Fluoroscopic guidance for placing a double lumen endotracheal tube in adults.

OBJECTIVE: The aim of this study was to assess the right placement of the double lumen endotracheal tube with fluoroscopic guidance, which is used in first intention prior to the fiberscope in our institution. METHODS: This was a prospective observational study. The study was conducted in vascular and thoracic operating rooms. We enrolled 205 patients scheduled for thoracic surgery, with ASA physical statuses of I (n = 37), II (n = 84), III (n = 80), and IV (n = 4). Thoracic procedures were biopsy (n = 20), wedge (n = 34), culminectomy (n = 6), lobectomy (n = 82), pneumonectomy (n = 4), sympathectomy (n = 9), symphysis (n = 47), and thymectomy (n = 3). The intubation with a double lumen tube was performed with the help of a laryngoscope. Tracheal and bronchial balloons were inflated and auscultation was performed after right and left exclusions. One shot was performed to locate the position of the bronchial tube and the hook. Fluoroscopic guidance was used to relocate the tube in case of a wrong position. When the fluoroscopic guidance failed to position the tube, a fiberscope was used. Perioperative collapse of the lung was assessed by the surgeon during the surgery. RESULTS: Correct fluoroscopic image was obtained after the first attempt in 58.5% of patients therefore a misplaced position was encountered in 41.5%. The fluoroscopic guidance allowed an exact repositioning in 99.5% of cases, and the mean duration of the procedure was 8 minutes. A fiberscope was required to move the hook for one patient. We did not notice a moving of the double lumen endotracheal tube during the surgery. The surgeon satisfaction was 100%. CONCLUSION: The fluoroscopy evidenced the right position of the double lumen tube and allowed a right repositioning in 99.5% of patients with a very simple implementation.

Toxic plasma concentration of ropivacaine after a paravertebral block in a patient suffering from severe hypoalbuminemia.

A case of systemic ropivacaine toxicity from a continuous thoracic paravertebral block in an adult patient who received a lobectomy is presented. The catheter was placed by the surgeon. Eleven hours after the start of the infusion, the patient experienced an arrhythmia leading to death. The total venous plasma concentration of ropivacaine was high (3.2 µg/mL). Furthermore, the patient had severe hypoalbuminemia (albumin 24 g/L), which resulted in the increase of the unbound ropivacaine plasma concentration that was responsible for the toxic side effects.

Temporary quadriplegia following continuous thoracic paravertebral block.

A case of temporary quadriplegia following a continuous thoracic paravertebral block in an adult patient scheduled for video-assisted thoracoscopy is presented. An 18-gauge Tuohy needle was inserted under direct vision by the surgeon but the tip of the catheter was not localized. Postoperatively, the patient developed temporary quadriplegia 90 minutes after the start of a continuous infusion of ropivacaine 0.2%. Imaging studies showed that the catheter was localized in the intrathecal space.