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We present two cases of dynamic left ventricular outflow tract obstruction in 2 patients who were undergoing living donor liver transplantation. On the preoperative transthoracic echocardiography, the first patient showed normal ventricular function and a normal wall thickness, but severe hemodynamic deterioration developed during the anhepatic period and this was further aggravated after reperfusion in spite of volume resuscitation and catecholamine therapy. Intraoperative transesophageal echocardiography revealed the systolic anterior motion of the mitral valve leaflet together with left ventricular outflow tract obstruction. The second patient showed left ventricular hypertrophy with left ventricular outflow tract obstruction on the preoperative echocardiography. Intraoperative transesophageal echocardiography was used to guide fluid administration and the hemodynamic management throughout the procedure and a temporary portocaval shunt was established to mitigate the venous pooling during the anhepatic period. The purpose of this report is to emphasize the clinical significance of dynamic left ventricular outflow tract obstruction in patients who are undergoing living donor liver transplantation and the role of intraoperative echocardiography to detect and manage it.

Pseudo-Meigs' syndrome is characterized by the presence of a benign ovarian tumor associated with ascites and a right-sided hydrothorax. The major problem associated with pseudo-Meigs' syndrome is the respiratory distress caused by a giant mass in the peritoneal space, massive ascites and pleural effusion. Even if there are no respiratory problems prior to surgery, potential respiratory dysfunction can occur during the peri-anesthetic period, leading to hypoxia, hypercapnea and respiratory acidosis. We report a case of hypoxia during recovery from anesthesia in a gynecological patient with pseudo-Meigs' syndrome.

The posterior fossa is surrounded by bone and tentorium, and an infratentorial brain tumor can compress normal brain structures, thus eliciting various symptoms. Surgery for an infratentorial tumor may stimulate deep brain structures, which can lead to cardiac autonomic responses. We report a brief sinus arrest immediately before dural closure following saline irrigation during removal of a cerebellar tumor. A 38-year-old female patient with no previous medical his tory underwent an elective surgery for resection of an infratentorial cerebellar tumor. The patient was premedicated with glycopyrrolate 0.2 mg and anesthesia was induced with propofol 80 mg and rocuronium 50 mg. Anesthesia was maintained with 50% O2 in air with 1.6-2.2% sevoflurane and infusion of remifentanil (0.1-0.15 μg/kg/min) and rocuronium (4.5-5.0 μg/kg/ min). The patient was placed in the left lateral park-bench posi tion with the head flexed and the midline suboccipital approach was used for the surgery. The tumor was removed successfully and the dura mater was almost closed except for a 2 mm-sized window for saline irrigation. The patient’s vital signs were stable, with blood pressure 110/70 mmHg, heart rate (HR) 68 beats per min (bpm), and peripheral oxygen saturation (SpO2) 100%. The end tidal carbon dioxide partial pressure (ETCO2) was adjusted to around 32 mmHg. Normothermia was maintained at 36.0-36.2 o C using a forced-air patient warming system (Bair Hugger Ⓡ warming unit, Arizant Healthcare, MN, USA). Room temperature saline was used as an irrigation solution and 30 ml of saline was administered in a 30 ml syringe with a 17 G curved needle tip through a small window of the dura mater. Instantly, the patient developed profound bradycardia and sinus arrest. Electrocardiogram rhythm and arterial blood pressure curve showed an 8-second period of sinus arrest followed by sinus bradycardia. Immediately after being informed of the events, the surgeon stopped the irrigation. The HR returned to normal sinus rhythm (65-70 bpm) without any other treatment and the patient experienced no additional events thereafter. The patient was extubated in the intensive care unit on the following day. Her mental status recovered well and vital signs were stable.

