Postherpetic neuralgia is the most common and serious complication of herpes zoster. Older age, greater acute pain, greater rash severity and prodromal pain have been identified as risk factors for postherpetic neuralgia. In patients with those risk factors, the combination of antiviral therapy and substantial and continuous efforts to reduce the severity of acute pain, such as nerve block therapy for immunocompetent patients or lidocaine intravenous infusion for immunocompromised patients, might prevent postherpetic neuralgia by attenuating nerve damage and acute pain.

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  Tricyclic antidepressants, gabapentin, opioids, and lidocaine patch were found to be effective in reducing the pain of postherpetic neuralgia. Clinician should know the value of numbers needed to treat (NNT) and number needed to harm (NNH) for each drug for successful pharmacotherapy of postherpetic neuralgia.

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  Postherpetic neuralgia (PHN) is still intractable, regardless of the multifaceted therapy available. Our department examined 58 cases of pain after herpes zoster. The patients received the first medical examination over 3 months after development of symptoms. Postherpetic pain continued for 3-5 months in 12 cases, PHN developed 6 months later in 46 cases. Pain relief was reported in 7 cases (58.3%) from the postherpetic pain group, and in 14 cases (30.4%) from the PHN group. Five cases (41.7%) and 6 cases (13.0%) , respectively were completed. We mainly applied the nerve block to the postherpetic pain and PHN. The 58 cases/patients included those that underwent multifaceted therapy previously, those that stopped treatment voluntarily, and those that rejected treatment out of fear of it being harmful. Thus, the above results suggest that multifaceted therapy for PHN has limitations.
  Moreover, we evaluated the curative effects, not by the drug therapy, but by the nerve block, thermocoagulation, and spinal cord stimulation, among various treatments for PHN. Although there are some cases in which thermocoagulation and spinal cord stimulation are effective, further examination is needed to analyze the problems and issues over a long period of time.
  Markedly progressed therapy for PHN has not been found yet. Rather than a single kind of treatment, the multifaceted therapy is mainly utilized at present. It is important to choose the treatments which aim for the maintenance and improvement in ADL and/or QOL for each case.

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  To evaluate patient satisfaction after anesthesia and improve the quality of our anesthesia administration, postoperative questionnaire surveys were conducted in our two affiliated institutions. Anonymous questionnaire sheets including 6 questions were distributed to 2,270 patients who underwent elective surgeries. The questions included those about appreciation of preoperative visits and their anxiolytic effects, actual postoperative pain, overall satisfaction with our anesthesia care, and familiarity with the anesthesia practice. Nine hundred ninety-four sheets (43.7%) were returned for evaluation. Nine hundred seventy-six patients (98.1%) appreciated our preoperative visits, which alleviated anxiety in 597 patients (60%) . The most common cause of preoperative anxiety was postoperative pain (661 patients, 66.5%) , and 325 patients (32.7%) actually suffered various degrees of pain after surgery. Despite these results, 750 patients (75.4%) answered “satisfied” or “very satisfied” with our anesthesia care, and only 2.7% of patients were “dissatisfied” with it. Not many patients (22.4%) were familiar with anesthesia. Although the majority of patients had a favorable impression of our anesthesia care, which may be associated with the anxiolytic effects of our preoperative visits, our surveys suggest that postoperative pain relief and patient education need to be improved. Post-anesthesia questionnaire surveys are useful tools to reevaluate and improve anesthesia administration, which will contribute to patient satisfaction and familiarity with the anesthesia practice.

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  Due to the current shift from a provider-driven to a patient-focused health care system, informed consent prior to anesthesia administration has become more important than ever. Patients undergoing anesthesia certainly expect it to be “painless and safe.” Since 1999, our hospital has implemented the Acute Pain Service (APS) based on a multidisciplinary team approach for controlling postoperative pain. To relieve postoperative pain, we primarily use electrically-driven patient- controlled analgesia (PCA) pumps, with which 4,000 or more patients have been treated. It is necessary to construct an appropriate system to operate and control multiple pumps safely. The cooperation of nurses and other medical personnel, such as clinical technicians and pharmacists, is also essential.

