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June 2008 Articles:

Tracheostomy In Intensive Care: A Necessary Evil?
Author: Dr Karen Stuart-Smith, Consultant Anaesthetist, Glan Clwyd Hospital, Denbighshire, Wales


Anaesthesia For Shoulder Surgery – What’s Current In Practice?
Authors:
Nick Goddard BA BM BCh – Specialty Trainee Anaesthetics (year 3), Portsmouth Hospitals NHS Trust
David Jones MB BCh FRCA - Consultant Anaesthetist, Portsmouth Hospitals NHS Trust
Gareth Harper BA BM BCh FRCS (Orth) - Consultant Orthopaedic Surgeon, Portsmouth Hospitals NHS Trust
Ford Qureshi MBBS FRCS (Trauma + Orth) - Consultant Orthopaedic Surgeon, Doncaster and Bassetlaw NHS Foundation Trust


Summary Of The First UK Cooled RF Workshop At Nottingham


Paediatric Tracheostomy
Authors: Juliet Wolf-Barry, Anaesthetic Fellow, Yorkhill Royal Hospital for Sick Children, Glasgow NHS Trust
Stephanie Bew, Consultant Paediatric Anaesthetist, Leeds Teaching Hospitals NHS Trust


Tracheostomy In Intensive Care: A Necessary Evil?
Author: Dr Karen Stuart-Smith, Consultant Anaesthetist, Glan Clwyd Hospital, Denbighshire, Wales

Those of us who do the routine emergency list are familiar with the request from our ITU colleagues to take one of their ventilated patients to theatre for a formal tracheostomy. Usually the procedure is requested in someone who has proved difficult to wean and/or is expected to require long-term ventilation (anything from several days to several months). There is a certain amount of hassle involved in bringing a sedated, immobile patient surrounded by infusion pumps from the ITU to theatre and getting them on and off the table without dislodging anything important or difficult to replace like that much-cherished arterial line. There are also the potential hazards of the operation itself, most commonly haemorrhage from an unseen anomalous vessel (anatomical variations in the path of the thyroid vessels are common) or just plain losing the airway in the midst of the endotracheal-to-tracheostomy tube switch. These complications do not occur very frequently, but everyone reading this has experienced at least one of these scenarios at least once. I can only think that the Intensivists who write glibly that surgical tracheostomy (ST) is easy and safe have never had to stand in theatre and watch the ENT surgeon struggle with a swollen neck and distorted anatomy (on the patient not the surgeon). For those who are getting ready to write in and praise percutaneous tracheostomy (PT), it is worth pointing out that while PT is certainly quicker and more cost-effective in the sense that it does not require the transfer of a sick patient or the use of theatre time and the associated staff, no meta-analysis has clearly shown a greater clinical benefit to the patient with this technique, principally because the same hazards of difficult anatomy, haemorrhage and losing the airway still apply.1,2 Other acute hazards include stomal infection (more common in ST because of the larger wound1), damage to the posterior tracheal mucosa, pneumomedaistinum, and prolonged hypercarbia during tracheostomy insertion (this last more common in PT).

Both surgical and percutaneous tracheostomies carry the potential for long-term complications, the most serious of which is tracheal stenosis.3,4 The topic of tracheal stenosis is of interest to me because in my previous incarnation as a thoracic anaesthetist, I saw several tracheal resections and reconstructions being performed on individuals who had had tracheostomies inserted as part of their ITU care, often several years beforehand. The overall incidence of post-tracheostomy tracheal stenosis in ITU survivors is unknown, or at least, I cannot find any longitudinal studies on the issue. I suspect because this is because the tracheal stenosis only becomes an issue after the patient has left hospital. They are then a problem for the thoracic surgeons rather than the intensivists, and so the data are never collected. In any case, only the most symptomatic ever come to surgery. We simply do not know whether a certain degree of tracheal stenosis is common or rare in post-ITU patients. What can be established is that previous tracheostomy is a more significant risk factor for subsequent tracheal stenosis than even laryngeal irradiation for cancer!4 Surgical tracheostomy carries the risk of stoma formation below the stoma, probably as a result of continual irritation by the tube and consequent granuloma formation. Percutaneous tracheostomy appears to be associated with a greater risk of suprastomal stenosis5, possibly because the dilational technique separates the tracheal rings, resulting in invagination of the tracheal cartilage3, as opposed to surgical tracheostomies, which involve removal of cartilage or the creation of a cartilage flap.6 On balance, the literature seems to suggest that percutaneous and surgical tracheostomies have a similar acute complication rate, although the type of complication shows a subtle variation between the two approaches. What can be established is that in general, the acute complications tend to be relatively minor and mortality directly related to the procedure is extremely low, although the data supporting this are very scanty. The incidence of the principle long-term complication, tracheal stenosis, is not known, but may be more common with the percutaneous technique. On balance, if I had to advise a patient or their relatives, my personal choice would be a surgical tracheostomy, in spite of all the hassle of theatre transfer for the procedure.

Having decided to place a tracheostomy, the next question is, does it do any good? The surprising answer to this question is that no-one knows for sure. It is assumed that tracheostomy is preferable to long term intubation in patients that are expected to be ventilated for some time. In theory, less sedation is required, the patient is more comfortable, and is able to communicate more clearly.7 These are very useful potential benefits and I hope they do occur. I say hope because nobody at all has looked into this in a large group of patients. Trust me, I’ve searched 20 years of literature for the evidence. Part of the problem, if the intensivists will forgive me, is that being an ITU patient has detrimental effects on the patients mental health whether they are sedated or not, and a multiplicity of issues makes comfort and communication extremely difficult. However I’m happy to accept that these benefits exist on intuitive grounds.