A tourniquet is used frequently in orthopedic surgeries, including total knee replacement, to reduce bleeding and enhance the visual field during surgery. Herein, we present a case with massive bleeding that occurred during a total knee replacement that had administered a tourniquet with adequate pressure. A 65-year-old man presented to the orthopaedic clinic for right total knee replacement due to osteoarthritis. The patient had right lower limb artery obstruction and a history of a right femoro-popliteal artery bypass graft 7 years prior to his visit. He was 169 cm tall weighing 68 kg. The patient had no other specific medical history, and no abnormal finding was covered on the preoperative examination. When the patient arrived at the operating room, his blood pressure was 150/90 mmHg. We provided propofol 120 mg and rocuronium 50 mg followed by induction with sevoflurane and 1 : 1 of oxygen and N2O. An inflation tourniquet with a pressure of 300 mmHg was applied to the right thigh. While the surgeon was making the skin incision to expose the joint, unpredicted massive bleeding occurred. Just before the tourniquet was applied, the patient's blood pressure was 95/65 mmHg, and right after the tourniquet was inflated, it was 130/80 mmHg. Based on the assumption of a tourniquet function error, we applied a new tourniquet with 300 mmHg of pressure on the right thigh. However, the bleeding continued even when we the raised pressure up to 400 mmHg. The bleeding decreased considerably when we deflated the cuff. Furthermore, with ultrasonographic guidance, we found that the femoral artery flow was not blocked by the tourniquet; therefore, the surgeon proceeded with the surgery without use of a tourniquet. During the surgery, 1,200 ml of crystalloid solution, 500 ml of colloid solution and packed RBC 4 units were administered and the estimated blood loss was 2,500 ml. Upon searching for the cause of the unpredicted bleeding, we examined the blood flow of the right femoro-popliteal artery bypass graft with ultrasonography 6 months later. It showed that both the femoro-popliteal artery bypass graft with or without 350 mmHg of tourniquet pressure had good blood flow (Fig. 1). A tourniquet is frequently used in total knee joint replacement surgeries to block the vascular flow of the limb during surgery. However, complications such as thigh pain, nerve injury, compartment syndrome, and nonalignment of the patella as well as systemic complications such as deep venous thrombosis, hypertension, and arrhythmia may occur. Therefore, it is important to maintain an adequate pressure and duration while using a tourniquet. There is no absolute limit on the pressure and duration when using a tourniquet, but Flatt [1] reported 2 hours is an adequate time if the patient has no hemodynamic problems. Horlocker et al. [2] reported 300 mmHg for the tourniquet pressure as being adequate for the lower limb. In this case, bleeding continued with an initial tourniquet pressure of 300 mmHg and even continued after we applied 400 mmHg of pressure. The use of the tourniquet instead increased the blood flow in our case. It is believed that the use of the tourniquet was unable to block the graft artery flow but collapsed the venous flow, which resulted in the increased blood loss. In case of artery occlusion above the knee, a polytetrafluroethylene (PTFE) bypass graft is used in elderly when an artery is in poor condition or there is no venous graft. For a PTFE bypass graft, it has good short outcomes compared to the use of a venous graft. For long term outcomes, a PTFE bypass graft shows less patency though. This case also used a PTFE bypass graft and this may have affected the blood flow when compared with a venous graft. However, there is no report on this issue yet. Complications from femoro-popliteal bypass grafts are myocardial ischemia, cerebral infarct, infection on the graft site, peripheral venous thrombosis, and sexual dysfunction by autonomic nerve injury. Infection on the graft site may result in permanent adhesion or fibrosis [3]. Therefore, in our case, it is believed that the patient had an asymptomatic infection, which resulted in adhesion and fibrosis around the artificial vessel graft. The adhesion and fibrosis blocked vessel collapsed even under high pressure causing severe bleeding afterwards. There is controversy about the use of a tourniquet in patients with peripheral artery occlusion. Some say it is safe not to use a tourniquet [4]. Others say there is no difference in postoperative vascular complications by using a tourniquet [5]. Therefore, adequate discussion must be carried out with orthopedists before use of a tourniquet. Patients with a history of a femoro-popliteal bypass graft should be evaluated first with ultrasonography on whether vascular flow can be blocked with a tourniquet. If it is decided that a tourniquet should not be used during surgery, care should be taken for the bleeding during surgery and for postoperative vascular complications.

