The endoplasmic reticulum (ER) plays a pivotal role in protein synthesis by attaching the carbohydrate side chain of the glycoprotein to the peptide backbone and formation of a disulfide bond, producing the complex conformation of the protein. Dysfunction of ER caused by ischemia is linked to neuronal cell damage. The decrease in amino acid, glucose and Ca²⁺ levels in ER cause immature protein production, leading to ER stress. Under this condition, the ER chaperone GRP78, some of which is usually bound to the kinase of PERK, ATF6 and IRE1 is dissociated and used for refolding the abnormal protein. This process activates these kinases, leading to induced expression of the ER stress gene (grp78) . Nevertheless, PERK phosphorylates eIF2α, shuts down translation, and stops protein synthesis. If the ischemia is strong enough, protein synthesis will never recover, even though the ER stress genes are up-regulated. When neuronal cells are preconditioned, GRP78 increases with reduction of phosphorylation of eIF2, and protein synthesis recovers after ischemia. Because impairment of ER function triggers secondary mitochondrial dysfunction, the preservation of ER function with up-regulation of chaperones using valproic acid may provide a substantial protective effect to the neuronal cells.

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 Neurological dysfunction after cardiac surgery is a devastating complication and is associated with increased mortality and prolonged hospital stay. The population is aging and elderly patients undergo a disproportionaly high rate of cardiac surgery. Advanced age is often associated with increased systemic atherosclerosis and a major risk factor for stroke after cardiac surgery. Postoperative neurological dysfunction is primary caused by cerebral emboli, hypoperfusion, systemic atherosclerosis or inflammation. Embolization is the most common cause of intraoperative strokes and is associated with advanced atherosclerosis in the ascending aorta. The operative strategies of preventing emboli and maintaining higher perfusion pressure during CPB confer protection against neurologic complications and attenuate the ischemic cascade in the brain following embolic load. Recently, off-pump CABG appears to promise elimination of microemboli from the ascending aorta and of inflammatory response, and may lead to a lower incidence of postoperative neuropsychological dysfunction. Diffusion-weighted imaging MRI (DWI-MRI) has found ischemic lesions in the brain after cardiac surgery and left cardiac catheterization. Patients with pre-existing cerebral injury may be more vulnerable to the adverse effects of cardiac surgery. Preoperative DWI-MRI allows convenient non-invasive assessment of preoperative cerebral ischemia and may be useful to decide optimal treatment strategies in cardiac surgery.

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 Neurological injury after neuroanesthesia can vary depending on the pathophysiology of disease and type of operative procedure. Various approaches including brain and spinal cord protection for injury of brain and spinal cord, perioperative management for blood glucose, neuromonitoring and identification of disease focus and eloquent areas are required. Indication of mild hypothermia has been changing based on the published data in clinical trials. Perioperative management for blood glucose levels is still being debated. Motor evoked potential monitoring and epileptic focus identification during surgery are critical, but can be affected by anesthetic management. Strategies for brain and spinal cord protection, including neuromonitoring, are described.

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 Brain microdialysis (MD) is a technique to monitor the concentration of the substances (m. w. under 20 kDa) in the brain's extracellular space using a dialysis probe located in the brain. Brain microdialysis is indicated in severe cases needing monitoring of intracranial pressure or cerebral perfusion pressure. In one patient of traumatic brain injury with brain herniation, extremely low MD glucose and extremely high MD lactate/pyruvate levels were found to suggest anaerobic glycolysis due to the poor supply of oxygen and/or glucose. We also found extremely high MD glutamate and MD glycerol levels which show degradation of the cellular membrane due to brain ischemia. Infusion of osmotic diuretic glycerol produces transient increases in MD glycerol (one case of traumatic brain injury, one case of coma patient after resuscitation from cardiac arrest) . These elevated MD glycerol levels returned to pre-infusion levels after 4-6 hours. Osmotic diuretics glycerol readily enters the brain through the blood brain barrier. We speculate that the infusion interval of osmotic diuretic glycerol was at least 4-6 hours.

