Assisted ventilation in severe acute asthma.

During the period 1973-85 assisted ventilation was used for the treatment of severe asthma on 48 occasions in 18 patients (one patient was ventilated 29 times). On each occasion arterial blood gas abnormalities were restored to normal as quickly as possible irrespective of peak inflation pressures. One patient was thought to be brain dead on transfer from another hospital but was ventilated for 48 hours while this diagnosis was confirmed. There was one episode of mediastinal emphysema. There were no other complications apart from transient hypotension (blood pressure less than 100/60 mm Hg), which occurred on 17 occasions but did not have any sequelae. There was no relationship between hypotension and inflation pressure but there was an association between hypotension and rate of fall of arterial carbon dioxide tension. It is concluded that the risks of barotrauma during the ventilation of patients with severe asthma are theoretical or extremely small. Rapid correction of respiratory acidosis abolishes hypercapnic respiratory drive, allowing ventilation without use of muscle relaxants. It may also enable a shorter duration of ventilation, thus decreasing the likelihood of complications.     

Robotic-assisted laparoscopic radical cystectomy: history, techniques and outcomes

Objective

Robotic-assisted radical cystectomy (RARC) is a less invasive means of performing the radical cystectomy operation, which holds promise for improved patient morbidity. We review the history, technique and current literature pertaining to RARC and place the current results in context with the open procedure.

Methods

All articles regarding RARC found in PubMed after January 2000 were examined. We selected articles that appeared in high-impact journals, had large patient population size (>80 patients), or were novel in technique or findings. We chose key laparoscopic articles to give reference to the history in transition to robotic radical cystectomy. In addition, we chose classic articles from open radical cystectomy to give reference regarding the newer robotic perioperative outcomes.

Results

Studies suggest that a 20-patient learning curve is needed to reach an operative time of 6.5 h, with 30 surgeries performed to reach lymph node counts in excess of 20 (International Robotic Cystectomy Consortium). The only randomized surgical trial comparing open and robotic techniques showed equivalent lymph node yield, which may be surgeon and volume dependent. Literature demonstrates lower estimated blood loss, transfusion rates, early return of bowel function and decreased complications in early small series.

Conclusion

RARC and urinary diversion are still early in development and limited to centers with extensive robotic experience and volume, although adoption of the robotic approach is becoming more common. Early studies have shown promise to reduce complications with equivalent oncologic results.     

Assisted ventilation and the Servo ventilator in infants

A laboratory assessment was made of systems used for Continuous Positive Airway Pressure/Intermittent Mandatory Ventilation (CPAP/IMV) with the Servo 900B and 900C ventilators. Pressure-volume loops recorded during sine wave oscillation using an external CPAP/IMV system were similar to those found during normal respiration. Pressure-volume loops using the systems based on the ventilator's inbuilt trigger mechanism were very different, particularly for the 900B. The results were confirmed by measurements in two infants. The implications of these findings with reference to the weaning of infants from mechanical ventilation are discussed.     

Emerging trends,techniques, and equipment for airway management in pediatric patients

Pediatric patients present unique anatomic and physiologic considerations in airway management, which impose significant physiologic limits on safe apnea time before the onset of hypoxemia and subsequent bradycardia. These issues are even more pronounced for the pediatric difficult airway. In the last decade, the development of pediatric sized supraglottic airways specifically designed for intubation, as well as advances in imaging technology such that current pediatric airway equipment now finally rival those for the adult population, has significantly expanded the pediatric anesthesiologist's tool kit for pediatric airway management. Equally important, techniques are increasingly implemented that maintain oxygen delivery to the lungs, safely extending the time available for pediatric airway management. This review will focus on emerging trends and techniques using existing tools to safely handle the pediatric airway including videolaryngoscopy, combination techniques for intubation, techniques for maintaining oxygenation during intubation, airway management in patients at risk for aspiration, and considerations in cannot intubate cannot oxygenate scenarios.     

Sleep. 1: Obstructive sleep apnoea/hypopnoea syndrome: definitions, epidemiology, and natural history

Arguments over the definition of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) have still not been satisfactorily resolved. As a result, robust estimates of the prevalence of OSAHS are not possible. New approaches are needed to identify those who have "CPAP responsive" disease, enabling more accurate estimates to be made of the prevalence of the sleep apnoea syndrome in the community.     

A history of pediatric anesthesia: a tale of pioneers and equipment

The history of pediatric anesthesia is fascinating in terms of how inventive anesthesiologists became over time to address the needs for advances in surgery. We have many pioneers and heroes. We hope you will enjoy this brief overview and that we have not left out any of the early contributors to our speciality. Obviously there is insufficient space to include everyone.     

Percutaneous nephrostomy: techniques, indications, and results.

During the past six years at our institution, percutaneous nephrostomy has been utilized for temporary diversion of the upper urinary tract in 33 patients and 42 individual kidneys. Two techniques are described, one of which has been developed recently by one of us (A.R.G.). Indications and results, including complications, are discussed. In our experience this procedure has been found to be safe and highly useful in the management of selected patients who have unilateral or bilateral urinary tract obstruction from a variety of reasons.     

Retroperitoneal sarcomas: 1. Natural history and preoperative evaluation]

The disease is usually disseminated via the blood stream. These large tumors displace adjacent organs and are usually close to vital structures. High rate of local or peritoneal recurrence may be explained by resection problems. Local recurrence is the most frequent cause of patient death. No adjuvant treatment has proved to be beneficial on survival. Diffusion of the disease is usually hematogenous. Hepatic and pulmonary metastases are the most common, while lymph node invasion is very rare. This account for no systematic lymph node dissection in these tumors. Preoperative biopsy through a retroperitoneal route under CT scan vision is advised, before operation. NMR and CT scan are the best tools to assess extension of tumor through anatomical structures. Quality of surgical resection is the main factor which determine prognosis in term of local or peritoneal recurrence risk. This risk is best evaluated by pathological examination which must determine whether the specimen is or not complete.