Moen et al. [1] reported that spinal hematoma occurred in 8 out of 1,260,000 cases of spinal anesthesia in Sweden, and subarachnoid hematoma is known to be very rare [2]. We report a case of subarachnoid hematoma after spinal anesthesia in a patient without coagulopathy. A 33-year-old man with a height of 170 cm and weight of 65 kg underwent emergency surgery for acute appendicitis without perforation. The patient had no specific medical history and was taking no medications. Preoperative laboratory examinations including platelet count (236,000/mm3), prothrombin time (12.2 seconds, with international normalized ratio 1.07), and activated partial thromboplastin time (29.5 seconds) were in the normal range. The patient was placed in the right lateral decubitus position, and spinal anesthesia was attempted at the L4-5 intervertebral space via a midline approach using a 25 G Quincke spinal needle (Hakko Co., Naganoken, Japan). On the first trial, the needle reached the spinous process before it passed the ligamentum flavum, so it was removed immediately. On the second trial, clear cerebrospinal fluid without blood was observed without any particular difficulties. Fourteen milligrams of 0.5% hyperbaric bupivacaine mixed with fentanyl 15 µg was injected without pain, numbness, or dysesthesia. The patient was placed in the supine position, and the level of sensory block was T7 at 5 minutes after intrathecal injection. The operation was uneventful, and he was discharged without any specific neurologic symptoms. Five days after the spinal anesthesia, the patient called complaining of lower back pain and numbness in the lower limbs without allodynia, hypoesthesia, or paralysis. The complications that can occur after spinal anesthesia, such as transient neurologic symptoms (TNS), hematoma, abscess, cauda equina syndrome, spinal neurological damage, muscle rigidity, and myofascial pain, were explained to the patient, and he was asked to come to the hospital. However, the patient wanted to go to another hospital because of his personal affairs. Magnetic resonance imaging performed at the other hospital showed the presence of a subarachnoid hematoma (Fig. 1). The patient was mornitored closely but received no other treatment because the lesion was not large and his symptoms were improving. Ten days after the spinal anesthesia, his symptoms had all resolved. Fig. 1 T2-weighted sagittal magnetic resonance imaging shows a subarachnoid hematoma near L5. The hypo-intense signal in the T2-weighted image is consistent with deoxyhemoglobin. Spinal subarachnoid hematoma cases reported up to now have occurred mostly in patients who had problems with blood coagulability or in instances when anticoagulant was administered. Recently, Karakosta et al. [3] reported a subarachnoid hematoma occurring after spinal anesthesia in a 74-year-old male patient without any known blood coagulability disorder. In Comparison, the case we report here is unusual in that subarachnoid hematoma is very uncommon in patients as young as 33 years old. Subarachnoid hematoma is very rare even among spinal canal hematomas. The cause of this rarity is thought to be that it is difficult to generate a hematoma even when bleeding occurs, because the blood is diluted with cerebrospinal fluid and flushed with the flow of the fluid. Therefore, it is thought that spondylosis, herniation of intervertebral discs, arachnoiditis, and ligamentum flavum hypertrophy that can disturb the flow of spinal fluid may contribute to the formation of hematomas [4]. On the other hand, even when there are no disorders in the spinal canal, hematoma can occur if there is sufficient bleeding. In practice, the major contributing factor to bleeding or hematoma formation after spinal anesthesia is thought to be a problem in blood coagulability. Out of the 31 subarachnoid hematoma cases occurring after spinal anesthesia analyzed by Domenicucci et al. [4], a blood coagulability disorder was present in 23 cases (74%). In many of these cases, the blood coagulability disorder was caused by the use of an anticoagulant. In addition, the use of anticoagulant may cause a hematoma even when blood coagulability test results are normal [5]. In many cases of failed spinal anesthesia due to lack of cerebrospinal fluid, subarachnoid hematomas have been reported. Therefore, regardless of cerebrospinal fluid, all spinal puncture trials should be specified [5]. Minor symptoms of small subarachnoid hematomas can be confused with TNS [5]. The conspicuous difference between the two for differential diagnosis is the duration of the symptoms. Most symptoms of TNS disappear within two days. In the case reported here, however, the pains of spinal hematoma were persistent until 5 days after spinal anesthesia. MRI is the most useful test to diagnose subarachnoid hematoma [2]. However, if the hematoma is closely attached to the arachnoid, especially when the hematoma is located in front of the spinal cord, it is difficult to distinguish between a hematoma, arachnoid, and dura mater, and consequently it is difficult to distinguish subarachnoid hematoma from subdural hematoma. In such cases, a definitive diagnosis can only be obtained through surgical exploration. In the case discussed here, the subarachnoid hematoma could be diagnosed easily because the hematoma was detached from the arachnoid and the hematoma was surrounded by cerebrospinal fluid. The basic treatment for subarachnoid hematoma is surgical decompression. Although the symptoms can be minor, as in our case, in most cases neurologic deficits such as sphincter disorder and lower limb paralysis are observed. In such cases, rapid surgical decompression is recommended. Recently, there have been reports of small subarachnoid hematomas with minor pains being cured by conservative treatment [3]. However, even a small hematoma should be monitored closely, as neurologic deficits might develop. In our case, the patient was observed closely and the symptoms resolved quickly. In conclusion, when spinal anesthesia or epidural anesthesia is administered, the possibility of hematoma occurrence should always be considered regardless of the use of anticoagulant or multiple or traumatic centesis trials.