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 An understanding of physiology is most important for anesthesia for neonates. Although neonates quickly adapt to extrauterine life at birth, it takes from hours to weeks until they stabilize and mature. If surgery is necessary soon after birth, the proper time to do it should be determined considering the infant's stability against the urgency of the illness. At preanesthetic visits, complications during pregnancy and labor must be evaluated. Examination of the heart by echocardiogram is essential. Anesthetic equipment and monitoring are similar to those in adults. A non-rebreathing circuit is preferred in a low-birth-weight infant. Capnography is useful but less reliable in the case of leakage from an endotracheal tube. The endotracheal tube should be fixed carefully to avoid displacement and kinking. Care must be taken to maintain body temperature using equipment such as a forced-air warmer. The plan for anesthesia should be devised corresponding to the pathophysiology of the disease and via discussion with the surgeons. Postoperative analgesia is essential even in neonates.

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 The evolution of technology has made great advances in laparoscopic surgery. It can be said that most types of abdominal surgery in pediatrics are attempted under laparoscopy. The anesthesia management of laparoscopic surgery in infants and children has unique features and potential pitfalls. Anesthesiologists should be familiar with the varieties of physiological changes in laparoscopic surgery, mainly resulting from increased intra-abdominal pressure by insufflated CO₂, increased absorption of CO₂, and patient positioning. Anesthetic management depends on each patient's clinical condition. Except for short diagnostic laparoscopy, patients are usually paralyzed with muscle relaxant and intubated. The cuffed endotracheal tube can be carefully used for effective positive pressure ventilation. Ventilatory strategy might be readjusted during pneumoperitonium. Anesthesiologists should also pay attention to intra-abdominal pressure because high pressure (>15 mmHg) will cause serious problems. Complications include difficulties in surgical techniques and problems related to pneumoperitoneum. The complication rate is known to largely depend on the surgeon's skill and experience.

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 Pediatric cardiac anesthesia is one of the most difficult types of anesthesia, and requires sufficient knowledge of both pediatric and cardiac anesthesia. It is best for the pediatric cardiac surgery patients if pulmonary vascular resistance is controlled as much as possible. Almost every anesthesiologist should understand the hemodynamics of each congenital heart disease, as the number of adult patients with congenital heart diseases will increase in the near future.

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 A pulmonary artery catheter (PAC) and transesophageal echocardiography (TEE) are important tools for monitoring circulation. The situation in which values measured by using a PAC are abnormal and we want to use TEE to determine the cause often arises in a clinical setting. A case in which values measured by using a PAC are abnormal and TEE is used for diagnosis is assumed, and an outline of the main points for diagnosis using TEE is given. The characteristics of measurement using a PAC and TEE, and the differences between them are then described so that TEE can be used effectively in risk management.

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 I discuss here rapid sequence induction/intubation (RSI) , focusing on the role of preoxygenation, muscle relaxants (suxamethonium and rocuronium) , and the method of applying cricoid pressure. To perform RSI safely, it is necessary to evaluate difficult airway during the pre-anesthetic visit and to carry out adequate preoxygenation before induction of anesthesia. It would be prudent to add opioid analgesics as induction agents to reduce hemodynamic changes at induction of anesthesia, especially for a patient with hypertension. Rocuronium is thought to be a useful muscle relaxant for RSI because of its rapid onset of action, but attention should be given to the fact that its duration of action increases when its dose is increased to more than 1.0 mg/kg.

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 In patients undergoing esophagus cancer surgery, we divided intraoperative fluid therapy into the group who mainly used acetic acid Ringer solution containing Magnesium (Mg) ions (group P) and the group who mainly used acetic acid Ringer solution without Mg ion (group V) . We measured Mg ion levels until the 3rd postoperative period. In both groups, Mg ion levels during operation were lower than pre operation levels. But when compared at the end of surgery, group P significantly inhibited a decrease in Mg ion levels. Mg ion levels in both groups were restored immediately after surgery. Therefore, using acetic acid Ringer solution containing Mg ions, which can prevent a reduction in Mg ion levels, should be recommended for esophageal cancer surgery from the viewpoint of perioperative fluids, metabolic management.

