In a randomised, controlled, single-blind trial, we examined the effect of a pre-emptive alveolar recruitment strategy on arterial oxygenation during subsequent pneumoperitoneum. After intubation, 50 patients were randomly allocated to receive either tidal volume 10 ml/kg with no positive end-expiratory pressure (group C) or alveolar recruitment strategy of 10 manual breaths with peak inspiratory pressure of 40 cmH2O plus positive end-expiratory pressure of 15 cmH2O before gas insufflation (group P). During pneumoperitoneum, group P was ventilated with the same setting as group C (FiO2=0.35, tidal volume 10 ml/kg). PaO2 measured during peumoperitoneum was higher in group P than in group C (166∓32 mmHg vs 145∓34 mmHg at 15 minutes, P=0.028, 155∓30 mmHg vs 136∓32 mmHg at 30 minutes, P=0.035). Alveolar-arterial oxygen gradient in group P increased less after gas insufflation (13∓9 to 60∓34 mmHg vs 10∓9 to 37∓31 mmHg, P=0.013). We conclude that the alveolar recruitment strategy we applied before insufflation of the peritoneal cavity may improve oxygenation during laparoscopic hysterectomy.
The purpose of this study was to examine possible peripheral mechanisms for the reduction of propofol injection pain by the addition of ketamine. We hypothesised that pH changes associated with the addition of ketamine to propofol decrease propofol-induced pain on injection. We compared the efficacy of intravenous ketamine pretreatment under tourniquet with ketamine added to the propofol. In the pre-treatment group, patients received ketamine 10 mg in a total volume of 1.0 ml with 0.9% saline (n=94; Group P) under tourniquet for 30 seconds before administration of propofol after release of the tourniquet. In the mixture group, propofol 9 ml was mixed with ketamine 10 mg in 0.9% NaCl 1.0 ml (n=94, Group M). Pain was assessed with a four-point scale: 0=no pain, 1=mild pain, 2=moderate pain, 3=severe pain at the time of propofol injection. The pH of propofol, ketamine and a range of propofol-ketamine mixtures were also measured. Forty-eight patients (51%) in Group P complained of pain on injection compared with 28 patients (30%) in Group M (P=0.005). The pH of the 1% propofol-ketamine mixture was 5.84 while 1% propofol had a pH of 7.86. Our results support pH changes as a more important cause for the decrease in propofol injection pain with the addition of ketamine to propofol than a peripheral effect of ketamine.
One-lung ventilation can be achieved with a double-lumen tube or a bronchial blocker. However, the larger outer diameters of double-lumen or Univent tubes may prevent their passage through an area of subglottic stenosiss. We present five cases of subglottic stenosis in which a Fogarty catheter was used as a bronchial blocker through a singlelumen endotracheal tube. The outer diameters of a double-lumen tube, Univent tube and single-lumen tube were compared. Despite special equipment designed for one-lung ventilation, the use of a bronchial blocker through a single-lumen tube, which has the thinnest available wall thickness, seems to be one of the most effective and safest ways of achieving one-lung ventilation in patients with subglottic stenosis or narrowing.
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