As a result of advances in surgical, anesthetic, and medical management, surgery can now be performed on older patients with more comorbid disease. Preoperative identification and preventive operative strategies can potentially reduce the incidence of neurological dysfunction after surgery in high risk patients. Patients with preexisting cerebrovascular disease are at high risk for stroke and neurological dysfunction. We recommend routine screening for preoperative cognitive dysfunction and cervical ultrasonography to detect underlying cerebral ischemia and carotid stenosis in elderly patients. In addition, cerebral MRI, cervical and intracranial MRA allow noninvasive observation of asymptomatic cerebral ischemic changes, and intracranial and carotid stenosis. In such cases, intraoperative and postoperative strategies can be employed to 1) decrease neurological deficits due to hypoperfusion by maintaining higher perfusion pressure during perioperative surgery, 2) decrease the incidence of postoperative thrombotic events by using early postoperative anticoagulation or antiplatelet therapy. Diffusion-weighted MRI demonstrates ischemic lesions quantitatively within several hours of onset and may provide clues to the association of ischemic lesions in the brain after surgery. We suggest that anesthesiologists take part in assisting their surgery colleagues in identifying those at risk for stroke and in preventing neurological dysfunction after surgery.

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  High quality care balanced with cost is required in ambulatory surgery. Side effects, such as postoperative pain, nausea and vomiting, dizziness, drowsiness and urinary retention, not only reduce patient satisfaction but also prolong the hospital stay and increase cost. It is not recommended to use techniques and agents that cause side effects and result in delayed discharge, as well as consume expensive drugs and resources without limitation. Postoperative pain, nausea and vomiting should be prevented and treated because these are the most important reasons for prolonged stay after ambulatory surgery. Multimodal balanced analgesia using local and/or regional anesthesia and other non-opioid analgesia provides superior analgesia with few side effects. Careful patient evaluation and selection, and education for patients and providers are essential for a successful outcome.

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  What can the anesthesiologist do for the patient to minimize discomfort just before induction of general anesthesia? Two major concerns which may compromise patient satisfaction were studied.
  First, we compared the induction profile between intravenously administered propofol and tidal breathing induction with 5% sevoflurane and 66% nitrous oxide. Induction time was significantly longer in the Sevo group, however, complication, patient discomfort, and facial scale evaluated by attended nurse were not different from the Propofol group. Thus, sevoflurane induction can be a suitable option if a vein is difficult to access.
  Second, patient discomfort during epidural tube insertion under sedation with midazolam or fentanyl were compared. When midazolam was administered to achieve a Ramsay sedation score of IIIto IV, 90% of the patients forgot the epidural catheterization procedure itself, but were able to address pain or abnormal sensations. Therefore, midazolam should be chosen if the patient is anxious about the procedure.

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  A novel Japanese system of post-graduate clinical training was launched and obligated in 2004 in order for all medical doctors to have the ability to provide primary care as well as have aptitude as a medical doctor. In this system, training in the department of anesthesiology is a required course defined as being a part of emergency medical service, and recommended in the first year of post-graduate medical training. This article summarizes the details that the residents can learn during the training period of anesthesia based on the Evaluation system of Postgraduate Clinical training (EPOC) which was developed and provided by University hospital Medical Information Network (UMIN) in Japan.

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  Awake OPCAB is a new OPCAB procedure, developed by Dr. Karagoz in 1998. Patients are anesthetized with high thoracic epidural anesthesia only, maintaining spontaneous breathing and consciousness during surgical procedures. High thoracic epidural anesthesia blocks sympathetic nerves, which reduces cardiac workload, dilates the stenotic coronary artery, and improves the balance between oxygen demand and supply. All these effects are preferable for the patient with ischemic heart disease. On the other hand, there are some disadvantages, such as epidural hematoma, epidural abscess, local anesthetic intoxication and so on. In particular, heparinization for surgical procedures increases the risk of hematoma. Awake OPCAB does not require intubation or extubation, which are the most invasive procedures perioperatively. We expect that the negative pressure produced by spontaneous breathing encourages venous return and cerebral perfusion, which might protect cerebral recognitive functions. The disadvantages of spontaneous breathing are the possibility of pneumothorax and aspiration. Also, transesophageal echo is not available. Since patients are kept conscious during the operation, anesthesiologists can examine neurological findings except the anesthetized area at any time, which enables an earlier diagnosis of epidural hematoma or cerebral infarction than conventional procedures. To establish this technique and increase its popularity, new findings and reliable data are necessary.

