Developments in endoscopic surgery, especially thoraco-and laparoscopic techniques has been remarkable in the last decade. Supported by the advancement of technologies such as thinner forceps and endoscopes, incision wounds become smaller. The hospitalization period has also been shortened, and now ambulatory surgery has become popular. On the downside, there have been many risks related to anesthetic management. Skills needed for anesthesiologists to maintain endoscopic-surgery anesthesia were discussed.
Despite the 70-year-long research history of arterial baroreflex function, it has only been a decade since the clinical implications of this fundamental circulatory reflex have been clearly defined. In 1998, the ATRAMI (Autonomic Tone and Reflexes After Myocardial Infarction) study published in the Lancet first demonstrated the prognostic value of cardiovagal baroreflex gain after myocardial infarction. Another important discovery in the last decade has been the gender difference in cardiovagal baroreflex function. In addition to these, methodologies of measuring baroreflex gains and effects of anesthetics and anesthesia-related medications on these reflex responses will be briefly discussed.
In our hospital operating room, the anesthesia patient data management system was introduced. Various problems by a computer will be classified into the following five categories if the generated failures are classified: 1) hard failure, 2) soft failure, 3) failure in use, 4) operation mistake, 5) and other failure. The cause of a hard failure is the problem of the hardness of a terminal itself. As a cause of soft failure and the failure in use, the problems with the defect of the compatibility of the computing environment by a data volume load, the electronic chart introduced in the hospital and the anesthesia patient data management system introduced in the operating room, are mentioned. An operation mistake is simply a human error. It was difficult to have involved various factors from many cases, when classifying system failures, and to distinguish correctly what kind of failure it actually is.
Epidural or spinal tap is often performed in the sitting position for a parturient. However, the distance from skin to the lumbar epidural space (SED) or epidural space to dura mater (EDD) based on the position in Japanese parturients is not available. Therefore, we examined SED and EDD in 230 parturients with epidural or spinal needles by measuring those distances in clinical practice. The SED and EDD were 38±6mm (26-66mm) (n=230) and 5±2 mm (1-10mm) (n=153) (mean±SD (range)) , respectively. SED was correlated with body weight or BMI, whereas EDD was not.
Na+ channel blockers (anti-arrhythmic) have been frequently used for the treatment of neuropathic pain. Lidocaine and mexiletine were mainly used as analgesic agents. In recent years, the effectiveness of flecainide (Vaughan-Williams classification: Ic) on neuropathic pain has been reported. This medicine can be used both orally and intravenously, with long-lasting effects. Twenty-four patients with severe neuropathic pain were treated with nerve block therapy. Patients with histories of severe cardiac diseases were excluded from the study. Patients who had positive drug challenge tests (DCT) with lidocaine (2mg/kg/10min) were prescribed mexiletine. Patients whose pain was not relieved with lidocaine then received intravenous infusion of flecainide (2mg/kg/10min) . In 13 out of 24 cases, neuropathic pain was relieved by flecainide more than by lidocaine or mexiletine. In the treatment of intractable pain, drugs should be used in combination with other drugs. In this study, the effectiveness of flecainide on neuropathic pain was suggested.
A 53-year-old female patient underwent implantation of myocardial electrode for high-grade atrioventricular block under general anesthesia. When an operator ablated fat on the pericardium, ventricular fibrillation suddenly occurred. Immediate electrical defibrillation following cardiac massage restored the patient's heartbeat successfully. Then we inserted a temporary transvenous pacing wire. After induction of electronic pacing to avoid fatal arrhythmia, the operation was performed uneventfully. The present case suggests that it is necessary to insert a temporary pacing wire before surgery in cases with high-grade atrioventricular block.
A 67-year-old man with hepatic cirrhosis in Child-Turcotte class B was scheduled for radiofrequency ablation (RFA) . He was not a candidate for surgical treatment because the tumor diameter was greater than 5.5 cm and he had poor hepatic function. RFA consisted of 56 ablations of 2-3 minutes' duration each. He suffered abdominal distension, ascites and persistent fever the first day after RFA, and died on the 7th day because of the hepatic failure. We should more fully understand the indications of RFA for cirrhosis.
