Rocuronium for caesarean section.

Sir,—I read with interest the article entitled "Trachea! rupture after tracheal intubation" by Regragui, Fagan and Natrajan [1]. The authors described the anaesthetic management of a patient with a distal tracheal tear. The trachea was intubated initially with an 8-mm tracheal rube under bronchoscopic guidance with the distal end of the tube above the tracheal tear. After right rhoracotomy was performed, a massive airleak resulted and the tracheal tube was changed to a left Robertshaw double-lumen tube, isolating the right lung. Endobronchial intubation with a Robertshaw tube with the patient lying laterally was found to present some difficulties and it is not clear if suxamethonium was used on this occasion. If a neuromuscular blocker was used, positive pressure ventilation before isolation of the trachea] disruption might further aggravate the mediastdnal emphysema and air leak. If neuromuscular block was not used, endobronchial intubation would be even more difficult. Moreover, intubation using a Robertshaw tube, even under fibreoptic guidance, carried the risk of extending the tracheal tear [2] because the Robertshaw tube is made of stiff red rubber and has a relatively large external diameter and curves in two planes. After placement of the endobronchial tube, the tracheal cuff would lie at the site of the tracheal injury and positive pressure ventilation through the tracheal lumen could expose the defect to further damage. Therefore, the tracheal lumen of the Robertshaw rube served minimal function in this case. This patient's airway could have been secured on anaesthetic induction using a left endobronchial tube inserted under fibreoptic guidance, using a small uncut tracheal tube to bypass the disruption and allow ventilation of one lung until the tear was repaired [3]. After trachcal repair, the tracheal tube can then be re-located by bronchoscopy to lie above trachcal structures and general anaesthesia can be maintained with the patient breathing spontaneously. Ventilation of both lungs in patients with tracheal disruption has also been reported with two small tracheal tubes passed into each main bronchus using fibreoptic control [4, 5] or by use of a modified Foley catheter [6]. K. O. SUN Department of Anaesthesia Kwong Wah Hospital Hong Kong