Chronic obstructive pulmonary disease (COPD) embraces many different pathophysiological conditions such as anatomical destrucion of alveolar walls (emphysema), bronchial inflamation (chronic bronchitis), bronchioral severe inflamation (diffuse pan bronchiolitis) and bronchial hypersensitivity (bronchial asthma).
Because anesthesic complications differ for each patho-physiological type of COPD, precise diagnosis of COPD is necessary. The clinical diagnosis of COPD had previously been made primarily from the aspect of pulmonary function or clinical symptoms.
However, morphological observation of the region extending from the small air way to the alveolus has been made available by selective alveolo-bronchography (SAB). The typical findings of each COPD type is as follows: bronchial asthma; spastic narrowing and stenosis at bifurcation; chronic bronchitis fringe, transverse stripe and irregularity of bronchial wall; diffuse panbronchiolitis irregularity, dilatation and stenosis at bronchioles; emphysema centrilobular and panlobular destruction of alveolar walls.
A comparative study was made of the morphology of the alveolo-bronchial system and pulmonary function tests.
After administration of aminophyllin, dilataton of the internal diameter was observed. The increased internal diameter of the intermediate airway correlated well with FEV 1.0 and MMF. Not only bronchial asthma but also allergic rhinitis, patients, revealed bronchial hyperresponsiveness.
To assess the bronchial hyperresponsiveness in allergic patients is important for the prevention of bronchoconstriction during anesthesia.
In chronic bronchitis or diffuse panbronchiloitis antibiotics are often indicated. The choice of agent is best guided by culture and sensitivity studies. SAB and bronchial hyper responsivenss tests can provide necessary information for the prevention of pulmonary complications following anesthesia and surgery.

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Recent advances in perioperative care has made patients with low respiratory function possible to enter the operating room. Occurence of respiratory complications may be mortal to such patients, so the preoperative evaluation of respiratory function is of great concern to the anesthesiologist.
We have studied the relation between postoperative respiratory complications and anesthetic method, operative site, operative duration, in severe low respiratory function cases with a % VC of under 50% or a FEV1.0% of under 50%, from the recent 5 years. As a result, occurrence of postoperative respiratory complications is more dependent on the grade of severity of the main disease, and site and duration of operation rather than the level of respiratory function. Also, in such cases as operations involving the extremities and lower abdomen in which epidural anesthesia can be applied, may be conducted safely even though in the presence of low respiratory function.

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We present 4 cases of rate-dependent bundle branch block (RDBBB). Tachycardia-dependent bundle branch block occurred when the heart rate exceeded a critical value after premedication or during intubation or extubation. And it reverted to normal when the heart rate decreased spontaneously or after the medication of anti-choline esterase or β-blocker. One of these cases was tachycardia- and bradycardia-dependent bundle branch block.
We are rarely aware of the depression of cardiac function when RDBBB develops. While we need not always to treat it immediately, it is important to diagnose it carefully during anesthesia for following some reasons. First, it is difficult to differentiate RDBBB from ishemic heart disease which some of RDBBB are in connection with. Second, we may mistake it for slow ventricular tachycardia and treat it inappropriately.

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We conducted exchange blood transfusion in a 48-year-old man with lung cancer complicated by sever hypercalcemia at the time of anesthesia for unilateral total pulmonectomy.
Immediately after induction of anesthesia, the patient received 1, 000ml of exchange blood transfusion together with physiological saline solution; the pre-operative serum calcium concentration of 16.0mg/dl was rapidly lowered to a level of 11.5mg/dl. No problems occurred during the operation except for hypocalcemia produced by hemodilution.
The present case suggests that exchange blood transfusion may purify blood more quickly and safely than blood dialysis. Moreover, the method has another advantage that it may be applicable even during operations, since it does not need complicated techniques or facilities. In short, it may be a method having a wide scope of applicability.

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A 30-year-old femele experienced a successful pregnacy without major complications. In her history, cavo-pulmonary shunt operation and replacement of common AV value was performed in a diagnosis of single ventricle and single atrium seven years ago. It was the first successful case of these operations in the world. She was admitted for disability (NYHA II) at the 27th week of pregnacy, and ceasrean section was scheduled due to heart failure (NYHA III) at the 36th week. General anesthesia was induced with fentanyl and ketamine and maintained with nitrous oxide, oxygen, fentanyl and diazepam. Since she possess no right atrium and ventricle, and pulmoary blood flow was dependent on the pressure difference between central vein and left atrium, we paid several attensions to maintain pulmonary blood flow. The points of this anesthetic management were considered as follows;
1) to keep appropriate central venous pressure (20-25torr)2) careful use of anesthetics, muscle relaxants and uterine stimulating drugs, especially which affect hemodynamics, 3) cardiac oscillation ventilation not to increase intrathoracic pressure, 4) to avoid over-infusion or-transfusion, 5) to avoid sudden circullatory collapse (spinal anesthesia may be contraindicated), 6) aorto-caval decompression, 7) to manage sleeping baby, etc. According to these managements, benign course of delivery was obtained.

