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SummaryAtelectasis occurs during general anaesthesia. This is partly responsible for the impairment of gas exchange that occurs peri-operatively. During cardiopulmonary bypass, this atelectasis is exacerbated by the physical collapse of the lungs. As a result, poor arterial oxygenation is often seen postoperatively. We tested the effect of an Ôalveolar recruitment strategyÕ on arterial oxygenation in a prospective randomised study of 78 patients undergoing cardiopulmonary bypass. Patients were divided equally into three groups of 26. Group Ôno PEEPÕ received a standard post bypass manual lung inflation, and no positive end-expiratory pressure was applied until arrival at intensive care unit. Group Ô5 PEEPÕ received a standard post bypass manual inflation, and then 5 cmH 2 O of positive end-expiratory pressure was applied and maintained until extubation on intensive care. The third group, Ôrecruitment groupÕ, received a pressure-controlled stepwise increase in positive end-expiratory pressure up to 15 cmH 2 O and tidal volumes of up to 18 ml.kg )1 until a peak inspiratory pressure of 40 cmH 2 O was reached. This was maintained for 10 cycles; the positive end-expiratory pressure of 5 cmH 2 O was maintained until extubation on intensive care. There was a significantly better oxygenation in the recruitment group at 30 min and 1 h post bypass when compared with the no PEEP and 5 PEEP groups. There was no significant difference in any of the groups beyond 1 h. Application of 5 cmH 2 O positive end-expiratory pressure alone had no significant effect on oxygenation. No complications due to the alveolar recruitment manoeuvre occurred. We conclude that the application of an alveolar recruitment strategy improves arterial oxygenation after cardiopulmonary bypass surgery.

We present a case of rupture of an intrahepatic choledochal cyst through the diaphragm resulting in a pleuro-biliary fistula and a right pleural empyema which was surgically treated. Hepatobiliary complications resulting in biliary empyema of the pleura are discussed.

A 38-year-old male patient was brought with alleged selfinflicted injury to neck using kitchen knives. He was a known epileptic with attempted suicides in the past. The two knives were in position at the time of his arrival (Figs. 1 and 2). Bronchoscopy ruled out tracheal injury. A transverse incision connecting both entry points was made under anaesthesia and the knives were removed. There was no injury to great vessels. Oesophagoscopy revealed a tear caused by knife on side of the neck (K2). The tear was repaired. Recovery was uneventful. Subsequently he was diagnosed as having postictal psychosis.

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