was no significant past medical and surgical history. On airway examination, there was a right cheek lesion with no mouth opening. The tumor involved both eyes and obscured right nostril completely, but the left nostril was patent. We discussed with patient, family, and surgical team about an alternative technique for procedure that does not require airway handling. We also explained awake fiberoptic intubation but its complications or failure may result in tracheostomy. We also did explain that there may be mild pain at certain step during the procedure can be treated.Sir,Palliative care aims to improve quality of life in patients facing problems associated with life‑threatening illness.[1] Incurable end‑stage head and neck cancer lead to distressing symptoms and patients face unique challenges in maintaining adequate nutrition. Nearly 40% of patient suffers from dysphagia, and this is largely due to mechanical and functional obstruction and drug‑induced side effects.[1] Placement of gastrostomy tubes is the most common approach to ensuring safe delivery of adequate nutrition.[2] Percutaneous endoscopic gastrostomy, surgically inserted open gastrostomy, and radiologically‑inserted gastrostomy are the choices.[2] Sometimes, the obstructing nature of tumor or limited mouth opening renders only the open surgical approach. At the same time, general anesthesia is required for the procedure with anticipated difficult airway. We are sharing our experience of ultrasound‑guided truncal block for open surgical gastrostomy.A 52‑year‑old female,  weighing 45 kg, known case of the right alveolar invasive squamous cell carcinoma was scheduled for palliative surgical gastrostomy. The mass was arising from the right upper jaw [Figure 1], involving nose, hard palate, eyes, and there was gross bony destruction with extension into the right maxillary sinus. The patient and family were counseled in detail by ear, nose, and throat (ENT) team about nonresectable nature of tumor and required gastrostomy for nutritional support. The family was not willing for tracheostomy, but they have been explained Figure 1: Large mass arising from the right cheek and upper jaw[Downloaded free from http://www.saudija.org on Friday, October 4, 2019, IP: 58.27.240.66]372 Saudi Journal of Anesthesia / Volume 12 / Issue 2 / April-June 2018Letters to EditorA regional technique in the form of ultrasound‑guided bilateral rectus sheath blocks was planned,[3] though all preparations for general anesthesia, resuscitation drugs, and equipment were kept ready along with standby ENT team for emergency tracheostomy. After applying the standard monitoring (noninvasive blood pressure, electrocardiography SpO2), area between xiphisternum and umbilicus (block site) was prepared with aseptic measures. High‑frequency linear array probe is positioned just lateral to the umbilicus in an axial (transverse) plane. After identifying the layers of anterior abdominal wall, the transducer moved cephalad between costal margin and umbilicus. Skin puncture site was infiltrated using 25‑gauge needle with 1 ml lignocaine 2%. We use Stimuplex needle exclusively for peripheral nerve blocks, so a 100 mmm needle was inserted 3 cm lateral to the lateral edge of the transducer and advanced “in plane” from lateral to medial and superficial to deep. The needle is positioned deep to potential space between posterior border of rectus abdominis muscle, but superficial to posterior aspect of rectus sheath [Figure 2].[4] This target site is referred as “posterior rectus sheath compartment.” Ropivacaine 0.25% 20 ml is incrementally injected while observing for the expanding anechoic fluid collection. The same procedure is repeated on the contralateral side.The patient tolerated surgery well, remained hemodynamically stable throughout, and the surgeon had no difficulty in performing the procedure. She was discharged home next day. This case highlights the utility of ultrasound‑guided rectus sheath block as a very useful regional technique[5] alternative to general anesthesia for short abdominal procedures, especially where airway is in jeopardy.Declaration of patient consentThe authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.Saima Rashid, Faisal Shamim,  Maha Khan, Robyna KhanDepartment of Anaesthesiology, Aga Khan University, Karachi, PakistanAddress for correspondence: Dr. Faisal Shamim, Department of Anaesthesiology, Aga Khan University, P. O. Box 3500, Stadium Road, Karachi 74800, Pakistan. E‑mail: faisal.shamim@aku.eduReferences1. Cocks H, Ah-See K, Capel M, Taylor P. Palliative and supportive care in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130:S198-207.2. Nugent B, Lewis S, O’Sullivan JM. Enteral feeding methods for nutritional management in patients with head and neck cancers being treated with radiotherapy and/or chemotherapy. Cochrane Database Syst Rev 