An unexpected difficult airway during the induction of general anesthesia may be challenging for anesthesiologists. We present the case of an unsuspected difficult intubation caused by an undiagnosed pharyngeal web and tracheal stenosis. An 85-year-old, 40 kg, 150 cm woman was scheduled for a combined operation of cataract and urinary incontinence. In her medical history, she had dementia and Parkinson's disease that were both treated with medication, and her preoperative ECG and chest X-ray showed a complete right bundle branch block and atelectasis in the left lower lobe. In the preanesthetic visit, she was classified as Mallampati I, showing no particular abnormality. General anesthesia was induced with fentanyl 50 µg, thiopental sodium 200 mg and rocuronium 40 mg. Under direct laryngoscopy (Macintosh curved blade #3), an oval structure different from the normal shape of the epiglottis and a narrow opening beneath it was seen, and their surrounding tissue presumed to be a pyriform sinus, was observed. After lifting up the epiglottic tip, two lumens were seen through the first opening, which were presumed to be the glottic and esophageal openings. We tried endotracheal intubation using a endotracheal tube with a 6.0 mm inner diameter (ID) and 8.4 mm outer diameter (OD). Because the glottis was not clearly observed and the tube could not easily pass the first opening, we reattempted intubation with a reinforced endotracheal tube 5.5 ID (7.5 OD). We could pass the first opening, but the sliding of the tube tip was performed blindly resulting in esophageal intubation. After failure of the third attempt, we recognized high pressure in the breathing bag even though the saturation was maintained at 100%, so we decided to try orotracheal intubation using a fiberoptic laryngoscope (LF-GP, Olympus, Tokyo, Japan). The first opening was confirmed, and as the fiberoptic laryngoscope was progressed slightly further, the glottic and esophageal opening were confirmed below the first opening. The vocal cords were observed as rudimentary and abnormal in shape, however we tried to slide in a reinforced endotracheal tube (5.5 ID), but the area seemed too tight after advancing 2-3 cm. We changed the tube to a smaller diameter and succeeded in fiberoptic intubation using a reinforced endotracheal tube 5.0 ID (6.9 OD). After the operation, the patient recovered without respiratory difficulty. In the postoperative interview, we found that she had suffered from dysphagia (solid food) since long ago but had not been treated, since the symptoms were not severe. A postoperative computed tomography (CT) showed a pharyngeal web covering the laryngeal part of the pharynx on the posterior pharyngeal wall in the upper part of the hypopharynx, with tracheal stenosis below the C6 level of the cricoid area, and upper esophageal wall thickening that extended to mid-esophagus which was suspected of esophageal cancer, accompanied by an elevation in the piriform sinus and esophageal dilatation. Her rigid laryngoscopic examination (Fig. 1) by otorhinolaryngologists had a similar review as the one that was found during endotracheal intubation and CT findings. Fig. 1 (A) The rigid laryngoscopic view of the hypopharyngeal web after the operation. It shows a shape similar to the glottis and did not show the esophagus. W: A web formation of the upper part of the hypopharyx. (B) The rigid laryngoscope view as it was advanced ... The true glottis and the esophageal opening were observed only after the rigid laryngoscope had passed the first opening that resembled the glottis. The true vocal cord was not developed well, the false vocal cord and pyriform sinus were very thickened, the cuneiform and the corniculate cartilage were enlarged, and the glottis entrance had become narrow. The patient was given a recommendation to undergo an examination of the pharyngeal membrane for esophageal cancer but the patient refused. After 6 months, she died of esophageal cancer. In this case, it is uncertain whether the anatomical abnormality of the pharyngeal web and the tracheal stenosis were congenital or acquired. Such a case report is rarely found even among reports in other countries. Considering that the patient had long suffered dysphagia when eating solid food and tracheal stenosis might have been caused by the thickening of the esophageal wall resulting from esophageal cancer, we could not rule out the possibility of Plummer-Vinson syndrome which is associated with pharyngeal web formation and esophageal cancer [1]. The pharyngeal web is not a particular inducer of difficult endotracheal intubation, but in this case, the web was formed on the upper part of the hypopharynx and covered parts of the esophagus and larynx. In addition to these severe anatomical variations, tracheal stenosis had accompanied, and these problems made endotracheal intubation difficult. According to the difficult airway algorithm suggested by the American Society of Anesthesiologists [2], when the first endotracheal intubation is unsuccessful, the anesthesiologist considers calling for help and determines whether he has to awaken the patient while ventilation continues. If mask ventilation is maintained properly, the anesthesiologist may consider some different methods including the use of different laryngoscope blades, a laryngeal airway mask (LMA), fiberoptic intubation, intubating stylet or tube changer, light wand, retrograde intubation, and blind oral or nasal intubation. As we chose fiberoptic intubation and it was successful, management was appropriate. But in the case of failure, the anesthesiologist may consider awakening the patient, performing an invasive airway access or other feasible options. In conclusion, it is ideal to predict a difficult airway during the patient's preoperative visit and to prevent difficult airway situations through full preparations, but thanks to recent advanced anesthetic methods and equipment we may be able to overcome difficulties in airway management through careful stepwise handling.

