We have been using the Type and Screen (T&S) system for efficient use of red blood cells in elective surgery since its introduction in 1992. Although the total number of elective surgery cases increased from 1, 546 in 1992 to 2, 654 in 2001, the rate of the number of blood-ordered cases to total cases decreased from 46.2% to 30.5% and orders using the T&S system increased. Crossmatched blood units reduced from 2, 511 units to 1, 281 units, but the crossmatch-to-transfusion ratio (C/T ratio) did not change.
The results show the usefulness of these systems in perioperative blood transfusion. In order to use blood more effectively, we should establish an appropriate standard for T&S and MSBOS, reconsider the standard at regular intervals and enlighten surgeons about the standard.

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We evaluated the blood loss of 24 TUR-P patients by measuring hemoglobin (Hb) concentration in waste irrigation fluid with HemoCue Plasma/Low Hemoglobin^TM. Blood loss volume was calculated as follows:
Blood loss volume (ml)=Hb concentration (g•l^-1) x fluid volume (ml)/mean of preoperative and postoperative Hb concentration (g•l^-1)
In two of the 24 patients, Hb concentration was lower than the detection limit (0.3g•l^-1). Blood loss volume of 22 patients was estimated as 374±1104ml (mean±SD) (range: 28-1486ml). Blood loss volume did not have a significant correlation with the length of surgery or the weight of the resected prostate.

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We successfully treated a patient with postoperative respiratory depression caused by accidental intrathecal morphine overdose with continuous intravenous naloxone. A 48-year-old woman underwent pneumonectomy, received an accidental morphine 3.2mg intrathecally during the operation and developed postoperative respiratory depression. She was treated with continuous intravenous naloxone. The infusion rate was 0.2-0.4mg•h^-1 over sixteen hours, the total naloxone dose being 5.7mg. She was discharged from the Intensive Care Unit on the first postoperative day without further complications. Continuous intravenous naloxone was useful for the treatment of respiratory depression due to intrathecal morphine overdose, but respiratory status should be monitored carefully.

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There have been 6 cases that had difficult to predict postoperative respiratory management in the last 14 years and 7 months in our department. These cases. were able to extubated after 1 or 2 postoperative days.
Aggravation of respiratory state after surgery may be induced by various factors, and postoperative respiratory management may be needed.
We should carefully monitor the patient's respiratory state during surgery with more useful parameters. We feel that the diagnosis and treatment is very important, even in those patients who do not show any special problems in the preoperative evaluation.

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An 81-year-old male with pulmonary cancer underwent a thoracoscopic right upper lobectomy. Anesthesia was induced with propofol and fentanyl. A left side # 37 French double-lumen tube (DLT) was inserted. Anesthesia was maintained with propofol and fentanyl in an oxygen-air mixture using a combination of thoracic epidural anesthesia. One-lung ventilation (OLV) with collapse of the right lung was applied for 210 minutes without significant hypoxemia.
Postoperative chest X-ray revealed alveolar infiltrates in the right lung. They were present only in the lung that had been collapsed and re-expanded. This pulmonary edema could be caused by reexpansion pulmonary edema. The patient received diuretics and oxygen therapy by mask. The radiographic evaluation on postoperative day 15 was greatly improved. Re-expansion pulmonary edema usually occurs when a chronically collapsed lung is re-expanded rapidly. Anesthesiologists should recognize the occurrence of re-expansion pulmonary edema following one-lung ventilation.

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A 72-year old man complained of dyspnea and was transferred to our hospital. Tracheal intubation was carried out due to hypoxemia, followed by improvement of his respiratory condition. On the day following the intubation, the patient was extubated, but dyspnea and cyanosis appeared immediately. He was intubated again, but his respiratory condition did not improve. Bronchofiberscopic examination revealed that an enormous vocal cord polyp obstructed the trachea. Tracheostomy was performed, and the polyp was removed under sevoflurane inhalation to recover spontaneous breathing.
Tracheal intubation should be performed carefully, especially in patients with enormous vocal cord polyps.

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Fukuyama type congenital progressive muscular dystrophy is a congenital myodystrophy specific to Japanese people. The incidence of this disease is 2.9 in 100, 000 persons: only sixth part of Duchenne's muscular dystrophy. We describ the anesthetic management of a 6-year-old patient with this disease who underwent tonsillectomy under total intravenous anesthesia. By using propofol as the main anesthetic agent, it was able to be managed without causing malignant hyperthermia, and with less likelihood of shivering and the delay of emergence. Moreover, to avoid respiratory depression, the amount of fentanyl was reduced by the concomitant use of local infiltrated lidocaine; neuromuscular monitoring was essential to minimize the dose of vecuronium so that it did not cause delayed recovery.

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Angelman syndrome is a hereditary disease that shows severe mental retardation, seizures, unprovoked laughter, balance disorder, protruding tongue, projection of the lower jaw, and increased sensitivity to heat. We report here a case of 2-years-old girl with this syndrome who underwent adenotomy for sleep apnea syndrome due to adenoid hypertrophy. Anesthesia was induced with 5% sevoflurane in 100% oxygen; her trachea was intubated easily. After anesthesia induction, her rectal temperature was 37.9°C. Cooling the operating room and a water blanket were needed to avoid increasing the patient's body temperature. It was thought that, besides airway or seizure control, the management of body temperature was important in anesthetizing patients with this syndrome.

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A 19-yr-old man with a large anterior mediastinal tumor underwent for diagnostic biopsy surgery under general anesthesia before the start of chemotherapy. Anesthesia was induced with propofol and fentanyl and the trachea was intubated after administration of vecuronium. Anesthesia was maintained with propofol and fentanyl in 100% oxygen. After intubation, the respiratory sounds of the left lung were not audible. About 60min later, the peak airway pressure gradually increased and SpO₂ decreased. Although the endotracheal tube was advanced beyond the stenotic portion of the trachea, this treatment did not increase SpO₂ in spite of dramatic improvement in ventilation. As SpO₂ was decreasing to less than 50%, the operation was discontinued and the use of PCPS was decided. Epinephrine was administered because his heart rate decreased to 40beats/min. After the start of PCPS, SpO₂ increased to more than 90% and circulatory stability was recovered. Cardiac angiography revealed complete obstruction of the right pulmonary artery and a left pulmonary artery with no signs of compression. These lead us to the conclusion that complete compressive obstructions of both the left main bronchus and the right pulmonary artery due to a large mediastinal tumor occurred simultaneously, resulting in severe gas exchange insufficency.

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In the developing countries, the poor supplies of oxygen, anesthetic gas and electric power make it difficult to anesthetize patients in the ordinary fashion.
In our past medical activities in Nepal and Cambodia, we practiced intravenous balanced anesthesia technique with air, oxygen and manual bag ventilation.
In this report, we compare three relatively simple respiratory devices such as Ambu-bagTM. Jackson -Rees circuit, and disposable bag-valve resuscitator to maintain artificial ventilation during balanced general anesthesia. We measured the level of patient end tidal CO₂ (ETCO₂), inspired oxygen concentration (FiO₂), peripheral oxygen saturation (SpO₂) and the required oxygen volume during anesthesia. Only SpO₂ was maintained at a desirable level in all devices, but high ETCO₂, unstable FiO₂ and a high required oxygen volume was observed in the Jackson-Rees circuit. Respiratory accidents, such as dislocation or kinking of the respiratory circuit, were detected more easily in the disposable bag-valve resuscitator than in Ambu-bagTM due to the softness of the bag of the former.
We concluded that disposable bag-valve resuscitators are an excellent device for the management of general anesthesia in developing countries.

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