This study examines whether there is a temporal relationship between tracheal extubation and myocardial ischaemia in haemodynamically stable patients extubated within 6 h of cardiac surgery. Fifty-two patients were studied during three time periods: 1, from 2 h until 30 min before extubation (90 min); 2, from 30 min before until 30 min after extubation (60 min); 3, from 30 min until 2 h after extubation (90 min). Significant ST segment changes were defined as a reversible ST segment depression of 2 mm or greater or an elevation of 3 mm or greater from baseline, lasting for 1 min or more. Fourteen patients (26.9%) had ST segment changes. The ischaemic burden in periods 2 and 3 was increased compared with that in period 1; the mean (SD) was: period 1, 19.2 (18.8) min; period 2, 35.4 (24.9) min; period 3, 39.6 (24.5) min; however, the mean ST deviation (mm) did not change. ST segment changes were associated with an increased heart rate; they were not related to arterial pressure. We conclude that there is a temporal relationship between ST segment changes and tracheal extubation after cardiac surgery.

Both intraoperative peak inspiratory pressure and FiO are independent factors significantly associated with development of a postoperative pulmonary complication in emergency laparotomy patients. Further studies are required to identify causality and to demonstrate if their manipulation could lead to better clinical outcomes.

Safe insertion of the first port during laparoscopic surgery has always been problematic, from the early use of the Veress needle to the open Hasson technique. We describe a novel, safe, and well-illuminated technique of port entry using the Killian nasal speculum. This technique has been used successfully in transperitoneal laparoscopic nephrectomy as well as extraperitoneal radical prostatectomy in our department. The Killian nasal speculum has an built-in light source allowing excellent vision, and its narrow "beak" perfectly separates the fat and rectus sheath, and allows muscle splitting without the need for any other instrument or assistant. This technique has been employed in obese patients, allowing easy access, and it creates a tight, leakproof entry port. The Killian nasal speculum is available in all hospitals that offer an ear, nose, and throat service, and comes in four different sizes and lengths to suit all types of patients.

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