2013. CD007904.3. Yarwood J, Berrill A. Nerve blocks of the anterior abdominal wall. Contin Educ Anaesth Crit Care Pain 2010;10:182-6.4. Salinas FV. How i do it: Ultrasound-guided bilateral rectus sheath blocks. ASRA News 2014;14:5-8.5. Hasan MS, Ling KU, Vijayan R, Mamat M, Chin KF. Open gastrostomy under ultrasound-guided bilateral oblique subcostal transversus abdominis plane block: A case series. Eur J Anaesthesiol 2011;28:888-9.Figure 2: Ultrasound-guided rectus sheath block. Sonoanatomy, technique, and needle position shown in the upper, middle, and lower portion, respectively[Downloaded free from http://www.saudija.org on Friday, October 4, 2019, IP: 58.27.240.66]373Saudi Journal of Anesthesia / Volume 12 / Issue 2 / April-June 2018Letters to EditorThis is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms.How to cite this article: Rashid S, Shamim F, Khan M, Khan R. Palliative surgical gastrostomy under ultrasound‑guided bilateral rectus sheath blocks in a head and neck cancer patient. Saudi J Anaesth 2018;12:371‑3.© 2018 Saudi Journal of Anesthesia | Published by Wolters Kluwer ‑ MedknowAccess this article onlineWebsite:www.saudija.orgQuick Response CodeDOI:10.4103/sja.SJA_770_17Intubation over a bougie: Nasal is not novelthe incidence and severity of nasal trauma, with less need for Magill forceps, than with the conventional technique of blind nasal passage and external tube manipulation.[9]The above literature outlines the increasing knowledge of, and experience with, nasotracheal intubation over bougies. With this evidence‑based foundation, the goal of achieving atraumatic nasal intubation inches closer. While the contribution of Bhat Pai et al. to the lexicon is appreciated, the above‑cited works clearly show that the suggestion of novelty is questionable.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest.Ron O. Abrons, Randy W. LoftusDepartment of Anesthesiology, The University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USAAddress for correspondence: Dr. Ron O. Abrons, Department of Anesthesiology, The University of Iowa Hospitals and Clinics, 6JCP, 200 Hawkins Drive, Iowa City, IA 52242, USA. E‑mail: ron‑abrons@uiowa.eduReferences1. Cossham PS. Nasotracheal tube placement over a bougie. Anaesthesia 1997;52:184-5.2. Arora MK, Karamchandani K, Trikha A. Use of a gum elastic bougie to facilitate blind nasotracheal intubation in children: A series of three cases. Anaesthesia 2006;61:291-4.3. Morimoto Y, Sugimura M, Hirose Y, Taki K, Niwa H. Nasotracheal intubation under curve-tipped suction catheter guidance reduces epistaxis. Can J Anaesth 2006;53:295-8.Dear Sir,We are writing in regards to a case series in the October‑December issue titled “Gum elastic bougie as a guide in nasotracheal intubation: A novel technique.” The authors described five cases in which difficult passage of a nasotracheal tube was overcome by the use of a nasally placed bougie as part of a Seldinger‑based technique. Bhat Pai et al. correctly point out that the use of an airway bougie can facilitate nasotracheal intubation in a variety of difficult clinical scenarios. The suggestion that this is a novel technique, though, is of question.As early as 1997, Cossham described the routine use of bougies in nasotracheal intubation.[1] In 2006, Arora et al. presented a series of three pediatric cases in which a gum‑elastic bougie was used to facilitate blind nasotracheal intubation in children.[2] Also in 2006, Morimoto et al. described the use of a curve‑tipped suction catheter as a guide for nasotracheal intubation, showing a significant decrease in nasal bleeding with the technique.[3] In 2010, Arisaka et al. described the successful use of a similar technique in 16 patients who had failed nasotracheal intubation through conventional methods.[4] In 2008 and 2014, Inoue and Kitano, respectively, described the use of gum‑elastic bougies as guides in cases of challenging nasotracheal intubation.[5,6] In 2013, Staar et al. studied the use of modified Magill forceps for glottic navigation of nasally placed bougies.[7] In 2015, Abrons et al. presented a case series in which pediatric bougies, guided by nasal trumpets, were utilized as guides for successful nasal intubation under challenging conditions.[8] In 2017, Abrons et al. prospectively studied this technique of nasotracheal intubation over a bougie passed through a nasopharyngeal airway in 257 patients, showing a significant decrease in both [Downloaded free from http://www.saudija.org on Friday, October 4, 2019, IP: 58.27.240.66]

Palliative surgical gastrostomy under ultrasound‑guided bilateral rectus sheath blocks in a head and neck cancer patient

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Palliative surgical gastrostomy under ultrasound‑guided bilateral rectus sheath blocks in a head and neck cancer patient

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