Correspondence Anaesthesia, 2005, 60, pages 287297 . ....................................................................................................................................................................................................................

5 Gurung AM, Tomlinson AA. Prepreparation of succinylcholine. Anaesthesia 2004; 59: 8256.

References
1 Wille J, Braams R, van Haren WH, van der Werken C. Pulse oximeter-induced digital injury: frequency rate and possible causative factors. Critical Care Medicine., 2000; 28: 35557. 2 Safety Notice 2001(08): Tissue Necrosis Caused by Pulse Oximeter Probes. London: Medicines and Healthcare Products Regulatory Agency, 2001.

Ear probe pulse oximeters and neonates

During anaesthesia for neonatal herniotomy an initially good pulse oximetry trace rapidly changed to a poor signal and the displayed peripheral blood oxygen saturation fell. The saturation was being measured with an OxyTip+ ear probe (Datex-Ohmeda, Helsinki, Finland) which has a new design incorporating a plastic clip. The probe was switched to the other ear and the same problem developed. The pressure generated between the probes light and sensor was measured using a size 6 FG urinary catheter balloon inated to a diameter of 5 mm (comparable to an infants digit or ear lobe) and transduced. The mean pressure was measured on three separate occasions. The mean pressure of two old-style probes (with a wire spring) was 39 and 64 mmHg and with four new-style probes 55 63 mmHg. One of the two old probes and all four new-style Datex-Ohmeda probes exerted a pressure greater than the mean arterial pressure of a neonate and much higher than previously reported for oximeter probes [1]. Although the pressure achieved may vary with different tissues, it would appear to be clinically signicant. We realise that the probe is marketed primarily for adults. Probes of this design are used extensively, however, on infants and neonates. There have been several reports of ischaemic or thermal injuries to neonates from pulse oximeter probes [1, 2], and new designs using stronger clips make this complication more likely. We advise clinicians to use a wrap around probe in small children.
C. Urquhart G. Bell Royal Hospital for Sick Children Glasgow G3 8SJ, UK E-mail: Graham.Bell@ yorkhill.nhs.scot.uk
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A reply As a result of Dr Bells research, we have subsequently made design improvements to the OxyTip+ Ear Sensor that have decreased the amount of pressure applied to the patients ear, while maintaining a secure t. It is important to note that the ear sensor is not recommended for use on neonates and infants and is intended for use on patients weighing 10 kg (22 lb) or more. As with all medical devices, the use of the OxyTip+ Ear Sensor must be in compliance with the manufacturers instructions for use to guarantee a safe, accurate and effective SpO2 measurement. SpO2 sensors designed for neonatal and infant use include our OxyTip+ Sensitive Skin sensor and OxyTip+ Wrap sensor, intended for weight ranges of < 1500 g and greater and 3 kg and greater, respectively. Both sensors can be applied to patients hands or feet by using a foam wrap, adhesive tape or our innovative foam sandal. A copy of sensor instructions for use, including approved patient weight ranges and recommended sensor sites, is supplied in each sensor box and is also available upon request.
A. Cooley Global Product Manager SpO2 Sensors GE Healthcare Louisville, CO 80027, USA

An easy to learn double lumen tube placement protocol

A breoptic scope remains the gold standard to determine the correct position of a double lumen tube (DLT). However, before a scope is inserted into

a DLT, conrmation of correct placement by auscultation should be achieved [1]. We are often confronted with difculties while teaching such a technique to our trainees, as it very hard for them to visualise the recommended protocol. We have devised a novel way to teach the placement of DLTs that is relatively inexpensive. We use our own hand, ngers held in the form of an inverted V (as in the victory sign) to simulate the trachea with its bifurcation to the two major bronchi. For the sake of convenience we have described the placement of a left-sided DLT. The DLT is inserted in the manner described [1], and after placement, steps 1 and 2 are followed: Step 1: To determine if the DLT is inserted too far, inate the tracheal cuff and auscultate for bilateral equal air entry. Consider three possibilities: correct, too far out or too far in Bilateral equal air entry present means that either the DLT is in the correct place (Fig. 5) or too far out (Fig. 6). Proceed to Step 2. Unilateral air entry implies too far in (Fig. 7), withdraw the DLT until equal air entry. Step 2: To determine whether the DLT is in the correct place or too far out, inate the bronchial cuff, occlude the tracheal lumen and auscultate. Consider three possibilities: correct, too far out or wrong side in Unilateral left-sided breath sounds only: the DLT is in the correct place (Fig. 5). Bilateral equal air entry: too far out (the bronchial cuff is in the trachea), insert the DLT further and return to Step 1 (Fig. 6). Unilateral right-sided breath sounds: the DLT is inserted in the wrong side (Fig. 8) remove DLT and start again. In summary: inate, auscultate, and look for the three possibilities: correct, too far out, too far in. One other advantage of this technique is that it helps trainees grasp the concept of determining correct placement of a DLT, which cannot be understood with the use of a breoptic scope.

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Anaesthesia, 2005, 60, pages 287297 Correspondence . ....................................................................................................................................................................................................................

Reference
1 Morgan GE, Mikhail MS, Murray MJ, Larson CP. Protocol for checking placement of a left-sided double lumen tube. In: Foltin J, Lebowitz H, Boyle PJ, eds. Clinical Anaesthesiology, 3rd edn. New Delhi: Lange Medical Book, 2002: 533. Arndt Endobronchial Blocker during oesophagectomy

Figure 5 Left-sided double lumen tube inserted correctly on the hand model.

Figure 7 Tube inserted too far.

Figure 6 Tube not inserted far enough.

J. S. Chhabra S. M. Ahmed Jawaharlal Nehru Medical College Aligarh 202002, UP, India E-mail: drjscanaes@rediffmail.com

Figure 8 Left-sided tube inserted in the right main bronchus.

I would like to report the advantages in using a bronchial blocker rather than a double lumen tube (DLT) for one lung ventilation (OLV) during oesophagectomy. The Arndt Endobronchial Blocker manufactured by Cook Medical Ltd (Castletroy, Limerick, Ireland) is designed to be inserted through a normal tracheal tube and is recommended for OLV if intubation is difcult [1]. A review on the use of bronchial blockers for OLV has recently been published [2] but does not discuss their use or particular advantages for this type of surgery. Anaesthesia for oesophagectomy needs a rapid sequence induction with cricoid pressure before intubation of the trachea to prevent regurgitation and aspiration. The DLT is more difcult to insert than a normal tracheal tube in this situation, especially if intubation is difcult [3]. Furthermore, the left-sided Mallinckrodt Broncho-Cath (Tyco Healthcare Ltd, Gosport, Hampshire, UK) is not easy to use with a gum elastic bougie. It is too long and either the proximal end of the bronchial tube needs to be shortened by about 4 cm if it is to be inserted rst (before railroading the tube), or they have to be inserted together, resulting in less control of the tip of the bougie. The bronchial lumen of the size 37 tube is small and does not slide easily over the standard 15 FG bougie. The endobronchial part of the tube often ends up in the right main bronchus instead of the left. A normal tracheal tube (with a single lumen) may therefore be safer than a DLT in securing the airway in these patients. Finally, there is no need to change the tube at the end of the operation if the patient needs postoperative ventilation in ICU.
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