with saline before insertion. Anesthesia was induced by 3.0%-5.0% sevoflurane with 50% nitrous oxide in oxygen. Before insertion of the LMA, anesthesia was maintained with 3.0% end-tidal sevoflurane concentration in oxygen for 5 min. No muscle relaxants were used. Another anesthesiologist assisted the performer to open the patient's mouth by pulling down the jaw. The standard insertion technique was described by Brain [4]. The LMA was inserted with the cuff fully deflated and against the palate; then the cuff was inflated after insertion. In the modified insertion technique, a two-thirds inflated LMA (2, 4, 6, 8, and 12 ml for size 1, 1.5, 2, 2.5, and 3 masks, respectively) was inserted with its lumen facing laterally left. While rotated clockwise 90°, it was passed downward into position behind the larynx. Then the cuff was completely inflated (Fig. 1).Successful insertion was clinically judged for whether (1) manual ventilation with the bag was easy and the chest wall movement was smooth, and (2) ventilation at a positive inspiratory pressure of approximately 10 cmH 2 O was possible without an air leak. The number of attempts on LMA insertion and the time to achieve satisfactory airway were recorded. Vital signs including blood pressure, heart rate, and pulse oximeter reading were recorded before and after insertion of the LMA. If three trials with the assigned procedure failed, the next trial with the opposite technique was applied only once. In case of unsuccessful LMA insertion, tracheal intubation was performed. After successful insertion, the position of the LMA was confirmed and classified by a fiberoptic laryngoscope (class 1, only glottis seen; class 2, epiglottis and glottis seen; class 3, epiglottis downfolded, glottis not seen; class 4, others). On removal of the LMA at the end of surgery, the attachment of blood clots to the surface of the LMA was noted. An observer blinded to the insertion technique assessed these data.

A 78-yr-old man was admitted to our hospital because of repeated episodes of pneumonia. Both fiberoptic bronchoscopy and esophagoscopy revealed a large tracheoesophageal fistula and protrusion of the metal stent from the esophagus into the trachea. Placement of a Dumon stent was planned for sealing this fistula under general anesthesia. Anesthetic management is difficult because of the care needed to prevent aspiration of esophageal contents and diversion of oxygen through the fistula into the stomach from the trachea when patients are under mechanical ventilation. Our method of sealing a large tracheoesophageal fistula with a Sengstaken-Blakemore tube was performed successfully.

Prognosis of the inpatients with successful cardiopulmonary resuscitation in the university hospital

We describe a patient who overdosed thyroid hormone to attempt suicide. A 26-year-old woman ingested an aggregate of 3.5mg (70 tablets) of levothyroxine. Gastric lavage followed by activated charcoal and a laxative was done in an ER and the patient was admitted to intensive care unit. She remained asymptomatic except for slight fever and discharged from the hospital on the fourth day. Thyroid function studies were repeated on follow-up until the 19th day after ingestion. The spouted up over normal range on the 7th day. Thyroid hormone values were normalized on the 19th day. Serious toxicity is uncommon after levothyroxine ingestion, but the onset of symptoms may be delayed because of long half-life and bioactivity of a metabolyte (T3). Close observation is necessary for a couple of weeks. Non-specific, supportive therapy is more beneficial than antithyroidal therapy because overdosed levothyroxine, as a result of homeostasis mechanism, suppresses thyroid gland and therefore aggressive antithyroidal therapy may cause critical overdepression.