The framework of basic CPR methods or techniques, namely artificial respiration, closed chest cardiac compression (CCCC), electric defibrillation and drug therapy, especially epinephrine administration, were developed during the first half of the 20th century. It can be said it was completed when Kouwenhoven introduced CCCC in 1960.
In 1974, American Heart Association and its related organizations collaborated to publish the first CPR guidelines. Since then they have revised the Guidelines every several years to renew the methods and techniques according to accumulated new achievements during these periods.
In 2000, it published the 7th edition (G2000) in collaboration with ILCOR, the International Liaison Committee On Resuscitation. Because of this it can be said that G2000 is the resuscitation guideline of the world.
One of the rules for the AHA guidelines is that it admits only methods which have bad their efficacy verified scientifically in humans, and G2000 emphasized the importance of evidence-based medicine in the science of resuscitation. But some of the methods have been used on an empirical basis without scientific proof of their efficacy. Some of the methods have been used without knowing the mechanisms by which they work on human. For example, CCCC was used for a long time without knowing logically its mechanism of pumping out the blood by simply compressing the sternum. The optimal dose of epinephrine when the initial dose of the drug fails has been controversial for long time.
Recently, new problems such as an avoidance of mouth to mouth respiration have arisen and caused some changes in the framework of CPR techniques. In this article I would like to discuss some of the problematic issues of CPR such as the following :
1. The mechanisms of CCCC by which blood flows by simply compressing the sternum
2. It has long been known that weak electric current causes ventricular fibrillation and strong one defibrillation. Why is that? And what is the optimal current for defibrillating?
3. Mouth to mouth respiration is far better in effectiveness than other types of basic artificial respiration. But recently not many citizens have been willing to practice it on a stranger. Because of this G2000 approved the use of compression—only CPR. How effective is it?
4. If the initial dose of epinephrine is ineffective the use of a dose of epinephrine that's 5-10 times greater is approved to use as a subsequent dose. What are the right doses of epinephrine in resuscitation?
5. Hypothermia is attracting the interest of clinicians because of its probable effects in brain resuscitation after successful cardiopulmonary resuscitation. What is the conclusion of recent studies on this matter?
Is it the best remedy for brain resuscitation?

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The purpose of this study is to evaluate the physical changes of patients entering the operating room (OR) by one of the following methods : walk-in method on foot, transportation by wheeled-stretcher and transportation by wheel-chair. One of the three methods were assigned to patients without premedication from the general ward to the OR (on foot) group W : group S, by wheeled-stretcher ; and group C, by wheel-chair. Blood pressure (BP) and pulse-rate (PR) were measured both in the ward and the OR. Upon arrival at the OR they were interviewed regarding their anxiety and satisfaction. Medical staff, nurses and anesthesiologists were also interviewed on their impressions of the methods of entering the OR. BP was significantly increased in all groups on arriving in the OR. PR significantly increased in group W (n=70) and C (n=92). There was no difference in the rate of patients who felt anxiety on entering the OR among three groups. Medical staff members felt the walk-in method and wheel-chair method were better than by wheeled-stretcher. We conclude that the walk-in method may produce significant physical changes and that the wheel-chair method is clinically applicable enough both for patients and staff members.

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We report a useful case of hepatic venous oxygen saturation (ShvO₂) monitoring, during hepatic blood flow blocking and restoration. The patient was scheduled for a pancreatectomy from a diagnosis of pancreatic body tumor in a 68-year-old man.
The proper hepatic artery that maintains the hepatic blood flow was resected accidentally, because the tumor invaded the organs and blood vessels around the liver. ShvO₂ decreased immediately because of interruption of the hepatic blood flow. The hepatic artery reconstruction was performed in order to maintain the hepatic blood flow. Thereafter, ShvO₂ was recovered. It has been suggested that monitoring of ShvO₂ is a useful index of hepatic blood flow.