What about physiological benefits of tracheostomy as opposed to long-term laryngotracheal intubation? Any tube placed in the trachea has, by definition, a smaller diameter than the trachea itself. As the resistance of a tube is inversely proportional to the fourth power of the radius (i.e. small decreases in radius result in large increases in resistance: Poiseuille’s equation) all tracheally-placed tubes have a proportionately greater resistance to the movement of air than the natural anatomy. This results in an increased work of breathing. The issue is more complicated than this, because an endotracheal tube (ETT) is long, whereas a tracheostomy tube is short. Poiseuille’s Law also states that resistance is directly proportional to the length of the tube, so obviously an ETT has greater resistance than the much shorter tracheostomy tube (TT)6. The TT also bypasses the dead space created by the upper airways, further reducing its impact on airway resistance. On these simple physical grounds, a tracheostomy results in a reduced work of breathing as compared with the ETT, and perhaps even in comparison to spontaneous ventilation.6 It should be noted, however, that a tracheostomy bypasses the warming and humidifying functions of the upper airways. Crusting of the inside of the tube will result in an inevitable decrease in diameter and rise in resistance, negating the benefits of the tracheostomy tube. Hence, I suppose, the vast array of humidifiers and suctioning equipment on the market.

Another profound influence on tracheal tube resistance is rate of flow. High inspiratory flow rates induce turbulent flow and therefore greater resistance. In theory therefore, the higher the minute ventilation the greater the resistance and the greater the work of breathing. One study in medical ICU patients breathing spontaneously suggests this is true8, but no similar studies have been carried out in surgical ITU patients on ventilator-assist modes to find out whether this property is relevant to these patients. However it is worth looking at the results of the ARDSNet trial in this context. As I am sure you are all aware the outcome of this trial was that that a tidal volume (TV) of 6ml/kg resulted in a very significant reduction in mortality as compared to a ‘standard’ TV of 12ml/kg (to cut a long story short).9 The trial authors initially speculated that the reduction in mortality was related to a reduction in pulmonary barotrauma, secondary to a reduction in plateau pressures below 30cm H2O10. In fact the incidence of barotrauma was similar in the high and low tidal volume groups, and the true effect of the low TV might be more subtle than this. An excellent study11 has demonstrated that the high respiratory rates required to reduce respiratory acidosis and help maintain pH within tolerable limits at low TV induce a high intrinsic PEEP which encourages alveolar recruitment and raises FRC. These authors attribute the phenomenon to the short time for elastic recoil to occur during the short expiratory phase, so that the alveoli effectively do not get a chance to close. It might also be speculated that high respiratory rates increase the degree of turbulence in the tracheostomy tube, contributing to an overall increase in resistance and thus enhancing intrinsic PEEP. In this context, the longer endotracheal tube, with its even greater resistance to flow, might raise PEEP to an intolerably high level, so that peek pressures exceed the golden figure of 30cm H2O. However this is all guesswork on my part. If anyone knows any different, please let me know.

It appears therefore that tracheostomy may carry significant psychological and physiological benefits for the patient. Does this translate into lower morbidity and mortality rates for tracheotomised patients (as opposed to prolonged endotracheal intubation)? The surprising answer is, no-one knows. The lack of good clinical trials in this area is lamented by many authors.7,12,13 For example, two papers, one showing no benefit of tracheostomy14 and one showing a positive benefit15, in terms of ITU stay and mortality rate, were published last year within three months of each other in Critical Care Medicine. However both papers seem to agree on one issue, which is that a benefit is less likely to be apparent if patients are selected at random and without a protocol, and by contrast there may be an unintended physician bias towards performing tracheostomy in patients who are expected to do better in any case. The fundamental problem is that everyone already has their own opinion (based, as we have seen, on little evidence) as to whether and when tracheostomy should be performed. This problem has made multi-centre randomised trials on the benefits or otherwise of tracheostomy in Intensive Care patients almost impossible, as it is very difficult to agree a common protocol.12 Perhaps even more important is that fact that most clinical syndromes encountered in ITU: sepsis, ARDS, the long-term sequelae of multiple trauma, the catabolic state, renal failure, nutrition problems, changes in neurological and muscular status, etc, etc, are still a black box with as yet unpredictable effects on the ability to wean the patient from ventilation. We have a fully validated scoring system for ITU mortality, but none for weaning from mechanical ventilation. Pierson summarised the problems facing clinical studies in this area as follows12:
  • Inability to blind investigators (and clinicians) as to groupings
  • Bias of clinicians managing patients
  • Inability to predict which patients will require prolonged ventilatory support
  • Varying weaning protocols
  • Varying criteria for weaning success and failure
  • Funding and reimbursement issues
  • Varying specialities performing procedure
  • Varying levels of training and experience among operators
Looking at this list, tracheostomy appears to be a much more haphazard clinical procedure than can be justified by the clinical evidence. No trial has separated out whether tracheostomy improves weaning or whether patients who are more likely to do well anyway receive tracheostomies. Tracheostomy performed to aid weaning and tracheostomy performed to aid long-term mechanical ventilation are two separate issues not always clearly defined in the minds of investigators, making conclusions even more difficult.

As far as I can glean, the facts are these. Weaning from ventilation should be an urgent goal from the moment the patient is ventilated13. A successful spontaneous breathing trial (SBT) at 24 hours should be the gold standard, and all factors contributing to delayed weaning (acidosis, cardiac failure, renal failure) should be compensated for as far as possible (e.g. inotropic support, dialysis) during this time.7 If the patient’s condition at 24 hours is unlikely to improve sufficiently for a successful SBT, or if an SBT is attempted without success, the likely natural history of the clinical condition should be assessed. This is the most difficult decision. If the patient is not yet well enough to wean, but is likely to be ready for weaning within a few days, there does not appear to be an advantage to performing a tracheostomy as opposed to maintaining endotracheal intubation.16 After three days, however, vocal chord damage may be an issue with the endotracheal tube, and tracheostomy should be considered at this point.16,17 This timing is crucial. Early tracheostomy in the right patient (whoever this may be) probably confers benefits in terms of weaning and mortality which may outweigh the potential hazards.18 Late tracheostomy, (probably any time after 10 days and certainly any time after 21 days18,19) is not going to improve outcome, probably because the damage, whether from sepsis, inflammation, or a critical mass of derecruited alveoli, is now entrenched. The trick is knowing which patients will be extubated quickly, and will not need a tracheostomy, and which will require long-term ventilation, and so should receive a tracheostomy as early as possible. For this we need to understand the disease process better, and that is a long way down the line.

