THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA Vol. 37(2017) No. 3

Among the complications associated with epidural puncture, epidural infection may result in severe neurological disorders if diagnosis and treatment are delayed. We retrospectively examined the onset, treatment, and prognosis of 12 cases of epidural abscess that occurred after epidural puncture between 1993 and 2013. There were 3 cases in which symptoms developed more than 3 weeks after the puncture, and in those cases the stages had already been progressing at the time of onset. Antibiotics were administered in all of the cases. Surgical treatments were performed for 4 cases, and 2 of them were left with paralysis. If the symptoms become apparent after a long period of time after epidural puncture, the stage may have been progressing at the time of symptom onset. Therefore, if fever or back pain occur after epidural puncture, irrespective of when the procedure was performed, epidural abscess should be suspected. It is necessary to diagnose and treat patients keeping epidural abscess in mind.

Shortening turnover time in the operating room is an effective way to increase the number of surgeries. In our hospital, a pharmacist has prepared injections and managed narcotics in the operating room since 2009. This study determined the effect on turnover time of adding a pharmacist to the staff in the operating room. The median turnover time from October-December 2014（pharmacist group）was significantly shorter than from October-December 2008（non-pharmacist group）. Furthermore, in the seven surgical departments tested, median turnover time was shorter in the pharmacist group than in the non-pharmacist group in five departments. Our results demonstrated that the inclusion of pharmacists to the staff in the operating room is effective at shortening turnover time.

Congenital coagulation Factor XIII deficiency is a rare coagulation disorder, and standardized perioperative management for this congenital deficiency has not been studied. We report on the anesthetic management of a patient with congenital Factor XIII deficiency who underwent cervical spine surgery. By measuring Factor XIII levels and having replacement therapy as preoperative preparation, we kept the Factor XIII level high enough to avoid induction of massive bleeding during the operation. Although we completed the operation without any complications, including hemorrhage, we noticed that the practical level of Factor XIII had decreased more than expected after the operation. Anesthesiologists should remain cognizant of the possibility of decreasing levels of Factor XIII.

We performed a retrospective study to investigate the influence of preoperative pain on the severity of postoperative pain, using the number of times of bolus dose（Bolus Number）of intravenous patient-controlled analgesia（IV-PCA）. Fifty-one patients who underwent abdominal surgery at Fukuoka Tokushukai Hospital were enrolled between April 2015 and December 2015. Patients were divided into two groups；Group P（n=26）with preoperative pain, and group NP（n=25）without preoperative pain. At the end of the operation, IV-PCA was started for postoperative analgesia. When IV-PCA was completed Bolus Number was counted in two groups. Bolus Number of IV-PCA in group P was 6±6 times, which was significantly decreased compared to that in group NP（10±8 times）. All patients in group P had acute pain before emergency surgery. Our results showed that group P required less postoperative analgesics than group NP, which suggests that acute pain before emergency surgery may decrease postoperative requirement for analgesics.

It is known that congestive heart failure may cause bacterial translocation with dysfunction of the intestinal mucosa. We herein report the case of a patient who had bacterial translocation, caused by congestive heart failure with aortic valve stenosis. The patient was 83 years old and had acute heart failure with aortic valve stenosis. After the acute heart failure was treated, he developed a fever of unknown origin and acute kidney injury repeatedly, both of which responded to antibiotics. While no infection focus could be found, we decided on a diagnosis of bacterial translocation due to low cardiac output and performed emergency aortic valve replacement. This improved his condition, and he recovered. In a practical clinical setting, it is difficult to make good decisions in cases like this.

The administration of antibiotics and performance of emergency surgery for patients with aortic valve stenosis made it possible to obtain a good clinical course.

We experienced anesthesia management of patient with inoperable ascending aortic aneurysm and rapidly occurring progressive airway stenosis. A 71-year-old man was scheduled for tracheobronchial stenting with silicone Y stent. First, with PCPS stand-by, endovascular coiling for aneurysm was performed to reduce the risk of rupture. General anesthesia was induced and a stent was successfully inserted with rigid bronchoscopy.