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We had a patient receiving several kinds of anticonvulsants who developed Wenckebach-type atrioventricular (AV) block after traumatic amputation of the left toes. Wenckebach-type AV block was changed to first-degree AV block before the operation. The autonomic nervous system imbalance caused by severe pain after the trauma was thought to have induced the AV block. In addition, the anticonvulsants, carbamazepine and fenytoin, might have contributed to the onset of the AV block, because both have the property of AV node suppression. Anesthesia was uneventfully performed by general anesthesia with inhaled sevoflurane and intravenous fentanyl. The AV block induced by autonomic nervous system imbalance can be easily treated with atropine, and is therefore considered to be comparatively benign. In the patient receiving anticonvulsants, the preoperative evaluation should be carefully carried out taking into account that there is a possibility of inducing AV block, and it may be induced by external causes, such as trauma, like in our patient.

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We experienced a case of left main bronchial rupture during surgery for esophageal cancer. The patient was a 62-year-old male with type II diabetes mellitus. Preoperative examinations did not reveal any bronchial or tracheal lesions. After induction of general anesthesia, his trachea and left main-stem bronchus were intubated with a left-sided double-lumen endobronchial tube guided by fiberscopy. The patient was then placed in the left lateral position and a right thoracotomy was performed followed by subtotal resection of the esophagus and lymphadenectomy in a procedure lasting two hours. One-lung ventilation of the left lung was performed without problems. However, a surgeon noticed herniation of the bronchial cuff through the proximal left main bronchial tear. The lesion was surgically repaired successfully. The patient was placed in a supine position and the esophagus was reconstructed using a gastric tube. The postoperative course was uneventful and the patient was discharged 30 days after surgery. We discuss the mechanisms of bronchial rupture related to bronchial intubation.

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Kainuma et al. have reported that monitoring of hepatic venous hemoglobin oxygen saturation (ShvO₂) is easy to accomplish and is a valuable technique in studying the extent of hepatic ischemia during liver surgery. Appleby operation is performed for pancreatic body and tail carcinoma, which often invades the celiac and common hepatic arteries. The most critical complication of this procedure is liver insufficiency due to hepatic ischemia. In order to prevent hepatic ischemia, we insert a hepatic venous catheter and continuously measure ShvO₂ in all patients undergoing Appleby operation. ShvO₂ monitoring plays a pivotal role in not only evaluating the extent of hepatic ischemia but also in deciding whether Appleby operation should be finally adopted or not. We hope that many studies will be reported to determine the usefulness and the significance of ShvO₂ monitoring in the Appleby operation.

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A good indication of the CSE technique is cesarean section and geriatric anesthesia, which make the level of anesthesia difficult to predict, and tend to make circulation dynamics under anesthesia unstable. In addition, there are many cases that can employ the advantages of CSE efficiently, so indication of the CSE technique is large. In this paper, my procedure in cesarean section and labor anesthesia was introduced. The back eye type CSE needle was compared with the open tip type, and there were no significant differences on use.

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In the present review, the author described some important information regarding epidural, spinal, or combined spinal and epidural anesthesia (CSEA). The author has demonstrated that the cephalad spread of the contrast medium in the subarachnoid space, and the compression of the subarachnoid space are observed after epidural injection of physiological saline solution using myelography and magnetic resonance imaging (MRI). These studies suggest the volume effect during CSEA. Furthermore, the author reported that the cauda equina moved to the gravity-dependent side, when changing from the supine to the lateral decubitus or prone position. These results differ from the previous studies, so that it is necessary for us to guard against movement of the cauda equina when we perform the spinal anesthesia.

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The technique of combined spinal epidural anesthesia is divided between single segment technique (SST) and double segment technique (DST). SST is known as the needle-through-needle technique, that is, a spinal needle is passed through an epidural needle. Since SST requires only one injection, it requires little time and induces little pain, and its degree of satisfaction for the patient is also high. SST, however, had a high failure rate of spinal anesthesia in early reports. In addition, the risk of subarachnoid catheter migration and transferance of epidural drugs into cerebrospinal fluid is considered. DST provides more certain spinal anesthesia. Since epidural catheter can be anywhere, it can be used for postoperative analgesia efficiently. However, the two injections of DST may theoretically increase the incidence of pain, infection, and formation of hematomas.
When the features and complications of SST and DST have been grasped, it is desirable to choose the technique in consideration of the kind of operation or the grade of postoperative pain.

