Background: Respiratory arterial pulse pressure variations (PPV) are the best predictors of fluid responsiveness in mechanically ventilated patients during general anesthesia.

Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Chronic statin therapy was associated with a reduction in all cardiac and vascular outcomes after major vascular surgery. Furthermore, in major adverse events, such as multiple organ dysfunction syndrome and surgical complications, statins were also associated with decreased mortality.

Systemic air embolism has been frequently reported after penetrating thoracic trauma. In blunt thoracic trauma, systemic air embolism has been rarely diagnosed, and then only after an invasive procedure such as thoracotomy. Transesophageal echocardiography has been recently introduced for the early assessment of trauma patients and is considered a sensitive noninvasive procedure to diagnose air embolism. We report three cases of systemic air embolism in patients with pulmonary contusion secondary to a blunt thoracic trauma requiring controlled ventilation. Transesophageal echocardiography was performed for evaluation of hemodynamic instability, and it showed air bubbles in the left atrium and left ventricle during the insufflation phase, which disappeared during apnea. A decrease in airway pressure (release of PEEP, low tidal volume, high frequency jet ventilation) significantly reduced the systemic air embolism. We concluded that systemic air embolism can occur after blunt thoracic trauma, and transesophageal echocardiography enables a rapid and accurate diagnosis that may be useful for therapeutic management.

S erious complications with central venous catheter (CVC) placement include vascular perforation, arrhythmias, and hydrothorax or cardiac tamponade. If an anatomic topographic method for accurate CVC placement could be devised, then the course of the central veins could be used to estimate the approximate insertion depths of CVCs. The clavicular notch is an oval articular surface on each side of the sternal manubrium and can be identified by palpation. The internal jugular vein (IJV) and subclavian vein (SCV) lie beneath the ipsilateral clavicular notch. This study attempted to determine whether the measurement of surface landmarks along the course of central veins, including the IJV, SCV, brachiocephalic vein, and superior vena cava, can estimate the approximate insertion depths of both right-and leftsided CVCs via the IJV and SCV.A total of 200 patients scheduled for neurosurgery or abdominal surgery were assigned randomly to 1 of 4 groups: right IVJ, left IJV, right SCV, and left SCV. Central venous catheterization was performed using a double-lumen CVC with the Seldinger technique. The anterior approach, using the sternocleidomastoid muscle as a landmark, was used for IJV catheterization, and the infraclavicular approach was used for SCV. Topographic measurement was performed by placing the catheter naturally with its own curvature over the draped skin, starting from the insertion point of the needle through the ipsilateral clavicular notch and to the insertion point of the second right costal cartilage to the manubriosternal joint. The CVC was then inserted and secured to the depth determined by the topographic procedure. The position of the CVC tip in relation to the carina was confirmed, and the angle of the left-sided CVC tip to the vertical was measured on a postoperative chest radiograph. One centimeter away from the carina was considered as a safe CVC tip level.Each group had 50 patients who did not differ in age, height, or weight. Central venous catheter insertion depths for the right IJV, right SCV, left IJV, and left SCV were 12.3 T 1.0, 12.9 T 0.9, 16.3 T 1.2, and 16.1 T 0.9 cm, respectively. The CVC tip position of a CVC placed via the right IJV was 0.1 cm above the carina, and that for placement via the right SCV was 0.0 cm in relation to the carina. Central venous catheter tip positions placed via the left IVJ and left SCV were 0.3 cm above the carina and 0.2 cm below the carina, respectively. The CVC locations could be predicted with a margin of error between 2.2 cm below the carina and 2.3 cm above the carina in 95% of the patients. Steeper (Q40 degrees) angles to the vertical were seen in the leftsided CVCs whose tips were above the carina (17 of 54) than below the carina (2 of 46). These results show that the CVC tip can be inserted to a location near the carina level when the CVC is inserted via the right or left IVJ or right or left SCV to a catheter depth that is measured topographically. COMMENTThis study is focused on trying to identify safe placement of the catheter tip of central ven...