Background: The aim of this study is to determine the effect of high dose fentanyl on the test dose containing 15 epinephrine during propofol anesthesia. Methods: One hundred patients with ASA physical status 1 were randomized to receive 2 mg/kg propofol with or without 10/kg fentanyl at the induction of anesthesia (n = 50 each). Anesthesia was maintained with propofol 8 mg/kg/h and 67% nitrous oxide in oxygen. Each group of patients were further divided into a test dose group receiving 1.5% lidocaine 3 ml plus epinephrine 15 or a saline group receiving 3 ml of isotonic saline (n = 25 each). Heart rate (HR) and systolic blood pressure (SBP) were monitored for 4 min after intravenous injection of the study drugs. Results: In the propofol and the propofol-fentanyl group, the intravenous injection of the test dose produced a HR increase 20 bpm (conventional HR criterion) in 25 and 23 out of the total 25 patients, respectively. Therefore, in the propofol-fentanyl group, sensitivity, specificity, positive predictive value, and negative predictive value were 82%, 100%, 100%, and 92.6%. According to the modified HR criterion (HR increase 10 bpm), all the values were 100%. All patients receiving test dose developed SBP increase 15 mmHg. Conclusions: Our results indicate that both HR increase 10 bpm or SBP increase 15 mmHg are clinically applicable during propofol-nitrous oxide anesthesia with 10/kg fentanyl.

Background: Almost all anesthesiologists are encounter a difficult airway occasionally, which is probably the most important cause of anesthesia related morbidity and mortality. The intubating laryngeal mask airway (ILMA; FastarachTM; laryngeal mask company, Henley-on-Thames, UK) is a new device for tracheal intubation. It is an ideal rescue airway since it can be placed quickly and used as a conduit for endotracheal intubation, while ventilation is ongoing. This prospective study was underttaken from January, 1997 to December, 2004 to evaluate the appropriateness of the ILMA for anticipated or unanticipated difficult airways. Methods: After institutional committee approval, seventy eight patients were enrolled in this study. The anticipated group compromised thirty five patients and the unanticipated group forty three. In the unanticipated group, anesthesia was induced with thiopental sodium and vecuronium and maintained with enflurane or isoflurane, whereas in the anticipated group, awake intubation with nerve block was done before intubation. The success of the technique (within five attempts), the number of attempts, the durations of the successful attempts, and adverse events (desaturation, bleeding) were recorded. Results: The rate of successful tracheal intubation with ILMA was 92.7%. The numbers of attempts and the times to success were not significantly different between the two groups. Adverse events occurred significantly more frequently in the unanticipated group. Conclusion: The ILMA is a useful device for the management of patients with a difficult airway and may be a valuable alternative to direct laryngoscopy or fiberoptic intubation when neck movement is unfavorable or in those with an unanticipated difficult airway.

