Management of complications of tracheal surgery--a case of dehiscence.

We report a case of tracheal stenosis in a patient with immune thrombocytopenia who presented 4 yr after splenectomy. The 20-yr progression of the stenosis and management, including resection, is charted. The period after resection was complicated by wound infection, surgical emphysema, mediastinitis and dehiscence of the anastomosis of the trachea. The management of patients with tracheal lesions is discussed, but concentrates on airway care after tracheal resection when complications developed. A laryngeal mask airway was used to stabilize an uncuffed tracheal tube at the site of dehiscence.

Use of intravenous immunoglobulins as an adjunct in the conservative management of chylothorax.

Two children who developed chylothorax after surgery for congenital heart disease are presented. The conservative management of chylothorax is reviewed and the use of immunoglobulins in the treatment of sepsis is discussed. One patient survived.

Anaesthesia for laparoscopic cholecystectomy in a patient with Eisenmenger's syndrome.

We describe the management of a patient with Eisenmenger's syndrome presenting for laparoscopic cholecystectomy. Of prime concern was maintenance of systemic vascular resistance and this was achieved using infusion of noradrenaline started before induction of anaesthesia and continued after operation. Avoidance of other factors that could potentially increase right to left shunt flow contributed to the successful outcome.

Chylothorax: an update.

Chylothorax is occasionally found in malignant disease and following sympathectomy, but is seen more frequently after cardiothoracic surgery. The varied anatomy of the thoracic duct, limited individual experience and a lack of appreciation of the factors indicating surgical intervention have led to controversy regarding its optimal management. This article reviews historical aspects, clinical features and guidelines for conservative and surgical management.

Bilateral chylothorax.

A 2.5-kg female developed bilateral chylothoraces 10 days after surgery for coarctation of the aorta. Initial conservative management consisted of intermittent positive pressure ventilation, drainage of chylous fluid and enteral feeding, but there was no diminution in loss of chyle. Ligation of the thoracic duct and pleurectomy were performed subsequently to reduce the large daily losses of chyle, amounting to nearly three times the child's circulating blood volume. Brawny oedema of the right upper quadrant of the body developed rapidly after the duct ligation and right pleurectomy. A further period of conservative treatment was required before the latter complication resolved. The literature relating to this iatrogenic complication and to fluid and nutritional losses in paediatric chylothorax is reviewed and discussed.

General anaesthesia for carbon dioxide laser surgery within the airway. A review.

Carbon dioxide laser surgery in the airway presents the anaesthetist with new problems. The mode of action of carbon dioxide lasers and its effects on anaesthetic agents and equipment are described. Complications, especially of fire hazards in the airway, and methods of avoiding them are set out in detail. Various anaesthetic techniques for both laryngeal and tracheobronchial laser surgery are described.

Combined unilateral high frequency jet ventilation and contralateral intermittent positive pressure ventilation.

The anaesthetic management of a patient who required right lower lobectomy for bronchial carcinoma associated with emphysema, pneumoconiosis and a previous thoracoplasty for pulmonary tuberculosis, is described. A technique of unilateral high frequency jet ventilation plus conventional intermittent positive pressure ventilation to the contralateral lung was used.

Carbon dioxide laser bronchoscopy. A review of problems and complications.

The records of 20 patients who underwent carbon dioxide laser bronchoscopy were analysed retrospectively. Many of the cases presented with evidence of severe obstruction of the trachea or major bronchi and were regarded as highly at risk from anaesthesia. The majority of problems in the 35 laser sessions related to the use of a rigid bronchoscope for delivering the laser and to the ventilatory difficulties associated with the airway pathology. Invasive arterial monitoring for blood gas analysis and blood pressure measurement proved essential to detect and correct changes of a potentially serious nature. This experience is compared and contrasted with that of others.

A ventilator for carbon dioxide laser bronchoscopy.

A jet ventilator is described. It is designed for use in patients undergoing carbon dioxide laser vaporization of intraluminal tumours, and obstructions in the trachea and main bronchi. The ventilator overcomes two major anaesthetic problems during laser vaporization in the tracheobronchial tree. It ensures adequate alveolar ventilation and it evacuates smoke generated by the laser. The device has two modes of operation, an automatic ventilation mode and a second mode in which ventilation and suction can be alternated--laser ventilation mode.

Anaesthesia for carbon dioxide laser surgery on the trachea. Taking turns in the airway.

A patient with post-tracheotomy stenosis underwent laser bronchoscopy. A total i.v. technique was used to maintain anaesthesia and provide a stable surgical field. The technique that evolved to allow the laser treatment to be carried out without impairment of ventilation or oxygenation is described.

Epidural analgesia following thoracic surgery. A review of two years' experience.

The use of thoracic epidurals for postoperative pain relief in 58 patients following thoracic surgery is reviewed. Epidural catheters were inserted at the end of the operative procedure and it was planned that analgesia was to be maintained with a continuous infusion of bupivacaine. In those patients with evidence of successful neurological blockade there was a high incidence of adverse effects. Hypotension occurred in nearly 80% of patients and inadequate analgesia necessitating intramuscular opiates in 30%. The results suggest that the method adopted is unsuitable for some patients who have undergone major pulmonary surgery, although it has proved a useful adjuvant for pain relief in patients who have had other intrathoracic operations.