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Key points• Autonomic dysreflexia (ADR) is a medical emergency characterized by severe hypertension. It can be brought on by a wide range of stimuli below the level of the lesion, often occurring intra-operatively. The anaesthetist must be aware of the presentation, prevention, and management.• Anaesthetic management is dependent on the level and completeness of the lesion in relation to the surgical site, the presence of ADR and muscle spasms, and patient wishes.• Thorough preoperative assessment is crucial to safe anaesthetic management.• Pathophysiological changes complicating perioperative care are multi-systemic. Important considerations include cardiovascular and respiratory complications.• Age-related comorbidities must be considered alongside the pathophysiological changes associated with the spinal cord injury.

Secondary cases of meningococcal disease among healthcare workers are rare and avoidable. In this report, we describe a secondary infection in a healthcare worker who did not have significant contact with respiratory secretions of the index case.

Fusco et al. raise some very interesting points regarding the spread of respiratory secretions in the form of aerosols caused by oxygen therapy. We believe this does indeed warrant further investigation, and a review of the guidelines regarding the chemoprophylaxis of staff involved in airway management.

We report a case of a 69-year-old gentleman who developed an acutely painful eye with loss of visual acuity whilst on the critical care unit. He was admitted three days previously with an infective exacerbation of chronic obstructive pulmonary disease requiring invasive mechanical ventilation. In addition, he received intravenous antibiotics, steroids, nebulised bronchodilators and intravenous aminophylline, together with noradrenaline for blood pressure support. On development of visual symptoms, an emergency ophthalmology review diagnosed acute angle closure glaucoma. Treatment with pilocarpine eye drops, intravenous acetazolamide and bilateral YAG laser iridotomies provided immediate symptom relief and he went on to make an excellent recovery. Acute angle closure glaucoma is a potentially devastating ophthalmic emergency. Critical care patients are at particular risk for the development of this condition due to the use of predisposing medications, such as sympathomimetics and beta agonists. Sedated patients also run a risk of delayed diagnosis so a high index of suspicion is required.