Der Anaesthesist
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This article reports a case of massive postoperative pneumocephalus in a patient following general anesthesia for a urological procedure. The patient had sustained a severe head injury more than 10 years ago with long-term treatment in an intensive care unit (ICU) including decompressive craniectomy, tracheostomy followed by rehabilitation, decanulation and cranioplasty. The patient recovered but suffered severe hemiparesis and mild neurocognitive deficits. ⋯ A cranial computed tomography (CT) scan revealed massive intracranial air and frontobasal skull defects. After frontobasal reconstruction, removal of an old lumboperitonal shunt and placement of a ventriculoperitoneal shunt, intracranial air was no longer observed. In summary a frontobasal injury may become symptomatic many years after injury, especially when face mask ventilation with positive pressure is applied during surgical interventions.
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New oral anticoagulants (NOAC) inhibit factor Xa (Stuart-Prower factor) or factor IIa (thrombin) and are alternatives to vitamin K antagonists. Perioperative indications are deep vein thrombosis prophylaxis for prosthetic hip and knee replacement, therapeutic anticoagulation for deep vein thrombosis as well as the prophylaxis of stroke for patients with atrial fibrillation. Patients on NOACs pose multiple perioperative challenges for all medical disciplines involved. ⋯ The individual risk for uncontrolled bleeding versus the urgency for surgery needs to be evaluated on an individual basis. The determination of drug serum levels enables a rough estimation of anticoagulant activity. Emergency procedures in coagulopathy due to active bleeding are treated with the unspecific administration of blood products and coagulation factor concentrates.