So, is tracheostomy a necessary evil? I have read huge amounts of literature and still don’t know. As usual I have been mildly depressed by the lack of research in a vital area, but since this happens with every article I write on topics in anaesthesia and intensive care, I don’t know why I continue to be surprised. Mechanical ventilation itself has all sorts of deleterious effects, never mind the potential contribution of the tracheostomy. Of course the straightforward answer is to avoid positive pressure ventilation, but that is a whole other story…

References
  1. Petros S. Percutaneous tracheostomy. Crit Care 1999:3:R5-R10
  2. Patel A et al. Does a percutaneous tracheostomy have a lower incidence of complications compared to an open surgical technique? Interact Cardiovasc Thorac Surg 2005;4:563-8
  3. Koitschev A et al. Tracheal stenosis and obliteration above the tracheostoma after percutaneous dilational tracheostomy. Crit Care Med 2003;31:1574-6
  4. Koshkareva Y et al. Risk factors for adult laryngotracheal stenosis: a review of 74 cases. Ann Otol Rhinol Laryngol 2007;116:206-10
  5. Koitshcev A et al. Suprasternal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients. Anaesthesia 2006;61:832-7
  6. Epstein SK. Anatomy and physiology of tracheostomy. Respir Care 2005;50:476-82
  7. MacIntyre NR et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 2001;120:375-96
  8. Diehl J-L et al. Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med 1999;159:383-8
  9. The Acute respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome. N Engl J Med 2000;342:1301-8
  10. Slutsky AS and Ranieri VM. Mechanical Ventilation: lessons from the ARDSNet trial. Respir Res 2000;1:73-7
  11. De Durante G et al. ARDSNet lower tidal volume ventilatory strategy may generate intrinsic positive end-expiratory pressure in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2002;165:1271-4
  12. Pierson DJ. Tracheostomy and weaning. Respir Care 2005;50:526-33
  13. MacIntyre N. Discontinuing mechanical ventilatory support. Chest 2007;132:1049-56
  14. Clech C et al. Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med 2007;35:132-8
  15. Combes A et al. Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation? Crit Care Med 2007;35:802-7
  16. Durbin CG Jr. Indications for and timing of tracheostomy. Respir Care 2005;50:483-7
  17. Boynton JH et al. Tracheostomy timing and the duration of weaning in patients with acute respiratory failure. Critical Care 2004;8:R261-7
  18. Groves DS and Durbin CG Jr. Tracheostomy in the critically ill; indications, timing and techniques. Curr Opin Crit Care 2007;13:90-7
  19. Hsu C-L et al. Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study. Critical Care 2005;9:R46-52

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Anaesthesia For Shoulder Surgery – What’s Current In Practice?
Authors:
Nick Goddard BA BM BCh – Specialty Trainee Anaesthetics (year 3), Portsmouth Hospitals NHS Trust
David Jones MB BCh FRCA - Consultant Anaesthetist, Portsmouth Hospitals NHS Trust
Gareth Harper BA BM BCh FRCS (Orth) - Consultant Orthopaedic Surgeon, Portsmouth Hospitals NHS Trust
Ford Qureshi MBBS FRCS (Trauma + Orth) - Consultant Orthopaedic Surgeon, Doncaster and Bassetlaw NHS Foundation Trust

INTRODUCTION
Four main pathologies affect the shoulder, and may require operative intervention. These are: arthritis of the glenohumeral and acromioclavicular joints, the stiff shoulder (including frozen shoulder/ adhesive capsulitis), rotator cuff pathology (representing a spectrum of pathology from subacromial impingement syndrome to cuff tear), and instability. Developments in minimally invasive techniques in recent years mean the anaesthetist is likely to encounter these conditions in the context of both arthroscopic and open procedures. Additionally, economic pressures have led to more surgery being undertaken in an ambulatory, day case setting, with high turnover lists and same day discharge. This trend requires anaesthetists to provide rapid, reversible anaesthesia with high quality peri-operative analgesia and minimal side effects. Recent technological advances in regional anaesthesia may help to meet these challenges1. This article aims to familiarize the reader with the general principles of anaesthesia for shoulder surgery, to review the evidence for current practice, and to consider the latest regional techniques, along with their feasibility in the UK setting.

Shoulder Surgery often generates high pain scores2-4 and thus effective pre-operative assessment and counselling is imperative.
Rotator cuff pathology is most commonly the cause of surgical intervention. Injuries to these muscles occur rarely in younger patients following trauma, and most commonly in older people (>45yrs) as a result of degeneration. Subacromial decompression and rotator cuff repair may be performed by an open or arthroscopic technique, with the latter being particularly painful, especially in the early rehabilitative phase. Frozen shoulder/adhesive capsulitits is perhaps the most painful shoulder condition and presents in the 40-65 year age group. It can be weakly associated with diabetes. Manipulation under anaesthetic or capsular release is undertaken for severe stiffness, with early physiotherapy and mobilisation required as an inpatient. Early postoperative analgesia is key to recovery in this scenario.

Degenerative disease of the glenohumeral joint is less common, and usually presents in those over 65 years. Shoulder arthroplasty is undertaken when arthritis is severe and may involve extensive bony surgery. Patients with advanced rheumatoid disease may present for this procedure, providing practical difficulties for the anaesthetist. A thorough airway assessment is required, and careful consideration should be given to intraoperative positioning. Regional anaesthesia is particularly indicated, often as an adjunct to general anaesthesia.

Shoulder instability is often related to sporting injuries, and accidents. This group of patients are young, fit and muscular. Recurrent instability may be associated with structural abnormalities needing repair, for example - Bankart’s procedure or capsular shift. Analgesic requirements will generally be greater in younger patients.

In summary, a wide range of patients present for anaesthesia from the athlete to the systemically unwell rheumatoid patient with advanced joint disease. Due care and time should be allocated to giving a full and adequate explanation of any planned regional procedure, along with benefits and risks.

PERIOPERATIVE CARE
Regional anaesthesia forms the cornerstone of a multimodal strategy to minimize perioperative discomfort. Advantages may include: attenuation of surgical stimuli with stable anaesthesia, use of minimal anaesthetic agents to achieve relative hypotension and reduced intraoperative bleeding (particularly useful in arthroscopic surgery). Relaxation of joint musculature may enhance visualisation of the joint. In addition, reduced postoperative pain leads to less need for opiate analgesics, and lower rates of unexpected admission2-4. Disadvantages include: side effects and complications from the regional technique, including failure, and nerve injury. Some centres offer awake regional techniques as the sole anaesthetic in selected patients5-8.