Background: Self inflating resuscitators are widely used for the patients who need positive pressure ventilation during transport. During self inflating resuscitator ventilation, the may decreases even with the use of the oxygen reservoir. Such phenomenon may increase the difficulty and risk of transport of the critically ill patients. Twin self inflating resuscitator was assembled by being modified from two conventional ones to achieve more stable . Methods: The twin self inflating resuscitator and one conventional adult self inflating resuscitator were tested on a test lung. In the twin resuscitator, two adult self inflating resuscitators were connected serially without distal unidirectional valve plate. The resuscitators were compressed at variable tidal volumes, respiratory rates and oxygen flow rates, guided by the monitor. Results: With conventional self inflating resuscitator ventilation, the was maintained over 95% until minute ventilation of at respectively 5, 10, 15 L/min oxygen flow rate. With serial type, the started to decrease with the minute ventilation over at 5, 10, 15 L/min oxygen flow rate. Conclusions: By simple connection of two self inflating resuscitators, the during self inflating resuscitator ventilation could be maintained during almost two times of minute ventilation compared to conventional ones.

Background: AVP (arginine vasopressin) shows unique hemodynamic characterisics, as a vasopressor. AVP has been tried in many cathecholamine refractory vasodilatory situations, andsometimes resulted in effective hemodynamic improvement. In dis study, we hypothesized that low dose AVP infusion could recoverthe decreased SVR (systemic vascular resistance) induced by milrinone infusion with minimal effect on PVR (pulmonary vasculr resistance). Methods: Sixteen patients undergoing OPCAB participated in this study. After a loading dose milrinone was infused, low dose vasopressin infusion was started and titrated until the ssremic blood pressure increased by 20%. During the study, hemodynamic factors including pulmonary capillary wedge pressur and cardiac output were measured using a continuous thermodilution technique with a Swan-Ganz catheter. Results: Milrinone infusion reduced both SVR and PVR. And vasopressin infusion increased SVR, but show relatively less effect on PVR. Conclusions: Low-dose vasopressin infusion could be used to recover the SVR decrease caused by milirinone infusion with little effect on PVR.

Background: The low cardiopulmonary resuscitation (CPR) survival rate in Korea might be associated with inadequate education, an insufficient number of trained medical personnel, the inappropriate management of instruments and drugs in CPR carts. The purpose of this study was to determine the current status of these factors in major Korean university hospitals. Methods: We surveyed the following items among anesthesiologists at 13 university hospitals via E-mail. The items in the questionnaire were; 1) the time allocated to CPR instruction for medical students and anesthesiology residents in a year, 2) the organization, call system, and the role of each member of the CPR team, 3) the establishment of standard in-hospital CPR protocol, 4) the CPR cart items list and their exchange intervals, and 5) post-CPR reporting. Results: The durations of education for anesthesiology residents and medical students were

Skin antisepsis prior to the induction of spinal anesthesia is essential because of the potential for infectious complications. Povidone-iodine is a widely used antiseptic solution for skin preparation before spinal anesthesia, and chlorhexidine alcohol solution is a commonly used alternative to povidone-iodine. Previous studies have shown that chlorhexidine is more effective than povidone-iodine for skin preparation before intravascular catheter insertion or blood culture collection. The bacterial contamination rate of needles used for spinal anesthesia disinfected with povidone-iodine has also been previously studied; however, no study has been carried out to evaluate the comparative anti-microbial efficacies of povidoneiodine and chlorhexidine for skin disinfection prior to spinal anesthesia. The aim of this prospective trial was to determine if an alcoholic solution of 0.5% chlorhexidine is more effective than an aqueous solution of 10% povidone-iodine at reducing the bacterial contamination rate of spinal needles.

