LETTERS TO THE EDITOR e31

Table 1. Demographic Characteristics and Outcome of 57 Patients Is Urinary Drainage Necessary in Patients
Undergoing Colonic Resection and Enhanced Recovery (Fast-Track
Program) With Thoracic Epidural Analgesia (T6-T8) and With a
With Thoracic Epidural Analgesia?
Removed Bladder Catheter at the End of Surgery A Prospective Analysis: Reply
POUR (n 12) No POUR (n 45)
Female 50% (6) 47% (21)
Male 50% (6) 53% (24) To the Editor:
Age (years) 61 14 57 13
Urinary infections 0% 4% (2) Thank you for giving us the opportunity to reply to the letter
Discharge 4D3 0% 8% (3) by Dr. Forget et al. We strongly agree with them claiming that
Satisfaction (0-10) 8.7 1.3 8.9 2.0
early drain removal encourages independence and facilitates
Intraoperative diuresis 725 850 403 176
patients being out of bed.
Ambulation time (minutes) 225 28 280 112
Walking distance (meters) 366 186 395 173
However, their experience raises several issues that we
would like to clarify since we consider that they carry
NOTE. p 4 0.05 for all comparisons. substantial importance when it comes to proper management
Abbreviation: POUR, postoperative urinary retention.
of ultra-rapid transurethral catheter removal dened as urinary
drainage removed before endotracheal extubation.
As a matter of fact, urinary retention is a common complica-
extubation. We have observed only a moderate incidence of tion after anesthesia and surgery. Surprisingly, a recent review
POUR and a low incidence of urinary infections. In addition, reported a wide range of its incidence starting at 5% and reaching
no correlation between POUR and worse outcome has been up to 70%.1 This wide range could be explained by 2 main
shown. Our data suggests that thoracic epidural analgesia is not factors. First, the concentration of local anesthetic injected in the
an absolute indication of urinary drainage. epidural space during the past 20 years has decreased signi-
cantly.2 Second, there are different methods used to diagnose
Patrice Forget, MD, PhD postoperative urinary retention (POUR), which have considerable
Laurent Veevaete, MD variances in accuracy. It has been shown that in almost 50% of
Fernande Lois, MD cases there is an important overestimation of bladder distention
Marc De Kock, MD, PhD when the urinary bladder volume is assessed by palpation
Christophe Remue, MD compared to its evaluation measured by ultrasound.1 In addition,
Daniel Leonard, MD, PhD dullness and pain could be masked by conduction blockade
Alex Kartheuser, MD, MSc, PhD provided by epidural analgesia. Thus, it could be advocated that,
Cliniques Universitaires Saint-Luc based on these considerations, the incidence of 21% of POUR
Universit Catholique de Louvain that Dr. Forget and his colleagues observed in their trial could
Brussels, Belgium have been different if ultrasound technologies were used to
determine the presence of bladder overdistention and, conse-
quently, decide whether recatheterization was necessary.
REFERENCES A literature review reported that POUR imputable to
1. Zaouter C, Ouattara A: How long is a transurethral catheter conduction blockade provoked by epidural analgesia has an
necessary in patients undergoing thoracotomy and receiving thoracic incidence of 14.7%.1 Such incidence includes investigations
epidural analgesia? Literature review. J Cardiothorac Vasc Anesth 2014 using lumbar and thoracic epidural analgesia. Since segments
Oct 3 [Epub ahead of print]. L1-S4 innervate the bladder, lower urinary tract dysfunction
2. Basse L, Werner M, Kehlet H: Is urinary drainage necessary leading to POUR might be attributable more often to a low
during continuous epidural analgesia after colonic resection? Reg
epidural catheter, which might have lumbar anesthetic solution
Anesth Pain Med 25:498-501, 2000
spread. Therefore, it could be claimed that if only high thoracic
3. Kim JY, Lee SJ, Koo BN, et al: The effect of epidural sufentanil
in ropivacaine on urinary retention in patients undergoing gastrectomy. epidural analgesia were considered, such incidence could be
Br J Anaesth 97:414-418, 2006 lower. This statement is conrmed by the results published in
4. Ladak SS, Katznelson R, Muscat M, et al: Incidence of urinary our review nding that high thoracic epidural catheter located
retention in patients with thoracic epidural analgesia (TPCEA) under- between T3 and T8 seems to be responsible for 5.5 % of
going thoracotomy. Pain Manag Nurs 10:94-98, 2009 POUR.3
5. Lassen K, Soop M, Nygren J, et al: Consensus review of optimal Another interesting point that could further decrease POUR
perioperative care in colorectal surgery: Enhanced Recovery After incidence is to measure patients maximum bladder capacity
Surgery (ERAS) Group recommendations. Arch Surg 144: preoperatively. In fact, rather than catheterizing the bladder when
961-969, 2009
a xed predetermined patient-independent amount of urinary
6. Pellegrino L, Lois F, Remue C, et al: Insights into fast-track
bladder threshold is detected, a safer approach would be to insert
colon surgery: A plea for a tailored program. Surg Endosc 27:
1178-1185, 2013 an intermittent indwelling catheter when patients maximum
bladder capacity is reached. This method could signicantly
http://dx.doi.org/10.1053/j.jvca.2015.01.032 reduce both the incidence of POUR and unnecessary recatheter-
e32
ization.4 This approach remains very simple and cost effective.
