Tracheal tube cuff damage usually requires tube replacement; however, in patients with a difficult airway, tube exchange can pose significant risks. We report a case in which cuff damage was successfully managed using an automatic cuff pressure controller. 　The patient was a man in his 70s who was scheduled for posterior decompression and fusion for cervical spondylotic myelopathy while wearing an external spinal fixation device. Awake nasotracheal intubation was performed using a flexible bronchoscope, during which cuff damage was identified. The tracheal tube was exchanged with a Tube Exchanger® but cuff damage recurred, requiring a second exchange using the same method. Although no cuff leak was observed immediately afterward, a gradual decrease in tidal volume developed after repositioning the patient to the prone position. Because the cuff leak was relatively minor, an automatic cuff pressure controller was connected, which maintained tidal volume without further decreases and allowed completion of the surgery. In situations where tube exchange carries high risk, an automatic cuff pressure controller may serve as a temporary rescue measure for cuff damage. The cause of cuff damage in this case was considered to be a nasal septal spur combined with the relatively large tube size.

Deep neck abscess can cause upper airway stenosis and obstruction, and sometimes emergency airway management is required. Here we present a case of deep neck abscess in which awake intubation with a video laryngoscope (McGRATH™ MAC) was more useful than with flexible bronchoscope. A man in his 80s was transported to our hospital with throat and chest pain. Contrast-enhanced computed tomography revealed a deep neck abscess (right peritonsillar abscess). The otolaryngologist attempted drainage by puncture, but this was ineffective. There was a risk of upper airway obstruction, and emergency airway management was required. First, we attempted endotracheal intubation with a flexible bronchoscope but could not secure the field of view because of the upper airway edema and stenosis. Next, we attempted tracheal intubation using a video laryngoscope, which ultimately was successful. The blade of the video laryngoscope compressed and lifted the soft tissue and then it secured the space of the upper airway.

We encountered a case in which decreased cardiac afterload due to intra-aortic balloon pumping (IABP) caused left ventricular outflow tract obstruction (LVOTO), resulting in cardiogenic shock in a patient with hypertrophic obstructive cardiomyopathy (HOCM). The patient was a woman in her 60 with HOCM and angina, which were had been diagnosed before endometrial cancer surgery. An intra-aortic balloon pump was placed before surgery to maintain coronary artery blood flow, and increases in diastolic blood pressure were observed. However, she went into shock upon induction of anesthesia and required a large dose of vasopressor. The patient remained in shock after surgery and was admitted to the ICU while unresponsive and intubated. Transthoracic echocardiography showed LVOTO and mitral regurgitation, indicating the possibility that lowered cardiac afterload by IABP caused LVOTO. Discontinuation of IABP resulted in striking recovery from shock such that no vasopressor was required, and echocardiography findings improved. Although IABP offers a variety of benefits such as maintenance of coronary artery blood flow, we should keep in mind that decreased cardiac afterload due to IABP may cause LVOTO in patients with HOCM.

Mushroom poisoning with Russula subnigricans can lead to severe rhabdomyolysis. Here we describe a case of severe mushroom poisoning that resulted in severe rhabdomyolysis with acute kidney injury, hypotension, and shock 12 h after oral ingestion of R. subnigricans. The patient's serum myoglobin was 6,475 ng/mL and his creatine phosphokinase (CK) level was 38,100 IU/L on admission. Although aggressive fluid resuscitation and on-line hemodiafiltration (OHDF) were initiated, vascular permeability and shock failed to improve. Continuous hemodiafiltration (CHDF) and OHDF was repeated, but their effects were limited. He later developed generalized edema, and his weight increased from 55 kg to 72.5 kg within 4 days. On day 5, his CK level reached 203,800 IU/L. He died 160 h after oral ingestion of R. subnigricans. CHDF and OHDF filter out circulating myoglobin, potassium, and some toxic substances released due to muscle cell disruption. Although OHDF was performed nearly 24 h a day in our patient, it failed to remove toxic intracellular components from muscle cells due to the severe R. subnigricans mushroom poisoning in this case.

A 68-year-old woman had unstable angina pectoris with asymptomatic right internal carotid artery and right middle cerebral artery occlusion with impaired cerebral perfusion reserve. The cardiology, cardiovascular surgery, anesthesiology, and neurosurgery departments discussed the treatment plan. We simultaneously performed superficial temporal artery-middle cerebral artery anastomosis and coronary artery bypass grafting to reduce the likelihood of perioperative ischemic stroke. Fortunately, neither cerebral ischemia nor myocardial ischemia occurred. Simultaneous superficial temporal artery-middle cerebral artery anastomosis and coronary artery bypass grafting can be a therapeutic option for patients with unstable angina and impaired cerebral perfusion reserve. However, the risk of bleeding associated with anticoagulation during coronary artery bypass grafting cannot be ignored.