We experienced anesthetic management for ten cases of overlapping cardiac volume reduction operation (OLCVR) for treating end-stage non-ischemic dilated cardiomyopathy. This is a new procedure for left ventricular volume reduction without any resection of cardiac muscle, and it has beneficial effects. The anesthesia was maintained with intravenous anesthetics and low-dose sevoflurane. When weaning from cardio-pulmonary bypass, transesophageal echocardiography provided information on determining cardiac dimensions and evaluating left ventricular wall motion. In the early stage of weaning, cardioplesia and bundle branch block induced asynergic wall motion. Therefore it is important to wait until coordinated wall motion appears. It was useful to use vasodilators, catecholamines, and phosphodiesterase III inhibitors to control preload and afterload. But dopamine and dobutamine should be avoided, because those might cause cardiac ischemia due to increase a heart rate and oxygen consumption without inotropic effect.

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The goals of preoperative medical assessment are to reduce the morbidity of surgery and to return a patient to normal functioning as quickly as possible. Usually, physicians believe that batteries of tests are able to effectively screen for disease. Although elective surgical patients have been undergone many medical examinations and laboratory tests, it is unclear whether all of them are necessary for all patients.
We performed a study to determine whether the routine preoperative testing, including the evaluation of preoperative complications, physical examinations and laboratory abnormalities, would help to reduce the incidence of intra-/post-operative complications. Seven hundred-fifty patients who underwent an operation were randomly selected for this study. In this study, the relationship between the occurrence of intra-/post-operative morbidities and the results of preoperative evaluations were compared among patients in these are brackets 20-39, 40-69, and over 70 years old.
The preoperative complications obtained from history and physical examinations, and the preoperative ECG abnormalities were significantly correlated with the occurrence of the intra-/postoperative morbidities associated with these preoperative abnormalities in elderly patients. An appropriate preoperative assessment of patients, especially elderly patients, may enable the anesthesiologists to formulate and implement a plan for the anesthetic management of the patient that will result in a reduction in the risk of perioperative morbidities and in the cost of the procedure.

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We report a clinical experience of CardioPump^TM used for bronchopulmonary lavage. A 54-year-old man with pulmonary alveolar proteinosis underwent bronchopulmonary lavage under general anesthesia. Anesthesia was induced and maintained with intravenous anesthetic, propofol. Continuous intra-arterial blood gas monitoring (Paratrend 7^TM) was used. It, along with pulse oximeter, was useful for the safe management of bronchopulmonary lavage. When the irrigating fluid filled the whole lung, we performed the chest physiotherapy. Using CardioPump^TM after conventional method increased mass in the effluent. CardioPump^TM, which can induce strong oscillation of the chest wall, is useful for bronchopulmonary lavage.

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We examined using a plastic container as an oxygen reservoir in an anesthetic circuit. The plastic container is connected between Ambu^® bag and oxygen concentrator using 3 meters of plastic hose. The plastic container is designed to mix the oxygen from the oxygen concentrator and the air. The examination was carried out in the following conditions ; respiratory volume of 4 stages from 300 to 900ml, respiratory rate of 8 or 12 times per min., oxygen flow from oxygen concentrator of 7 stages from 1.5 to 7l·min^-1. Although the result was 88.2% of theoretical value at respiratory volume 900ml and respiratory rate 12 times per min., the results of the rest of setting were 98.9% of the theoretical value. A plastic container is practical as an oxygen reservoir from good results of this experiment and is readily available.

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Human Patient Simulator (HPS) family and Emergency Care Simulator (ECS), both manufactured by Medical Education Technologies Inc., (METI), are very unique model-driven high fidelity patient simulators in the world. We arranged two presentations, HPS FOR BEGINNER and HPS FOR INTERMEDIATE, for these workshops.
HPS FOR BEGINNER : It contains a history of HPS & ECS, an overview of unique hardware & software, and a training & simulation area with HPS & ECS. And hands-on demonstration covers the use of HPS with a real patient monitor and a real anesthesia machine.
HPS FOR INTERMEDIATE : It contains an HPS movement according to physiology & pharmacology models, philosophy of patients & scenarios & training with HPS family & ECS. And hands-on also cover new patient and new scenario developing technique & operating technique with these created patient & scenario.

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A simulated anesthesia environment was constructed with a full-scale mannequin-based simulator as a patient, and exactly the same set of anesthesia-related instruments and information systems as that used clinically. This environment was used to improve skills of anesthesia residents in managing anesthesia-related instruments. It was concluded that the training in simulated environment was as effective as in real clinical environment.

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We introduced training of artificial ventilation for medical students using the Human Patient Simulator (HPS). HPS is a high fidelity full-scale simulator that can be used to ventilate, cause spontaneous ventilation, regulate oxygenation and airway resistance. It is not only suitable for the training of anesthesia and emergency medicine, but is also suitable for artificial ventilation. Scenarios of this training include endotracheal intubation for patients with respiratory failure, ventilation in various clinical settings, and events such as tension pneumothorax. Although it is popular with medical students, a shortage of teaching staff who operates HPS is a critical problem.