We were able to safely manage anesthesia with the cooperation of several medical departments. The patient died about one month after stenting. In order to avoid over-treatment, healthcare providers should carefully evaluate how far they should go in the treatment of patients with a poor prognosis.

Many anticonvulsant drugs can cause cross-resistance to non-depolarizing muscle relaxants（NDMRs）. However, few drugs have been reported in this context except for carbamazepine and phenytoin. Recently, a report that valproic acid（VPA）affects the duration of the action of NDMRs was published. We present the case of a 19-year-old woman with juvenile myoclonus epilepsy who had been taking VPA 700 mg/day for 6 years. In this case, the effect of rocuronium lasted an average of 22 min, so resistance due to VPA was thought to have shortened the duration of rocuronium-induced neuromuscular block. we believe that more attention should be paid to drug therapy in patients on long-term VPA therapy owing to possible resistance to NDMRs.

We report a case of bronchial rupture associated with use of a double-lumen endobronchial tube（DLT）. A 52-year-old, previously healthy female was scheduled for thoracoscopic left upper lobectomy. Physical examination was unremarkable. After anesthesia was induced, her trachea was intubated easily with a 35-Fr left sided DLT（Blue Line endobronchial tube^®, Smiths Medical Japan, Tokyo）. Surgery proceeded uneventfully under general anesthesia using oxygen, air, sevoflurane, and remifentanyl. Post-lobectomy, when the airway pressure was increased for a leak test, we observed an air leak from mediastinum. The bronchial tip of the DLT was observed in mediastinum through the thoracoscope, and we found that the DLT ruptured the membranous portion at the root of the left main bronchus. An urgent open thoracotomy was performed to repair the bronchial injury, but otherwise she had an uneventful recovery. In conclusion, anesthesiologists should be alerted to the risk of tracheobronchial rupture associated with use of a DLT.

In 2012, the Japanese Society of Anesthesiologists published a practice guideline for preoperative fasting which is based on reliable studies including a multi-center randomized controlled trial in Japan which was comparable in criteria to those of Europe and United States. This review is to confirm the validity of the Japanese guideline referring to research performed in Japan after its publication. In particular, preoperative fasting effect of clear fluid is focused on, because it is supported by papers of level I in the Japanese guideline. Two studies evaluating gastric residual volume after oral intake of clear fluid are available, which support that the Japanese guideline provides safe criteria for preoperative fasting of clear fluid. Also, the studies show that a certain clear fluid runs out from stomach faster than others. It is suggested that the fasting period could be shortened when proper clear fluid is served to patients.

Postanesthesia care units（PACUs）could be a solution for improving postoperative management in Japan. A PACU delivers general medical supervision as well as care closely and constantly to patients who have just undergone a surgical procedure under anesthesia. Although PACU management is considered a standard procedure in other developed countries, only 16.1％ of hospitals in Japan currently have PACUs. The identifying advantages of a PACU are 1）to optimize the patient’s safety, 2）to improve the patient’s comfort and satisfaction, and 3）to increase surgical turnover and operating room efficiency. However, more detailed evidence to support these advantages is required. The lack of space and a shortage of human resources appear to be the two main factors which make it difficult to manage PACUs at present even though 60.0％ of institutions recognize the merits of having one. Nevertheless, the establishment of PACUs will likely need to be modified in Japan due to its unique medical systems and traditions. This article describes the management techniques, progress in verifying the associated benefits, and future considerations for PACUs in Japan.

The amount of viruses in donated blood is too small to be detectable by infection examination（window period）just after a blood donor is infected with hepatitis B or C or HIV. In these cases, blood recipients may be at risk for these virus infections. In addition, recipients may also have donated blood-caused adverse reactions such as hemolytic transfusion reactions, anaphylaxis, TRALI and GVHD. For these reasons, we promote hemodilutional autologous transfusion（HAT）to avoid allogeneic transfusion. Based on our data analysis in patients undergoing non-cardiac surgery, the rate of HAT-caused hypotention with requirement of vasopressor was around 6%, and the rate of allogeneic transfusion avoidance by HAT was 94% and 40% when blood loss was less than and more than 2000 g, respectively. Therefore, HAT may be a useful technique in anesthesia management. However, HAT may not be suitable for aged patients and patients with coronary stenosis.