Only 20-30% of patients with hepatocellular carcinoma can be candidates for hepatectomy because of underlying cirrhosis or multiple lesions. Even worse, 80% of patients who undergo "curative" resection develop recurrence within 5 years because of micrometastasis or metachronous multicentric carcinogenesis. Thus, non-surgical therapies play an important role in the treatment of hepatocellular carcinoma. Percutaneous radiofrequency ablation (RFA) has become widely performed because it is curative, minimally invasive, and can be performed multiple times. We have performed RFA on more than 2,500 patients. Among 556 patients who received RFA as the initial treatment, survival rates were 96% at 1 year, 88% at 2 years, 79% at 3 years, 69% at 4 years, and 55% at 5 years. Complications occurred in 4% of the cases. Only two out of over 2,500 patients died within 30 days. One died of cerebellar bleeding that occurred 7 days after RFA. The other died of ARDS and liver failure following pleural and peritoneal bleeding. Over 1,400 institutions have introduced RFA into clinical practice in Japan. However, not all groups have sufficient experience and skills. It is necessary to enrich training courses, set up a qualifying system, and control the quality of RFA in all institutions.
I consider the problem of the refusal of blood transfusions as a kind of cultural conflict caused by new medical technology. From a cultural, anthropological viewpoint, Jehovah's Witnesses seem not to be an abnormal, antisocial religious group. Recently, they have tried to solve this problem by exercising the patient's right to self-determination, and they decided to select treatments that did not rely on the blood transfusion. On the other hand, the Watch Tower Bible and Tract Society have enabled each believer to select for their treatment some parts of the medicine that originated in the blood. Thus, they are adapting to the social situation with regards to the problem of the blood transfusion refusal. It is natural that children are socialized according to the world-view and the lifestyle of their parents and the community to which they belong. Because the Supreme Court of Japan upholds their world-view and their right to self-determination in 2000, it seems that it is difficult to assume their children to be the exception in Japan.
In Japan, as is in the USA, Jehovah's Witness patients refuse transfusion for religious reasons. At first medical providers ignored their refusal because transfusions can be critical in saving the patient. But in time, medical providers began to respect their request and treated patients without effective means. Now their refusals are honored as an informed decision. The result of violating the refusal was litigated in court. Supreme Court upheld the damages award of violating the patient's will. Problems are still in dispute as for children, whose will must also be respected, but in the case of not expressing their own will, parents of Jehovah's Witness children refuse to get a transfusion.
Patients must have competence in order to grant consent for medical procedures. This consent is valid only when the patient is competent. If not, the consent is invalid, and in this case, the designation of a representative decision-maker will be required. It is commonly understood that the concept of competence as a criterion to assess the patient's ability to determine whether or not to designate a representative decision-maker is “the ability to understand the details, characteristics, and advantages and disadvantages of the medical procedure in his or her own body, and to determine whether or not to grant consent for the procedure on the basis of this understanding” . In this framework of understanding, the concept of competence is established on the basis of the relevant, specific medical procedure. However, with this in mind, if the relevant medical procedure is difficult for a patient to understand and decide on, it will require the patient to be highly competent, meaning an adult patient who is capable of making decisions regarding general social matters, but not the relevant, highly demanding medical procedure, may be regarded as “not competent” and his or her consent will be “invalid” . In such cases, the patient will usually rely on his or her physician's judgment or request a second opinion to grant consent regarding the relevant medical procedure. Consent given in this way cannot be called invalid, and herein lies the contradiction. To avoid this, the concept of competence as a criterion to assess the patient's ability to determine whether or not to designate a representative decision-maker shall be established on the basis of the concept of “medical practice” in general or abstract sense. That is to say, competence is “the ability to understand and make decisions regarding the concept of medical practice in general or abstract sense” .
The paper discusses the relationship between Jehovah's Witnesses as a special Christian denomination which is known for refusal of blood transfusion, and bioethics as a relatively new, interdisciplinary and multi-disciplinary scientific field which is focused on ethical issues in medicine and the health care system. This relationship is situated in the context of bioethics first principle of autonomy, as one of four basic bioethics principles, and the doctrine of informed consent which arose from this principle. The author claims that, due to bioethics, a discriminating position of Jehova's Witnesses has increasingly changed in many countries. Jehovah's Witnesses were denied and in some countries they are still denied - the right to refuse blood transfusion even at the cost of life. The author supports his thesis with experiences from Croatia where bioethicists initiated a debate on religious refusal of blood transfusion a few years ago. After that, in Croatian hospitals, the attitude towards Jehovah's Witnesses began to change in the sense of understanding and respect for their behaviour.