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High Fidelity Human Patient Simulator (HF-HPS) has been introduced into Kyushu University Hospital since 1995 for bedside teaching to medical students. Before and after the clinical training with patients, students practice anesthesia simulation according to their plan. They often start the induction of general anesthesia without oxygenation nor respiratory assistance. Consequently, they recognize their clinical level and the risk of medical practice clearly through the results of their medical practice and decision. Without any stress to patients, HF-HPS can provide positive motivation to medical students. Further investigations are necessary to evaluate the effective utility of HF-HPS.

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In recent years, simulation training using a high fidelity simulator for medical students and residents has quickly spread in the US and European countries. Many institutions have started to organize simulation teaching, and provided the facilities. In Japan however, only a small number of medical schools have introduced simulation training into a routine practical program for students. Our anesthesiology department has been using patient simulators to educate students and residents for a practical course of anesthesiology and intensive care medicine for the past three years. We have noticed that to teach by simulation training the role of an instructor is very important. It is no exaggeration to say that whether the simulation teaching results in success or not depends on the instructor's capability. Instructors must coordinate the teaching program according to the trainee's understanding, especially during scenario-based simulation, and give the positive and negative feedback at the end of the training. Our instructors always try to give comfort, confidence and responsibility to the trainee in simulation learning. We will present here our several teaching programs using the fidelity simulators.

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As an example of education for JSA Board Certified Anesthesiologists, the curriculum involving simulators in preceptor training deepens participants' understanding.
The education of simulators for JSA Board Certified Anesthesiologists is effective, however, it is necessary to develop operation-team-simulation by introduction of the CRM skill.
The future of education by simulation is repository of various possibilities.

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The new training system for residents called “Super-rotate” started in April 2004 in Japan. In order to obtain the knowledge and skill of primary care, they are supposed to rotate some assigned departments including anesthesiology. We have to prepare a new training program accordingly. We are planning to use High-Fidelity Human Patient Simulator (HPS) for this training program. In the text, we introduce our original program for coming residents using HPS.

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This presentation reviews merits and problems with a training program for anesthesia management of inhalation anesthetics using a High-Fidelity Human Patient Simulator. In order to use an inhalation anesthetic drug, the room for simulator has to be equipped with a scavenging system of gas. The Scenario for the training of medical students, contains the followings : 1) Oxygenation and denitrogenation, 2) Intravenous administration of IV anesthetics and muscle relaxants, 3) Intubations and Confirmation, 4) Variation on depth of anesthesia by the concentration of inhalation anesthetics and fentanyl, 5) The response to surgical stimulation and the treatment, 6) Procedures of Emergence from anesthesia, 7) Reverse of muscle relaxant, and 8) Check list after anesthesia. We also introduce the “VIMA preceptor training seminar” as the training program for certified anesthesiologists.

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It is quite difficult to perform clinical training for medical students in the critical care field because educational opportunity is not always experienced due to its incidents. In an effort to model the clinical setting, a mannequin-based simulator (MBS) to mimic a variety of patient scenarios has been available. We set up a simulation center at the corner of our department it consists of control and training rooms separated by one-way observation mirror. MBS, which looks like a real clinical setting, lies down in the center of the training room, equipped with an anesthesia machine, patient monitor, drug administration system and three video-cameras. After completion of training, we discuss with medical students in order to identify specific patterns of errors in diagnosis and treatment, while watching video-taped pictures. This MBS training system is expected to be effective in improving skills of medical students.

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The Monitor-Emulator (ME) is a device, which is directly connected to the controller of a High-Fidelity Human Patient Simulator, and displays vital signs of simulator. The ME is usually used to perform training without conventional clinical monitor. The original ME can display only a limited number of simulator parameters. We introduce the customization of ME by modifying the configuration files of ME and simulator. The ME can display blood-gas data, concentrations of drugs and gases in various components of the human body, after customizing ME. The ME can be used as an assistant device at the time of writing scenario. Institutions which have already purchased a Human Patient Simulator and those with a plan to purchase one should also plan to install the ME.

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We visited The Winter Institute for Simulation, Education and Research (WISER), which belongs to the University of Pittsburgh Medical Center (UPMC), from the 15th to the 19th October 2003. The WISER is the largest simulation training center in the USA, and is running a lot of training programs using full-scale human simulators. We attended the anesthesia difficult airway management training (DAM) course. After the DAM course orientation, a pre-course scenario was performed. All cases using pre-scenario simulate real cases which occurred at the UPMC. Our decision processes were recorded on the computer log during the scenarios, and course feedback was performed using the log records. Following a pre-course scenario, a concept of DAM was lectured and many practices were trained using DAM. Almost all such practices were well-known only in the textbook, and could hardly be trained on patients. Thus, using a simulator is the only method for training such practices. The importance of simulation training is increasing in the medical field, and a base arrangement of this education system is urgently needed.

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The present status and expectation of the use of a High-Fidelity Human Patient Simulator in Japan were investigated. A questionnaire was sent by mail to 80 anesthesia departments of medical school, and 78% of institutions replied. The main users of a simulator were medical students, followed by anesthesia residents. The average use time was 3.7 hours/week. No institution, had a full-time or part-time personnel to maintain and manage a simulator. To appropriately manage simulators institutions must take into consideration economical and human resources. A simulation society to exchange information among institutions should be established in Japan in cooperation with similar societies in other countries.

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