One lung anesthesia

Thoracic anesthesia with one lung ventilation is challenging. The anesthetist is faced with demands of establishing proper isolation of one lung from the other in order to facilitate good surgical exposure and prevent intraoperative complications. Due to advances in one lung ventilation [OLV] strategies and equipment, complex intrathoracic procedures are being performed with success. During onelung ventilation, mismatch of perfusion leads to an increase in shunt and dead space. Hypoxemia is an inevitable adverse consequence of OLV. Prompt management is required. This may particularly occur with high airway pressure caused by malpositioned double lumen tube or endobronchial blocker causing incomplete lung ventilation and/or airway obstruction. Other causes may be bronchospasm, air trapping with dynamic hyperinflation pneumothorax of the ventilated lung and coughing due to inadequate muscle relaxation. One lung induced acute lung injury [ALI] must be recognized. Acute lung injury [ALI] is a major cause of overall mortality after thoracic surgery. Protective ventilation strategies have been identified and recommended by researchers for implementation during OLV. This includes small tidal volumes based on ideal body weight, reducing the fraction of inspired oxygen [FiO2], use of positive end-expiratory pressure [PEEP] to the ventilated lung, and low peak and plateau airway pressures. One-lung ventilation has to be managed from the start before beginning OLV till the end of OLV [in order to prevent complications like ALI]. Extreme care is required during re-expansion of the lung towards the end of OLV. Noninvasive ventilation may be used during this period to improve oxygenation

Trans-sternal thymectomy in myasthenia gravis patients with laryngeal mask airway

TUIP is as effective as TURP in achieving maximum flow rate but TUIP was superior in terms of shorter operative time, less retrograde ejaculation and less need of blood transfusion. A descriptive case series. Department of Anaesthesia, Jinnah Postgraduate Medical Centre Karachi, from June 2006 to December 2010. All patients who underwent trans-sternal thymectomy for myasthenia gravis under laryngeal mask airway [Prosea] were included. They were maintained with inhalation agent and analgesics. Muscle relaxants were avoided in all the patients. The haemodynamics and blood gases were monitored perioperatively. A total of sixteen patients underwent the procedure using laryngeal mask airway [Proseal]. There were ten females and 6 males. Mean age at presentation was 26.5 +/- 10.4 year. The haemodynamics and blood gases were well maintained perioperatively. Fourteen patients [87.5%] could be extubated successfully. Two patients needed intubation and ventilation; one for 9 hours and other for 24 hours. These patients were identified as those who were on higher doses of pyridostigmine [>240 mg] and had severe pre-operative muscle weakness. The use of laryngeal mask airway [Prosea] for patients undergoing trans-sternal thymectomy is a satisfactory alternative to tracheal intubation for those patients of myasthenia gravis who do not require airway protection. Avoidance of muscle relaxants and use of laryngeal mask airway [prosea] in facilitate rapid emergence and allowed early extubation