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  The evaluation of services by patients is an essential component of quality improvement in anesthesiology. We reviewed post-anesthesia consultation notes for elective-surgery patients seen at the Nara Medical University Hospital since 1996 to determine what led to patient satisfaction. We concluded that patient satisfaction correlates with safety, comfort, and attention from the anesthesiologist. Anesthesiologists made every effort to improve the safety of anesthesia and the comfort of patients after anesthesia. However, we did not obtain satisfactory results from these efforts. There was a wide range of patient perceptions. We concluded that informed consent is important for patient satisfaction with anesthesia. The preoperative explanation by an anesthesiologist is thought to be important for patient understanding of anesthesia, and influences patient satisfaction with anesthesia. We present a novel system for an anesthesia consultation clinic in Nara Prefectural Mimuro Hospital to obtain better patient understanding of anesthesia.

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  An 80-year-old man was scheduled for total knee arthroplasty under combined spinal and epidural anesthesia. He had no neurological symptoms before surgery. During continuous epidural infusion for postoperative analgesia, weakness of the left leg was noted. After continuous epidural injection was stopped, however, the left leg pain reappeared and epidural infusion was re-started. Movement in the left leg was then recovered. On the 1st postoperative day, the epidural catheter was removed, but weakness of both legs gradually developed. Urinary and bowel dysfunction were also found. Magnetic Resonance Imaging revealed severe lumbar spinal canal stenosis and a hematoma-like lesion. An emergent lumbar laminectomy was performed, during which no hematoma, but fluid and edematous fat, were found in the epidural space.
  Elderly patients, with possible spinal canal stenosis, may have a potential risk for developing neurologic complications due to epidural anesthesia. Thus, a careful preoperative interview and thorough post-anesthesia neurological examinations are mandatory in aged subjects undergoing epidural anesthesia and analgesia.

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  Pulmonary embolism is one of the major perioperative complications and is mainly caused by pulmonary thromboembolism (PTE) . To establish countermeasures, the Japanese Society of Anesthesiologists investigated the treatment of perioperative pulmonary embolism using data obtained from anesthesia teaching hospitals in Japan from 2002, and it was suggested that treatment was insufficient in patients with perioperative PTE. We recommend transesophageal echocardiography for the diagnosis of PTE. Heparin should be administered immediately taking the risk of hemorrhage into consideration, while maintaining proper circulation and respiration. To perform further treatment smoothly and properly, we also recommend making a diagnosis and treatment manual for PTE which is based on the available staff and equipment at various institutions. Anesthesiologists will play an important role in this.

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  While the sniffing position has traditionally been considered the standard head and neck position for laryngoscopy, recent evidence suggests that the sniffing position provides no significant advantage over simple head extension. At present, what is the optimal head and neck position for laryngoscopy and endotracheal intubation is controversial. Thus, we reconsider this topic as follows ; 1) the role of the head and neck position on obtaining a good glottic view during laryngoscopy based on the obstacle theory ; 2) the head and neck position and cervical spine motion ; 3) the most important segment of the cervical spine for obtaining a good laryngoscopic view-extension of the occipitoatlantoaxial (OAA) complex ; and 4) the head and neck position for establishing a greater OAA extension angle. In addition, we describe the problems and solutions of preoperative evaluation of the extension capacity of the OAA complex.

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  The spread and intensity of epidural anesthesia is determined by the choice of concentration, volume and dosage of local anesthetics.
  However, conventional methods of assessing the effects of epidural anesthesia give neither accurate spread nor intensity of blockade at all. In addition, there are more cases where balance anesthesia is performed nowadays, and anesthesiologists could not tell whether epidural anesthesia they are giving to the patients are sufficient enough.
  In this article, we summarized the results of recent clinical studies concerning methods of assessing the spread and intensity of epidural anesthesia and the relationship between concentration, volume and dosage of local anesthetics and the effects of epidural anesthesia. We conclude that administration of a higher concentration of local anesthetics is recommended.

