In a prospective study, patients undergoing cholecystectomy were randomly allocated to receive (a) intermittent intramuscular morphine (n = 25), (b) continuous intravenous morphine infusion (n = 25) or (c) epidural bupivacaine (n = 25) for postoperative pain relief. Morphine by intravenous infusion provided comparable pain relief to intermittent intramuscular morphine; there was no significant difference in the incidence of postoperative pulmonary complications. Patients receiving epidural bupivacaine for 12 h had better analgesia than patients receiving morphine (P less than 0.001). Arterial oxygen tensions were also significantly higher in the epidural group for the first three postoperative days (P less than 0.05). Epidural analgesia was associated with a significant reduction in the incidence of pulmonary complications (P less than 0.01) and chest infection (P less than 0.05).

A cute arterial injuries can often be complicated by the development of an arteriovenous fistula (AVF). In the acute setting, an AVF may present at the same time as the arterial injury. There may be signs of bleeding followed by the development of shock, an expanding pulsatile hematoma, an absence of distal pulses and the onset of neurological deficiency. Careful examination reveals a pathognomonic machinery murmur and thrill over the site of injury. However, diagnosis of this entity may be overlooked if these physical findings are not present. Early diagnosis and prompt treatment of AVFs are necessary to avoid delayed complications.The present case report describes an occurrence of traumatic AVF and emphasizes the importance of vascular imaging in patients with penetrating injury in the territory of major vessels, even if the clinical vascular examination is normal. CASE prESEntAtionA 27-year-old man presented with a stab wound from a kitchen knife in his left thigh and was admitted to the care of general surgeons. His medical history included Perthes disease of the left hip. He was hemodynamically stable on presentation. He had a 2 cm wound on the posterolateral aspect of his mid thigh with no active bleeding. There was no distal neurovascular deficit. The following day, his thigh had a disproportionate swelling in relation to the size of the wound, and he was referred to vascular surgeons. A duplex scan showed an AVF in the distal thigh region. Blood flow in the superficial femoral vein was pulsatile, with high-velocity flow in the distal thigh but low-velocity flow in the proximal superficial femoral vein. Digital subtraction angiography (Figures 1 and 2) confirmed an AVF between the superficial femoral artery and vein in the left distal thigh.He underwent an exploration and repair of the AVF under general anesthesia. Through a medial incision in the distal thigh, the saphenous nerve was identified and preserved. Proximal and distal control of the superficial femoral artery was achieved and the fistula was identified, dissected and disconnected. Repair of the artery and vein was undertaken by interrupted 5/0 prolene sutures. A 5 mg glyceryl trinitrate patch was placed on the thigh for 24 h. No heparin was used. Postoperative recovery was uneventful and he was discharged after five days. Subsequent duplex scanning confirmed closure of the fistula. At six-month follow-up, the patient was healthy with good distal pulses and no lower limb swelling. Acute arterial injuries are often complicated by the development of an arteriovenous fistula (AVF). In the acute setting, an AVF may present at the same time as the arterial injury. A case of traumatic AVF in the thigh that presented with normal neurovascular examination findings is reported. AVF was diagnosed by duplex scan and managed promptly. The authors suggest that duplex imaging together with arteriography, where appropriate, should be performed routinely when penetrating wounds are in close proximity to major vessels despite a normal clinical neurovascular exa...

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