Management of life-threatening acute severe asthma in children and adults may require anaesthetic and intensive care. The inhaled route for drug delivery is not appropriate when only small respiratory gas volumes are shifted; the i.v. route may be associated with greater side-effects. Magnesium sulphate i.v. has a place in acute asthma management because it is a mild bronchodilator, and has a stabilizing effect on the atria which may attenuate tachycardia occurring after inhaled and i.v. salbutamol. If intubation and ventilation are required, a reduction in bronchoconstriction by any means before and during these procedures should reduce morbidity. This narrative review aims to show strengths and weakness of the evidence, present controversies, and forward opinions of the author. The review contains a practical guide to the setting up, use and efficiency of nebulizers, metered dose inhalers, and spacers (chambers). It also presents a commonsense approach to the management of severe asthmatics in whom delay in bronchodilatation would cause clinical deterioration. When self-inhaled agents have had no effect, i.v. drugs may help avoid intubation and ventilation. The review includes suggestions for the use of inhaled anaesthetics, anaesthetic induction, and brief notes on subsequent ventilation of the lungs.

Introduction An anterior approach to lumbar interbody fusion is a widely utilized method of access to the lumbar spine. Due to the potential for vascular complications with spine exposure, vascular surgeons are frequently included in the care of these patients as part of a team-based approach. Identifying risk factors for such complications is difficult and not well-defined in the literature. In this investigation, we evaluate the potential risk factors for complications during anterior lumbar inter-body fusion (ALIF). Methods This is a retrospective review of 106 patients who underwent ALIF at a single institution between May 1, 2007, and April 30, 2017. Patients were identified through operating room case logs and Current Procedural Terminology (CPT) codes correlating with ALIF. Vascular surgeons performed all anterior exposures. Patient demographics and data regarding their surgical care and postoperative course were obtained from a review of operative and progress notes in the electronic medical record. Statistical methods employed included a t-test for normally distributed data and the Wilcoxon rank-sum test for non-normally distributed data. Categorical variables were compared using Fisher’s exact and chi-square tests. A logistic regression model was applied to predict complications by controlling other significant covariates. Results Of the 106 patients included in this analysis, 16 patients experienced a defined complication, giving an overall complication rate of 15%. Patients with complications were more likely to be of male gender (n=11, P=0.016), with older average age (54.6, P=0.017), with higher estimated blood loss, with higher use of blood products, and with higher use of cell-saver. A venous injury was the most common complication (n=11, 10.4%); ileus and nerve injury were the next most common (n=3, 2.8%). The 30-day mortality was 0%. Male gender demonstrated an odds ratio of 3.78 (P=0 .034) in a logistic regression model after adjusting for age and blood products. Conclusions Overall complication rates were comparable to those in the published literature and male gender was identified as a predictor for risk of complications in those undergoing ALIF. This is the first study to identify male sex as a risk factor for complications following ALIF. The results of this study will hopefully guide future studies in gaining more insight into the predictors of complications in larger series.

Background: Current pressurised metered dose asthma inhaler (pMDI) propellants are not inert pharmacologically as were previous chlorofluorocarbons, have smooth muscle relaxant‚ partial pressure effects in the lungs and inhaled hydrofluoroalkane 134a (norflurane) has anaesthetic effects. Volumes of propellant gas per actuation have never been measured. Methods:In-vitro studies measured gas volumes produced by pMDIs on air oxygen (O 2 ) levels in valved holding chambers (VHC) and the falls in O 2 % following actuation into lung ventilator delivery devices.Results: Volumes of propellant gas hydrofluoroalkane (HFA) 134a and 227ea and redundant chlorofluorocarbons (CFC) varied from 7 ml per actuation from a small salbutamol HFA inhaler to 16 ml from the larger. Similar-sized CFC pMDI volumes were 15.6 and 20.4 ml. Each HFA salbutamol inhaler has 220 full volume discharges; total volume of gas from a small 134a pMDI was 1640 ml, and large 3885 ml. Sensing the presence of liquid propellant by shaking was felt at the 220th discharge in both large and small inhalers. Because of a partial pressure effect, VHC O 2 % in air was reduced to 11% in the smallest 127 ml volume VHC following 10 actuations of a large 134a salbutamol inhaler. The four ventilator delivery devices studied lowered 100% oxygen levels to a range of 93 to 81% after five actuations, depending on the device and type of pMDI used. Conclusion:Pressurised inhaler propellants require further study to assess smooth muscle relaxing properties.

SummaryEleven patients in the intensive care unit following major abdominal surgery with a nasogastric tube in situ and receiving oxygen via facemask were allocated to receive in a random sequence oxygen at 4l.min-' via a Hudson mask, nasal cannulae or a nasal catheter with foam collar at the distal end. A signijcantly greater Pao, was achieved using both the nasal catheter with foam collar (p < 0.01) and Hudson mask ( p < 0.05) compared to the nasal cannulae. There were no signifcant differences in the Paco, or Spo, values obtained between the devices. In the majority of postoperative patients in whom a variable performance device is indicated, nasal devices appear preferable in terms of patient comfort and compliance. The nasal catheter with foam collar produced a significantly greater P a o , than nasal cannulae in patients with a nasogastric tube in situ.

Enterovesical fistulas are a well-known complication of inflammatory and malignant bowel disease. Bladder carcinoma, however, is an extremely rare etiology. We describe a case of squamous cell carcinoma of the bladder with an enterovesical fistula. This rare phenomenon has never been previously reported in western literature. We review the diagnosis, work up and treatment of enterovesical fistulas. Unfortunately, the prognosis for these highly invasive tumors is very poor and the treatment is often palliative. The high morbidity and mortality makes management of these patients exceptionally challenging.

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We describe the use of intravenous boluses of salbutamol given rapidly (over 1-2 min) in children (5 lg.kg )1 ) and young adults (250 lg) with acute severe asthma who were not improving with doses of nebulised salbutamol. Intravenous boluses were repeated within a short time until improvement was seen. Two of the seven patients required tracheal intubation and ventilation.

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