Complications: Rare and Unusual Stephen N. Steen, Marcos Cafias, and Vladimir Zelman W E WERE, HARD PRESSED in titling this article Complications: Rare and Un- usual." The tautologist in our midst stated the redundancy, but then consider the whole of the F word! 1 To paraphrase Sykes 2 an anesthesiolo- gist's complications tend to be permanent and final--however rare and unusual--in contrast to those of the surgeon, which usually can be recti- fied by a more skillful surgeon at a later date. 2 Notwithstanding, we have used a somewhat arbitrary anatomic grouping for such complica- tions, which includes those we ran across (or conversely), from head to toe. More specifically, for anatomic sites, we shall consider cognitive psychomotor impairment (brain), other compli- cations therein (such as headache and hearing), and airway, the eye, and taste, and smell. Edema, embolism, and nerve injuries have been allotted sections, as have diseases and drugs (including sensitivity, toxicity, and transfusions), which last two groups cover a multiplicity of anatomic sites of the human body. Because of space limitations, we only discuss catheters as part of our newfound friendly monitoring equipment. E'en copious Dryden wanted, or for- got The last and greatest art--the art to blot Imitations of Horace, "Epistle 1" Alexander Pope AIRWAY For the nonce, the airway is the only way for air to permit of ventilation (air conditioning and enfluided rodents excluded). Upper airway ob- struction and neck swelling after carotid endar- terectomy (CEA) have been reported in six cases. 3 Of 596 CEAs, 2.5% required evacuation From the Department of Anesthesiology, University of Southern California, School of Medicine, Los Angeles, CA. Address reprint requests to Stephen N. Steen, ScD, MD, University of Southern California School of Medicine, 1200 N State St, Rm L14-901, Los Angeles, CA 90033. Copyright 9 1996 by W.B. Saunders Company 0277-0326/96/1503-000455.00/0 of wound hematoma. In an earlier study, 4 local anesthetic was recommended by the surgeon. For CEAs (particularly during operative stag- ing), vocal cord and tongue function should be evaluated, preferably by "speech pathologists who have outlined abnormalities at a higher fre- quency than clinical evaluation and laryngos- copy" to avoid airway obstruction. 5 Even hoarseness is suspect. A recent case of airway obstruction after bilateral CEA has been re- ported, 6 and the authors "postulate that bilateral hypoglossal nerve deficit resulted in a loss of upper pharyngeal muscle control" that "led to respiratory and cardiac arrests." A most informative case report after a CEA was the rupture of an unrecognized cervicothora- cic epidural venous angioma after a cervical epi- dural anesthesia in the same metamere in a 71-year-old who also had a cutaneous venous angioma over the left clavicular area. 7 Because "twenty percent of patients with congenital cuta- neous arteriovenous abnormalities have associ- ated spinal angiomas in the same metamere, ''7'8 we agree with the advisability to look for cuta- neous angiomas "when administering spinal or epidural anesthesia in the same metamere. ''7 A recent case of massive swelling of the tongue of a 28-year-old man requiring partial glossectomy on the 20th day after total resection of an intracranial tumor extending into the frontal cranial fossa from an upper nasal cavity has been reported. It was thought to be caused by mechani- cal obstruction of venous and lymphatic drainage by pharyngeal packs--though the patient was in the supine position during the 11-hour surgery. 9 Upper airway obstruction after multilevel cer- vical corpectomy for myelopathy has also been reported in seven patients. The authors "believed [the obstruction] to be due to edema rather than to the formation of a hematoma." 10They recom- mend "that extra caution should be used in the postoperative management of the airway when multilevel corpectomy is performed in patients who have" moderate or severe myelopathy and underlying pulmonary disease ("six patients had a history of heavy smoking and 1, of asthma").1~ 238 Seminars in Anesthesia, Vo115, No 3 (September),1996: pp 238-249