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  Invasive airway access is a fundamental technique that anesthesiologists must acquire in preparation for “cannot ventilate-cannot intubate” situations. Cricothyrotomy, which can be performed surgically or percutaneously, is suitable in an emergency because it is quick and safe and can be performed reliably compared to tracheostomy. There are a variety of commercially available kits for cricothyrotomy, which vary in the sizes of the cannula and insertion procedures, such as the Seldinger and catheter-over-needle methods. Therefore, anesthesiologists must know the strengths and weaknesses of each kit to determine which one is appropriate for each case. The choice of method for cricothyrotomy, which includes surgical incision, depends on the individual circumstances, i.e., the degree of urgency of the situation, desired ventilation volume, skill of the operator, condition of the insertion site in the neck, and the availability of the kit. Needle cricothyrotomy requiring a high-pressure oxygen source (transtracheal jet ventilation) is not a definite measure for securing the airway because it might cause barotrauma and circulatory collapse, unless the upper airway is kept patent to release expired gas. Therefore, it is necessary to select a kit with a cannula with an internal diameter of more than 4 mm to ensure successful ventilation.

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  Coronary spasm is defined as an abnormal contraction of the epicardial coronary artery resulting in myocardial ischemia. Coronary spasm plays an important role in the pathogenesis of stable or unstable ischemic heart disease including acute coronary syndrome (ACS) . It is well known that coronary thrombosis is the cause of ACS. Therefore coronary spasm per se could induce coronary thrombosis. We have shown that coronary spasm increased the activity of platelets and the blood coagulation system and decreased fibrinolytic activity clinically. These changes together facilitate coronary thrombus formation. On the other hand, mechanical stress induced by coronary spasm easily provokes rupture of the thin fibrous cap of atheromatous coronary plaques. In this way, coronary spasm is responsible for the very early phase of the coronary thrombus formation and for its growth and maintenance. One of the significant underlying conditions of coronary spasm is endothelial dysfunction. Normal vascular endothelium releases nitric oxide (NO) which relaxes vascular smooth muscle. Because endothelial function is impaired in coronary spasm cases, the most essential therapeutic strategy is complement of exogenous NO. Therefore nitrates are useful for preventing coronary spasm. Calcium antagonists and smoking cessation are also effective.

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  Recently, there has been growing enthusiasm regarding the use of ultrasound in the field of peripheral nerve block. Peripheral nerve block has been recognized to improve patient satisfaction, reduce perioperative complications and facilitate patient recovery. However, because of its high failure rate, possible complications and technical difficulties, peripheral nerve block was not popular among anesthesiologists in the past. Conventional peripheral nerve block relies mainly on surface anatomic landmarks and electrical stimulation to localize nerves. Invisibility of the needle and local anesthetic accounts for the shortcomings of conventional peripheral nerve block. Ultrasound guidance enables anesthesiologists to localize nerves, secure an accurate needle placement and monitor the distribution of the local anesthetic in real time. The advantages over conventional guidance techniques, such as surface landmark, nerve stimulation and loss-of-resistance procedures, are significant. This article reviews the advantages, basic principles and practices of ultrasound-guided peripheral anesthesia.

