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The three ways to observe the lungs using ultrasonography are transthoracic echography, transesophageal echography and endobronchial ultrasonography. All methods have their own advantages. Consolidation and pleural effusion are evaluated with transthoracic echography and transesophageal echography. The advent of comet-tail artifact observation made the transthoracic echography worthwhile.

A 44-year-old man (ASA-PS 1) underwent right lobectomy of the liver under total intravenous anesthesia with propofol, remifentanil, ketamine and rocuronium. In order to evade allogeneic blood transfusion, 1,200 g of the patient's blood was taken and hemodilution was induced for autologous blood transfusion (HAT) after the induction of anesthesia. As intraoperative blood loss amounted to about 4,000 g, Hb level decreased from 13.6 to 6.2 g x dl(-1). However, as intraoperative hemodynamics was relatively stable with crystalloidal and colloidal transfusion with no ischemic change on ECG and no metabolic acidosis, autologous blood transfusion was withheld. After returning the autologous blood, Hb increased to 9.8 g x dl(-1). Any postoperative complications related to the low Hb level were not recognized. HAT is a useful method to evade or at least decrease the amount of allogeneic blood transfusion by anesthesiologists.

A 15-year-old man developed cardiopulmonary dysfunction 4 days after flu-like symptom, and was transfered to our hospital and diagnosed as a fulminant myocarditis (FM). Intraaortic ballon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were immediately initiated. However, cardiac function did not recover until 7 days after admission to the ICU, and bilateral ventricular assist devices (BiVAD) were introduced with extracorporeal membrane oxygenation (ECMO). Right ventricular assist device (RVAD) with ECMO was established by right atrial blood withdrawal and pulmonary arterial blood supply using centrifugal pump. After operation of BiVAD, to main LVAD flow, frequent blood-and-fluids volume loading and increase in RVAD flow were necessary due to postoperative bleeding and massive foamy sputum. However, even after hemostasis had been established, the pulmonary edema continued and it was difficult to maintain LVAD flow because of endless transudation from the lungs. Eventually, he developed MOF and passed away 9 days after the admission to ICU. As in cases of end-stage dilated cardiomyopathy, outflow of RVAD into the left atrium instead of the pulmonary artery was demonstrated effective in avoiding trans-pulmonary leakage, and outflow of RVAD into the left atrium may be beneficial to patients with FM who need BiVAD but suffered severe pulmonary edema.

We describe a case of 65-year-old obese female patient with pulmonary embolism and life-threatening hypernatremia after removal of craniopharyngioma. On the 18th day after neurosurgical procedure, pulmonary embolism developed abruptly. Immediately after placement of inferior vena cava filter, surgical removal of the pulmonary thrombus was performed under cardiopulmonary bypass. Although mechanical ventilatory support and infusion of noradrenaline were required postoperatively, the trachea was extubated on the 10th postoperative day. Meanwhile, daily serum Na level increased gradually and reached 178 mEq x l(-1). We suspected that dehydration and pituitary dysfunction were mainly responsible for the hypernatremia. Human atrial natriuretic peptide (hANP) was infused from the 2nd to the 4th postoperative day, and her urinary Na excretion became increased and serum Na level became normal. After discontinuation of hANP, urinary Na excretion became decreased again and serum Na levels increased transiently. However, her consciousness level and cardiopulmonary condition improved and she was discharged from the ICU after twelve days of ICU stay. HANP may be useful for treatment of life-threatening hypernatremia.

We report a case of surgical vertical-section of the nasoendotracheal tube during operation, resulting in intra-operative ventilatory difficulties. The patient was a 32-year-old female, scheduled for Maxillo-Mandibular osteotomy under general anesthesia. She was intubated with I.D. 6.0 mm non-kinking tube via left nasal cavity. Forty minutes into a maxillar osteotomy, sudden tracheal tube leak sound was noticed by surgeon. Ten more minutes later, ventilation became difficult, and laryngeal packing was done temporarily. We tried to exchange the nasotracheal tube with Airway Scope, but not with endotracheal tube exchanger, because there was a possibility of complete tube section or difficult extubation from nasal cavity. We could examine the larynx whether it was with edema or not, and two tracheal tubes at the same time. Therefore, we performed tube exchange smoothly and safely. The extubated tracheal tube had serious cut on cuff inflation line made by surgical maneuver. In the case of suspected laryngeal edema or tracheal tube injury, use of Airway Scope for tube exchange may be a safe and reliable method.

We report a case of bilateral giant bullae in a patient with multiple traumas. He had his arm amputated at the shoulder because of a machine accident and admitted to our hospital. Chest X-ray showed right-sided pneumothorax with bilateral giant bullae. Trimming of the stump was performed immediately after the placement of a right chest tube. He gradually developed hypoxia and hypercapnia with acidemia during the operation because of atelectasis due to sputum. Postoperatively, enlargement of right giant bulla led to frequent respiratory failure and he received a bilateral bullectomy through a median sternotomy 3 weeks after the accident. It was difficult to ventilate him due to air leak from the bilateral bulla and SpO2 dropped to below 70% with 100% oxygen. We continued the operation with standby extracorporeal membrane oxygenator (ECMO). Although the operation was finished without ECMO finally, ECMO had better been kept ready during anethesia with giant bullae when life threatening complication may occur at any point.

We report two cases of left ventricular outflow tract (LVOT) obstruction with systolic anterior motion (SAM) of anterior mitral valve due to specific (secondary) cardiomyopathy during operation. The LVOT obstructions occurred and led to hypotension just after the induction of anesthesia in one case, and following the administration of nicardipine in another case. In both cases, preoperative diagnosis of the specific cardiomyopathy was not made. We revealed the LVOT obstruction with SAM using a transesophageal echocardiography (TEE) when the unstable hemodynamics developed. After the operations the valvular cardiomyopathy without LOVT obstruction was diagnosed by a cardiologist. Careful management is required including the TEE monitoring when we anesthetize a patient who is complicated not only with idiopathic cardiomyopathy but also with specific cardiomyopathy such as valvular or hypertensive cardiomyopathy because both types of cardiomyopathy develop LVOT obstruction with SAM in some pathophysiological conditions during operation.

Brugada syndrome should not be neglected in terms of anesthetic management because its perioperative autonomic imbalance may cause ventricular fibrillation and sudden cardiac arrest. Diagnosis of Brugada syndrome is easily made by unique electrocardiographic pattern of right bundle branch block and ST segment elevation in the right precordial leads. Thus the number of patients with Brugada syndrome for anesthetic management tends to increase. We review current concept of anesthetic management for patients with Brugada syndrome including fourteen cases in our institution, two out of which developed VF during operation.

We report a case of left ventricular outflow tract (LVOT) obstruction caused by systolic anterior motion of the mitral valve (SAM) following mitral valve plasity (MVP). A 65-year-old man underwent mitral valve plasty for grade III mitral valve regurgitation. The plasty was done smoothly and the patient was weaned from cardiopulmonary bypass successfully with continuous dobutamine infusion. However, about 30 minutes after the weaning, severe cardiovascular collapse developed. Inotropic agent, such as dobutamine, ephedrine, or calcium hydrochloride was not effective. Trans-esophageal echocardiography (TEE) showed severe mitral valve regurgitation with LVOT obstruction due to SAM. The collapse was successfully treated with volume loading and a small amount of a beta1-adrenergic antagonist, landiolol hydrochloride. We conclude that acute LVOT obstruction with SAM could develop following MVP. TEE was a much useful tool for early diagnosis and landiolol hydrochloride would be a notable agent for nonsurgical treatment of LVOT obstruction with SAM.