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Needles for Combined Spinal-Epidural Anesthesia (CSEA) have been classified into the following three types:
1) Needle through needle type,
2) Needle through needle with back-eye type,
3) Needle beside needle type,
Each type of Combined Spinal-Epidural Needle has an individual maximal protrusion length of the spinal needle (7mm-15mm).
The subarachnoid puncture cannot be successfully performed, if the epidural needle is deflected from the midline of the epidural space, or the protrusion length of the spinal needle is not long enough to penetrate the dura.
The techniques of epidural puncture have also influenced the protrusion length of spinal needle at the subarachnoid puncture.
Paramedian approach required a longer protrusion length than the midline approach (8.0mm vs. 5.5mm, respectively).
To identify the epidural space, injection of saline (5ml) resulted in a longer protrusion length than that of air (9.7mm vs. 5.4mm, respectively).
It is important for successful CSEA to perform correct epidural and subarachnoid puncture, and to understand the protrusion length of spinal needle beyond the end of epidural needle related to the characteristics of needles and the techniques of puncture.

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Inhalation induction with high concentration sevoflurane has been popular because of its characteristics. Sevoflurane is an ideal agent for inhalation induction of anesthesia. Sevoflurane produces quick induction with low pungency to upper airways. Furthermore, inhalation induction with high concentration sevoflurane provides additional advantages, such as good cardiovascular stability, smooth transition between induction and maintenance and rapid onset of non-depolarizing muscle relaxant. Thus, it is very important to understand and be familiar with inhalation induction with high concentration sevoflurane. It is very difficult to compare induction with intravenous agents with inhalation induction with high concentration sevoflurane. Although inhalation induction with high concentration sevoflurane is not a completely alterable method from induction with intravenous induction, it should be considered for one of anesthetic induction methods. In the present article, I described the techniques and characteristics of inhalation induction with high concentration sevoflurane for each patient.

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We studied thirty-five patients of ASA physical status I and II with difficult airway to compare a bolus inhalation of sevoflurane with a target-controlled infusion (TCI) of propofol for establishment of the safety and feasibility of a novice training program for fiberoptic intubation. Patients were randomly assigned to three study groups : a group receiving a bolus inhalation of 5% sevoflurane (SVIMA group ; n = 15), and two groups receiving an effect-site concentration of either 2.8 or 4.0μg·ml^-1 of propofol (LTCI group or HTCI group, respectively ; n = 10 each). Time with loss of response to verbal commands was significantly shorter (p < 0.01) in this order SVIMA, HTCI and LTCI groups. Respiratory depression (apnea for > 30s) occurred significantly more (p < 0.05) in the HTCI group than in the SVIMA group. Three patients in LTCI group demonstrated BIS value > 75 during an intubational procedure. Mean artery pressures and heart rates after tracheal intubation increased significantly more in the SVIMA and HTCI groups compared with their baselines. Incidence of adverse effects related to tracheal intubation such as coughing and laryngospasm was similar in all study groups. These results suggested that a bolus inhalation of 5% sevoflurane was superior to propofol TCI on fiberoptic nasotracheal intubation in terms of maintaining spontaneous breathing and hypnotic effects during the intubation procedure except for large hemodynamic changes after tracheal intubation.

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Venous thromboembolism (VTE) has been a common illness even in Japan and was gotten increased social as well as medical attention, especially during postoperative period. However, we cannot use western guidelines in Japan, because the incidence of VTE might be lower, available medicine has differences such as low molecular weight heparin, and public awareness of VTE is much lower in Japan. Therefore, Japanese guidelines is necessary. Although we have little data on the prevention of VTE, we completed the creation of Japanese own guideline together with 10 medical societies. The guidelines are based on the 6th ACCP guidelines which employ the 4-risk category style. We assumed that the incidence of VTE in Japanese was one level lower than in western people. We used the coverage medicine only, and gave priority to mechanical prevention because we wanted to avoid bleeding complications. Our future tasks are release of these guideline, reevaluation of the guideline after using this one, and data collection of Japanese VTE.

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Unfractionated heparin is used for the prevention of venous thromboembolism before, during, and after surgery, especially in high-risk patients. Epidural bleeding is the major complication of anticoagulant therapy during epidural analgesia. The calculated incidence of epidural hematoma is approximated to be less than 1 in 150,000 epidurals. However, this incidence is increased by anticoagulant therapy. The symptoms of acute epidural hematoma include a sharp radiating back pain and sensory and motor deficits. In most of the patients who had good recovery of neurologic function, emergency decompressive laminectomies were performed within 8 hours of the development of paraplegia. The following precautions are recommended to be taken : (1) epidural block should be avoided in patients with known coagulopathy from any cause ; (2) time from epidural to systemic heparinization should exceed 1 hour ; (3) epidural opioid with or without lower dose of local anesthetic should be used for early detection of paraplegia ; and (4) epidural catheter should be removed when normal coagulation is restored.

