Nitric oxide and high frequency jet ventilation in a patient with bilateral bronchopleural fistulae and ARDS.

PURPOSE: To describe a method of delivering nitric oxide during high frequency jet ventilation. CLINICAL FEATURES: A 63-yr-old man underwent reduction pneumoplasty for bullous emphysema. Postoperatively, ventilation was inadequate, secondary to bilateral high output bronchopleural fistulae. High frequency jet ventilation was initiated and achieved adequate ventilation (pH>7.2). Over the following 24 hr, progressive hypoxemia (SaO2 <86%) developed along with the acute respiratory distress syndrome. Nitric oxide was delivered by continuous flow at the patient Y-connector during combined high frequency jet and conventional ventilation (two conventional low volume breaths/minute). Substantial improvement in oxygenation (FiO2 0.8 0.5, SaO2 >92%) was noted initially and was sustained over 72 hr. Subsequently, the patient was weaned to conventional ventilation without difficulty. Mechanical ventilation was discontinued on postoperative day sixteen. CONCLUSION: The simultaneous use of nitric oxide and high-frequency jet ventilation was used safely and effectively in this patient as a method of support for acute respiratory distress syndrome with co-existing large bilateral bronchopleural fistulae.

Perioperative resuscitation knowledge base.

PURPOSE: To assess the knowledge base of Canadian anesthesiologists regarding the management of perioperative cardiac arrest. METHODS: A random sample of 200 Canadian Anesthesia Society members were mailed a survey composed of 10 clinical vignettes, each involving a special perioperative resuscitation situation, with six multiple choice options for optimum management. Fourteen possible "lethal errors" (options which are unequivocally harmful to the patient) were identified among the possible choices. Each question had a single correct answer and contributed a single point towards a possible maximum of ten. An arbitrary passing score of 70%, similar to the American Heart Association (AHA) standard for Advanced Cardiac Life Support course (ACLS), was selected. Respondents were asked demographic information including: time since completing residency, time since last ACLS course, provision of cardiac anesthesia and attitude towards utility of AHA protocols in anesthesia practice. RESULTS: A total of 124 surveys were returned. The median score was five with a range of scores from zero to nine. Fifty-eight (56.3%) participants chose at least one "lethal error". Only 17 respondents (13.7%) attained the minimum score of 70% and avoided a "lethal error". Respondents who practiced cardiac anesthesia tended to achieve higher scores (P < 0.05) than generalists. All but one participant indicated that a Continuing Medical Education resource covering this material would be useful. CONCLUSIONS: This survey demonstrates a knowledge deficit concerning special perioperative resuscitation situations. Development of further appropriate research and educational material in this area is justified.