A 62-year-old man with a history of bronchiectasis was listed for a total nephroureterectomy for urological malignancy. General anaesthesia was induced and facemask ventilation was performed with ease. A 7.5-mm internal diameter tracheal tube (Parker Flex Tip, P3 Medical, Bristol, United Kingdom) was easily advanced into the trachea, to a depth of 22 cm. A large cuff leak was noted despite gradual inflation of the cuff with 15 ml of air. Mechanical ventilation was ineffective. The tracheal tube was exchanged for tubes of 8.0 mm then 9.0 mm internal diameter but a large cuff leak persisted. A supraglottic airway device provided sufficient seal for the provision of mechanical ventilation whilst discussion ensued on how to proceed. Figure 1 Computed tomography images of the thorax and corresponding tracheal schematic: (a) upper trachea; (b) mid trachea; (c) distal trachea.

Summary Electrical cardioversion is usually performed when ventricular tachycardia and ventricular fibrillation occur following the release of the aortic cross‐clamp during cardiopulmonary bypass. However, electrical cardioversion has been associated with myocardial damage. Pharmacological cardioversion for ventricular dysrhythmia in cardiac surgery may be advantageous. We report four successful cases of pharmacological cardioversion using nifekalant, a pure potassium‐channel blocker, for ventricular tachycardia and ventricular fibrillation following the release of aortic cross‐clamp during cardiac surgery. We argue that pharmacological cardioversion by nifekalant has certain advantages over electrical cardioversion because it may suppress myocardial damage.