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  Because postoperative pain poses many disadvantages to patients, it should be elminated to the best of our ability.
  There are various kinds of methods for postoperative pain management. The usefulness of preemptive analgesia as postoperative pain management is controversial, however, this method rarely has any disadvantage for patients. Therefore, we think that preemptive analgesia should be tried as much as possible.
  The selection of the postoperative pain management technique varies according to the degree of the invasion and the intensity of the postoperative pain. Postoperative pain management for a minimally invasive operation will correspond to the oral intake, rectal administration, or intramuscular injection of analgesics. On the other hand, an invasive operation or one which induces severe postoperative pain will need an epidural analgesia combined with PCA. However, continuous intravenous or subcutaneous infusion of analgesics combined with PCA should be selected for patients contraindicated for epidural analgesia.
  Postoperative pain management includes many problems for patients, attending physicians and anesthesiologists, and it is important to resolve these problems. On the other hand, from the viewpoint of insurance, the circumstances surrounding postoperative pain management is far from ideal.

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  Recently, computerized anesthesia-recording systems have been introduced at an accelerating pace with the increased use of electronic medical charts. The systems themselves have limited appeal and are only recognized for their ability to automatically input numeric data from the monitor. However, once they become utilized in a network, new developments are possible. In addition, anesthesia apparatuses with their various sensors and computerized controls are no longer a mere tool for anesthesiologists, but are also general electronic devices. Great changes are possible if the data output from a computerized anesthesia apparatus could be integrated, for example, if the operating record of the apparatus with a time stamp could be used as evidence in a lawsuit. Further, clinical navigation, as well as precise and high-quality clinical studies and trials, may be conducted if some parameters obtained by the apparatus, such as anesthetic drug concentrations and gas flow, were integrated with the data from the anesthesia monitor. In the present article, the present status and future of automatic anesthesia-recording systems, the limitations of the present systems, and their future involvement in mutual development with other systems are discussed.

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  The Japanese population will become increasingly older in the 21st century, with more elderly people and less children. This means more patients undergoing surgery and less anesthesiologists to take care of them. Therefore, I predict that anesthesia for the ASA class I to II patients undergoing minimally invasive surgery will be automated or supervised via LAN by the anesthesiologist outside the operating room. The anesthesia machine in the 21st century should be digitalized and connected to the network.

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  High doses of local anesthetics are used to block nociceptive stimuli from surgery at the spinal cord level, even utilizing epidural anesthesia combined with general anesthesia. When epidural anesthesia attains a wide range and shows sufficient anesthetic effect, general anesthesia can be maintained with only small doses of a general anesthetic. This leads to a smooth awakening with analgesia.

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  It is controversial whether epidural anesthesia combined with general anesthesia can reduce postoperative morbidity and mortality. The quality of the epidural anesthesia is considered to have an important role in improving those outcomes. Adequate intensity of epidural anesthesia, which can block the stress responses to the surgical stimulation, is needed to provide beneficial effects for the outcome. However, it is impossible to estimate the intensity of neuraxial blockade with classical methods, i.e., cold and pinprick test. Thus, it is recommended that larger concentrations of local anesthetic be used to make the most of epidural anesthesia.

