Spinal deformities can result in increasing thoracic kyphosis or loss of lumbar lordosis, leading to imbalance in the sagittal plane. Such deformities can be functionally and psychologically debilitating. The Smith-Petersen osteotomy can achieve approximately 10 degrees of correction in the sagittal plane at each spinal level at which it is performed. This osteotomy is beneficial for patients who have a degenerative imbalance in the sagittal plane. The pedicle subtraction osteotomy can achieve approximately 30 degrees to 40 degrees of correction in the sagittal plane at each spinal level at which it is performed. It is the preferred osteotomy for patients with ankylosing spondylitis who have an imbalance of the spine in the sagittal plane. The cervical extension osteotomy is performed in the cervical spine, at the cervicothoracic junction, in patients who have a cervical flexion deformity that impedes their ability to look straight ahead while walking or who have difficulty swallowing. The vertebral column resection is used when the imbalance is severe enough that the other osteotomies cannot correct the deformity, especially in patients who have a combined sagittal and coronal spinal imbalance. Neurologic problems, whether transient or permanent, are the most commonly encountered complications following these procedures. Recent results have shown a high patient satisfaction rate and good functional outcomes after spinal osteotomies done to treat a variety of disorders.

Aprotinin, tranexamic acid, and epsilon-aminocaproic acid are effective for reducing blood loss and transfusions in patients managed with spine surgery. With the exception of aprotinin, the side-effect profiles of these agents have not been shown to cause any substantial morbidity or to increase the rate of thromboembolic events. Epsilon-aminocaproic acid had a greater effect on reducing blood transfusions as the complexity of surgery increased. The surgeon and/or the anesthesiologist should consider the use of antifibrinolytic agents for patients undergoing spinal procedures in which a large amount of blood loss can be expected; however, at the present time, this is not a United States Food and Drug Administration-approved indication for these agents.

Accidental intravascular administration of bupivacaine during performance of a brachial block precipitated convulsions followed by asystole. The patient was rapidly resuscitated using cardiopulmonary resuscitation, supplemented by 150 mL of 20% lipid emulsion. Nonetheless, cardiac toxicity reappeared 40 min after completion of the lipid emulsion. In the absence of further lipid emulsion, amiodarone and inotropic support were used to treat cardiotoxicity. This case suggests that local anesthetic systemic toxicity may recur after initial lipid rescue. Since recurrence of toxicity may necessitate administration of additional doses of lipid emulsion, a sufficient quantity of lipid emulsion should be available when regional anesthesia is performed.

Background: Neuraxial analgesia is currently considered the most effective method of labour analgesia. While well studied in developed countries, it is uncertain whether the results, particularly regarding epidural analgesia complication rates, can be extrapolated to the context of the South African public hospital. Method: A retrospective one-year audit reviewed available records for indications for-, complications of-, and patient satisfaction with labour epidural analgesia at Tygerberg Hospital, Western Cape. Results: During the period audited, 157 (2.2%) of 7 005 parturients received labour epidural analgesia. One hundred and forty nine records were retrieved for analysis. Epidural analgesia was not provided on patient request. Rather, specific indications for epidural analgesia in 73.2% of these cases were preeclampsia, cardiovascular disease and morbid obesity. The incidence of complications was 32.3%, comprising hypotension (13.4%) and all other complications (18.9%). Most complications were minor and self-limiting (97.9%). One serious adverse event (cardiac arrest) due to accidental intravenous infusion of bupivacaine was recorded. Resuscitation with lipid emulsion was successful. Parturients reported being "happy" or "very happy" (50% and 36% respectively) with epidural analgesia. Conclusions: At this tertiary referral hospital in the Western Cape, only 2.2% of parturients received labour epidural analgesia, possibly because of personnel time constraints. Indications comprised predominantly preeclampsia, cardiovascular disease and morbid obesity. The incidence of complications from labour epidural analgesia was in line with that observed in developed countries. Most patients were happy with their analgesia. This audit identifies an urgent need for improvement of the labour epidural service at this institution.

The effects of anesthesia techniques on oxygen consumption, cardiac output and therefore mixed venous oxygenation can significantly affect arterial oxygenation during one-lung anesthesia. While pursuing increases in cardiac output may, under limited circumstances, benefit arterial oxygenation during one-lung ventilation, this approach is not a panacea and does not obviate the necessity to optimize dependent lung volume.

Pneumopericardium, and especially tension pneumopericardium, are relatively rare consequences of penetrating, blunt or iatrogenic injury. Despite its rarity and the compressibility of air, pneumopericardium can result in life threatening cardiac tamponade. We present two recent cases of this rare condition with divergent aetiologies from which lessons can be learned. The pathophysiology, diagnosis and treatment of pneumopericardium are reviewed.

Forceful manual syringing caused significant hemolysis and high free Hb concentrations. Pressurizing RBC bags induced no more hemolysis than after gravity-facilitated transfusions. Syringing to expedite RBC transfusions should be avoided in favor of pneumatic RBC bag pressurization.

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