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  The use of dietary supplements (DS) is prevalent in Japan and other countries. However, information on the prevalence of DS use before surgery and their adverse effects is still scarce. Therefore, we investigated the prevalence of DS use before surgery and their perioperative adverse effects in surgical patients. DS use before surgery in 1,100 patients was investigated by direct interview after the surgery. The unanticipated perioperative events were surveyed by reviewing the patients, clinical charts. Among the 1,100 patients, 515 patients (46.8%) had a history of using DS for 5 years before the surgery. Two weeks before the surgery, 98 out of 515 patients (19.0%) were still taking them, and one week before the surgery, 13 patients (2.5%) were still taking them, and none of them informed the medical staff of this fact. The incidence of prolonged prothrombin time (PT) , activated partial thromboplastin time (aPTT) , and bleeding time was not statistically different between the two groups. No perioperative events secondary to their use were observed. Anesthesiologists and surgeons should be aware of the potential risk of the use of these supplements, and should inquire about their use before surgery. Since reliable information on the risk of supplement use before surgery is lacking, prospective randomized studies are needed.

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  We studied the negative effects of hypothermia on the blood coagulation system and investigated the thermogenetic effects of amino-acid infusion on the blood coagulation system using a mesenteric artery hemorrhagic model in the rat.
  Rat plasma was incubated at several different temperatures. Activated partial thromboplastin time (APTT) and prothrombin time (PT) were measured. The mesenteric artery was cut under anesthesia with or without maintaining a warm body temperature, and then bleeding time and blood loss were measured. Two-percent amino acids (800mg/kg/h×1.5h) or saline was infused into rats under anesthesia, and bleeding time and blood loss were measured.
  APTT and PT tended to be prolonged as temperature decreased. As body temperatures decreased, blood loss was significantly increased, but not bleeding time. An amino-acid infusion significantly suppressed hypothermia and decreased blood loss as compared with saline.
  The amino-acid infusion reduces blood loss in an animal model probably because of its thermogenesis.

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  A 22-year-old male with pheochromocytoma and a substantially elevated level of plasma norepinephrine was scheduled to undergo left adrenectomy under general anesthesia. Preoperatively, his plasma norepinephrine level was 25,481 pg/ml, and hypertension (>200/100 mmHg) and tachycardia were aggressively controlled using alpha adrenergic blockers and other antihypertensive drugs. His dietary salt intake was restricted to less than 7g per day. His activity was restricted to a wheelchair on the ward only. Finally, his blood pressure was stabilized at approximately 130/70 mmHg, and he proceeded with the operation. The intraoperative systolic blood pressure was within the range of 70 mmHg to 165 mmHg, and no perioperative complications were detected. This case suggests that the strict control of blood pressure in the preoperative period is essential for uncomplicated management of pheochromocytoma.

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  A 56-year-old man suffering from multiple myeloma and medicated with high-dose oxycodone underwent surgery under general anesthesia. Anesthesia was maintained with inhalation of 2-3% sevoflurane and intermittent administration of intravenous fentanyl. The intraoperative course was uneventful. He recovered from the anesthesia quickly, and there were no complications from fentanyl during the perioperative course. Postoperative pain management was performed with continuous administration of fentanyl. The conversion rate from oxycodone to fentanyl occurred according to opioid rotation.

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  Epidural anesthesia and analgesia has become popular and the number of patients receiving anticoagulation therapy is increasing. The prevention of perioperative venous thromboembolism is being established as a medical standard. These circumstances may lead to increase incidences of epidural hematoma. Epidural hematoma is a rare event, but recent reports have elucidated that the incidence of epidural hematoma varies depending on certain characteristics of the subjects, such as disease, sex, and age, and that the past small studies bias the incidence of complications. Patient safety can be increased by careful preoperative evaluation of risk factors and scrupulous postoperative surveillance.

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  The spread of epidural anesthesia is highly variable among individuals. A large number of studies have attempted to clarify the reason for this variability. Some of the variability is intrinsic to the patient, and is not dependent on variations in technique or the drugs administered. Some intrinsic factors, such as age, are poorly correlated with the spread of anesthesia. The author proposed the hypothesis that differences in the surface area of the lumbosacral dura, epidural fat volume, and epidural venous plexus velocity might explain the variability in the extent and duration of epidural anesthesia with ropivacaine. According to the results of the study performed by the authors, the dural surface area may influence the spread of epidural anesthesia with ropivacaine, and posterior fat volume may influence the duration of epidural anesthesia in healthy patients within a narrow age range.

