To determine if a relationship exists between intraoperative regional wall-motio abnormalities (RWMAs) and postoperative adverse outcomes, 87 patients who were undergoing elective coronary artery bypass graft surgery were studied prospectively using continuous transesophageal echocardiography (TEE). New RWMAs occured in 47% (41) of the patients during operation and in 31% (27) during cardio-pulmonary bypass terminating period (WEAN). Thirty patients had abnornal CK-MB level at ICU arrival (ENZ), and there were 10 perioperative myocardial infarctions (PMI) and 17 low-output syndromes (LOS) during ICU stay. RWMA in WEAN was significantly assosiated with all of the postoperative adverse outcomes and had 4.0-fold increase in the odds of PMI (95% confidence interval: 1.03-15.6), 3.3-fold of LOS (C.I.: 1.1-9.7), and 4.8-fold of ENZ (C.I.: 1.8-12.6). We conclude that patient subgroup who are at high risk for developing postoperative adverse outcomes can be identified intraoperatively by TEE.

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This review explains the physiological bases of oxygen transport and evaluation of the heart muscle contractility when we stop the assist circulation of the cardio-pulmonary bypass. When the cardiac index becomes more than two l/min/m² and the pressure of the left atrium becomes less than 18mmHg, we usually stop the assist circulation. And we also know Forrester's indication of the heart failure. However, there are controversies about the timing of the weaning from the assist circulation. We refereed the relationship of cardiac output and oxygen consumption which were obtained both at the resting condition and during mild to severe exercise. Then we interpolated the value of the minimum cardiac output to survive from the results. The value indicates 1.0l/min/m² in the cardiac index. The another limitation may be the maximum pressure of the left atrium to be proof against the lung damage. Forrester noted when the value becomes more than 18mmHg, the congestive lung will occur. But the actual lung can tolerate higher pressures, Judging from our analyois of pulmonary lymphatic drainage, 25mmHg of LAP within 30 minutes will never induce acute pulmonary edema.
In this article, I also introduce the QD and DS time during the cardiac surgery as the indices of the cardiac contractility. QD time is the duration time from R wave of ECG to the arterial end diastolic pressure. DS time is the duration time from the end diastolic pressure to the systolic pressure. When the duration of the DS time decrease less than 200 msec, the patients weaned from the cardio-pulmonary assist circulation. The evaluation of these indicator is not certain now, but the electrical circuit can measure these values easily and we can measure them continuously during and after the cardio-pulmonary bypass.

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吸入麻酔薬を使用した全身麻酔中27人の患者で房室接合部調律(atrio-ventricular junctional rhythm: AVJR)を記録した.セボフルラン3.0%,エンフルラン1.8%,イソフルラン1.5%にAVJR出現をみた.各吸入麻酔薬による出現率の間に統計学的に有意差はなかった.硬膜外麻酔併用群と全身麻酔単独群との間のAVJR出現率に有意差は認められなかった.AVJRをSethnaの分類に従い,等頻度房室解離(1型),wandering pacemaker(2型),A-V nodal rhythm(3型)に分けた.各型ごとのAVJR出現頻度は順に3型>1型>2型であり,循環動態の変化では血圧低下の大きいものから1型>3型>2型となり心房の輸送機能(atrial kick)の消失による心拍出量低下が1型でより強く起こることが示唆された.

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インスリン依存型糖尿病に膵腎複合移植を行なった10症例のICUでの術後管理を経験した.移植術中の血糖は人工膵臓を用いて管理した.術後は,免疫抑制療法と抗血栓療法を行なった.膵液や尿中のアミラーゼの量や濃度,細胞診,超音波ドプラー等で,拒絶反応や血栓の早期診断に努めた.また,血糖,血清Cペプタイドや尿量,血清クレアチニンを移植した膵および腎機能の指標とした.現在までのところ5例で膵機能が,9例で腎機能が得られている.膵腎複合移植の術後は呼吸,循環管理のほかに血栓症,膵腎機能不全,拒絶反応,感染症等の予防と早期発見に努めることが重要である.

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腹腔鏡操作中に発症した気胸2例を経験した.症例1は25歳女性で子宮内膜症疑いにて全身麻酔下に腹腔鏡検査中,気腹開始直後からSpO₂の低下,右呼吸音減弱が出現した.右胸腔ドレナージを行なったが術後空気漏出はなく,胸部CTでも肺野に異常はなかった.症例2は70歳男性で,胆石症にて全身麻酔下に腹腔鏡下胆嚢摘出術を施行中,炭酸ガスによる気腹開始約45分後に突然のSpO₂の低下,左呼吸音減弱,皮下気腫が出現した.左胸腔ドレナージを施行したが,胸腔ドレーンバツグの水封室内の水のPCO₂が722mmHgであり,胸腔と腹腔の交通が証明された.両症例とも医原性の横隔膜損傷はなく,横隔膜の欠損部や脆弱部の存在が強く示唆された.

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