Figure 1: Patient in beach chair position. Note the distance of the airway and intravenous lines from the anaesthetic machine.
Surgery may be performed in the lateral position or deck chair (beach chair) position (figure 1). A good fitting laryngeal mask airway is acceptable, but the airway may not be easily accessed. It is necessary to have a low threshold for inserting an endotracheal tube. Peripheral pooling of blood can lead to excessive hypotension and should be avoided. A pressure cuff sited on the forearm or calf is an alternative to the upper arm in the lateral position. Secure intravenous access of the non-operative hand will need to be accessed via an extension port. Over 8 litres of irrigation may be used for prolonged arthroscopy. As such, water resistant drapes should be used, alongside forced air warming devices to avoid hypothermia. Systemic absorption of irrigation fluid can lead to disturbances in fluid balance, and subcutaneous spread of fluid may be extensive, leading to further postoperative patient discomfort.

Figure 2: Sites of portals for arthroscopic surgery.
ANATOMY
There are up to five portal sites used for arthroscopic procedures. Occasionally a Nevaiser port is inserted between the posterior aspect of the clavicle and anterior to the scapula of spine (figure 2). The brachial plexus (C4-T1 nerve roots) supplies most of the superficial sensation to the shoulder, except for a “cape” like cephalad portion of skin above the clavicle, which is innervated by the supraclavicular nerves, originating from the lower part of the superficial cervical plexus (C3-C4). For open procedures, there are three major incisions: anterior (deltopectoral), antero-lateral (McKenzie or deltoid split, and posterior.

The cutaneous supply to the shoulder is derived from the upper lateral brachial cutaneous nerve (C5-C6), which is a branch of the axillary nerve, and the lower lateral cutaneous nerve, which is a branch of the radial nerve. Together, these supply the skin over the deltoid and lateral side of shoulder.
Figure 3: Superficial innervation of  shoulder(anterior). AN = axillary nerve, IBN = intercostobrachial nerve, MBC = medial brachial cutaneous nerve (branch of medial cord).
The intercostobrachial nerve (which is the lateral cutaneous branch of T2 intercostal nerve) supplies the skin over the medial portion of the shoulder and upper arm9 (figure 3). The intercostobrachial nerve is not part of the brachial plexus and may have to be blocked separately5.

The innervation of the joint itself, including its supporting structures is not fully known, but Hilton’s rule states that the nerves supplying the muscles surrounding a joint usually offer some sensory supply to the joint. The clinically relevant nerves supplying the joint are the suprascapular nerve (SSN), the axillary nerve (AN), with varying contributions from the musculocutaneous nerve, subscapular nerve and lateral pectoral nerve. The SSN originates from the upper trunk of the brachial plexus (C5-6 nerve roots), travels posteriorly beneath the border of trapezius, then through the suprascapular foramen, to supply the supraspinatus muscle. Sensory branches to the joint and tendinous portion of the rotator cuff are given off as the nerve continues to descend laterally to the spine of the scapula to supply infraspinatus10. The AN is a branch of the posterior cord (C5-6), and the musculocutaneous nerve is a branch of the lateral cord (C5-7). Thus, it can be seen that the glenohumeral joint is largely supplied by C5-6 nerve roots.

REGIONAL TECHNIQUES
Nociceptive signals from the shoulder can be blocked at the level of the brachial plexus, terminal nerves, or at the shoulder itself. Both single injection and catheter techniques are possible. In 1970, Alon Winnie11 described the interscalene plexus block (ISB). It rests on the concept that there is a continuous, fascia-enclosed perineural space surrounding the brachial plexus, from its origin at the cervical transverse processes to its terminal distributions in the upper third of the arm. With this concept, brachial plexus anaesthesia becomes analogous to peridural anaesthesia, with only a single injection being necessary to provide analgesia. Once the perineural space has been entered, the extent of anaesthesia depends on the both the volume of anaesthetic solution used and the level at which it is injected.

In this approach, the interscalene groove is located at the level of the sixth cervical vertebra between the anterior and middle interscalene muscles, and a short-bevel 22G needle is inserted in a direction perpendicular to the skin in every plane
Figure 4: Relevant anatomical landmarks for Winnie’s approach to the interscalene space.
(figure 4). The needle is advanced until paresthesiae are elicited in the shoulder or the arm. The introduction of the nerve stimulator has since allowed accurate nerve identification, and avoids intentional contact of the needle with nerves. Using a “fixed needle” technique, 20-30 ml of local anaesthetic is injected, with the density of block being largely determined by the strength of solution used.

The advantage of brachial plexus blockade over other techniques is the quality of analgesia provided. Using a continuous infusion or intermittent bolus administration system through an interscalene catheter (patient controlled interscalene analgesia or PCIA), analgesia can be extended into the postoperative period. PCIA has been shown to have good efficacy and patient satisfaction compared to patient controlled intravenous analgesia (PCA)12. However, this technique requires specialist equipment, patient education, and some form of ongoing medical supervision or technical support. Problems may include: local anaesthetic leakage, catheter disconnection or dislocation, pump malfunction, accidental
Figure 5: Baxter Multirate Infusor. Elastomeric reservoir (300ml) with patient control module, and flow rate module with variable rate adjustment.
administration of toxic does of anaesthetic, and responsibility for catheter removal. A number of ambulatory pump systems exist to facilitate same day discharge and continued infusion at home13. Commonly, these are disposable, elastomeric infusion reservoirs, able to deliver agents for up to five days postoperatively (figure 5).

