SummaryDuring neurosurgery procedures it is vital to assure optimal cerebral perfusion and oxygenation. Despite physiological autoregulation of brain perfusion, maintaining hemodynamic stability and good oxygenation during anesthesia is vital for success. General anesthesia with mechanical ventilation and current drugs provide excellent hemodynamic condition and it is the first choice for most neurosurgery procedures. However, sometimes it is very hard to avoid brief increase or decrease in blood pressure especially during period of intense pain, or without pain stimulation. This could be detrimental for patients presented with high intracranial pressure and brain edema. Modifying anesthesia depth or treatment with vasoactive drugs usually is needed to overcome such circumstances. On the other hand it is important to wake the patients quickly after anesthesia for neurological exam. That is why regional anesthesia of scalp and spine could show beneficial effects by decreasing pain stimuli and hemodynamic variability with sparing effect of anesthetics drugs. Also regional techniques provide excellent postoperative pain relief, especially after spinal surgery

For many years, physicians’ approach to the transfusion of allogeneic red blood cells (RBC) was not individualized. It was accepted that a hemoglobin concentration (Hb) of less than 10 g/dL was a general transfusion threshold and the majority of patients were transfused immediately. In recent years, there has been increasing evidence that even significantly lower hemoglobin concentrations can be survived in the short term without sequelae. This somehow contradicts the observation that moderate or mild anemia is associated with relevant long-term morbidity and mortality. To resolve this apparent contradiction, it must be recognized that we have to avoid acute anemia or treat it by alternative methods. The aim of this article is to describe the physiological limits of acute anemia, match these considerations with clinical realities, and then present “patient blood management” (PBM) as the therapeutic concept that can prevent both anemia and unnecessary transfusion of RBC concentrates in a clinical context, especially in Intensive Care Units (ICU). This treatment concept may prove to be the key to high-quality patient care in the ICU setting in the future.

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Although arterial puncture of the carotid artery during the Seldinger technique is well-known life-threatening complication which can be recognized by light red pulsatile blood during aspiration, smaller arteries such as the thyreocervical trunk branch can be punctured during the procedure and lead to serious complications.

The porphyrias are rare inherited metabolic disorders of the heme biosynthesis pathway. Acute intermittent porphyria is the most common form that may result in acute porphyric crises with abdominal pain, vomiting, hemodynamic disturbances, autonomic dysfunction, pyrexia and neurological deterioration. Provocative factors include hormonal fluctuations, fasting, dehydration, smoking, excessive alcohol or illegal drugs intake and stress from illness or surgery. However, the most frequent triggers are cytochrome P450-inducing drugs, especially in relation to anaesthesia. We report a case of a 63-year-old female with acute intermittent porphyria and severe hemodynamic instability during and after liver resection taken for hepatocellular carcinoma. The procedure was predominantly characterized by unusual hemodynamic instability with refractory hypertension, despite adequate analgesia and depth of anaesthesia. Several different treatments failed to reduce high blood pressure. There is a possibility that some drugs used in the perioperative period caused acute porphyric crises, which was manifested by severe hemodynamic instability. Autonomic neuropathy might have caused labile blood pressure as well. A precise etiology of hemodynamic instability in the presented case is difficult to assess, since other provocative factors like fasting, dehydration and stress from surgery were also present. A careful anaesthetic plan and treatment and postoperative surveillance in the ICU are cornerstones in the management of patients with porphyria subjected to major surgical procedures.