Vocal cord dysfunction can be an easily overlooked complication after open heart surgery. It can be the cause of respiratory insufficiency following tracheal extubation and may lead to reintubation and reventilation. The cause of the problem cannot always be traced but it may be due to direct trauma of the vocal cords during tracheal intubation, or trauma of the recurrent laryngeal nerve from the cuff of the endotracheal tube. A less likely possibility is that it may result from nerve injury due to central venous cannulation, or from cold. The condition may resolve within months, but, in rare cases, may lead to permanent morbidity.

54 patients who had posterolateral thoracotomy were prospectively studied to compare the efficacy of intrapleural bupivacaine with that of bupivacaine intercostal block and cryofreezing. Patients were randomized into three groups. The intrapleural catheter group included 16 patients who had intermittent intrapleural instillation of 20 ml of 0.25% bupivacaine for forty-eight hours postoperatively. The second group included sixteen patients who were given perioperative bupivacaine intercostal block. The third group included fifteen patients treated by cryofreezing of the intercostal nerves. Visual analogue four-hourly pain score was compared between the three groups during the first forty-eight hours postoperatively. The analgesic requirements during the first postoperative week were also assessed. There was no significant difference between the three groups in the average pain score (3.61 +/- 1.37, 3.54 +/- 1.15, and 3.33 +/- 1.47 respectively). During the first forty-eight hours postoperatively, the percentage of patients who required papaveretum in the intrapleural catheter group (56.3%) was significantly less than that in the other two groups (both 100%). The average papaveretum requirement (mg per patient) in the intrapleural catheter group (27.33 +/- 25.27) was significantly less than that in the second group (52.66 +/- 26.85) but the difference was not statistically significant from that in the third group (37.66 +/- 20.95). No complications related to the use of the intrapleural catheter or to bupivacaine toxicity were encountered. In conclusion, the technique of intermittent intrapleural bupivacaine is safe and comparable in efficacy to bupivacaine intercostal block and cryofreezing. Narcotic requirements may be reduced when this technique is used.

Rupture of abdominal aortic aneurysm (AAA) in elderly patients carries a high mortality rate. The decision to operate on a patient more than a hundred ten years of age is controversial and will depend on many factors. In this case report, the authors describe a successful repair of a ruptured giant (15 cm in diameter) AAA eroding into the vertebral column in a one-hundred-ten-year-old patient. This is likely to be the oldest case reported in the literature with successful outcome.

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Percutaneous insertion of a catheter for intra-aortic balloon pumping (IABP) was introduced in 1979 by Bregman and Casarella and has become a popular technique. Rupture of the balloon, allowing clot to form inside it, is rare. When the clot is large, it may cause entrapping of the balloon. This is a potentially dangerous complication of IABP. We are aware of only one case report of this complication, by Aru and co-workers. The entrapping of the balloon in their report occurred at the site of insertion in the femoral artery. We report here a case in which the entrapping occurred in the descending aorta, and its removal required extensive exposure of the aortic bifurcation.