Discovery of a rare aberrant artery overlying trachea during open tracheostomy.

Tracheostomy is a common surgical procedure for securing a patent airway. Anatomical variations of major vessels overlying the trachea may pose significant bleeding risk during the procedure. Hence, thorough preoperative assessment of the neck and surgeon's intraoperative vigilance are essential. Open tracheostomy is a safer option than percutaneous dilatational tracheostomy. Extra caution with stoma wound care and change of tracheostomy tube are necessary postoperatively if any major vessel is detected in close proximity with the tracheal stoma.

Intraoperative remifentanil infusion does not increase postoperative opioid consumption compared with 70% nitrous oxide.

BACKGROUND: Remifentanil is commonly used to replace nitrous oxide in general anesthesia to avoid the side effects of the latter. However, there are reports that intraoperative remifentanil infusion can lead to acute opioid tolerance. In this study, the authors tried to determine the dose of remifentanil comparable in efficacy to 70% nitrous oxide and to evaluate its effect on postoperative pain and morphine consumption after colorectal surgery using isoflurane anesthesia. METHODS: Sixty adult patients undergoing open colorectal surgery were randomly assigned to receive either remifentanil or 70% nitrous oxide along with isoflurane anesthesia. After morphine analgesia titration in the postanesthesia care unit, patient-controlled analgesia was commenced. Morphine consumption and pain were scored at rest and during cough or movement for 24 h. RESULTS: The mean remifentanil infusion rate was 0.17 mug . kg . min. The median visual analog pain score on arrival in the postanesthesia care unit was 1 (0-10) in the nitrous oxide group and 3 (0-9) in the remifentanil group (P < 0.05). Otherwise, there was no difference in pain scores at 5, 10, and 15 min and no difference in the total morphine consumption during the stay in the postanesthesia care unit. The two groups had similar total morphine consumption in the first 24 h and pain scores at rest and during movement. The incidence of postoperative nausea and vomiting was 10% in both groups. There was no difference in the sedation scores. CONCLUSION: The substitution of 70% nitrous oxide with remifentanil at a mean infusion rate of 0.17 mug . kg . minute for colorectal surgery did not affect postoperative opioid consumption.

Acute intraoperative hemolysis and hemoglobinuria during radiofrequency ablation of hepatocellular carcinoma.

Radiofrequency ablation is a safe and effective treatment for small primary or secondary liver tumors. Development of new probes has allowed the use of radiofrequency ablation for ablation of tumors > 5 cm in the liver. We present a case of acute intravascular hemolysis and hemoglobinuria during radiofrequency ablation of a large 8-cm hepatocellular carcinoma via laparotomy. The hemolysis was recognized during the operation by change of urine color, and prompt management was initiated to prevent acute renal failure. Literature search revealed that radiofrequency ablation can induce hemolysis in experimental setting, but this is the first clinical report of acute hemolysis during radiofrequency ablation for liver tumors.