Acute respiratory distress syndrome (ARDS) is characterized by sudden onset of respiratory distress, infiltrates on radiographs consistent with pulmonary oedema, hypoxaemia and increased work in breathing. Infiltrates on radiographs are bilateral, but may be patchy or diffuse and fluffy or dense. It is associated with absence of left heart failure and a PaO2/FiO2 ratio of < or =200. Ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide (DMSO), which was approved by the US FDA in July 2005, is used as an embolic agent for cerebral arteriovenous malformation (AVM). It is a biocompatible liquid polymer that precipitates and solidifies on contact with blood, thus forming a soft and spongy embolus. We report a case of ARDS following therapeutic embolization with ethylene vinyl alcohol copolymer for cerebral AVM under general anaesthesia. Experienced perioperative physicians adopted standard anaesthetic technique and monitoring for this procedure. Acute respiratory distress and hypoxaemia developed in the patient following extubation of the trachea. Infiltrates seen on postprocedural chest radiographs were consistent with pulmonary oedema. DMSO, the solvent for the ethylene vinyl alcohol copolymer, is excreted via the lungs after administration and we postulate that DMSO was the possible cause of ARDS in this patient. Monitoring of haemodynamic parameters (invasive blood pressure, electrocardiography) and ventilatory parameters (ETCO2, SpO2, airway pressure monitoring) are important in the recognition of this possible event. One should be vigilant and anticipate this complication following therapeutic embolization with ethylene vinyl alcohol polymer for the treatment of cerebral AVM.

Objective: To determine whether novices can distinguish between properly and improperly placed guidewires in a vascular access model after only minimal training. Methods: This was a prospective study involving trainees with no previous training in sonographic guidewire visualization. A vascular access model was created with guidewires positioned inside or adjacent to simulated veins. Subjects were taught to scan each wire to determine its location. Afterward, participants scanned a test model of five vein-wire pairs and recorded their answers as ''inside,'' ''outside,'' or ''unsure.'' The test characteristics of sonographic guidewire localization were determined using actual wire location as the criterion standard. Results: Forty trainees (21 emergency medicine residents, 19 medical students) participated, and each examined five simulated veins. There were 156 true positives (intravascular wire correctly identified), 38 true negatives (extravascular wire correctly identified), 2 false negatives, 2 false positives, and 2 cases in which the participant marked ''not sure,'' which were reclassified as false negatives. Test characteristics were sensitivity 97.5% (95% CI 93.3-99.2) and specificity 95.0% (95% CI 81.8-99.1). The overall accuracy was 97.0%. Conclusions: Sonographic guidewire visualization, a step recommended for ensuring proper vessel cannulation during central venous access, can be accomplished by novices with a high degree of accuracy. RÉ SUMÉObjectif: L'é tude visait à dé terminer si des dé butants pouvaient faire la distinction entre des fils-guides bien placé s et des fils-guides mal placé s dans un modè le d'accè s vasculaire, aprè s une formation minimale seulement. Mé thodes: Il s'agit d'une é tude prospective à laquelle ont participé des stagiaires sans formation pré alable dans la visualisation de fils-guides à l'é chographie. Un modè le d'accè s vasculaire a é té cré é , avec des fils-guides placé s à l'inté rieur ou à l'exté rieur des veines factices. Les sujets ont d'abord appris à é chographier chaque fil-guide pour dé terminer son emplacement, puis ont é chographié un modè le comptant cinq ensembles veine-fil-guide, et indiqué leurs ré ponses comme suit: « À l'inté rieur », « À l'exté rieur », ou « Incertain ». Les caracté ristiques du test sur la localisation des fils-guides à l'é chographie ont é té dé terminé es à partir de l'emplacement ré el des fils-guides, critè re constitué en norme. Ré sultats: Quarante stagiaires (21 ré sidents en mé decine d'urgence, 19 é tudiants en mé decine) ont participé à l'é tude, et chacun a examiné cinq veines factices. Il y a eu 156 vraies ré ponses positives (fil-guide intravasculaire: bonne ré ponse), 38 vraies ré ponses né gatives (fil-guide extraravasculaire: bonne ré ponse), 2 fausses ré ponses né gatives, 2 fausses ré ponses positives, et 2 ré ponses noté es « Incertain » et traité es comme fausses ré ponses né gatives. Le test avait pour caracté ristiques une sensibilité de 97.5% (IC à 95%: 93.3-99.2) et une spé cificité de 95.0% (IC à 95...

Perioperative anaesthetic management of the VentrAssist™ left ventricular assist device (LVAD) is a challenge for anaesthesiologists because patients presenting for this operation have long-standing cardiac failure and often have associated hepatic and renal impairment, which may significantly alter the pharmacokinetics of administered drugs and render the patients coagulopathic. The VentrAssist is implanted by midline sternotomy. A brief period of cardiopulmonary bypass (CPB) for apical cannulation of left ventricle is needed. The centrifugal pump, which produces non-pulsatile, continuous flow, is positioned in the left sub-diaphragmatic pocket. This LVAD is preload dependent and afterload sensitive. Transoesophageal echocardiography is an essential tool to rule out contraindications and to ensure proper inflow cannula position, and following the implantation of LVAD, to ensure right ventricular (RV) function. The anaesthesiologist should be prepared to manage cardiac decompensation and acute desaturation before initiation of CPB, as well as RV failure and severe coagulopathic bleeding after CPB. Three patients had undergone implantation of VentrAssist in our hospital. This pump provides flow of 5 l/min depending on preload, afterload and pump speed. All the patients were discharged after an average of 30 days. There was no perioperative mortality.