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The case of a patient who might have developed nasogastric tube syndrome at the end of anesthesia is presented. A 62-year-old woman was scheduled for a general anesthesia with fiberscopic oro-tracheal intubation because of a predicted difficult airway. After the smooth and gentle intubation without any trauma and injury, a nasogastric tube was inserted blindly. At the end of surgery, the anesthesiologists observed the pharyngeal tissue and found significant edema on the epiglottis and arytenoids. Extubation was cancelled and the patient was moved to an intensive care unit for respiratory management. On the next day, fiberscopic observation revealed a complete recovery and the endotracheal tube was removed without any difficulty. We strongly suspected the pharyngeal injury as acute nasogastric tube syndrome and an attention to this rare complication is required by anesthesiologists.

We describe a case of marked swelling of the tongue in a patient after a long prone position neurosurgery, who was treated for hypertension with alacepril. The tongue was not congestive and history of taking an angiotensin-converting enzyme inhibitor suggested an alacepril-induced angioedema. The day after surgery, the patient's tongue was still swollen; however, fibrescopic observation of the larynx and pharynx through the nasal cavity revealed that the edema was limited to anterior tongue, and the oral cavity and oropharynx were not involved. Although, tongue angioedema was observed, we introduced a 3-mm tube exchanger to the patient's trachea and removed the endotracheal tube. The ventilation and oxygenation were maintained, and 30 min later, the exchanger was detached. On the second postoperative day, the angioedema disappeared completely and the patient was transferred to a ward without any complication.

Cold agglutinin (CA) reacts reversibly with red blood cells at a low temperature and may cause thromboembolism of various organs. Therefore, special consideration is required in patients with cold agglutinin disease (CAD) undergoing cardiovascular surgery requiring hypothermia. Case 1: A 71-year-old man with elevated CA was scheduled to undergo total aortic arch replacement. Preoperatively, the patient received double filtration plasmapheresis to reduce CAs. The operation was performed at a higher temperature than the patient's thermal amplitude (TA) of 30 degrees C. Case 2: A 72-year-old man with CAD underwent a coronary artery bypass grafting. The patient's TA was 32 degrees C. The operation was performed on the beating heart with normothermic cardiopulmonary bypass. We performed an agglutination test at the temperature of 24 degrees C using the blood sample from the cardiopulmonary bypass circuit and no signs of agglutination were found. In both cases, no symptom of microembolism due to cold agglutination was recognized. This may indicate the possibility that the clinical risk is smaller than the risk recognized in vitro analysis. However, no safety standards for perioperative management of patients with CA are clearly established. Generally, it is more important to figure out the TA and to prevent the low-temperature exposure below the TA. In cases of normothermic procedures, further consideration for cerebral and myocardial protection is important.