The role of nonopioid analgesics in the pharmacotherapy of cancer pain is important. The use of nonopioid analgesics may allow the side effect reduction of opioids. Nonopioid analgesics are classified roughly into non-steroidal anti-inflammatory drugs（NSAIDs）and acetaminophen. From their mechanism of action, NSAIDs pose the risk of gastrointestinal disturbance, renal dysfunction, and platelet disorder. In recent years a cardiovascular risk has been found as well. Whereas acetaminophen requires attention about liver dysfunction. We give an outline around the point where you should be careful about nonopioid choice.

Cancer pain is multifactorial and often difficult to treat with opioids alone. Although many adjuvant analgesics such as anticonvulsants, antidepressants and NMDA receptor antagonists are currently used in conjunction with opioids, evidence of their efficacy pertaining to cancer pain is still limited. It is important to select appropriate adjuvant analgesics individually based on mechanisms of pain. Further, providers must take into account drug interactions as well as side effects of the medication. Continuous assessment of pain is essential to get maximum analgesia with fewest side-effects.

We anesthesiologists should have knowledge of the environmental arrangement of operating rooms（OR）since the management of OR is part of our role. The “Guideline for Prevention of Surgical Site Infection, 1999” presents the recommendations of Centers for Disease Control and Prevention（CDC）, which are based on the scientific evidence of the time. Although it was published more than a decade ago, it is still the foundation of present surgical practices. This document presents an overview of concepts for managing the OR environment, such as air conditioning, cleaning, and sterilization based on the CDC guideline, with some elements of the current Japanese guidelines.

Patients with chronic pain have specific issues important for perioperative management. In such cases, there are many elements that contribute to difficulty in perioperative pain control and increase the risk of chronic pain after surgery. Anesthesiologists must understand the importance of the distinct preoperative evaluation of chronic pain patients, especially those using opioids. The amount of daily opioid consumption must be assessed, and perioperative opioid use, including type, dose, and postoperative analgesic method, must be considered. At present, there is insufficient information about the anesthetic management of patients with chronic pain and the perioperative management of patients using opioids. The optimal anesthetic method and analgesic dose must be individually titrated. An insufficient opioid dose might result in withdrawal symptoms. Opioids should not be inadvertently reduced or discontinued during the acute perioperative period in chronic users.

Psychological factors can increase the severity, intensity and duration of pain. Psychophysiological studies on anger, anger expression and chronic pain were reviewed and summarized. Anger is a negative affection. When anger increases, it will increase the unpleasant emotional component of pain. Some studies revealed that the anger management style ‘anger-in’ shows more intense and frequent pain than ‘anger-out’ style in chronic pain patients. We use the ‘expression poster’ and the ‘expression cards’ so that the chronic pain patient is able to express the authentic feelings, because some of the patients are alexithymic, and/or often express racket feelings. From the angle of the anger management, several therapeutic approaches, such as transactional analysis, assertiveness training, expressive arts therapy, mindfulness training, and validation strategies in dialectical behavioral therapy were outlined.

Anesthesiologists usually consider future careers in their own working positions such us resident, certified physician of anesthesiologist or anesthesia specialist. Any career that anesthesiologists choose is acceptable. Anesthesiologists first should acquire the license of anesthesia specialist recognized by the Japanese Society of Anesthesiologists. I would like to discuss the subspecialized license after acquiring a qualification called anesthesia specialist. When we think about how anesthesiologists keep a cardiovascular anesthesiologist as the subspecialized license, this qualification is thought to be very useful for anesthesiologists. The main reasons are as follows. First, I think that cardiovascular anesthesiologists have the characteristics of general medical treatment specialists, and that general medical treatment specialists are required by the Japanese Medical Specialty Board. Next, I think that cardiovascular anesthesiologists will be beneficial human resources in the field of medical practice, medical education and clinical research in the future.