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A closed loop system was applied to control the administration of muscle relaxant in ten patients. The integrated evoked electromyographic (IEMG) response to stimulation of the ulnar nerve was measured with a DATEX anesthesia and brain activity monitor (ABM). The digital output of the ABM was transferred to an NEC PC8201 microcomputer through an RS-232C interface and was used as the feed-back signal. Alcuronium chloride was used as muscle relaxant and simple ON/OFF action of a syringe pump was selected for the controller algorithm. Following a bolus injection of alcuronium chloride (0.2mgkg^-1), muscle relaxation was regulated to the initial set point (ten percent of the control IEMG) by this system over the period of 82 to 588 minutes. During the period the level of muscle relaxation was stable with the mean IEMG response of 9.4 to 11.0 percent of the control. The mean dose of the drug infused during the period was 1.2μgkg^-1min^-1 and roughly proportional to the duration of the period. The simple ON/OFF algorithm was proved to be capable of successfully maintaining the level of muscle relaxation during anesthesia.

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In this article, perioperative management of patients with pheochromocytoma in our hospital were reviewed chronologically.
22 patients with peochromocytoma, who underwent surgery between 1964 and 1985, were classified into four groups according to their courses of anesthetic management.
Patients in group 1 managed without any sympatholytic agents. Patients in group 2 managed intraoperatively with phentolamine but not with β-blocker. Patients in group 3 were under phentolamine or phenoxybenzamine administration preoperatively, and managed with phentolamine and propranolol intraoperativery. Patients in group 4 were under prazocine or labetalol administration preoperatively, and managed with prostaglandin E₁, nitroglycerin or diltiazem hydrochlride intraoperatively.
The introduction of new agents to clinical practice, and their effects on the management of patients with pheochromocytoma.

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Effect of modified neuroleptic anesthesia consisted of flunitrazepam-buprenorphine-nitrous oxide and surgery on plasma cortisol levels was evaluated in thirty patients, aged from 16y to 74y, who underwent general surgery.
Anesthesia was induced with intravenous injection of thiopental and succinylcholine to facilitate the tracheal intubation. Immediately after the intubation, both flunitrazepam 20μg/kg and buprenorphine 3μg/kg were injected intravenously combined with inhalation of 70% of nitrous oxide and 30% of oxygen to maintain the anesthesia. As muscle relaxant pancuronium bromide or d-Tc was administered when needed.
Flunitrazepam-buprenorphine-nitrous oxide anesthesia alone for 30min did not exert any significant effect on plasma cortisol levels itself, but the levels increased gradually during surgery, with a peak value detected at the emergence from anesthesia. Plasma cortisol levels in patients undergoing non-abdominal surgery were lower than those in abdominal surgery during surgery and after the recovery from anesthesia. The findings was speculated that the magnitude of surgical stress was attributable to this difference.

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The authers investigated the influence of extracorporeal circulation (ECC) to surface skeltal muscle oxygen tension (PtO₂). For this purpose continuous monitoring of PtO₂ by modified polarographic technique was carried out in 8 patients with no intracardiac shunt. Cardiac index (CI), blood pressure, body temperature, sistemic vascular resistance index (SVRI) and dose of chlorpromazine were recorded simultaneously. The significance between these factors and PtO₂ were tested statistically. By the initiation of ECC, SVRI decreased significantly (P<0.05) and PtO₂ showed the tendency to decrease.
There are significant correlation between PtO₂ and CI in pre-ECC period but there are significant correlation between PtO₂ and PaO₂, systolic blood pressure (mean perfusion pressure in ECC) in pre-and mid•ECC period. There is no significant difference in PtO₂ between CPZ administered group and control group. These findings suggest that the arteriola-venule anastomosis opens during ECC.

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Epidural injection of 0.1mg Buprenorphine was performed on 107 postoperative patients. Side effects related to this therapy and duration of analgesia were studied. The results obtained were as follows; mean duration of analgesia was 17.7±10.5 hours and nausea and vomiting were observed in 24 patients. Few other types of adverse reaction were encountered.
In conclusion, it was found that epidural injection of 0.1mg Buprenorphine is as useful as an intravenous administration of 0.2mg Buprenorphine in many respects. Therefore, it seems that there is no significant difference in clinical validity between epidural and systemic intravenous administration of this drug because same duration of analgesia and similar degree of side effects were likely to occur in these two types of drug administration.

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We investigated the usefulness of buprenorphine (0mg, 0.05mg, 0.1mg, 0.2mg) as an assistant drug of enflurane anesthesia with nitrous oxide and pancuronium bromide for the upper abdominal surgery.
We judged the optimal dose of buprenorphine for these operations by an assessment of the duration of the postoperative analgesia, the respiratory suppression and the recovery status from the anesthesia. Each group produced prolonged analgesia except 0mg group. No respiratory suppression was observed in 0.05mg group. The recovery status from the anesthesia was better in buprenorphine groups than in 0mg group.
The results showed that 0.05mg of buprenorphine was optimal dose for this method of anesthesia.

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Recently, we experienced two dangerous troubles of anesthetic machines with oxygen failure protection devices.
One of cases was the trouble of the needle valve. Nitrous oxide flew though only the oxygen flow control valve was opened. The cause of this accident was that a foreign body slipped into the nitrous oxide flow control valve and the valve could not be closed completely.
The other was the trouble of the oxygen failure protection devices themselves. The valve that regulates the ratio of oxygen to nitrous oxide failed and oxygen concentration got incorrect. Lossening between the shaft of the valve and the gear took place, the valve did not operate accurately. Fortunately, there occured no hypoxic accidents, because these troubles were found before starting anesthesia.
In conclusion, we anesthesiologists always have to check anesthetic machines and observe patients carefully even if oxygen failure protection devices are equipped.

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