Importance for bilateral palpation of pulse old fact rediscovered

Subsequent investigation revealed that on the previous day gas hoses of the same OR were disconnected for maintenance. Subsequently, only the O2 hose was connected by the maintenance staff and the N2O hose remained disconnected from the terminal unit overnight. It was possible that the water vapour entering from the atmosphere could have condensed under pressure on reconnection in the morning. A routine morning check of the machine did not reveal any problem due to the small quantity of water, which took some time to reach up to the flowmeter. A similar incident had been reported earlier, where a central air pipeline was found contaminated by water condensation, as it was kept open to atmosphere during maintenance.[1] We feel that purging of hoses must be done with central pipeline dry gases before connecting the yoke adapter to the machine for prevention of this problem. In addition to patient safety concerns, any water in the gas supply would also lead to malfunction of vaporisers and a major break down in the modern anaesthesia machines with electronic components.

unit and connecting yoke, some water was found emerging from the yoke adapter [ Figure 2]. On purging the terminal units no contamination of gases with any fluid was observed. No problem was encountered after using new hoses and a new anaesthesia machine.
Subsequent investigation revealed that on the previous day gas hoses of the same OR were disconnected for maintenance. Subsequently, only the O 2 hose was connected by the maintenance staff and the N 2 O hose remained disconnected from the terminal unit overnight. It was possible that the water vapour entering from the atmosphere could have condensed under pressure on reconnection in the morning. A routine morning check of the machine did not reveal any problem due to the small quantity of water, which took some time to reach up to the flowmeter. A similar incident had been reported earlier, where a central air pipeline was found contaminated by water condensation, as it was kept open to atmosphere during maintenance. [1] We feel that purging of hoses must be done with central pipeline dry gases before connecting the yoke adapter to the machine for prevention of this problem. In addition to patient safety concerns, any water in the gas supply would also lead to malfunction of vaporisers and a major break down in the modern anaesthesia machines with electronic components.

Sir,
A 20-year-old female patient, weighing 30 kg, of ASA status I, was scheduled for laparoscopic cholecystectomy under general anaesthesia. On conducting a preanaesthetic check up two days prior, no abnormality was detected and laboratory investigations were within normal limits. In the operation theatre an IV line was established on the right forearm and monitors were applied. When the pulsoximetry probe was put on left index finger it did not pick up the signals. Non-invasive blood pressure also could not be measured on the left arm. Thereafter all peripheral pulses including radial, brachial, axillary and subclavian were checked and they were not palpable on the left side, whereas, peripheral pulses on the right side were palpable, but were of low volume. Both carotids and lower limb pulses were normal. The non-invasive blood pressure measured in the right arm was 100 / 70 mm Hg and pulse rate was 86 / minute. The electrocardiogram (ECG) was normal. The patient was again enquired, but no abnormal symptoms (such as, dizziness, vertigo, visual changes, transient ischaemic attack (TIA), or stroke) [1] could be detected. The differential diagnosis of diminished or absent pulses in one limb were thought to be due to cervical rib, peripheral vascular diseases, vasculitis, such as, Takayasu arteritis, or diseases like atherosclerosis. However, according to the age and signs we presumed the probable cause as Takayasu arteritis. The probable diagnosis and risk of surgery were explained to patient and attendants. But as insisted by the patient and attendants we decided to proceed with the surgery keeping in mind the problems associated with Takayasu arteritis (avoidance of hyperextension of the cervical spine and maintaining perfusion pressure of the vital organs). [2,3] Standard general anaesthesia was induced with sodium pentothal, midazolam and fentanyl. Endotracheal intubation was facilitated with vecuronim bromide.
Anaesthesia was maintained with O 2 in 60% N 2 O, halothane and vecuronium. The surgery lasted for 45 minutes and the intraoperative course was uneventful. We investigated the patient postoperatively. X-ray of the chest and ECG were normal. The Colour Doppler showed diffuse wall thickening of the proximal and middle parts of left and right subclavian arteries with severe luminal narrowing on the left side and partial luminal narrowing on the right side. Damped (reduced) blood flow was seen in the distal arterial system of the left upper limb. Thickening in the wall of the abdominal aorta was also seen.
We missed the diagnosis of Takayasu arteritis, because radial pulses were not palpated on both sides. We are reporting this case just to make the anaesthetist more vigilant and re-emphasize the importance of the old fact of bilateral palpation of pulses during physical examination.

Sir,
We read with interest the case report "Capnography guided awake nasal intubation in a 4 month infant with pierre robin syndrome for cleft lip repair: A better technique" by Patra P. [1] It is laudable that Dr. Patra has managed the case efficiently with available resources.
The technique ofcapnography guiding and confirming tracheal intubation has long been taught and practiced. However pediatric fibroscope-assisted intubation is unarguably the technique of choice.
This case report raises a few concerns. The technique of awake blind nasal intubation is challenging even for experienced practitioners. It requires prolonged attempts and results in airway trauma. Neonates and infants sense noxious stimuli such as tracheal intubation. The physiological stress increases the risk of intraventricular brain haemorrhage. Risk factors include hypoxia and hypertension, both of which have been observed in awake intubation. [2] Nasal bleeding can lead to aspiration and endanger life in such infants. Intubation is more difficult in a conscious struggling infant. The author has not specified whether expert help,an airway cart with alternative devices for difficult intubation like Laryngeal mask airway (LMA) and gadgets to performa surgical airway were readily available. This was clearly not an emergency. The assistance of a skilled help, another anaesthetist, is highly valuable and essential in such situations.
Ravishankar et al. [3] reported an alternative intubation technique using a rigid nasendoscope and a video camera monitor system in two infants with Pierre-Robin sequence presenting for palatoplasty. In the absence of a flexible paediatric fibrescope, a rigid endoscope (2.7 mm, 70° lateral illumination) was passed orally to provide a view of the glottis on the monitor screen. A tracheal tube, bent into a J-shape using a stylet, was inserted orally and manipulated into the trachea, under video guidance.
We also tried this technique in two cases of difficult intubation in adults. We used a rigid endoscope (4 mm, 45° lateral illumination) passed orally and nasotracheal intubation was performedunder video guidance and spontaneous ventilation. Throughout the procedure a nasopharyngeal airway was passed through the other nostril and O 2 was administered through a T-piece to prevent hypoxia.
It is a pity that even 150 years after the advent of modern anaesthesia, we are struggling with ageold techniques. Nevertheless, awake intubation is a valuable technique to learn and use when other techniques are inappropriate. Tracheal intubation using a rigid nasendoscope and video camera system proves to be simple technique, permitting a favourable view of the glottis. It should be considered for passing