In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.

Background Perioperative hypothermia has been reported to increase the occurrence of cardiovascular complications. By increasing sympathetic nervous system activity, perioperative hypothermia also has the potential to increase cardiac injury and dysfunction associated with subarachnoid hemorrhage. Methods The Intraoperative Hypothermia for Aneurysm Surgery Trial randomized patients undergoing cerebral aneurysm surgery to intraoperative hypothermia (n = 499, 33.3 ± 0.8°C) or normothermia (n = 501, 36.7 ± 0.5°C). Cardiovascular events (hypotension, arrhythmias, vasopressor use, myocardial infarction, etc.) were prospectively followed until 3 month follow-up and were compared between hypothermic and normothermic patients. A subset of 62 patients (hypothermia, n = 33; normothermia, n = 29) also had preoperative and postoperative (within 24 h) measurement of cardiac troponin-I and echocardiography to explore the association between perioperative hypothermia and subarachnoid hemorrhage-associated myocardial injury and left ventricular function. Results There was no difference between hypothermic and normothermic patients in the occurrence of any single cardiovascular event or in composite cardiovascular events. There was no difference in mortality (6%) between groups and there was only a single primary cardiovascular death (normothermia). There was no difference between hypothermic and normothermic patients in post- vs. preoperative left ventricular regional wall motion or ejection fraction. Compared with preoperative values, hypothermic patients had no postoperative increase in cardiac troponin-I (median change 0.00 μg/L) whereas normothermic patients had a small postoperative increase (median change + 0.01 μg/L, P = 0.038). Conclusion In patients undergoing cerebral aneurysm surgery, perioperative hypothermia was not associated with an increased occurrence of cardiovascular events.

These results suggest that anoplasty deserves further evaluation in the treatment of anorectal incontinence due to discrete IAS defects, but that the place of IAS repair remains uncertain.

Background We explored the relationship between nitrous oxide use and neurological and neuropsychological outcome in a population of patients likely to experience intraoperative cerebral ischemia: i.e., those who had temporary cerebral arterial occlusion during aneurysm clipping surgery. Methods A post hoc analysis of a subset of the data from the Intraoperative Hypothermia for Aneurysm Surgery Trial was conducted. Only subjects who had temporary arterial occlusion during surgery were included in the analysis. Metrics of short-term and long-term (i.e., 3 months post-surgery) outcome were evaluated via both univariate and multivariate logistic regression analysis. An odds ratio (OR) of greater than 1.0 denotes a worse outcome in patients receiving nitrous oxide. Results We evaluated 441 patients, of which 199 received nitrous oxide. Patients receiving nitrous oxide had a greater risk of delayed ischemic neurologic deficits (i.e., the clinical manifestation of vasospasm) (OR=1.78, 95% confidence interval [CI]=1.08–2.95, p=0.025). However, at 3 months after surgery, there was no difference in any metric of gross neurologic outcome: Glasgow Outcome Score (OR=0.67, CI=0.44–1.03, p=0.065), Rankin Score (OR=0.74, CI=0.47–1.16, p=0.192), National Institutes of Health Stroke Scale (OR=1.02, CI=0.66–1.56, p=0.937), or Barthel’s Index (OR=0.69, CI=0.38–1.25, p=0.22). The risk of impairment on at least one test of neuropsychological function was reduced in those who received nitrous oxide (OR=0.56, CI=0.36–0.89, p=0.013). Conclusion In our patient population, use of nitrous oxide was associated with an increased risk for the development of delayed ischemic neurologic deficits; however, there was no evidence of detriment to long-term gross neurologic or neuropsychological outcome.

SummaryA case is presented of near ,fatal haemorrhuge into the pleural space following laceration of u rertebral artery during attempted cannulation of the internal jugulur uein before cardiopulmonary bypass. The literature on similar cases is reoiewed and recommendations made. Key words ComplicationsVeins; cannulation.Central venous cannulation (CVC) carries risks which are considerable. It is usually justified on the basis that a centrally placed catheter can provide valuable haemodynamic information and can also act as a reliable and safe route for drug administration.The entry point for CVC has a bearing on the incidence and the severity of complications.', Larger and deeper vessels, for example, the subclavian and internal jugular veins, are often chosen as the catheter tip may be more confidently sited in a large central vein: especially if there is a paucity of peripheral veins.We describe here a near fatal complication which followed CVC via the internal jugular vein using a high a p p r~a c h .~ Case historyA 55-year-old woman who had undergone a previous mitral valvotomy was prepared and anaesthetised routinely for mitral valve replacement. Peripheral venous and radial artery lines were placed. Unsuccessful attempts were made to canulate the right internal jugular vein using a Bard I-Cath (1914) catheter which incorporates a 14-Gauge introducer needle. During this insertion, two important observations were made. Firstly, some air was aspirated into the attached syringe and although this was attributed to a faulty needle/syringe connexion, such a malconnexion could not be confirmed. The second observation was that although blood was easily aspirated from the probing needle on several occasions, the catheter would not advance more than 1 cm beyond the tip. It was felt that the aspirated blood was from a haematoma and this site was abandoned. CVC was then easily and rapidly performed via the right external jugular vein. Surgery was uneventful and no surgical incursion was made into the right pleural space. Post-bypass ventilation was remarkable for a dec- R.N. W. Morgun und D.F. Morrellreased but manageable compliance, which was accompanied by a central venous pressure reading of 25-30 cmHzO in the presence of a visibly underfilled right atrium. At the completion of surgery, bruising and distension of the lower neck were observed and a chest X-ray ( Fig. 1) showed an opaque right lung field. A right intercostal drain yielded 1 G 1 . 5 litres of fresh blood with concomitant decompression of the neck and drainage of the haemothorax, as demonstrated by chest X-ray (Fig. 2). The patient appeared haemodynamically stable and was returned to the Intensive Care Unit. Two hours later, however, her condition deteriorated rapidly and she was rushed back to theatre almost moribund. Anaesthesia and resuscitation were immediately commenced. Following large infusions of blood, plasma and crystalloid plus internal cardiac massage and intravenous vasopressors, the patient was eventually returned to a reasonably stable...