The length of the lumbar spine determined by ultrasound, rather than the lumbar spine volume, combined with the weight or body mass index of the subject, is of particular value in predicting the intrathecal spread of isobaric bupivacaine during CSE analgesia for labor.

The estimates of the US-determined distance to the epidural space in the PSO are comparable to those in the TM plane. The ability to use both estimates interchangeably for midline punctures may prove useful in patients presenting with poor visibility in the TM plane.

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We describe a case of bilateral infraoptic origin of the anterior cerebral arteries associated with an anterior communicating artery (ACOM) aneurysm. Anatomical variations of the anterior cerebral artery (ACA) are common; however, bilateral infraoptic course of the anterior cerebral artery is extremely rare. Since an infraoptic course of the ACA is associated with ACOM aneurysm formation, an understanding of the cerebrovascular anatomy and embryology is important for appropriate management of the aneurysm.

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T he failure rate for placement of epidural catheters for labor analgesia may be as high as 42% in obese parturients. Complications such as inadvertent dural or vascular puncture are related to the inability to identify spinal anatomic landmarks by palpation and to predict the distance from the skin to the epidural space. Use of spinal ultrasound (US) may increase the success rate. Spinal US in the transverse median (TM) plane underestimates the distance to the epidural space in obese parturients, likely because of the compression of the subcutaneous tissue during the assessment. This observational cohort study was performed to test whether scanning in the paramedian sagittal oblique (PSO) plane compared with the TM plane would provide a more accurate estimate of the actual skinYepidural space measurement in these women.The patients were in World Health Organization classes I, II, and III for obesity and requested labor epidural analgesia or combined spinal-epidural anesthesia (CSE) for cesarean delivery. All had US imaging of the lumbar spine before the epidural or CSE was placed. Ultrasound imaging was done with a 5-2 MHz curved array probe to determine the insertion point and estimate the skinYepidural space distance (US-estimated depth, UD). In the PSO plane, the posterior complex, anterior complex, and intrathecal space were identified. The posterior and anterior complexes were referred to as the ligamentum flavumYdura mater (Lf-Dm) unit and the vertebral body, respectively. The distance from the skin to the inner aspect of the Lf-Dm unit was measured as US depth in the PSO plane (UD/PSO). For the TM plane, scanning was performed at the same lumbar interspace with the US probe in transverse orientation, and scanning was conducted in a plane perpendicular to the long axis of the spine to obtain a TM view of the vertebral canal. The Lf-Dm unit, vertebral body, transverse processes, and the articular processes were identified. The depth from the skin to an imaginary line connecting the most posterior measurements was performed with the least possible compression of the subcutaneous tissue by the US probe. The epidural/CSE procedures were done using conventional techniques at the predetermined insertion point. The actual needle distance from the skin to the epidural space (needle depth [ND]) was marked. The primary outcome was the accuracy of the estimated depth to the Lf determined by US in the PSO plane (UD/PSO) compared with the depth to the epidural space during needle insertion via midline (ND) and with the estimated depth by US in the TM plane. Bland-Altman analysis was used to determine the differences and 95% limits of agreement between US depth and ND.Twenty patients from each World Health Organization obesity class were included, and data on all 60 were analyzed. Their mean age and body mass index were 33.2 years and 39.6 kg/m 2 . Epidural analgesia and CSE for cesarean delivery were performed in 32 and 28 patients, respectively. A mean difference of j0.05 cm was found between UD/PSO and UD/ TM. A mean...

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This chapter explores acute diastolic heart failure, which presents a difficult management scenario in the early post–cardiac surgery period. Initial diagnosis is assisted by knowledge of the patient's medical history and intraoperative course. It is made using both clinical and echocardiographic parameters. Diastolic dysfunction often remains asymptomatic until late in the disease process. When it presents clinically, it can be associated with an abnormal ejection fraction or, more commonly, with preserved ejection fraction. The diagnosis of diastolic dysfunction requires 3 conditions: the presence of signs and/or symptoms, normal left ventricular systolic function, and increased diastolic filling pressures. Treatment for diastolic heart failure includes fluid therapy, diuretics, vasoactive medicines, control of ventricular rate in atrial fibrillation, and amiodarone.