In this lecture I will try to give you an overview of the current status of Cardiopulmonary Resuscitation (CPR) in the Netherlands and in Europe. After a short introduction concerning the subject and a brief description of CPR in a historical perspective, I will go on with a description of Basic Life Support (BLS) as it is advised and performed in the Netherlands and in the rest of Europe. I will talk about the different BLS-CPR schemes that (used to) exist in Europe, and the controversy between the ABC and CAB schemes. I will describe the proven and suggested advantages and disadvantages of both schemes.
  Thereafter I will go into the subject “CPR without rescue ventilation” , because different studies suggest that the importance of the P-part (Pulmonary-part) in CPR is overestimated, and that under certain circumstances BLS without rescue ventilation is as good as the more common variant BLS with ventilation. These studies can also be used to support the CAB sequence or so to say the “Dutch view on BLS” .
  After a summary I will come to a conclusion.

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  Preoperative laboratory tests play an important role in preoperative assessment. The primary goals of preoperative tests are to assess the severity of the pathological condition suggested by the past history and physical examination, and to make plans for perioperative management including anesthesia. The results of laboratory tests should be evaluated in the light of the sensitivity and specificity of the test and the incidence of the pathological condition in the population to which the patient belongs. False positive tests will result in an unnecessary psychological, physical, and economical burden to the patient. False negative tests will lead to a false sense of security and result in an unfavorable outcome. So-called routine tests such as chest radiographs, electrocardiogram, and hemoglobin determination are not effective screening tools, and may not be warranted for asymptomatic patients undergoing minor surgery.

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  Medicine is one of mandate or contract for work. It is the reason why a duty to disclose a patient's information has been occurred by medical doctor as follows ; First, it is necessary to obtain a patient's consent for justification for illegality with physical invasion. Second, a human being has the right to decide for his life by himself. Third, it is necessary to inform as concerns the judgement of leading him to adequate treatment including to transport a patient to another doctor. Fourth, if the patient is harmed in some way, it is important to explain the cause. If the doctor explains medical information to a patient, he should explain as clearly as possible on the basis of patients' appreciation, cognition, judgement, age, and mental state. According to patient cognition, the doctor should explain his information using schema and/or photography. It is useful that the doctor delivers simple guidance on medical practice to the patient. The conditions of valid explanation are as follows ; First, the doctor who explains the state of affairs to the patient understands his clinical situation very well. Second, he has a lot of knowledge and abilities about clinical practice to explain to the patient cleary. Third, there is enough time for the doctor to explain to his patient. Fourth, the patient has sufficient ability to understand his medical situation. Fifth, the patient's mental state is stable. In my institute, an anesthesiologist supervisor examines every patient as pre-rounds of anesthesia in an exclusive consulting room befor surgical procedure. At the same time, the anesthesiologist obtains written informed consent from the patient, concerning anesthetic method, clinical procedure (for example ; tracheal intubation, intravenous infusion and epidural catheterization) , risk of anesthesia on the basis of statistical data, possible adverse effects and rare serious complications. In conclusion, today's medical relationship between doctor and patient tends to be considered an unfriendly obligation and /or opposed to each other. We must recognize that all medicine consists of a confidential relationship between doctor and patient, and this is required to treat the patient for his disease.

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  Since preoperative visit, physical examination and explanation of anesthetics procedure are time-consuming and inefficient, many hospitals have abandoned this traditional method and switched to evaluating at preoperative outpatient clinics. As a result, the anesthesiologist who examines the patient is not always the anesthesiologist in charge. At our institute, anesthesiologists and/or trainees in charge still visit patients at bedside to perform a routine preoperative anesthetic evaluation. Patients who need extra evaluation go to a preoperative consultation clinic in advance. Favorable responses were obtained from 60 patients in a survey of preoperative visits, but they requested the explanation in plain Japanese without technical terms and further consideration of their privacy. In Japan, trainees start their first year of residency from the Division of Anesthesia and Emergency Care. Trainees can learn basic skills as a general physician from preoperative visits. We believe this traditional way of preoperative evaluation is still useful in the teaching hospital when the above points are improved.

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  Preoperative assessment is an initial step in perioperative management. Patients scheduled to undergo operations want to have detailed information regarding the risk of anesthesia and receive the best preoperative treatment. Recent social trends indicate an increased requirement for the optimal provision of information to facilitate patient understanding. Thus, it is important to establish a system suitable for providing satisfactory preoperative information regarding the risks associated with anesthesia.