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 We investigated the effects of a novel, highly cardioselective short-acting β-blocker, landiolol on cardiac index with or without propofol anesthesia. Seven ASA class I - II patients received landiolol (0.1 mg/kg) before induction of anesthesia and during a target controlled infusion of propofol (effect-site concentration 2-4μg/ml) . We measured beat-to-beat heart rate (HR) , cardiac index (CI) , stroke volume index (SVI) , and end diastolic volume index (EDVI) by using the method of transthoracic bioimpedance measurement. HR and CI significantly decreased after landiolol injection in awake patients (86% and 89% of control value, respectively) , while SVI and EDVI did not change. This action was independent of propofol anesthesia. Our results suggest that 0.1 mg/kg bolus injection of landiolol induces a decrease in CI, which is associated with a decrease in HR.

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 This study was designed to determine whether cyclic variations of integrated backscatter from the left ventricular wall could reflect the regional wall motion and functional reserve during cardiac surgery. We investigated 48 patients that underwent off-pump coronary artery bypass grafting (OPCAB) , including 4 patients with acute myocardial infarction. Cyclic variations of integrated back scatter were measured in anterior and inferior left ventricular segments before and after OPCAB. Myocardial segments were classified into three groups according to the patterns of cyclic variations of integrated backscatter: normal patterns of cyclic variation, reduced magnitude of cyclic variation, and abnormal cyclic variations. Systolic peak radial strain was also assessed by 2D tissue tracking in each segment. The average peak radial strain was significantly higher in the segments with normal patterns of cyclic variations compared with those with reduced magnitude or abnormal patterns of cyclic variations in chronic ischemic segments. In contrast, acutely infarcted segments had a normal magnitude of cyclic variation and extremely low systolic peak strain, which was improved significantly after myocardial revascularization. Our data suggest that assessment of cyclic variations of integrated back scatter enables estimation of regional myocardial function and prediction of functional recovery following OPCAB.

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 We describe our experience of managing anesthesia three times in a single patient with Brugada type electrocardiogram. We performed spinal anesthesia twice for his transurethral resection of bladder tumor (TUR) and combined general and epidural anesthesia for his subsequent total cystectomy. During spinal anesthesia, we maintained the level of sensory blockade below the mid-thoracic level because suppression of cardiac sympathetic nerve activity may predispose the Brugada heart to ventricular fibrillation. For the same reason, we avoided propofol and neostigmine during general anesthesia. He was uneventfully managed for each operation.

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 Since 1991 when endovascular aortic aneurysm repair (EVAR) was first described in the literature, it has emerged as a less invasive alternative for conventional open surgical repair. As of 2007, two randomized controlled trials have demonstrated better outcomes with EVAR than with conventional open repair, at least in the first month after the procedure. Due to being less invasive, EVAR has been thought to be especially useful for patients unfit for elective open surgery. EVAR is minimally invasive compared to conventional open repair, nonetheless, only a few reports in the literature thus far have described the efficacy of the less invasive loco-regional anesthesia technique for EVAR. We describe here a case with abdominal aortic aneurysm complicated by severe obstructive respiratory insufficiency and angina pectoris that successfully underwent EVAR under the loco-regional anesthesia with ultra-sound guided iliohypogastric and ilioinguinal nerve block. The case described here suggests that in a patient in poor health who is considered unfit for open surgical repair, a less invasive anesthetic technique such as loco-regional anesthesia must be considered for the anesthetic management of EVAR.

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 A 33-year-old female was scheduled for myomectomy under a combination of general and epidural anesthesia. Circulatory collapse that required immediate resuscitation occurred unexpectedly during surgery. Latex anaphylaxis was suspected because the patient had a flushed and edematous face, and red flare was observed in the precordial region. The patient fully recovered 3 hours after surgery. It is important to check allergic history in detail preoperatively to prevent latex anaphylaxis.

