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(J Clin Anesth. 2018;44:123–124) In this correspondence, the authors described a patient who presented with simultaneous pneumocephalus and cavernoma after receiving combined spinal-epidural analgesia for labor. However, unlike most cases of combined spinal-epidural analgesia for labor, which use loss of resistance to air to identify the epidural space, the authors used loss of resistance to saline. To the author’s knowledge, there are no published reports of the use of loss of resistance to saline for this purpose. Identification of the epidural space was successful upon the fourth attempt with the patient in a sitting position. Upon injection of local anesthetic, the patient immediately complained of a severe headache, that was unremitting with postural changes and continued into the postpartum period. On postpartum day 2, the patient presented with a tonic-clonic seizure. Magnetic resonance imaging showed intraventricular pneumocephalus and cavernoma in the right frontal region, and electroencephalogram showed abundant epileptic activity. Oxygen was added to the patient’s therapy with clinical improvement; complete reabsorption of air on radiologic examination was seen on the sixth day and the asymptomatic patient was discharged.

Objectives: The current standard of care to deliver invasive mechanical ventilation support is the protective ventilation approach. One pillar of this approach is the limitation of tidal volume to less than 6 mL/Kg of predicted body weight. Predicted body weight is calculated from patient’s height. Yet, little is known about the potential impact of errors arising from visual height estimation, a common practice, to calculate tidal volumes. The aim of this study was to evaluate that impact on tidal volume calculation to use during protective ventilation. Design: Prospective observational study. Setting: An eight-bed polyvalent ICU. Patients: Adult patients (≥ 18 yr). Interventions: None. Measurements and Main Results: Tidal volumes were calculated from visual height estimates made by physicians, nurses, and patients themselves and compared with tidal volumes calculated from measured heights. Comparisons were made using the paired t test. Modified Bland-Altman plots were used to assess agreement between height estimates and measurements. One-hundred patients were recruited. Regardless of the height estimator, all the mean tidal volumes would be greater than 6 mL/Kg predicted body weight (all p < 0.001). Additionally, tidal volumes would be greater than or equal to 6.5 mL/Kg predicted body weight in 18% of patients’ estimates, 25% of physicians’ estimates, and 30% of nurses’ estimates. Patients with lower stature (< 165 cm), older age, and surgical typology of admission were at increased risk of being ventilated with tidal volumes above protective threshold. Conclusions: The clinical benefit of the protective ventilation strategy can be offset by using visual height estimates to calculate tidal volumes. Additionally, this approach can be harmful and potentially increase mortality by exposing patients to tidal volumes greater than or equal to 6.5 mL/Kg predicted body weight. In the interest of patient safety, every ICU patient should have his or her height accurately measured.

This letter is intended to present an innovative approach to regional anesthesia (RA) in small ex-premature babies.Preterm infants often have a history of apnea of prematurity, bronchopulmonary dysplasia and chronic lung disease. Spinal anesthesia is a well-accepted anesthetic technique for ex-premature infants undergoing lower abdominal surgery. Its major advantages over general anesthesia are the minimization of postoperative apnea risk and the need for ventilatory support [1].The practice of general anesthesia (GA) might have a negative impact regarding those issues.Ultrasound equipment has enabled the development of new anesthetic approaches to neuraxial anesthesia.After obtaining written parental consent to publish, we report the case of an ex-premature infant submitted to supraumbilical abdominal surgery under ultrasound-guided trans-caudal, combined spinal-epidural anesthesia. Fig. 1. Spinal needle piercing the dural sac.