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  Rapid development of stabilizers, apical suction devices, and other devices for off-pump coronary artery bypass (OPCAB) have increased graft patency and rendered this procedure highly safe, and in recent years, OPCAB has become a standard procedure in many medical facilities. However, some remaining problems include myocardial ischemia during anastomosis and hemodynamic instability due to mechanical displacement of the heart. Direct ventricular compression by stabilizers and disturbed diastolic filling of the right ventricle have been suggested as causes of hemodynamic instability during OPCAB, and we found that measurement of left ventricular end-diastolic volume index (LVEDVI) by 3-dimensional transesophageal echocardiography (3D-TEE) demonstrated a preloading reduction of up to nearly 60% during coronary artery anastomosis. These results suggest that decreased LVEDVI, and in some cases, additional complications such as myocardial ischemia or mitral regurgitation are integral causes of hemodynamic instability during OPCAB.

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  Anesthesiologists can reflect the findings of TEE directly in thier anesthetic management. However, it is a key issue to perform intraoperative TEE examination efficiently and to make a clinical diagnosis accurately during a busy cardiac anesthesia. For good practice of intraoperative TEE, it is important to decide the points to evaluate before the surgery, to eyeball more than use time-consuming measurements, and to share the findings with the surgeon and perfusionist. In coronary artery bypass grafting (CABG) , regional wall motion abnormalities, left ventricular systolic and diastolic function and a lesion which has not been recognized before surgery, including atheroma in the aorta and valvular disease, should be evaluated. In off-pump CABG cases the finding of compression due to the displacement of the heart and an increase in tricuspid and mitral regurgitation should be also examined. Moreover, it is very useful for the patient's safety to guide the placement of various catheters and cannulae and to estimate residual air in the heart during weaning from cardiopulmonary bypass with TEE.

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  Coronary artery bypass surgery complicated with mitral regurgitation is significant both as a poor prognosis and because there are diverse treatment options. Ischemic mitral regurgitation (IMR) is not a disease of the mitral valve but of the left ventricle. It is caused mainly by the tethering of leaflets from the chordae tendinae, which is due to local remodeling of the ischemic left ventricle and geometric distortion of the papillary muscles. Annular enlargement plays only a secondary role in the mechanism of IMR. Intraoperative evaluation of MR severity should be performed with caution considering the changes in loading conditions under general anesthesia. There have been many arguments and a lot of controversy among surgeons and cardiologists about the treatment options for IMR, especially for moderate IMR. Some IMR can be relieved after coronary artery bypass surgery (CABG) without the mitral valve procedure, but if it persists after CABG, poor prognosis as well as an additional risk in case of reoperation is implicated. Various kinds of new treatment strategies, including resection of the anterior wall of the myocardium and ‘off-pump’ , or even percutaneous mitral valve plasty, have emerged. As an anesthesiologist, one needs to have a deep understanding of the pathophysiology of IMR and the surgical techniques to treat it.

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  The majority of catheter-related bloodstream infections (CRBSI) are associated with central venous catheter in serious patients. The CRBSI is an important issue for the control of infection in hospitals. The use of catheters coated on the external surface with chlorhexidine/silver sulfadiazine (ARROWgard Blue^® Catheters, Arrow international) significantly reduced the risk for catheter colonization and CR-BSI compared with standard noncoated catheters. Although rare, anaphylaxis has been reported with the use of these chlorhexidine/silver sulfadiazine catheters, and a patient allergic to chlorhexidine should not be exposed to chlorhexidine/silver sulfadiazine-impregnated catheters. The actual risk of anaphylaxis is likely quite small with the estimated prevalence of 0.005% or 1/415,000 (0.0002%) . Concern has been expressed with regard to the potential risk (anaphylaxis) , but the catheter should be effective to reduce CRBSI in patients who need central venous catheter in ICU.