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Nurses' roles are to explain DVT to patients, to perform some prophylactic measures, and to detect early signs of DVT and venous thromboembolism, etc. In our hospital ICU nurses started a care program to prevent DVT. We found that 72% of ICU patients (N = 109) need some prophylactics. We use mainly intermittent pneumatic compression devices whenever patients have no contraindications. We also apply other prophylactic measures when necessary. Afterwards, Kanto Medical Center Safety Committee made the DVT prevention manual based on the ICU DVT manual. Future subjects are to conduct clinical research to evaluate prevention measures, to create a teaching program for DVT prevention, and to establish a nursing care to program prevent the complications of prophylactic measures, and to perform them safety.

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The Japanese Society of Legal Medicine and Japan Surgical Society created the guidelines on unexpected death. Following these guidelines, the reporting system related to adverse events and negligent adverse events has been disturbed. The reporting system and the announcement of adverse anesthetic outcomes from malpractice reports are important but the establishment of a safety system related to anesthesia is more important.

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Unusual (unnatural) deaths are defined as deaths which clinicians cannot diagnose during their attendance to patients, and as those to be reportable to a public organization for death investigation. The Medical Act Article 21 in Japan states the doctor's duty to report unusual deaths to the police. The Japanese Society of Legal Medicine (JSLM) recommended that “potentially therapeutic unexpected deaths are reportable irrespective of malpractice” (1994). However, since the beginning of litigation on a famous medical malpractice suit on injection of a disinfectant in the Tokyo Metropolitan Prefectural Hospital at Hiro-o (2000), several Clinical Societies have argued against the JSLM's guideline, and insisted that not therapeutic complications but obvious or doubtful medical malpractice, as judged by doctors, are reportable. In April 13^th, 2004, the Supreme Court judged that the attendant doctors must report such medical accidents, but the “reportable deaths” have not been defined by the law. On April 2^nd, 2004, the Japanese Societies of Medicine, Surgery, Pathology, and Legal Medicine together placed an ad in the paper for a new organization of death investigation on therapeutic deaths, which ceased the dispute and launched the set up of the organization. In response to the announcement, the Ministry of Health, Labor, and Welfare created a budget for a project for such investigation organizations in several districts. In this review, I would like to introduce and discuss the significance of and problems with the report of several categories of therapeutic deaths. Additionally, I would like to introduce the public organizations for death investigation in USA and UK, as compared with the police system in Japan. Finally, I would like to briefly overview the direction of the public organization that will be created in Japan in the near future.

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We experienced a case of chemical dermatitis following application of povidone-iodine preparation for surgery. A patient with no preoperative complications underwent abdominal surgery in the lithotomy position under general anesthesia. After the completion of surgical procedure, a red linear skin lesion was observed in the right inguinal region. The skin lesion developed to ulceration on the 9th postoperative day. Patch test with povidone-iodine gave a negative allergic response. On the 109^th postoperative day, the patient brought a medical malpractice suit against the surgeon and the hospital. The surgeon paid damages to settle the dispute on the 601^st day after the beginning of the suit. This case and the previous reports demonstrated that the prolonged exposure to wet povidone-iodine could be harmful and could cause chemical dermatitis. It is important to wipe off povidone-iodine with a solution of ethanol and sodium thiosulfate, and not to let excess povidone-iodine remain on the skin.

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Before anesthetic induction, the losing of consciousness of a patient, who had left lower lobectomy for lung cancer and has coronary heart disease, was reported.
A brain CT was planned because of the patient lost consciousness before anesthesia, after informed consent was obtained the family. At the time of transport to the CT center, it was noticed that an inhaled anesthetic agent had been administrated after we turned off the vaporizer. After explaining the cause of that episode, the operation was performed uneventfully. This case was not malpractice resulting in any disorder. However, we felt that our simple human error caused the patient mental anguish.

