Cervicofacial subcutaneous emphysema is an unusual complication following tonsillectomy. We present a 37-year-old male patient who, after receiving tonsillectomy, developed cervicofacial subcutaneous emphysema immediately following endotracheal extubation. Valsalva maneuvers evidenced by coughing and straining of the patient, and positive pressure ventilation by mask to alleviate laryngospasm in an emergency were believed to induce and exacerbate the emphysema. Fortunately, the patient was re-intubated and protected from further complication of pneumomediastinum or pneumothorax. The emphysema resolved 7 days later with conservative treatment, including broad-spectrum antibiotics and abstention from enteral intake. This case serves as a reminder that an unusual and unexpected complication can occur in a routine procedure. Methods to prevent this complication are discussed.

Iatrogenic intra-abdominal vascular injury can result from lumbar discectomy via the posterior approach. Although it is well known and documented in the literature, few anesthesiologists have personal experience with this life-threatening incident. Here, we report a patient who sustained perforation of the left internal iliac artery at the L(4-5) level during posterior lumbar discectomy. The patient experienced refractory hypotension with tachycardia at the end of surgery, even with prompt fluid resuscitation and medical treatment. Abdominal distension and tenderness of the left lower abdominal quadrant were also noted. Emergency laparotomy was performed by the consulting vascular surgeon and revealed perforation of the left internal iliac artery. The vascular injury was successfully repaired. It is important that, as anesthesiologists, we must be aware of this potentially fatal complication. Prompt diagnosis and immediate laparotomy to control hemorrhage can result in favorable outcomes.

SummaryThe prone position can reduce cardiac output by up to 25% due to reduced preload. We hypothesised that preload optimisation targeted to stroke volume variation before turning prone might alleviate this. A supine threshold stroke volume variation of 14% in a preliminary study identified patients whose cardiac outputs would decline when turned prone. In 45 patients, cardiac output declined only in the group whose supine stroke volume variation was high (mean (SD) 5.1 (2.0) to 3.9 (1.9) l.min )1 ; p < 0.001), but not in patients in whom it was low, or in those in whom stroke volume variation was high, but who received volume preload (p = 0.525 and 0.941, respectively). We conclude that targeted preload optimisation using a supine stroke volume variation value < 14% is effective in preventing falls in cardiac output induced by the prone position. A reduction in cardiac output (CO) by up to 25% of baseline while turning surgical patients from supine to prone positions has been reported and this is due to a reduction in preload in this position [1]. Although volume status plays an important role, pre-operative optimisation of preload, to alleviate the decrease in CO in the prone position, may not be feasible by conventional static monitoring such as central venous pressure [2]. The use of stroke volume variation (SVV) has been shown to be a reliable indicator of fluid responsiveness in both supine and prone positions [3]. Therefore, we hypothesised that pre-operative preload optimisation guided by SVV may be effective in alleviating the decline in CO induced by turning prone.In a preliminary study, we first tried to define the threshold SVV in the supine position that would predict which patients would or would not experience a reduction in CO on turning prone. Then in the substantive study, we examined the effectiveness of preload optimisation in preventing the prone positioninduced decline in CO. MethodsAfter approval from the institutional review board and written informed consent, an observational pilot study of 30 patients receiving lumbar spine surgery was conducted to estimate the threshold SVV value in the supine position that was predictive of a prone positioninduced 25% decline in CO. The surgical and anaesthesia protocols for this pilot study were the same as for the main study (see below). We found that a 14% supine SVV predicted a decline in CO with a sensitivity of 100% (95% CI 60-100), specificity of 78% (95% CI 56-93) and area under the receiver operator-characteristic (ROC)

Intrathecal morphine delivery by using totally implantable programmable IDDS is an effective method to relieve refractory cancer pain.

We report a case of severe reexpansion pulmonary edema that occurred immediately after reinflation of a collapsed lung by rapid negative pressure drainage of prolonged malignant pleural effusion and pneumohemothorax. Although hemodynamic stability was difficult to maintain under aggressive treatment with inhalation of nitric oxide, inotropics and prostacyclin infusion, conventional pulmonary artery catheterization was not adequate for surveillance and adjustment of fluid therapy. For balancing the preload and the extent of pulmonary edema, pulse contour cardiac output monitoring using a single transpulmonary thermal dilution technique was applied to achieve optimal cardiac preload for organ perfusion and to prevent worsening of pulmonary edema from fluid overload.