The disadvantage of brachial plexus block is the potential for significant complications and side effects. Phrenic nerve paralysis has been estimated to occur in 100% of cases by Urmey et al14 and may be tolerated poorly where there is respiratory compromise. Other side effects include: Horner’s syndrome, laryngeal nerve palsy, pneumothorax, intravenous injection of local anaesthetic, spinal or epidural injection, and insensate limb - which is not liked by patients, and carries further risk of injury, especially during sleep. In a study of 520 patients receiving interscalene block for shoulder surgery, Borgeat et al15 prospectively recorded success and complication rates over a 9 month period. Although success rates (defined as sensory and motor blockade occurring within 20 minutes) were 94-96%, acute complications included: pneumothorax (0.2%, 1 patient), and CNS toxicity (0.2%, 1 patient). By the tenth postoperative day, 14% (74) of patients also reported paraesthesiae, dysaesthesiae, or pain unrelated to the surgery. Residual neurological symptoms persisted in 7.9% (41 patients) at one month, 3.9% (20 patients) at three months and 0.2% (1 patient) still with residual dysaesthesia at 9 months.

Of further concern is that symptoms occurred as late as 2-3 weeks after ISB. Injury to nerves may be caused by the surgery itself, patient positioning, physical injury by the operator, or may represent toxicity to local anaesthetic agents. Nerve injury is a well recognised complication of anaesthesia in general, as demonstrated by Cheney et al16. Additionally, 234 patients also had an interscalene catheter placed, and this was not associated with a higher risk of developing neural injury, making direct injury and toxicity less clearly implicate.

In order to minimize morbidity from brachial plexus blockade, other approaches have been described, including the those of Pippa17, and Meier18. The first of these involves insertion of the needle posteriorly at the upper edge of C7 transverse process. The posterior and middle scalene muscles are crossed and the needle reaches the interscalene space from behind, using loss of resistance to air. This approach avoids lung tissue, but still places the needle close to midline central neuraxial structures. The lateral modified technique of Meier18 uses the same landmarks as for Winnie’s approach, but the point of needle insertion is 3 cm cranial and the needle is directed 30 degrees caudad. As well as directing the needle tip further away from central structures, this technique is ideal for placement of an interscalene catheter and has been further adapted by groups such as Borgeat et al6.

An alternative to interscalene block, is to target individual nerves, thus gaining a proportion of the analgesia of brachial plexus blockade, but with an improved safety profile. The suprascapular nerve can be easily blocked as it passes through the suprascapular foramen, located approximately 1-2cm above the midpoint of the spine of the scapula10. A nerve stimulator will increase accuracy of needle placement (if a rotator cuff is present). External rotation and abduction of the arm is sought, with the risk of pneumothorax being minimal. In a randomized controlled trial, Ritchie et al19 showed less pain, a 51% reduction in demand and a 31% reduction in consumption of morphine delivered by a PCA device following arthroscopic shoulder surgery, and no complications at 24 hours.

Local analgesic techniques include injection of anaesthetic (and opiates) into the joint, the bursa, or subcutaneously at the site of surgical incision, with the option of catheter placement for extended analgesia. Evidence for the efficacy of these techniques is controversial. Axelsson et al20 have shown analgesic benefit after Bankart repair, using intraarticular ropivacaine combined with ketorolac, and morphine. For acromioplasty, Muittari et al21 have similarly shown benefits using bupivacaine 0.25% and morphine. However, a randomized comparison of these techniques was made by Singelyn et al22 following arthroscopic acromioplasty. Both SSNB and ISB were effective (ISB>SSNB), but no differences were found between the intraarticular and control group. For acromioplasty at least, it is more difficult to justify the increased risks of an ISB, where SSNB provides a clinically appropriate alternative, used in conjunction with local anaesthetic techniques.

FUTURE DIRECTIONS
Both technological improvements in image quality, and reductions in costs, have led to ultrasound imaging becoming more widely available for regional anaesthesia in recent years. This is the most dynamic imaging tool available today, allowing
Figure 6: Sonosite S-Nerve is purpose built for regional anaesthesia. It is simple to use, and with fewer buttons than other models. It has three USB 2.0 ports  for easy data transfer.
real-time visualisation of structures, needle placement, and local anaesthetic spread (figure 6). For interscalene block, a high-frequency linear (10-15 MHz; 38mm) transducer is appropriate for visualising superficial structures up to 3cm depth. It is recommended to first scan the plexus dynamically from the cricoid cartilage to the supraclavicular region in order to identify anatomical landmarks23. The nerve structures of the interscalene plexus
Figure 7: High-frequency ultrasound image of the interscalene groove using a linear probe. The roots/trunks appear as hypoechoic nodules between the anterior and medial scalene muscles. Note that image resolution obtained in day to day practice may not be as high, depending on various factors. ASM = anterior scalene muscle, MSM = medial scalene muscle, SCM = sternocleidomastoid muscle. 
appear hypoechoic, resembling bunches of grapes, sandwiched between the anterior and middle scalene muscles (figure 7). Needle insertion can either be out-of-plane (OOP) or in-plane (IP). Needle approach with the OOP method more closely resembles the classical approach of Winnie11. However, the IP method allows visualisation of the entire length of needle as it approaches the plexus from lateral to medial. Unlike traditional descriptions of nerve blockade, choice of technique is highly individual, and for this reason, more difficult to compare to traditional techniques. The claimed benefits of ultrasound-guided regional anaesthesia are: that it is easier to learn and perform, is quicker, has faster onset of block, results in higher success rates and more complete blocks, requires lower volumes of local anaesthetic, and increases safety. Evidence to support these claims is scanty, but some argue that common sense dictates its use, and that safety implications are self-evident24. Although the skill of a single operator cannot be easily compared to another, evidence for improved safety has been provided by Sinha et al25, who used ultrasound in 61 patients undergoing ISB in combination with nerve stimulation. They used ultrasound to locate the trunks/roots, then determined the threshold currents for motor response prior to injection of local anaesthetic, discovering that an observed motor response below or above 0.5 mA had no impact on success or duration of upper trunk block. All blocks were successful, and so this is the clearest study to date exposing potential deficiencies in nerve stimulation techniques as compared to ultrasound for guiding ISB. Visualisation may allow fewer passes of the needle, and also less volume is required as anaesthetic can be placed directly at the point of interest. Thus, targeted block of the C5-6 nerve roots may be possible, with the advantage of avoiding blockade of the inferior trunk, and preserving more distal motor function.

