[Tension pneumothorax associated with re-intubation through percutaneous tracheostoma site].

Percutaneous tracheostomy (PT) has become popular recently, but occasionally cannula exchange can be difficult and hazardous. A 55-year-old woman with pontine hemorrhage was admitted to our ICU after oral intubation. On the 3 rd day, PT was performed with no complication to prepare for prolonged airway management. On the 14 th day, surgical removal of the pontine hematoma was scheduled. Since our neurosurgeon requested a prone position with maximal neck anteflexion, she was re-intubated orally and the tracheostomy cannula was removed during the operation. At the end of the operation, the tracheostoma had already been narrowed and re-insertion of a narrower tracheostomy cannula was unsuccessful even with bronchoscopic guidance. Following several attempts, her Spo2 gradually decreased and her blood pressure dropped. A chest X-ray showed right pneumothorax and a chest drainage tube was inserted. Posterior tracheal wall injury was suspected, though the exact injury site was not identified bronchoscopically. She was treated conservatively because no air leak was observed after advancing the oral tube. Three weeks later, surgical tracheostomy was performed without major abnormal findings. A small tracheostoma characteristic of PT might be associated with an increased risk of delayed airway complication. Cannula exchange should be performed more carefully after PT compared with surgical tracheostomy.

[How should we perform acute normovolemic hemodilution during radical prostatectomy? Comparison with a mathematical model].

BACKGROUND: Although allogenic blood transfusion has become safer than ever, there still exist some risks such as infection and immunomodulation. The importance of autologous blood transfusion is emphasized. METHODS: Fourteen cases of radical prostatectomy performed with the use of acute normovolemic hemodilution (ANH) were examined retrospectively. The efficacy of ANH was evaluated in comparison with a mathematical model. RESULTS: The average blood loss was 1321 ml and the average blood volume collected during ANH was 637 ml. In no cases, allogenic blood transfusion was necessary. According to a mathematical model, however, the actual blood loss was smaller than the calculated allowable blood loss in all the cases, which implied allogenic blood transfusion would have been avoidable even without ANH. It was also suggested that only a limited efficacy was obtained due to a relatively small blood volume collected during ANH. CONCLUSIONS: Our way of performing ANH was considered suboptimal in that no efficacy was found as to avoidance of allogenic blood transfusion and the extent of ANH was not sufficient to prepare for unexpected massive blood loss. It seemed necessary to reconsider the indications for ANH to increase the efficacy. The importance of the informed consent was also recognized.

[Spinal anesthesia in a parturient complicated with idiopathic thrombocytopenic purpura].

A 27-yr-old parturient with idiopathic thrombocytopenic purpura was scheduled to undergo resection of a left ovarian cyst at 15 weeks gestation. Platelet counts were between 46,000 and 64,000.microliter-1, bleeding time was 2 min, and she denied having unusual bleeding diathesis. As the patient was reluctant to receive general anesthesia for fear of latent adverse effects of the drugs on the fetus, we selected spinal anesthesia and the perioperative course was uneventful. However, it is questionable to perform regional anesthesia in patients with coagulation disorders, for spinal hematomas leading to paraplegia can be a rare but devastating complication of regional anesthesia. According to our extensive literature review, it was revealed that platelet insufficiency, both in terms of function and count, did not represent a major risk factor for spinal hematomas associated with regional anesthesia, especially for spinal anesthesia. We suggest that spinal anesthesia may be safely performed in patients if their platelet counts exceed around 50,000.microliter-1.