Background: The isolated lung model is a very useful model in investigation of hypoxic pulmonary vasoconstriction (HPV), and angiotensin II is extensively used in this model. But the exact role of angiotensin II in HPV is not clear in the isolated rabbit lung. Thus we were concerned about the role of angiotensin II in the blood-perfused rabbit lung. Methods: New Zealand white rabbits (n = 28) lungs were isolated and perfused with a constant pulmonary perfusate flow; acid-base status and temperature were maintained at constant levels. Deoxyglucose (DOG group, n = 7), angiotension II and deoxyglucose (AG-DOG group, n = 7), calcium (CA group, n = 7), angiotensin II and calcium (AG-CA group, n = 7) were administered, and then hypoxic responses were measured. Three ratios were calculated and compared (P$_{}$: ratio of hypoxic response to pulmonary arterial pressure at normoxia, P$_{}$: ratio of hypoxic response to baseline hypoxic response, P$_{}$: ratio of pulmonary arterial pressure at hypoxia to pulmonary arterial pressure at baseline). Results: Angiotensin II increased the pulmonary arterial pressure by 14%, and increased HPV. Baseline pulmonary pressure was increased in the AG-DOG group and in the AG-CA group (P ＜ 0.05). P$_{}$ significantly increased in the AG-DOG and AG-CA groups (P ＜ 0.05). The first HPV increased but the second HPV decreased in the AG-DOG group (P$_{}$: P ＜ 0.05) and in the AG-CA group. P$_{}$ showed no difference between groups. Conclusions: Angiotensin II resulted in an increase of pulmonary arterial pressure in the isolated rabbit lung. One may misinterpret this as an potentiation of HPV, but HPV was not changed by angiotensin II. Therefore we deny the necessity for angiotensin II in the isolated rabbit lung model.

Background: Potent inhalational agents are widely used for thoracic anesthesia. They have several desirable properties, including ease of administration, rapid onset and offset, and bronchodilation. One potential drawback is their ability to directly inhibit hypoxic pulmonary vasoconstriction. Desflurane does not directly inhibit hypoxic pulmonary vasoconstriction in vivo, in contrast to isoflurane using the same animal model. In this study, we compared the effects of desflurane and isoflurane on arterial oxygenation and hemodynamics during one lung ventilation in a humans. Methods: Thirty five patients scheduled for coronary artery bypass graft were randomly assigned to one of group D/I and I/D. Group D/I consisted of four steps. Hemodynamics and oxygenation parameters were checked in each step. Step 1 was checked when they received desflurane to an end tidal concentration of 6% in 93% oxygen from induction until the end of 30 min of two lung ventilation. Step 2 was checked at the end of 30 min after starting one lung ventilation. Step 3 was checked at the end of 30 min after receiving isoflurane to an end tidal concentration of 1.2% in 93% oxygen during one lung ventilation. Step 4 was checked at the end of 30 min after restarting two lung ventilation. Group I/D received the two anesthetic agents in reverse order. We used the simple cross-over design methodology for treatment and period effect. Results: We found no significant difference in hemodynamic and oxygenation parameters between the two inhalational agents except for a significant increase in mean pulmonary arterial pressure and pulmonary capillary wedge pressure caused by desflurane. Conclusions: During one lung ventilation, the choice between desflurane and isoflurane does not significantly influence arterial oxygenation and shunt fraction but desflurane should be administered with great caution if it is used as an alternative anesthetic in patients with ischemic heart disease.

We report a case of fatal pulmonary hemorrhage developed after reperfusion of grafted liver during a living-related liver transplantation. A 53 year-old man who had hepatic encephalopathy grade 4 with fulminant hepatic failure was scheduled for a living-related liver transplantation. Preoperative evaluation showed fever, hypoxia, hypotension, pneumonia, and pulmonary edema. Cardiopulmonary stability was maintained with oxygen therapy and inotropic agents. During the anhepatic period, the patient's vital signs remained stable with inotropic agents except one episode of sudden hypotension presumably due to right heart strain. However, hypoxia, acidosis, and electrolyte imbalance were becoming worsen in spite of variable treatments for correction. Immediately after reperfusion, a sudden increase of central venous pressure and pulmonary artery pressure was noticed. Severe bradyarrhythmia, hypotension, hemoptysis, hypoxia, and acidosis were followed by cardiac arrest. Cardiopulmonary resuscitation was not successful and the patient expired.

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered to be an aberrant outcome of acute pulmonary thromboembolism, due to inadequate thrombus dissolution. However, the mechanism of thrombi dissolution failure remains unclear. With respect to inherited thrombophilia, the co-occurrence of natural anticoagulant deficiencies with CTEPH was found to be rare. Pulmonary thromboendarterectomy (PTE) is a potentially curative surgical procedure for CTEPH, but it is associated with considerable mortality due to postoperative complications, such as reperfusion pulmonary edema and right heart failure. The postoperative course after PTE poses a unique series of ventilatory care and hemodynamic management challenges. We present the case of a 42-year-old woman with unilateral CTEPH combined with thrombophilia (Protein S deficiency). Successful PTE was followed by independent lung ventilation with unilateral nitric oxide (NO) inhalation, which resulted in functional improvement without postoperative complications.

