症例は77歳，女性。呼吸困難を主訴に救急外来に搬送された。来院時，心拍数111 /min，血圧70/52 mmHg，経皮的動脈血酸素飽和度91％（room air）であった。心電図で右側胸部誘導のST低下を認め，経胸壁心エコーでは右室は著明に拡大し，造影CTで両側肺動脈に広範囲の血栓を認めたため，急性広範囲型肺血栓塞栓症と診断された。抗凝固療法に並行し，肺動脈血栓摘除術の方針とした。急激な循環虚脱に備え，経皮的心肺補助装置を準備の上，肺動脈血栓摘出術を施行した。術後の呼吸循環動態は安定しており，術翌日に人工呼吸器から離脱し，カテコラミン投与を終了した。術後4日目にはICUを退室した。急性広範囲型肺血栓塞栓症では，早期診断と適切な早期治療が大きく死亡率を改善させる。救命するには呼吸循環補助を含め，各部門と連携した集学的治療が必要であり，常に外科的治療を念頭に置き対応する必要がある。

Thyroid storm is a rare, life-threatening condition characterized by severe manifestations of thyrotoxico- sis. Acute heart failure is one of the well-known com- plications of thyrotoxicosis. Thyrotoxicosis-induced heart failure sometimes causes circulatory collapse with high mortality. A 43-year-old woman had palpitations and exertional dyspnea without medical history. She developed con- gestive heart failure, due to tachycardiac atrial fibrilla- tion with no acute ischemic changes. High serum level of FT3 and FT4, and low level of TSH were shown in thyroid function tests, and thyromegaly in carotid ultrasound test She was admitted to the intensive care unit for acute heart failure caused by thyroid storm. Two days after admission, cardiopulmonary resuscitation and endotracheal intubation were necessary due to sudden cardiac arrest Transthoracic echocardiogram showed normal cardiac function after successful resuscitation. Five days after admission, her condition deteriorated with severe cardiac dysfunction, and she received PCPS (percutaneous cardiopulmonary support) for cardiovascular collapse resulting in persistent tachy- cardiac atrial fibrillation. Ten days after initiation of PCPS, the patient's cardiovascular function improved with estimated left ventricular ejection fraction of 50 percent and she was weaned off PCPS. In the case of acute heart failure with untreated hyperthyroid and refractory atrial fibrillation, careful hemodynamic management is required to avoid cardio- vascular collapse.

The use of femoral nerve block (FNB) combined with sciatic nerve block (SNB) after total knee arthroplasty (TKA) has recently become controversial. Local infiltration analgesia (LIA) has been reported to be effective for postoperative TKA pain control. We aimed to assess whether LIA with continuous FNB is as effective as SNB combined with continuous FNB.

Left ventricular non-compaction (LVNC) is a rare congenital cardiomyopathy characterized by heart failure, arrhythmia, and embolic events. A 65-year-old man, previously diagnosed as LVNC, was admitted to the emergency department with severe abdominal pain. He was diagnosed as appendicitis and treated conservatively with antibiotics. The echocardiogram examination showed left ventricular ejection fraction of less than 25%, and his B-type natriuretic peptide assay was > 5,000 pg x ml(-1) on admission. Ten days after admission, he underwent emergency surgery for suspected perforation of vermiform appendix. Transesophageal echocardiography (TEE) was used for real-time evaluation of cardiac function and restrictive fluid management during surgery. He was transferred to intensive care unit (ICU) for postoperative care, and extubated 16 hours after surgery. On the third postoperative day, he was discharged from ICU without any complications. We consider that perioperative hemodynamic management with TEE may be useful for gastrointestinal tract surgeries in patients with severe cardiac disease, such as LVNC.

We conducted a prospective randomized controlled trial to test the null hypothesis that there is no difference between sciatic nerve block (SNB) and local infiltration of analgesia (LIA) regarding postoperative analgesia after total knee arthroplasty (TKA), when administrated in addition to femoral nerve block (FNB). Forty-six patients scheduled for TKA were randomized into two groups: concomitant administration of FNB and SNB or FNB and LIA. Average pain scores during the first 21days after surgery were similar in the two groups and remained at low level. There was no significant difference in the need for adjuvant analgesics, patient satisfaction level, the time to achieve rehabilitation goals, and length of hospital stay. The LIA offers a potentially safer alternative to SNB as an adjunct to FNB.

We experienced two cases of difficult airway management using laryngeal mask airway (LMA) in children. LMA Classic (LMA-C) was used for a 4-year-old female patient and SOFTSEAL LMA (LMA-S) was used for a 15-year-old female patient. Both patients were successfully intubated by fiberoptic tracheal intubation through LMA. We compare these two kinds of LMA in fiberoptic intubation method. Because the diameter of the shaft is wider than LMA-C, LMA-S could pass through much larger size endotracheal tube (ETT). 4.0 mm ETT could pass through LMA #1 and #1.5 in both LMAs. 5.0 mm ETT could pass through LMA-S #2, but only 4.5 mm ETT could pass through LMA-C #2. In #2.5, LMA-S and LMA-C could be passed by 6.0 mm ETT and 5.5 mm ETT respectively. Also LMA-S and LMA-C #3 could be passed by 7.0 mm ETT and 6.5 mm ETT respectively. We conclude that SOFTSEAL LMA is more useful than LMA Classic for fiberoptic tracheal intubation technique.