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 We report a case of advanced laryngeal cancer with severe tracheal stenosis. A 39-year-old male presented with progressive severe dyspnea and neck pain. An emergency tracheotomy was planned, however, the otolaryngologist was reluctant to perform an awake-tracheotomy under local anesthesia because the patient's neck was slightly flexed and mobility was very limited, and the patient could not be positioned properly for surgery. We decided to use the AWS for awake-intubation in the sitting position. In preparation for tracheal intubation, the non-sedated semi-sitting patient was given oxygen through the AWS attached to a tracheal tube. Inserted AWS showed that the tumor partially obstructed the glottis and the space of the glottis lesion was very narrow. It enabled us to insert the tube into the trachea-guiding GEB. After induction of general anesthesia, the patient was placed in the supine position and a tracheotomy was performed successfully. We believe that combined use of AWS and GEB may be useful for awake tracheal-intubation in patients with a difficult airway.

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 Doppler echocardiography has become accepted as a routine technique for the evaluation of cardiac function. Traditional Doppler echocardiography has been used to evaluate blood flow velocity with red blood cells as the moving target. Current ultrasound systems can also apply the Doppler principles to assess velocity within cardiac tissue. Integrated backscatter, regional deformation (strain) and deformation rate (strain rate) can be calculated non-invasively. Speckle tracking is a new echocardiographic method developed based on tracking characteristic speckle patterns created by interference of ultrasound beams in the myocardium. This review concentrates on recent advances in this technique with emphasis on integrated backscatter and strain/strain rate. The biggest concern is how to translate the results of these new technologies in patients with ischemic disease.

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 To prevent body movement and bucking during an operation, we must keep the concentration of rocuronium at an adequate level. However, it is difficult to determine whether the administration technique was suitable for maintaining neuromuscular blockade with rocuronium bromide.
 We can use bolus infusion of rocuronium in a similar manner as before, because the duration of action is comparable to other intermediate drugs such as vecuronium. However, there are other infusion methods for rocuronium, such as continuous infusion and target controlled infusion (TCI) . We should select these methods depending on the situation.
 To better use rocuronium, we must know these methods' advantages and disadvantages, and recognize the correct way to use neuromuscular monitor and pharmacokinetics of rocuronium.

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 The most prominent characteristic of rocuronium is rapid onset, but the duration of action is similar to vecuronium.
 During abdominal surgery, adequate muscle relaxation is essential, especially at the time of peritoneal closure. Nevertheless, prompt recovery of neuromuscular transmission is also required at the end of surgery. To achieve these difficult goals with rocuronium, objective monitoring of neuromuscular transmission is recommended. In particular, deep neuromuscular block is required at diaphragm and abdominal muscles. Either post-tetanic count (PTC) measured at the adductor pollicis or train-of-four count measured at the corrugator supercilii is more reliable than the standard train-of-four ratio measured at the adductor pollicis.
 Many ophthalmic, otorhinolaryngologic and plastic surgeries have been performed under ambulatory settings. Short duration of neuromuscular blocking action is desirable in this setting. For rocuronium, reduced intubating doses such as 0.45 mg/kg and 0.3 mg/kg have been reported to achieve this goal. Also, a reduced supplemental dose as low as 0.075 mg/kg may be used.

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 When rocuronium is used during cesarean section, one should be aware of the effects of the agent on the maternal-fetal unit. For the sake of its safe and effective usage, the effects of physiological change with pregnancy and pathophysiology on the indication of general anesthesia should be well acquainted. At this point, there is little difference between rocuronium and suxamethonium. Although rocuronium has less disadvantageous effects than suxamethonium, it is not always superior in terms of onset and duration for cesarean section. Whenever either muscle relaxant is utilized in the induction of general anesthesia for cesarean section, one should be prepared in case of difficult airway.

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  “Rapid onset” is the main characteristic of rocuronium. The risk of hypoventilation and aspiration during the induction of anesthesia can be reduced as a result of this property of this muscle relaxant. Rocuronium is expected to have a rapid onset of action equal to suxamethonium, but has the advantage of causing considerably fewer side effects. It is convenient in pediatric surgery where most procedures are of short duration because its duration of action in children is shorter than that in adults. However, since its duration of action in neonates and infants may be longer than that in older children or adults due to the different pharmacokinetics and pharmacodynamics, careful attention should be paid when we use this product in this population.

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