Propofol and peanut allergy

practice to check the length of the tube against the patient and if this is adequate to use a smaller size tube to minimise nasal trauma. Following intubation the patient was difficult to ventilate with airway pressures of 40 mmHg on squeezing the bag, there was no capnograph trace, no breath sounds and no sounds on auscultating over the stomach. Repeat laryngoscopy confirmed tracheal placement of the tube with the black line being visible just above the vocal cords. Initially the diagnoses considered were anaphylaxis, tension pneumothorax or severe bronchospasm. After overcoming the temptation to administer a small dose of adrenaline (a primitive anaesthetic reflex, I believe) the tracheal tube was removed, the patient ventilated with bag and mask and the situation resolved. He was re-intubated with a size 7 mm Portex Blue Line tube and the case proceeded uneventfully. When the size 6 mm tube was removed it was noted that the end had folded back on itself (Fig. 1). On closer examination it was apparent that it had bent double at the point where the pilot tube for inflating the balloon pierces the sidewall of the tube. I believe there are three contributing factors. Firstly, the use of a smaller than recommended size tube meant that there was room for the tube to fold double within the lumen of the trachea. Secondly, the use of Magill’s forceps might have also encouraged the bend in the tube, either by compressing it or making it snag on the anterior tracheal wall or anterior commissure. Lastly, it appears that the Portex Blue Line tubes are susceptible to kinking at the point where the pilot tube pierces the sidewall of the tube. Obviously, care should used when using soft nasal tubes and Magill’s forceps and the appropriate size tube should be used for the patient.