In the area of postoperative analgesia, work is taking place to investigate the feasibility of exporting gold standard analgesia into the community setting. Ilfeld et al26 have published a pilot feasibility study using ambulatory perineural local anaesthetic for total shoulder arthroplasty, performed as an outpatient procedure. In the ambulatory phase of the study, 5 out of 6 patients were successfully discharged directly home from the recovery room. All patients benefited from good analgesia and there were no equipment failures. Similarly in the UK, Russon et al8 have published a pilot study, demonstrating that it is feasible to undertake major surgery as a day case procedure. Operations performed included Copeland hemiarthroplasty and open rotator cuff repair. A district nurse was responsible for follow up in the community and catheter removal. Five out of five patients were discharged home successfully with a pump in situ, however, one of these was re-admitted because the catheter fell out. Further questions remain regarding the efficacy, safety, and cost-effectiveness of this care model on a larger scale, but if an appropriate subset of patients can be identified for this technique, there is potential for this area of practice to expand significantly.

Finally, in contrast to major open surgery of the shoulder, an alternative technique has recently been described by Price27. Price describes a method for independent blockade of both axillary and suprascapular nerves (“the shoulder block”). Thus, a substantial part of the innervation of the shoulder joint is targeted, without the risks associated with global blockade of the brachial plexus. Price has used this block in 70 patients undergoing subacromial decompression, anterior stabilisations, rotator cuff repairs, and total joint replacement where interscalene block was contraindicated. He reports 57% of cases requiring no morphine in the post anaesthesia care unit. The only side effects reported were blockade of the radial nerve in 2 instances. Although this is only the first published case series describing the technique, further studies will be able to further qualify its utility and safety.

CONCLUSIONS
In the area of ultrasound guided anaesthesia more research is required to prove efficacy and safety of this rapidly expanding and exciting area of clinical practice. Pinpoint accuracy may allow rapid, targeted blocks of C5-6 nerve roots in isolation, with inferior trunk sparing. There is a role for targeted peripheral nerve blocks in combination with local anaesthetic techniques for arthroscopic procedures, but which block is most appropriate for which procedure needs to be further qualified. Advances in ambulatory pump technology mean it is feasible to perform major joint surgery as a day case procedure on a small scale, but further studies are needed to evaluate cost effectiveness and safety before these techniques are used on a larger scale.

ACKNOWLEDGEMENTS
Permission was obtained from patients involved in photographs. Thank-you to SonoSite UK and Baxter Healthcare Ltd for pictures.

References
  1. Nielson KC, Steele SM. Outcome after regional anaesthesia in the ambulatory setting – is it really worth it? Best Practice & Research Clinical Anaesthesiology 2002; 16(2): 145-157
  2. Chung FC et al. Postoperative Pain in Ambulatory Surgery. Anesthesia and Analgesia 1997;85: 808-16
  3. Anderson R, Krohg K. Pain as a major cause of postoperative nausea. Canadian Journal of Anaesthesia 1976;23(4): 366-9
  4. Chung F. Recovery Pattern and Home-Readiness after Ambulatory Surgery. Anesthesia and Analgesia 1995;80: 896-902
  5. Peterson D. Shoulder Block Anesthesia for Shoulder Reconstruction Surgery. Anesthesia and Analgesia 1985; 64: 373-5
  6. Borgeat A, Ekatodramis G. Anaesthesia for shoulder surgery. Best Practice & Research Clinical Anaesthesiology 2002; 16(2): 211-225
  7. Klein S et al. Peripheral Nerve block Techniques for Ambulatory Surgery. Anesthesia and Analgesia 2005;101: 1663-76
  8. Russon K et al. Postoperative shoulder surgery initiative (POSSI): an interim report of major shoulder surgery as a day case procedure. British Journal of Anaesthesia 2006; 97(6): 869-73
  9. Hall-Craggs ECB. Anatomy as a Basis for Clinical Medicine - third edition 1995. Williams and Wilkins.
  10. Parris WC. Regional Anesthesia: An Atlas of Anatomy and Techniques. Marc B. Hahn, Patrick M. McQuillan, George J. Sheplock.
  11. Winnie AP. Interscalene brachial plexus block. Anesthesia and Analgesia 1970;49: 455-466
  12. Borgeat A et al. Patient-controlled interscalene analgesia with ropivacaine after major shoulder surgery: PCIA vs PCA. British Journal of Anaesthesia 1998;81: 603-605
  13. Ilfeld BM, Kayser Enneking F. Continuous Peripheral Nerve Blocks at Home: A Review. Anesthesia and Analgesia 2005;100: 1822-33
  14. Urmey WF et al. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesthesia and Analgesia 1991;72: 498-503
  15. Borgeat A et al. Acute and Nonacute Comlications Associated with Interscalene Block and Shoulder Surgery – A Prospective Study. Anesthesiology 2001;95(4): 875-80
  16. Cheney FW et al. Nerve Injury Associated with Anesthesia - A Closed Claims Analysis. Anesthesiology 1999;90: 1062-9
  17. Pippa P et al. Brachial plexus block using the posterior approach. European Journal of Anesthesia 1990;7: 411-420
  18. Meier G et al. Der interscalenare Plexuskatheter zur Anasthesie und postoperativen Schmerztherapie: Erfahrungen mit einer modifizierten Technik. Der Anaesthesist 1997;46: 715-719
  19. Ritchie E et al. Suprascapular Nerve Block for Postoperative Pain Relief in Arthroscopic Shoulder Surgery: A New Modality? Regional Anesthesia and Pain Management 1997;84: 1306-12
  20. Axelsson K et al. Intraarticular Administration of Ketorolac, Morphine, and Ropivacaine combined with Intraarticular Patient-Controlled Regional Analgesia for Pain Relief After Shoulder Surgery: A Randomized, Double-Blind Study. Regional Anesthesia 2008;(106)1: 328-333
  21. Muittari P et al. Comparison of the Analgesic Effects of Intrabursal Oxycodone and Bupivacaine After Acromioplasty. Journal of Clinical Anesthesia 1999;11: 11-16
  22. Singelyn FJ et al. Pain Relief After Arthroscopic Shoulder Surgery: A Comparison of Intraarticular Analgesia, Suprascapular Nerve Block, and Interscalene block. Anesthesia and Analgesia 2004;99: 589-92
  23. Tsui B. Atlas of Ultrasound and Nerve stimulation-Guided Regional Anesthesia. Springer 2007.
  24. Ting P. Evidence-based review of ultrasound imaging for regional anesthesia. Seminars in Anesthesia Perioperative Medicine and Pain 2007;26: 218-228
  25. Sinha S et al. Ultrasound-Guided Interscalene Needle Placement Produces Successful Anesthesia Regardless of Motor Stimulation Above or Below 0.5 mA. Regional Anesthesia 2007;105(3): 848-852
  26. Ilfeld BM. Total Shoulder Arthroplasty as an Outpatient Procedure Using Ambulatory Perineural Local Anaesthetic Infusion: A Pilot Feasibility Study. Anesthesia and Analgesia 2005;101: 1319-22
  27. Price DJ. The Shoulder block: a new alternative to interscalene brachial plexus blockade for the control of postoperative shoulder pain. Anaesthesia and Intensive Care 2007;35: 575-581