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  Although assessment of cardiac function using the Starling curve has been widely accepted for management of critically ill patients, the method does not contain the idea of oxygen demand and supply. The mixed venous oxygen saturation (Svo₂) is determined by arterial oxygen saturation (Sao₂) , oxygen consumption (Vo₂) , hemoglobin (Hb) , and cardiac output (CO) . Then, since Svo₂ can assess the abnormal balance between oxygen demand (Vo₂) and supply (Sao₂, Hb, CO) , it is useful for cardiac and metabolic management, i.e., during anesthesia as a lower oxygen demand state or in septic shock as a higher oxygen demand state. High Svo₂ does not always means a good condition because arterio-venous shunt or impaired oxygen utilization in septic shock increases Svo₂. Plasma lactate level can complement the disadvantages of Svo₂ in such pathological states. The meaning and utility of Svo₂ and lactate monitoring are discussed in the text.

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  High-frequency jet ventilation (HFJV) provides a good surgical field for laryngomicrosurgery. However, since measurements of end-tital CO₂ and tidal volume are difficult to obtain during HFJV, it may cause hypercapnea. We examined the effects of driving pressure, inspiratory time and the fraction of inspired oxygen (FiO₂) on arterial blood gas analysis with 125 adult ASA I - II patients. Ventilation frequency was fixed at 2Hz in all groups. PaO₂ was lower in the driving pressure 1.5 kg/cm² group in comparison with the driving pressure 2.0kg/cm² group. In the group with 30% inspiratory time, CO₂ elimination decreased in comparison with the 50% inspiratory time group at driving pressure either 1.5kg/cm²(PaCO₂ 50 vs 46mmHg) or 2.0kg/cm²(51 vs 45mmHg) (p<0.05) . The FiO₂ 0.6 group showed lower and normal PaCO₂ (39mmHg) in comparison with the FiO₂ 1.0 groups, and good oxygenation. The results suggest that HFJV with FiO₂ 0.6, driving pressure 2.0kg/cm², and 50% inspiratory time is optimal for laryngomicrosurgery in patients without obstructive pulmonary diseases.

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  We prospectively examined awareness during general anesthesia over the past two years. We discovered two cases of awareness with recall during anesthesia in 1,872 patients who underwent general anesthesia. Both patients were in hemorrhagic shock preoperatively, and had intraoperative BIS values less than 60. The amount of anesthetic administered during operation was insufficient, because their hemodynamic parameters were unstable. Monitoring of BIS does not appear to be reliable for detection of awareness, when intraoperative administration of analgesics is insufficient.

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  A 2-year-old male diagnosed as having tetralogy of Fallot (TOF) without an obvious medical history of anoxic spell underwent elective infundibulectomy of right ventricular outflow, pulmonary valvotomy, and patch closure of ventricular septal defect. Abrupt decreases in systolic arterial pressure from 100 to 60mmHg and SpO₂ from 100 to 92% occurred during the maneuver of right atrial cannulation prior to cardiopulmonary bypass. Bolus landiolol 0.4mg/kg for the possible occurrence of anoxic spell restored not only the systemic arterial pressure but also the arterial oxygenation without any occurrences of bradycardia and hypotension through the course. Landiolol is a shorter-acting and less cardiodepressive beta 1 adrenoceptor antagonist than esmolol. This case suggests that landiolol might become a choice among agents treating anoxic spell in pediatric patient with TOF, even if cardiovascular status is unstable.

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  We report a case of renal transplantation in a child who developed pericardial effusion perioperatively. A 10-year-old girl was scheduled to undergo ABO-incompatible kidney transplantation. She underwent a preoperative plasma transfusion. Perioperative blood loss was over 1,500ml and a large quantity of blood was required. Perioperative transesophageal echocardiography revealed pericardial effusion expanding in a short time about 4 hours after the operation started. The authors consider that in the present case, pericardial effusion expanded due to severe blood loss and a large blood transfusion, in addition to the influence of the preoperative plasma exchange. In the present case, TEE was a useful monitor for detecting pericardial effusion.

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  The purpose of this survey was to investigate the quality of medical care provided by our outpatient pain clinic. The prospective study utilized 29 questions to inquire about staffing services provided for the patients, convenience and comfort of the clinic, scheduling, the amount of medical information offered, and the overall impression of medical expertise. The degree of satisfaction for each area of concern was rated from excellent (5 points) to poor (1 point) . Thirty-two patients (6 males, 24 females, 2 gender not noted ; mean age 68±11-years-old, range, 34- to 84-years-old) of 41 queried completed the questionnaire. Regarding the services provided by the staff, scheduling, and the overall impression of medical expertise, more than 60% of the patients gave a rating of 4 or 5 points, while fewer than 60% gave a 4 or 5 rating for the convenience and comfort of the clinic, and the amount of medical information offered. Based on our results, we concluded that clinic convenience and comfort, and medical information provided to the patients are areas that require improvement.