Background: Inadequate preoperative evaluation leads to delay or cancellation of elective surgery. To minimize this problem, we launched an anesthesia preoperative evaluation clinic. We analyzed major causes of referral, requested departments and distribution of age to make guidelines of management and laboratory tests. Methods: The data was collected based on 6,902 patients referred to the anesthesia preoperative evaluation clinic from August 1997 to February 2002. The number of patients each year, distribution of sex, age, requested departments and clinical causes of referral were analyzed retrospectively. Results: The sex ratio (M/F) was 42：58. Twenty-three percent of the patients were in their 7th decade. Obstetrics and gynecology (24.3%), general surgery (20.7%), and orthopedic surgery (15.4%) were the main requested departments. Major causes of referral were cardiovascular problems (27.5%) and pulmonary problems (21.0%). Irrespective of age and department, the most common consultations were related to cardiovascular or pulmonary problems. Nineteen percent of patients had more than two problems that included diabetes mellitus and hypertension. Conclusions: We concluded that increases in the number of referral patients and making guidelines related to cardiovascular and pulmonary problems will contribute to reduce delay or cancellation of elective surgery.

Background: Echocardiography is usually performed for preoperative cardiac evaluation before coronary bypass graft surgery. If the variables detected by this noninvasive method could predict the outcome of the off-pump coronary bypass surgery (OPCAB), it would be very helpful. The purpose of this study is the evaluation of preoperative transthoracic echocardiographic findings as the predictor of OPCAB outcome. Methods: We evaluated the relationships between preoperative variables identified by the transthoracic echocardiography and postoperative outcomes. Results: Among the doppler findings trans-mitral flow shows no relationship with the postoperative outcome. But, left ventricular mass had the predictability of postoperative time of extubation, ICU stay, and hospital stay. Conclusions: Left ventricular mass can be used to predict the outcome after OPCAB and There are the need of further study to find out the reason the left ventricular mass show relationship with the postoperative outcome.

Background: Several studies have suggested that the spinal cord may be an important site of anesthetic action and have established that general anesthetics potentiate the effects of GABA at the receptor. It was, therefore, hypothesized that the suppression of nocifensive movements during anesthesia is due to an enhancement of receptor-mediated transmission. Therefore, the aim of this study was to determine behaviorally whether intrathecal GABA, glycine, or opioid receptor antagonists may change the anesthetic effect of isoflurane and enflurane. Methods: The minimal alveolar concentration (MAC) of isoflurane and enflurane was determined in Sprague-Dawley rats, by the tail-clamp technique. First, MAC was determined and then concentration of each inhalation agent was increased by 0.2% from the sub-MAC level. Moving latencies were observed after the intrathecal administration of each receptor antagonist. Rectal temperature was measured and maintained at a steady level during the experiment. Results: The spinal antinociceptive effects of isoflurane and enflurane were significantly reversed by the receptor antagonist bicuculline and picrotoxin (P ＜ 0.05). The rectal temperature was well maintained within the range of 37-39. Conclusions: Our results suggest that the general anesthesia induced by isoflurane and enflurane, which are similar in terms of their action mechanism, is likely to be related to the spinal receptor system.

Cerebral protection during aortic arch surgery is an anesthetic challenge, since the surgical procedures for aortic arch aneurysm involve an interruption of cerebral blood flow. We report a successfully managed case of aortic arch aneurysm repair with antegrade selective cerebral perfusion (SCP) during TCA (total circulatory arrest) using a transcranial oximeter, cerebral oxygenation was monitored during surgery. Although at the beginning of TCA a decrease in the regional cerebral oxygen saturation was observed, this was soon recovered by SCP. Except for the short period of TCA without SCP, regional cerebral oxygen saturation () value were well maintained during surgery.

Cold agglutinins are serum autoantibodies activated at reduced body temperatures to produce red blood cell agglutination and hemolysis. They are commonly found in the sera of healthy people but rarely become clinically important, because most of them exist at very low titers, and exert their greatest effect at low temperatures. By contrast, during open heart surgery, systemic hypothermia and cold cardioplegia are commonly used, and cold agglutinins can be a appreciable threat. This report describes a patient with documented cold agglutinins who successfully underwent atrial septal defect closure and patent ductus arteriosus ligation by normothermic cardiopulmonary bypass in an effort to avoid the adverse effects of hypothermia.