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  Epidural anesthesia combined with general anesthesia is a commonly used for abdominal and lower extremity surgeries. We investigated the effects of low doses of mepivacaine for abdominal and lower extremity surgeries. Epidural anesthesia was achieved with 8ml of 1.5% mepivacaine initial dose (test dose : 3 ml, plus bolus before incision : 5ml) followed by continuous epidural infusion of 1.5% mepivacaine at 5ml/hr. Stable hemodynamics were obtained in upper abdominal surgeries with this method. In lower abdominal and lower extremity surgeries, a stable hemodynamic condition was detected with epidural anesthesia and inhalation of nitric oxide and parenteral fentanyl. Somatic, visceral, and tourniquet pain are caused along with the surgical procedures. Somatic pain is sensitive to epidural analgesia with local anesthetics, whereas visceral and tourniquet pains are resistant to that. Those types of pains are effectively diminished by opioid analgesics. Therefore, analgesia during surgery should be obtained with epidural injection of local anesthetics and systemically administered opioids. We recommend epidural analgesia with low dose mepivacaine.

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  It is important to understand the anatomy of the spinal canal, when we induce epidural and spinal anesthesia. We examined morphological changes in the spinal cord and cauda equina using myelography, magnetic resonance imaging and cadavers. In the present review, we show some interesting data on epidural and spinal anesthesia such as : 1) The spinal cord and cauda equina dynamically move in the subarachnoid space by changing positions, 2) The subarachnoid space is markedly compressed from the dorsal side by epidural injection, 3) The subarachnoid space is compressed from the ventral side by the engorged vein in pregnant women, 4) Idiopathic epidural lipomatosis, which is occasionally observed in obese people, causes the compression of the subarachnoid space because of increased epidural fat, and 5) Severe spinal canal stenosis contributes to narrowing of the subarachnoid and epidural space, resulting in failure of epidural and spinal anesthesia. These data are very beneficial for performing epidural and spinal anesthesia safely and effectively.

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  Cancer and inflammatory cells around the nociceptive fibers release various chemical transmitters and stimulate nociceptors continuously, resulting in a sensitization of the pain transmission system. Spinal sensitization also stimulates efferent fibers of the motor neuron and sympathetic system, resulting in a muscle contraction and pain around the muscle, or contraction of piloerection, and hyperhidrosis apart from original site, so-called referred pain. Cutaneous hyperalgesia also occurs due to the misinterpretation of visceral nociception to cutaneous input (viscer-somatic convergence) . It is important to understand the dermatome, myotome, viscerotome, and osteotome, because referred pain of visceral and deep somatic tissues emerge to the skin and muscle which occupied in the same spinal segment. It is also important to distinguish the cause of cutaneous hyperalgesia, neuropathic or nociceptive according to the characterisitics of referred pain.

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  The progress in the treatment of advanced cancer may be accompanied by the increasing incidence of cancer-related pain. In our pain clinical department, the therapy in combination with nerve block is given to patients who are suffering from uncontrollable cancer pain. The continuous epidural block is frequently used for the treatment of cancer pain by bone metastasis due to the difficulty of remission by narcotics. We have employed an epidural access device for analgesics infusion to eliminate persistent pain for patients at home. The efficacy of the continuous epidural block by the access device has been confirmed in 21 patients with cancer pain. Hence, application of a nerve block as well as narcotics should be considered for the patients with persistent cancer pain, and a continuous epidural block by the access device is recommended to control cancer pain for patients at home.

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  Ninety-six percent of elective cesarean sections are performed under spinal anesthesia in our institution. The intrathecal solution is composed of 2.5mL of 0.5% hyperbaric bupivacaine and 0.1 mg morphine. Intrathecal bupivacaine provides excellent analgesia without supplemental analgesics during surgery. An addition of morphine to local anesthetics enhances and prolongs intra-and post-operative analgesia. Spinal anesthesia is easy and effective and provides better motor blockade and faster onset than epidural anesthesia and CSEA (combined spinal-epidural anesthesia) . Its main drawback is a high incidence of hypotension.