We believe that adopting this approach would bring another
important piece to the puzzle of enhanced recovery after surgery.
In summary, we judge that proper ultra-rapid transurethral
catheter removal in patients with a thoracic epidural analgesia
should include measuring patients maximum bladder capacity
preoperatively. The latter should be assessed postoperatively
employing ultrasound devices and used, as the threshold, to re-
insert a urinary catheter to avoid bladder over-distention. We
consider that this strategy is the most accurate to manage POUR
and can reduce signicantly avoidable bladder recatheterization.
We conclude asserting Dr. Forget et als correspondence
adds value to our review, reinforcing the message that further
prospective studies need to be conducted to ascertain that
transurethral catheter removal at the end of surgical interven-
tions before patients extubation is safe. This consideration is of
paramount importance since early bladder catheter removal is
associated with faster recovery. In the light of low POUR
incidence in the thoracic surgical population,3 we strongly
believe that the latter is the one that will benet the most from
ultra-rapid transurethral catheter removal.
Cdrick Zaouter, MD, MSc*
Alexandre Ouattara, MD, PhD*
*CHU de Bordeaux, Service dAnesthsie-Ranimation II
Bordeaux, France
Univ. Bordeaux, Adaptation cardiovasculaire l'ischmie
INSERM, Adaptation cardiovasculaire l'ischmie
Pessac, France
REFERENCES
1. Baldini G, Bagry H, Aprikian A, et al: Postoperative urinary
retention: Anesthetic and perioperative considerations. Anesthesiology
110:1139-1157, 2009
2. Zaouter C, Kaneva P, Carli F: Less urinary tract infection by earlier
removal of bladder catheter in surgical patients receiving thoracic epidural
analgesia. Regional Anesthesia and Pain Medicine 34:542-548, 2009
3. Zaouter C, Ouattara A: How long is a transurethral catheter
necessary in patients undergoing thoracotomy and receiving thoracic
epidural analgesia? Literature Review. J Cardiothorac Vasc Anesth,
2014
4. Brouwer TA, Rosier PF, Moons KG, et al: Postoperative bladder
catheterization based on individual bladder capacity: A Randomized
Trial. Anesthesiology, 2014
http://dx.doi.org/10.1053/j.jvca.2015.01.033
EZ-Blocker and One-Lung Ventilation
via Tracheostomy
To the Editor:
Patients with a tracheostomy tube can be considered at
risk of having a difcult airway during one-lung ventilation
and isolation.1 One-lung ventilation can be achieved by
LETTERS TO THE EDITOR
replacing the tracheostomy tube with a shortened version
of a double-lumen endotracheal tube or using a single-lumen
tube combined with Fogarty catheter or endobronchial blocker
(BB) or introducing a BB through the tracheostomy tube.25
BB can be considered appropriate for many cases, but it has
some disadvantages in its use like technical difculties,
frequent dislodgment, limited suction, and slow lung collapse.5
In this case report, authors describe how to obtain lung
isolation in a patient with a recent tracheostomy using an
EZ-Blocker.
A 72-year-old woman (60 kg; 160 cm; BMI 23.4) with a
large venous hemangioma extended from the base of the
tongue to the left part of the free edge of the epiglottis,
including the left aryepiglottic fold, and the right laryngeal
vestibule (Fig 1), was scheduled for left lung surgery for a left
upper lobe adenocarcinoma. The location of the hemangioma
would have made orotracheal intubation difcult and the
hemorrhagic risk of direct laryngoscopy was elevated, so it
was decided to proceed to a surgical tracheostomy the same
day of lung surgery. Under local anesthesia, the ear, nose, and
throat surgeon performed the tracheostomy and a ShileyTM
(Convidien, Boulder, CO) tracheostomy tube 8.0 mm ID cuffed
with disposal inner cannula was inserted, and general anesthe-
sia was induced with propofol, fentanyl, and rocuronium
bromide and maintained with desurane. Analgesia was
obtained with 0.5% ropivacaine boluses through the epidural
catheter and intravenous fentanyl.
In order to achieve one-lung ventilation, an EZ-Blockers
(AnaesthetIQ, Rotterdam, The Netherlands) was used. An
endoscopic video camera was attached to the head of a exible
3.4 mm ber optic bronchoscope (Pentax FI-10BS), and
the EZ-Blockers was advanced under direct vision into the
tracheostomy tube until the carina was visualized. Since
the tracheostomy tube lied more deeply in the trachea than
the endobronchial tube, lacking enough space to permit the
Y-shaped distal part of the EZ-Blocker to deploy properly
could have been a real problem. The distance between the distal
end of the tracheostomy tube and the carina on the chest x-ray
image was about 3.6 cm, smaller than that actually required.6
Before introducing the BB, the tracheostomy tube was retracted
for 1 cm, and the distal tips of the Y extensions were gently
curved outward, and the device was maintained in a horizontal
Fig 1. Hemangioma extension.