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A 32-year-old man complained of right shoulder and neck pain, so he visited the outpatient clinic of the Emergency Center at 13:55 on June 16, 1986. He had felt light shoulder pain and general fatigue since early April 1986.
While examining him at the clinic, his general condition had been getting worse sub-acutely, finally he went into somnolence with tachycardia, tachypnoe and hypotension. He was immediately transferred to the ICU at 15:30. Several clinical exams such as echographies of chest, neck and abdomen, chest radiography, and blood exams were carried out and these exams revealed severe anemia, hypovolemia, acidosis and massive hemorrhage in both pleural cavity and r-neck region. Finally, he went unconscious and then into respiratory arrest followed by cardiac arrest at 17:56. Autopsy was permitted. As a result of autopsy, pathological diagnosis of massive hemorrhage that occurred in possibly teratoma, arising from r-neck that extended into upper anterior mediastinum was made. Diagnosis of the tumor was as a teratoma, which is a benign and mature teratoma, Grade I by Gonzalez-Crussi's classification.

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In the last ten years, medical malpractice litigation has been increasing in Japan.
The Supreme Court records revealed that the number of medical lawsuits each year has increased (from 442 in 1992 to 896 in 2002).
We reviewed the medical malpractice claims reported by 5,000 Japan Medical Association (JMA) members' offices and 500 group-subscripted hospitals in Osaka. The reported number of claims each by year has increased (from 190 in 1992 to 306 in 2002).
The claims in JMA members' office gradually increased (from 65 in 1992 to 82 in 2002), while the claims in hospitals showed a marked increase during the same period (from 125 to 224).
The yearly trends were basically similar in both the Supreme Court lawsuit records and the medical malpractice claims in Osaka.
It turned out that both those claims with a payment amount of less than $9,000 and with severe injury induced by substandard care were mainly settled out-of-court. Those types of cases have been increasing recently in Osaka (now 60% of total claims).
The increase in payment for compensation has brought an increased cost of insurance coverage for hospitals in the group subscription already. Medical risk management in hospital is very important to avoid a medical malpractice crisis in Japan.

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We searched for articles dealing with lawsuits of anesthesia-related accidents including dental anesthesia among 893 newspapers and magazine published in Japan between 1980 and 2003.
1. There were a total of 614 articles dealing with lawsuits of anesthesia-related accidents involving 257 lawsuits (2.4 articles/lawsuit). Of these, there were a total of 26 articles dealing with dental anesthesia accidents (1.9 articles/lawsuit).
2. The classificatium was as follows : 214 articles on “Institution of legal action” ; 148 articles on “Court-ordered compensation” ; 147 articles on “Settlement and out-of-court settlement” ; 56 articles on “Oral argument” ; 39 artcles on “Dismissal”. The most articles were Court-ordered compensation with 3.1 articles/lawsuit.
3. The average size of lawsuits at the time of instituting legal action was 89.63 million yen (range : 4.09 to 216.00 million yen), while at time of settlement, out-of-court settlement or court-ordered compensation was 53.34 million yen (range : 2.2 to 150 million yen).

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In recent years, incidence of lawsuits have become increasing in the field of pain management. We reviewed the judicial decisions and discussed what should be done in order to prevent litigations.
The objects are nine cases between 1975 and 2000. The number of judgments against defendants as well as the total cases of lawsuits have been increasing. Furthermore, the decisions call for restrictions on the indication of blocks. Improper emergency procedure for complications and lack of patient education (in and out of hospital) are also considered to create liability.
Recently the Japanese Society of Pain Clinicians released guidelines for therapy. The members of the society are required to improve their knowledge and skill on pain control as well as cardiovascular life support. At the same time, the public should recognize that the total number of anesthesiologists is insufficient.

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Among criminal medical suits that appeared in publications after World War II, 6 precedents of misidentification of the patient or the operation site were reviewed. In all 6 cases, the defendent was found guilty for bodily injury due to professional negligence. In 4 cases, members of the medical staff other than physicians made the error, followed by mistaken medical actions by physicians. The attending physicians, even when they were residents, were judged to bear the greatest responsibility for confirming the operation site before surgery. Modern medical treatment is performed as team care, and it is important to prepare a manual for identifying the patient and the operation site on the assumption that several members of the medical staff may make mistakes. As few members of the staff as possible should perform the monitoring so that other members are exempt from liability.

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