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  Studies have been done on clinical anesthesia and risk management specialty concerning legality. These studies have been supported by The Japan Anesthesia Risk Management Association founded ten years ago.
  Medical conflict between patients and hospitals and/or doctors are increasing. All medical malpractice in medical practice are not leniently to the legal process. Informed consent between doctors and patients is an important procedure for medical rapport and the prevention of medical conflict.

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  Incident reports provide information about the things that went wrong, and have the potential to improve the quality of patient's care. We compared incident reporting identified in 1999 and 2004 to elucidate how it works. Our evaluation mainly concerned the incidental total number, anesthesia machine, and drugs. There were 59 and 33 incidents reported in 1999 and 2004, respectively. Critical incidents were markedly decreased in 2004. Incidents related to the anesthesia machine decreased from 10 to 5, however, the same incidents occurred repeatedly. On the other hand, incidents associated with drugs increased from 7 to 10. Decrease of critical incidents may have resulted from awareness of mishaps and thus infomation sharing that have been highlighted by incident reporting. Nevertheless, incidents involving anesthesia machine occurred repeatedly and incidents of drugs increased. Because human factors should be closely involved in incidents associated with the anesthesia machine and drugs, and incidents are mainly caused by human error, some mechanical preventive strategies should be provided to lessen the risk in anesthetic practice.

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  Recently, more and more attention has been paid to achieve safety in medical practice. Nagasaki University Hospital eagerly tackles risk management, but achieving error-free medical practice is difficult.
  We report three cases in which complications associated with epidural anesthesia occurred. The complications were pneumothorax, complex regional pain syndrome (CRPS) and spinal cord injury. None of the cases led to a lawsuit because of sufficient explanation and sincere care after the adverse event. When an anesthesia-related adverse event happens, close and attentive care, in cooperation with other departments, is important.

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  We experienced a case of cervical hematoma caused by stellate ganglion block (SGB) .
  SGB was selected for cervical root pain. The patient showed no coagulopathy in a blood examination before SGB.
  The patient had no problems during SGB. Four hours after the SGB, he had progressive cervical swelling and dyspnea, and was admitted as an emergency. He had an emergency operation for massive and progressive cervical hematoma, and recovered.
  He claimed cervical problems after SGB, and then the negotiations started. He and the manager of our hospital each had a lawyers for smooth management of the negotiation. After negotiating for 1.5 years, the settlement out of court was concluded.

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  Trauma to a sensory nerve often occurs during common dental treatment such as tooth extraction and root canal treatment. Therefore, oral sensory disturbance following dental treatment is by no means infrequent. Sensory disturbance affecting the orofacial area is devastating to patients, since the dysesthesia can be elicited easily by the most common activities of daily living such as speaking and eating. Thus, it sometimes turns into medical malpractice claim.
  Here, we feature five cases (case 1: post-implant placement, case 2, 3: post-root canal filling treatments, case 4, 5: post-tooth extraction) among patients with sensory disturbance following dental treatments at the Orofacial Pain Center at Tokyo Dental College Suidoubashi Hospital, and reported on the trends.
  Most cases claimed that informed consent and/or after care were insufficient. Informed consent before the treatment in ordinary dental therapies and after care for patient with oral sensory disturbance following dental treatment have not been sufficiently elucidated yet.

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  We evaluate judicial precedents published in law journals associated with anesthesiological departments such as ‘Hanreijiho’ until the end of 2003. Concerning general and epidural anesthesia, anesthesia management by anesthesia specialists was also the object of lawsuits. The anesthesiologist in-charge (include no specialists) together with the hospital founder was the defendant in 50% of the precedents. In emergency medical care, there was a judicial decision by the Supreme Court that was against the medical care side in 2000. Due to the influences of this judicial decision, 3 similar decisions were subsequently observed in the emergency medical care field. When there was not adequate informed consent even if no medical error, the lower court decision was overturned, and the medical care side was judged responsible. In the future, anesthesiologists may be required to provide medical care consistent with the medical care level as well as adequate explanation.

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