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Sixty-six patients scheduled for coronary artery bypass graft and/or valve surgery were recruited in a prospective, randomized study designed to compare the effectiveness of three analgesic regimens for chest drain removal. Patients were randomized to receive 0.1 mg/kg IV morphine, 20 mL of 0.5% bupivacaine infiltrated subcutaneously, or inhaled 50% nitrous oxide in oxygen (Entonox) via a demand valve. We assessed pain by measuring visual analog scale pain scores before and during drain removal. Median (25th, 75th centile) visual analog scale pain scores associated with drain removal in the bupivacaine, Entonox, and morphine groups were 9.5 mm (3, 18 mm), 37.0 mm (13, 56 mm), and 15.0 mm (7, 27 mm), respectively. The pain scores were higher in the Entonox group compared with the bupivacaine group (P=0.005) and the morphine group (P=0.047). Differences between baseline and drain-removal scores were -0.5 mm (-13, 7 mm), +10 mm (1, 29 mm), and -3.0 mm (-11, 12 mm), respectively. There was no difference among groups in arterial blood pressure, heart rate, PaCO2, oxygenation, or sedation. Bupivacaine and morphine, unlike Entonox, produce lower pain scores associated with drain removal.

SummaryHigh-volume, low-pressure tracheal cuffs of disposable double lumen tubes may offer limited protection to the dependent lung if fluid leaks through folds in the inflated cuffs. This study was undertaken to determine the incidence of fluid leakage past the tracheal cuff and whether gel lubrication reduces the incidence. Fifty-five patients were randomly assigned to receive a double lumen tube with or without gel lubrication. The dependent lung was intubated. With the patient in the lateral position, methylthionium chloride was administered above the tracheal cuff via a pre-attached catheter. Fibreoptic bronchoscopy was performed to determine if dye had passed the tracheal cuff. Three patients were excluded. Dye leakage was seen in 12 ⁄ 27 and 3 ⁄ 25 patients in the unlubricated and lubricated group, respectively (p = 0.014). Gel lubrication significantly reduces fluid leakage past the tracheal cuff of a double lumen tube and should be considered for all thoracic surgical patients requiring one-lung ventilation. Post-thoracotomy pulmonary complications are the major cause of morbidity and mortality in patients undergoing lung resection [1] but their aetiology is not well understood. Intra-operative lung contamination may contribute to the development of pulmonary complications. For patients undergoing thoracotomy in the lateral position, the inflated tracheal cuff of a double lumen tube (DLT) is often the last barrier to lung contamination by oropharyngeal material, including refluxed gastric acid. Gastro-oesophageal reflux is relatively common during thoracotomy in the lateral position and the trachea proximal to the tracheal cuff of the DLT becomes contaminated with gastric acid in 8% of patients [2].Although gross contamination of the lungs with gastric contents is prevented by an adequately inflated tracheal cuff, modern high-volume, low-pressure (HVLP) cuffs may not completely protect the lungs from contamination [3,4]. Fluid leakage may occur along folds in adequately inflated HVLP cuffs [5]. It has been shown that the application of aqueous gel to the tracheal cuff of a single lumen tracheal tube reduces fluid leakage [6]. The incidence of fluid leakage past the tracheal cuffs of modern DLTs is not known. Design differences between double and single lumen tubes make it difficult to extrapolate data from studies of single lumen tubes to double lumen tubes. Unlike single lumen tubes, the main body of DLTs are not usually round in cross-section. The outer diameter of DLTs are usually much larger, relative to the trachea, than that of single lumen tubes. The outer diameter of the main body of a 41 FG left Mallinckrodt Ò , Broncho-Cath (Mallinckrodt Ò , Athlone, Ireland) double lumen tube is 14-15 mm. The tracheal cuff of a DLT is usually considerably longer than the tracheal cuff of a single lumen tube. We therefore conducted this randomised, double blind study in patients undergoing surgery in the lateral position to determine the incidence of dye leakage past the tracheal cuff of DLTs (Mallinckrodt Ò ,...

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