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  Anesthesia is a medical system that involves anesthesiologists, surgeons, nurses, pharmacists, and the anesthesia machine. Many latent risks remain in anesthesia. To err is human, and human error plays a central role in anesthesia mishaps. Therefore, reducing human error is the important issue in lessening critical incidents. One of the most common sources for revealing mishaps is the incident report. Incident reporting highlights problems in anesthetic practice and complements our quality of anesthesia induction. Reported incidents give information in the development of anesthesia mishaps to individual anesthesiologists, however, awareness of potential problems may not prevent the occurrence of incidents. Organizational intervention should be the major preventive strategy for reducing human errors. This paper reviews the terms related to risk management, strategies for preventing human errors, and the key points for reducing mishaps in clinical anesthesia.

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  We analyzed the wasting of drugs in anesthesia subspecialties in our institution for four weeks. Except for cardiac anesthesia, anesthesia was inducted by propofol with vecuronium, and maintained with sevoflurane, N₂O in oxygen. Each anesthetist was free to use to anesthetics or other drugs to keep the systemic hemodynamics stable.
  The average cost of drug waste was 1,096 yen per case. Propofol was discarded in 169 out of 222 cases, and its mean dose wasted was 88±48 mg. Vecuronium was discarded in 162 out of 222 cases, and its mean dose wasted was 4.5±2.8 mg. Ephedrine was discarded in 156 out of 222 cases, and its mean dose wasted was 34±7mg. Our data showed that anesthetists should be interested in reducing of the amount of drugs wasted during anesthesia.

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  We investigated the usefulness of eptazocine for postoperative analgesia by continuous epidural infusion after abdominal total hysterectomy (ATH) . Ninety patients who had undergone ATH under general anesthesia with lower thoracic epidural anesthesia were randomly assigned to receive either 0.5% ropivacaine only (R group, n=30) , 0.5% ropivacaine with 2.7mg/mL eptazocine (E group, n=30) , or 0.5% ropivacaine with 4μg/mL buprenorphine (B group, n=30) epidurally. All of them received 2.1mL/hr epidural infusion of each solution for 20 hrs for postoperative analgesia. Supplemental analgesia, if required, was provided with rectal diclofenac (25/50mg) and/or i.v. pentazocine (15/30mg) . Postoperative analgesic/sedated states, postoperative nausea and vomiting (PONV) , and postoperative complications such as urinary disturbance were evaluated. Postoperative analgesic score in the E group was significantly better than the scores in the other two groups. Duration until the first supplemental analgesia in the E group was significantly longer than that in the R group, and the scores of supplemental analgesia in the E and B groups were lower than that in the R group. PONV score in the B group was significantly higher than the scores in the other groups. Postoperative complications after self-walking were observed only in the B group (n=7) : leg weakness (n=3) , deteriorated PONV (n=3) , and urinary disturbance (n=1) . Eptazocine, a κ opioid receptor agonist, is useful for postoperative epidural analgesia in combination with the local anesthetic ropivacaine.

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  Since only 3 percent of patients with uncorrected tetralogy of Fallot (TOF) survive up to 40 years of age without surgical intervention, there have been few reports on anesthetic management in patients with total correction of TOF who are over 60 years of age. A male patient in his 60's underwent total correction of TOF under general anesthesia. Adults with TOF often show chronic cyanosis whereas children have sudden anoxic spells. Therefore, they may have erythrocytosis which results in hyperviscosity, abnormalities of hemostasis, cerebral abscesses, cerebral infarction and cardiothrombus as marked preoperative complications. The anesthetic plan should be mainly considered to keep SpO₂ similar to that for children. For this reason, maintaining euvolemia, avoiding tachycardia and preserving the systemic vascular resistance not to worsen the right-to-left-shunt are important approachs of intraoperative anesthetic management. Attention should be paid to preoperative complications, and anesthesiologist must be prepared to maintain SpO₂ intraoperatively in adult patients with total correction of TOF.

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