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Summary Of The First UK Cooled RF Workshop At Nottingham

Summary
BVM markets the Baylis Radio Frequency Pain Management System in the UK for treatment of chronic pain. A practical ‘hands-on’ cadaver workshop was organised by BVM, and held at the Nottingham City Hospital on 1st March 2008. Fifteen Pain Management Specialists from across Europe attended the workshop, which was conducted by Dr A R Cooper (Coleraine NI) and Dr Neal Evans (High Wycombe). Delegate evaluation forms clearly showed a high appreciation of the content of the workshop and called for many more to be run throughout the country in future.

Background to Cooled-RF treatment for SIJ Syndrome
The Baylis Pain Management Systems for the treatment of Discogenic pain (TransDiscal™) and for treatment of the Sacro-Iliac joint Syndrome (SInergy™), uses Cooled RF technology. The Baylis Cooled RF system allows to create lesions in nervous tissue to disrupt pain originating from discs, or the SI joint, and surrounding connective tissue. The consistence of lesion shape and size is precisely maintained by the Baylis Pain management Generator.

The TransDiscal™ system uses Cooled Bipolar RF, while the SInergy™ system uses Cooled monopolar RF. In particular, the treatment of the SIJ has often not resulted in lasting pain relief, so the SInergy™ system is of particular interest.

In this minimally invasive procedure, a SInergy™ introducer is placed at a point between the SI posterior sacral foramen and the sacro-iliac joint. A SInergy™ probe is then inserted through the introducer and into the tissue just superficial to the sacrum. RF energy is delivered from, and concentrated around the electrode, while the electrode is internally cooled with circulating water. RF energy heats the tissue and cooling moderates the heating in close proximity to the electrode. This combination then creates large volume lesions and successive lesions are created until lateral branches have been disrupted.

Patients typically experience some level of relief from the SIJ pain within 2-10 days of the procedure, which does not involved a general anaesthetic, and is typically completed in 45 minutes.

The key benefits of the SInergy™ system are as follows:
  • Internally cooled RF for greater power applications
  • Temperature control for consistent lesion shape and size
  • Spherical lesions produced (not elliptical) to enable multi-directional approach to the target structure
  • Placement of the probe is straightforward and results in minimum disturbance to the overlying soft tissue
  • Target energy for effective and lasting pain relief
The Workshop Presentations
Mr Naheed Visram from Baylis spoke about the physics of Cooled-RF. This included the mechanisms of the RF systems, the advantages of Cooled-RF and practical tips of equipment handling.

Dr Ron Cooper discussed discogenic pain, its prevalence, innervation of the discogenic area and pathology. He touched on existing treatments, the history of heat therapies, and finally Disc Biacuplasty procedure. He went on to detail patient selection, the procedure, inclusion/exclusion criteria, potential complications (rare) and follow up.

Dr Neal Evans quickly reviewed SIJ anatomy and SIJ innervation studies, before discussing the technique, electrode/probe placement, prevalence of the problems, lesion properties and patterns, plus procedure time savings.

Both Pain Specialists discussed practical ‘tips and traps’ of the two therapies – and these proved particularly helpful during the practical sessions.

The Workshop Practicum’s
Delegates were divided into two groups for the practical workshop. While Group A had the chance to look at, and handle the equipment, Group B were in theatre, involved in hands on activity on cadaver, under the watchful eyes of both Dr Cooper and Dr Evans.

Equipment for the two systems is similar and comprises Introducers, probes, burettes, Pain Management Generator and pump unit. The latter controls flow rate of sterile water to the probes, and is connected to the generator which provides the RF energy. Delegates were able to look at the parameters measured and functionality of the system, via LCDs on the generator. They were also able to handle the introducers and slide into place the appropriate probe.

In the theatre, attendees were especially concerned with locating the needles, under C-arm vision on monitors. These were placed into the appropriate space, depending on whether they were undertaking a Biacuplasty procedure with the TransDiscal™ system (Dr Cooper), or the SIJ procedure with the SInergy™ system (Dr Evans). The hands-on sessions were especially appreciated and delegates benefited from each others experiences in establishing correct locations for the probes, in order to (ultimately) direct the RF energy. ‘Tips of the trade’ such as placing a little broad spectrum antibiotic solution into the needle track, once the procedure had been completed, were enthusiastically received by the delegates from the consultant experts.

All attendees were then able to ask further questions in a wrap-up session. It was emphasised that the most benefit of workshop attendance would be for these specialists already having experience of back pain management, such as with facet joint injections etc.

Course Conclusions
Asked to rate six key aspects of the workshop on a 1-5 basis, with 5 being excellent, all boxes were in the 4-5 range exclusively.

The main requirements from delegates were for:
  • Further training sessions and workshops
  • More hands-on activities within the practical sessions
  • Gaining accreditation from the Royal College of Anaesthetists, so that CME points could be awarded in future
Most of the hospitals represented at the workshop were planning to introduce the relevant procedures in the near future.

Both BVM Medical and Baylis Medical expressed their thanks to Dr Evans, Dr Cooper and the two technicians who attended to operate the C-Arms, provided by GE Healthcare.