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  To provide effective labor epidural analgesia, additional epidural infusion following the initial loading dose is required. For this purpose, either patient-controlled epidural analgesia (PCEA) or continuous epidural infusion (CEI) has been used and has improved the quality and safety of labor analgesia by reducing local anesthetic usage. By comparing PCEA and CEI, it has been reported that patients who receive PCEA are less likely to require anesthetic interventions, require lower doses of local anesthetic and have less motor block than those who receive CEI. However, regardless of the choice, anesthesiologists should visit the patient throughout her delivery to optimize epidural infusion for labor analgesia.

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  In order to practice obstetric analgesia, an anesthetist should consider the influence of analgesia on the mother's image of labor and delivery, the process of labor and her child-care after birth, as well as the analgesia itself based on the anesthesiology. The anesthetist in charge should communicate with the mother, her family, obstetricians, neonatologists, and midwives for a safe and comfortable delivery. Therefore, obstetric anesthesiologists as sub-specialists have to be established. They are not only the provider of epidural analgesia but are also the supporter who realizes the maternal comprehensive care of the pregnant women at all stages of pregnancy.

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  Labor epidural analgesia provides the most effective pain relief, and is indicated for patients with panic disorder or spinal cord injury. Labor pain stresses the respiratory and cardiovascular systems. Labor epidural analgesia reduces such stresses in patients with medical complications (e.g., bronchial asthma, myasthenia gravis, ischemic heart disease, mitral valve stenosis, cerebral aneurysm) . Labor epidural analgesia is also preferred in preeclamptic parturients, because it facilitates the control of blood pressure and may improve blood blow to the fetus.
  Complications of labor epidural analgesia include hypotension, intravascular or spinal catheterization, nerve injury, and epidural hematoma or abscess. They are well recognized as complications of epidural anesthesia for surgery, but are reviewed from the obstetric perspective in this paper. Fetal transient bradycardia and maternal fever are unique complications of labor epidural analgesia. Measures to prevent and treat these complications are also discussed.

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  There have been many publications about the association between the use of epidural analgesia during labor and labor outcomes. A fall in plasma oxytocin concentrations during labor with epidural analgesia and an increased use of oxytocin augmentation were reported. Although epidural analgesia has been reported to be associated with a longer first stage of labor, it is still controversial. Recent meta-analysis showed a longer second stage of labor and higher incidence of instrumental delivery in patients with epidural analgesia compared to those without it. However, they concluded that epidural analgesia does not increase the rates of cesarean delivery. It is suggested that a delay in the second stage is not harmful to the infant or mother provided that it is confirmed that the mother and fetus are doing well. Recent randomized trials made it clear that effective pain relief with regional anesthesia should not be withheld simply because an arbitrary degree of cervical dilatation has not yet been achieved.

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  Total intravenous anesthesia (TIVA) with the target-controlled infusion (TCI) technique using propofol is increasingly common in Japan. Epidural anesthesia established with local anesthetic blocks transmission of perception from peripheral nerves to the spine, thereby reducing the level of consciousness. Reducing the level of consciousness leads to a decrease in the requirements for sedatives such as midazolam and thiopental. Hemodynamic status was depressed significantly by use of either propofol or sevoflurane in the patients receiving epidural anesthesia upon anesthetic induction, compared with the patients not receiving epidural anesthesia. Combination with epidural anesthesia significantly decreased in an effect-site concentration of propofol during anesthetic maintenance under a similar plasma fentanyl concentration (1.5μg/ml) . In the emergence from general anesthesia from similar sedation level, the epidural anesthesia shortened the time to awakening from propofol anesthesia (i.e., the patient opening his/her eyes in response to verbal command alone) . A strong analgesic effect elicited by an epidural local anesthetic is likely to be one of important factors in easing TIVA using the TCI technique.

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