Forde-Thielen and Konia Journal of Medical Case Reports 2011, 5:257 http://www.jmedicalcasereports.com/content/5/1/257 pressure were observed during their study in laparoscopic procedures. We propose that the lung of our patient was not fully deflated at initiation of insufflation. The intrathoracic pressure increased instantaneously with high flows of insufflation and most likely exceeded 10 mmHg, at least temporarily. This caused a pro- nounced mediastinal shift, an immediate drop in venous return, with little time for the sympathetic nervous sys- tem to slowly compensate, and either vagal stimulation or activation of the Bezold-Jarisch reflex leading to asystole. Conclusion In the literature it is suggested that insufflation flows should be kept at 2-3 L/min [1,5,7]. In the authors’ experience the insufflation flows vary and high flows are often utilized, which may not promote patient safety. Also, with rapid insufflation using high flows the insuf- flator may overshoot and increase intrathoracic pressure over the safe limit. We therefore propose that, to pre- vent events like this from occurring, insufflation pres- sures should be kept below 10 mmHg [5,9]. We suggest giving enough time for full deflation of the lung. It would be prudent to initiate one-lung ventilation as soon as possible and use 100% oxygen to accelerate lung deflation [11]. It has also previously been recommended that the lung should be exposed to ambient pressure for 60 seconds before the initiation of insufflations [5]. This will allow for hypoxic pulmonary vasoconstriction to limit shunting and for the sympathetic response to com- pensate for decreased venous return. Insufflation should be used primarily in patients with unsatisfactory surgical exposure following passive lung deflation. Consent Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Authors’ contributions Both authors participated in the clinical care of the patient and participated in the collection and review of the literature and writing of the case report. Both authors have read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 13 October 2010 Accepted: 30 June 2011 Published: 30 June 2011 References 1. Ohtsuka T, Nakajima J, Kotsuka Y, Takamoto S: Hemodynamic responses to intrapleural insufflation with hemipulmonary collapse. Surg Endosc 2001, 15(11):1327-1330. 2. Stensrud PE: Anesthesia for Thoracoscopy. Semin Cardiothorac Vasc Anesth 2000, 4(1):18-25. Page 3 of 3 3. Vassiliades TA Jr: The cardiopulmonary effects of single-lung ventilation and carbon dioxide insufflation during thoracoscopic internal mammary artery harvesting. Heart Surg Forum 2002, 5(1):22-24. 4. 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Ann Thorac Surg 1994, 58(2):404-407, discussion 407-408. 9. Byhahn C, Mierdl S, Meininger D, Wimmer-Greinecker G, Matheis G, Westphal K: Hemodynamics and gas exchange during carbon dioxide insufflation for totally endoscopic coronary artery bypass grafting. Ann Thorac Surg 2001, 71(5):1496-1501, discussion 1501-1502. 10. Jacobs VR, Morrison JE Jr: The real intraabdominal pressure during laparoscopy: comparison of different insufflators. J Minim Invasive Gynecol 2007, 14(1):103-107. 11. Ko R, McRae K, Darling G, Waddell TK, McGlade D, Cheung K, Katz J, Slinger P: The use of air in the inspired gas mixture during two-lung ventilation delays lung collapse during one-lung ventilation. Anesth Analg 2009, 108(4):1092-1096. doi:10.1186/1752-1947-5-257 Cite this article as: Forde-Thielen and Konia: Asystole following positive pressure insufflation of right pleural cavity: a case report. Journal of Medical Case Reports 2011 5:257. 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