The health care system with universal access in Japan has increased the life expectancy of the Japanese population to one of the longest in the world. The rapidly aging population, however, has resulted in a tremendous financial burden on the system and it is considered to be on the brink of collapse without a major overhaul. It is believed that the system will not be able to function effectively beyond the year 2000 without a radical reform. The current system, however, is rigid and inefficient to cope with the crisis because it is constrained by many goverment regulations. It appears that an agreement for a reform plan will not be reached by the interest groups in the immediate future. The Ministry of Health and Welfare also does not seem to have a comprehensive policy to resolve the differences, and has decided to postpone a major reform as of the end of November, 1999. The health care system of Japan has some inherent problems as compared to the systems in other developed nations. Although the total health care cost is relatively low, the cost of prescribed medicines is substantially higher and health care costs for the elderly constitute more than one third of the total cost. Furthermore, the number of hospital beds is the largest and the average hospital stay is the longest among G7 countries. Other problems are the lack of an effective system that assures the quality of health care and limited access to information on the quality of health care by consumers. Any reform plan to save the system will need to take these factors into consideration.

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The bacterial contamination of _ETCO₂ monitor apparatus routinely used in operating rooms has been found at a high rate, with increases occurring according to the duration of use. The transfer of the bacteria from a patient having airway infections to the _ETCO₂ monitor apparatus was studied in an ICU unit with the installation of an apparatus for 1, 3 or 7 days. The same bacteria were detected after all the periods, indicating the transference of bacteria from airways to the machine within 24 hours. The results indicate that the _ETCO₂ monitor circuit should be limited to only one patient. Furthermore it may be necessary to use bacterial defense filters for the prevention of bacterial contamination.

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The aim of this study was to evaluate which factors affected recovery from anesthesia in 50 postoperative patients undergoing coronary artery bypass grafting surgery (3 to 5 bypasses) Patients who had either renal or hepatic dysfunction, or any perioperative complications were excluded. Anesthetics used for the surgery included fentanyl (38 to 80μg•kg-1), midazolam, and vecuronium. Of all the factors evaluated perioperatively, either youth, better postoperative cardiac indexes, or shorter extracorporeal circulation time were associated with earlier emergence from anesthesia, However, no correlation was observed between the total dose of either fentanyl or midazolam. These data suggest that the emergence from anesthesia in patients undergoing CABG depends upon postoperative cardiac function, and surgical invasiveness, rather than the anesthetics used.

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A 75-year-old male had emergency ophthalmic surgery under general anesthesia. Preoperatively, his chest X-P revealed mild cardiomegaly and an ECG showed atrial fibrillation. Upon arrival at the operating theater, it was found that supraventricular tachyarrhythmia had developed. Valsalvas maneuver, carotid sinus massage and intravenous administration of verapamil were not effective. Anesthesia was induced with 125mg of thiamylal followed by vecuronium, and maintained with 50% O₂-N₂O-1% sevoflurane. A few minutes after endotracheal intubation, his blood pressure and pulse oxymeter oxygen saturation decreased. Congestive heart failure was diagnosed by a chest X-P and hemodynamic assessment with a pulmonary artery catheter. After administration of an inotropic agent, his blood pressure and arterial oxygenation improved gradually. ECG showed the return to a normal sinus rhythm after treatments with bolus administration of ATP and cardioversion. Surgery was postponed and the echocardiogram revealed dilated ventriculus and gross impairment of ventricular systolic function, with suspected dilated cardiomyopathy. We conclude that preoperative evaluation of cardiac function is essential in a patient in whom cardiovascular abnormality is suspected.

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A 49-year-old man was diagnosed with inoperable lung cancer. Tumor growth was so rapid that his dyspnea worsened in spite of several courses of laser treatment. He was then scheduled for endobronchial stent insertion. Inherently his right lung was anaplastic and the right main bronchus was completely occluded by the carcinoma. Over 90% of the left main bronchus was occluded, and the bronchoscopy was impossible to use because of stenosis. As difficulty in placing the endobronchial stent and the possibility of complete occlusion of the airway were expected, percutaneous cardiopulmonary support (PCPS) to maintain oxygenation during apnea was placed.
Anesthesia was induced with pentazocine and propofol followed by a propofol infusion to maintain anesthesia without disturbing spontaneous breathing. PCPS was prepared (supporting blood flow: 1∼1.5l•min-1, FIO₂: 1.0), then veculonium IV was administered and apnea occluded. After resection and coagulation of the tumor using a Yttrium-Aluminum-Garnet laser, the endobronchial stent was placed into the left main bronchus. Several minutes later, the patient began breathing again and recovered from the anesthesia smoothly.
This case suggests that PCPS is useful as an extracorporeal lung assist for surgical procedures involving possible apnea.

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We report a case of mediastinal and subcutaneous emphysema that developed postoperatively in a 52-year-old patient with Down's syndrome. The patient was mentally retarded, and moderately obese (137cm, 47kg), but had no apparent pulmonary or cardiovascular diseases preoperatively. She had undergone uneventful general anesthesia five years previously. She was scheduled for ophthalmic surgery under general anesthesia. On arrival, moderate hypoxia (SpO₂ 93%) was noted. After administering thiamylal and vecuronium intravenously, the trachea was intubated easily without requiring a stylet. After intubation, auscultation revealed moist vesicular sounds. A suction tube aspirated bloody fluid through the tracheal tube. No other abnormal signs were noted during the operation. The patient was extubated at the end of the operation. After recovering, she started to complain of chest pain 210 minutes later. Six to seven hours postoperatively, profound subcutaneous emphysema and pneumomediastinum were confirmed by physical and radiological examinations. This may be partly attributable to the fragile tissues of Down's syndrome patient, in middle age.

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We encountered a case of pyrogenic lumbar spondylitis after spinal anesthesia, which was thought to be caused by methicillin resistant Staphylococcus aureus.
This case was a 63-year-old woman whose medical history included the removal of a brain tumor 12 years ago. She was diagnosed with acute appendicitis and an appendectomy was performed under spinal anesthesia. Although cefotiam had been administrated, high fever, lumbago and lower leg pain in both legs appeared postoperatively. MRI films revealed edema of the lumbar spines (L3 and 4) and intervertebral disk (L3/4). We diagnosed this as acute pyrogenic lumbar spondylitis and began to administer wide spectrum antibiotics. On the 26th postoperative day, urinary disturbance appeared and MRI films revealed the existence of an epidural abcess. Immediately, a lumbar laminectomy (L2-4) was performed to remove the compression of the epidural abcess and the symptoms improved transiently. We were unable to detect causative organisms even from the intraoperative specimens. Fever (37.7°C), lower leg pain and inflammatory responses worsened a few days after the laminectomy. We suspected methicillin resistant Staphylococcus aureus (MRSA) as a causative organism and start to administer vancomicin, which improved the symptoms and inflammatory responses gradually. Three months after admission, the patient was discharged with slight lumbago.

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One of the problems of using anesthesia in conflict areas is the difficulty of obtaining oxygen for medical usage. One solution for this problem is to use an oxygen concentrator and an air compressor. In this report, we examined an oxygen concentrator and an air compressor which are available in Japan. Connecting them with three different anesthetic machines, we measured what concentration and flow of oxygen they could produce.
Though the oxygen concentrator itself did not produce a high flow of gas, the combined use of an air compressor and an oxygen concentrator proved to provide a gas flow rate of more than 6l•min-1, and an oxygen concentration of more than 45% with any make of anesthetic machines. The combined use of an oxygen concentrator and an air compressor with an anesthetic machine, is a practical method of administering anesthesia in conflict areas.

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