The application of the combined double frequency HFJV was effective in maintaining gas exchange in the presence of laryngeal or tracheal stenoses. It provided good visibility of anatomical structures and offered space for surgical manipulation, avoiding the use of combustible material inside the larynx or trachea.
We have developed a new technique of combined high-frequency jet ventilation (HFJV), characterized by simultaneous application of a low-frequency (LF) and a high-frequency (HF) jet stream. Tubeless supralaryngeal jet ventilation was delivered via a modified Kleinsasser laryngoscope. We studied 44 adults undergoing 45 elective surgical procedures of the larynx and trachea using a carbon dioxide laser during HFJV. Applied inspiratory oxygen ratios ranged from 0.4 to 1.0. Mean driving pressures of the HF and LF jet streams were 1.5 bar and 1.8 bar in adults, respectively. Mean duration of HFJV was 41 (range 10-180) min. HFJV resulted in mean PaO2 and PaCO2 values of 16.6 (range 9.8-26.9) kPa and 5.7 (3.0-7.6) kPa, respectively. Tubeless supralaryngeal HFJV was safe and effective in maintaining gas exchange in the presence of laryngeal or tracheal stenoses, providing optimal visibility of anatomical structures, offering maximum space for surgical manipulation, and avoiding the use of combustible material inside the larynx or trachea.
Laparoscopy is an established procedure of minimally invasive surgery. Although risks and complications during laparoscopy are rare, complications arise from hemorrhage or intestinal perforation, and hemodynamic compromise may result from extensive pneumoperitoneum. Massive gas embolism is a potentially life threatening complication (1-5). We report an incident of severe paradoxical CO 2 embolism verified by an intraoperative transesophageal echocardiogram.
Case reportA twenty-three-year-old woman (59 kg, 158 cm) was submitted to gynecologic laparoscopy because of a suspected tubalovarian abscess. She presented with normal hemodynamics, chest X-ray and electrocardiogram. Physical examination revealed no pathological findings except pain on pressure in the lower abdomen. Serum levels of white blood cells were increased to 18500 G/L. Except for a nickel allergy and nicotine abuse (20 cigarettes per day) the patient had no notable previous diseases, and previous surgeries (tonsillectomy and appendectomy) had been uneventful. The patient was submitted to total intravenous anesthesia (midazolam, fentanyl, propofol, vercuronium) and was monitored by ECG, non-invasive blood pressure monitoring, capnometry (i.e. measuring the CO 2 concentration of expired air) and pulse oximetry. Mechanical ventilation using 35% oxygen in air resulted in an oxygen saturation of 98%. In the anti-Trendelenburg's position the patient remained stable until gas was insufflated into the peritoneal cavity through a Veress' needle. Suddenly, end-expiratory CO 2 and peripheral oxygen saturation level dropped below 30 mmHg and 85%, respectively, with the lips turning cyanotic. Blood pressure was no longer measureable non-invasively, peripheral pulses were no longer perceivable. An inital increase in heart rate was followed by bradycardia and ST-segment elevation. Gas insufflation was terminated immediately, and 100% oxygen combined with a high positive end-expiratory pressure (PEEP) was administered. Pharmacological resuscitation had to be performed with repeated doses of epinephrine. Transesophageal C Acta Obstet Gynecol Scand 79 (2000) echocardiography revealed severe gas embolism, but gas bubbles were also detected in the left atrium and ventricle (Fig. 1). After stabilization of the patient's hemodynamics, laparotomy was performed, but no injured large blood vessels nor bleeding could be detected. The ovarian abscess was removed surgically, and the patient was transferred to the ICU.At the ICU the patient's oxygenation returned to normal. A CT examination of the head and chest was performed, but showed no evidence of thromboembolism or any gas-related incident. Finally, extubation was performed successfully twelve hours after the initial event. A left-sided hemiparesis was observed and a second cerebral CT scan was performed. It did not show signs of local ischemia, but the ventricular system appeared slightly narrowed and a diffuse brain edema was diagnosed. The patient received 10% mannitol and the neurological symptoms resolved completely ...
The authors report the utility of transesophageal echocardiography for diagnosis and management of an intramural left atrial hematoma during coronary artery surgery.
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