I rencently had the challenging task of giving a single lung ventilation to a 5 year-old 25kg child who had been in a traffic accident and had a large hemothorax. The surgeons wanted to explore and repair on one lung if possible. The case was urgent enough for there to be no time to transfer to a dedicated pediatric hospital.

I managed to put a standard 5.5 ETT into the right main bronchus, with a big enough leak to allow the left lung to deflate. The surgeons were happy with their access and the bleeder was repaired.

My problems started when the surgeons requested repeated inflations and deflations of the left lung to identify persisting air leaks. I managed to pull the tube back and pass it down again several times, each time hoping it would go back into the right main bronchus. This worked well but was a very cumbersome technique.

I thought about putting in a Fogarty catheter as a bronchial blocker, but could not fit the catheter and bronchoscope together down the lumen. My smallest double lumen tube was a 32F - too big for this child.

Any other ways of tackling this situation?

I have recently become a convert to IT morphine. I am using 200mcg in 2.5mL heavy bupivacaine for my spinal Cesareans. The post-op analgesia is superb and rarely requires rescue narcotic in the forst 24 hours.

I am concerned that our glass morphine ampoules are not packaged sterile. What if I am introducing bacteria simply by contaminating the morphine solution when I crack the ampoule?

So I ran an informal, personal trial. I painted the outside of the morphine ampoule with sterile methylene blue, let it dry before cracking it. About one third of the morphine solutions showed some blue discoloration from the methylene blue, indicating that a small amount of whats outside the ampoule gets inside. I now get my assistant to wipe the ampoule with alcohol (and let it dry) before they crack it.

Any other ideas?

I am using parecoxib a lot since they tell me its the best thing since sliced bread.

But I am yet to be conviced that its as good as the old fashioned NSAIDS that we gave as suppositories.

I know we are supposed to wait 90 minutes for tis epak effect, even with IV administration, but I just getthe impression that patients were more confortable with my old regimen.

Anyone care to agree or argue?