A new treatment modality for pneumoperitoneum associated with mechanical ventilation.

significantly higher than the proposed therapeutic range of 500-1,500 ng/ml.3 Evaluation of this patient's response to bretylium suggests that a broader therapeutic range exists for the drug than previously reported. Our experience with this patient and the wide range of doses summarized above suggests that some patients may require substantially higher parenteral doses of bretylium tosylate than are commonly recommended and that these doses may be administered with minimal adverse effects. Unlike many other antiarrhyth-mic drugs, bretylium has a positive inotropic effect and does not produce conduction disturbances. Since supine hypotension is the most serious side effect of rapid bretylium administration and some patients may respond only to doses far in excess of current recommended doses, it seems prudent to treat selected patients with increasing doses of bretylium tosylate until supine hypotension occurs before the drug is abandoned as ineffective. We would recommend small increments of bretylium in such situations with frequent monitoring of blood pressure if the total infusion rate exceeds 2 mgI minute or total dosage is increased beyond 15-20 mgI kg. Chronic oral administration of bretylium poses a significant problem due to poor bioavailability. Thus, it may be impractical to attempt conversion to oral therapy except in cases where there may be a diminished need for high plasma levels. 3 Heissenbuttel RH, Bigger JT. Bretylium tosylate: A newly available antiarrhythmic drug for ventricular arrhythmias. Pneumoperitoneum as a complication of mechanical ventilation is described in a 55-year-old woman with COPD. Exploratory laparotomy revealed no perforation of viscus. Therefore, a peritoneal ffenckhoff) catheter was connected to chest lube drainage and placed to water seal permitting respirator weaning which previously had been prevented by pneumoperitoneum. T our knowledge, pneumopenitoneum has not prevented weaning from mechanical ventilation, nor has its relief been reported to permit successful weaning. The following case is believed to be an example of this problem and its solution. CASE REPORT Three weeks prior to her admission to Louisville Veterans Administration Medical Center, this 55-year-old white woman with a long history of respiratory insufficiency secondary to chronic obstructive lung disease, was admitted to another hospital with acute respiratory failure. She had endotracheal intubation and received assisted mechanical ventilation. Several days afterwards, her abdomen became distended. There was radiologic evidence of free penitoneal air. Pen-forated viscus was suspected, but not confirmed by exploratory laparotomy which revealed only a dilated cecum and ascending colon with colonic adhesions. Tracheostomy and feeding …