Further similar events are planned and, for information on these, or for more information on the Baylis RF systems, please telephone BVM on 01455 614555
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Paediatric Tracheostomy
Authors: Juliet Wolf-Barry, Anaesthetic Fellow, Yorkhill Royal Hospital for Sick Children, Glasgow NHS Trust
Stephanie Bew, Consultant Paediatric Anaesthetist, Leeds Teaching Hospitals NHS Trust

The indications for paediatric tracheostomy have changed over the past 30 years due to changing patterns of disease and improvements in management of premature babies and children in intensive care. In the 1970’s the majority were performed urgently for upper airway obstruction secondary to infection. This is a rare indication nowadays with the majority sited for congenital airway obstruction (fig 1) , acquired subglottic stenosis (fig 2) or ventilator dependency. In recent retrospective studies from UK centres 50% were sited in children under the age of one with the most common indication being airway obstruction1. In older children the indication is more commonly ventilator dependency secondary to progressive neuromuscular disease or in the management of severe head injury.

Tracheostomy in children is usually performed as a surgical procedure in theatre with the patient positioned with the neck in full extension. (fig 3) The stoma is usually sited between the 2nd and 3rd tracheal rings. The tracheostomy tube is chosen based on the internal diameter expected for the age and size of the child. This should be an appropriate length with the tip lying 1-2cm above the carina and the intratracheal part of the tube coaxial to the tracheal wall. The position of the distal end of the tube can be checked using a fibreoptic scope at the time of surgery or post operatively with a chest X-ray. The small size of the airway usually precludes the use of a tracheostomy tube with an inner tube, and up to size 5.5mm internal diameter, tubes are usually single piece. The smallest size available is usually 3.0mm and many tubes are available in paediatric or shorter neonatal lengths. Tubes are usually silicon or PVC and for most children an off the shelf tube is suitable. Occasionally custom made tubes are required, or tubes with an adjustable flange to provide variable intratracheal length. Tracheostomies are usually secured with velcro or cotton tape as preferred by the parents. As paediatric tracheostomy tubes are a single piece with no inner tube the whole tube must be changed on a regular basis, usually weekly. Many have an obturator to aid insertion. (fig 4) Most silicone or PVC tracheostomy tubes have a standard 15mm fitting incorporated to allow bag ventilation in an emergency, however there are some which require the attachment of an adaptor to allow connection to a standard 15mm connector. (fig 5)

The small size of the infant and paediatric airway precludes the use of cuffed tubes. Paediatric tracheostomies are rarely performed to prevent airway soiling so a close fitting tube is not usually necessary. In most spontaneously breathing children a leak around the tube which allows air to pass the larynx is beneficial, being very important for speech development. Some children who depend on positive pressure ventilation will need a closer fitting tube to allow satisfactory ventilation. If children with tubes with a large leak come to theatre for procedures requiring IPPV it may be necessary to insert a larger tracheostomy tube to enable adequate ventilation. Alternatively a small cuffed armoured tube can be used and taped to the chest away from the surgical field. Children with tracheostomies often have gaseous induction of anaesthesia and a relatively small tube with a large leak can lead to a very slow induction if a significant proportion of the gas exchange is via the natural airway.

Humidification and suctioning
Not all children use humidification after the initial period, but some find a HME useful. (fig 6) Speaking valves such as the Passy-Muir valve are sometimes used, but many children prefer to occlude the end of the tracheostomy with their finger or by tipping down their chin to cover the end of the tube when they want to speak.

When suctioning, the largest catheter which will fit down the tube should be used. It is important to remember the short length of the tracheostomy tube. Suction catheters should be inserted to a length pre measured against the tube. Repeatedly inserting the catheter until it meets resistance will over time cause trauma to the carina. 2

Most children and infants with a tracheostomy are cared for at home by their parents who perform all the regular tube changes. Before they leave hospital parents and all carers must be trained in all aspects of tracheostomy care and management of emergencies. Appropriate support from community nurses and supplies of all necessary equipment need to be arranged. After a new tracheostomy is formed the first tube change is generally done one week later by the surgical team. Parents are then taken through a training programme until they are competent and confident in performing routine tube changes, dealing with complications and emergency situations including giving basic life support. Where ever the child goes, carers must take portable suction and an emergency bag. This should contain a new tracheostomy tube ready for insertion with ties attached (fig 7) and a tube of smaller size in case of difficulty in inserting a replacement tube.

Decannulation
In some children the need for a tracheostomy will be life long, but for many it is required for a period of months or years with decannulation the eventual aim. The trachea can be decannulated when the problem which required tracheostomy has resolved and the child can maintain a clear airway and adequate ventilation. This is often after surgical procedures to overcome the airway obstruction such as serial dilatations, laser treatment or tracheal reconstructions. Before decannulation the child usually has the airway examined under general anaesthesia and the tracheostomy tube is removed prior to waking. Frequently a suprastomal granuloma is found within the trachea which may be large enough to cause airway obstruction on waking. This is excised or removed by laser during the airway examination prior to decannulation. The child remains in hospital for at least one night for observation and monitoring. The stoma is allowed to close spontaneously. Later surgical closure is often necessary if there is a residual fistula, or to revise the scar.

Complications
Immediate complications at the time of surgery are rare in most published series. A relatively small proportion of tracheostomies are performed as an emergency procedure, and most will be done during normal working hours by experienced ENT or paediatric surgeons working with experienced paediatric anaesthetists. Early complications, within the first 7 days, are more common, but most are relatively minor problems with the stoma or bleeding. Major early complications such as pneumothorax, pneumomediastinum, tube obstruction or dislodgement are rare. Minor late complications are relatively common and include external granulomas and bleeding from the stoma or bleeding on suctioning. Potentially catastrophic late complications are erosion of the tube into major vessels or tube obstruction and dislodgement leading to hypoxia and eventually cardiorespiratory arrest.

Mortality
Overall mortality in children and infants with a tracheostomy is 20-30% but the majority of this is due to the high level of co morbidity in infants and children who need this form of airway management. Mortality directly related to the tracheostomy varies from 0-5% in most recently published series.

References
  1. Corbett H J, Mann K S et al. Tracheostomy – A 10-year experience from a UK pediatric surgical center. Journal of Pediatric Surgery 2007 42: 1251-1254.
  2. Care of the Child with a Chronic Tracheostomy. Consensus statement of the American Thoracic Society. American Journal of Respiratory Critical Care 2000 161; 1: 297-308.

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