THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA
Online ISSN : 1349-9149
Print ISSN : 0285-4945
ISSN-L : 0285-4945
Volume 26, Issue 7
Displaying 1-25 of 25 articles from this issue
Journal Symposium (1)
  • Takashi MASHIMO
    2006 Volume 26 Issue 7 Pages 615
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
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  • Yuichi KANMURA
    2006 Volume 26 Issue 7 Pages 616-620
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      Education on clinical anesthesia has been focused on certified anesthesiologists. But, recently educating residents on anesthesia has also become important because of compulsory residency (super-rotation) . The quality of life of anesthesiologists has been regarded as the most important problem in improving the number of anesthesiologists. However, medical school education on anesthesiology is more important because medical students are the candidates to become future anesthesiologists. Among new medical students, those who wish to become anesthesiologists are quite rare. So, the most important points of medical school education on anesthesiology are to encourage the students to become interested in anesthesiology. To do so, it is also important to set up an education system for anesthesiology in medical schools.
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  • Kiyoshi TAKEDA
    2006 Volume 26 Issue 7 Pages 621-626
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      Clinical training in anesthesia has become an essential part of the new resident education system which was started in 2004. Although this system may give us the opportunity to help residents become familiar with clinical anesthesia, the education program might have to be changed so as to reduce the complications which are mainly related to a lack of skilled technique. Using a self-assessment questionnaire, we evaluated the resident learning curves of anesthesia-related issues and found that technical improvement preceded the accrual of medical knowledge. It might be difficult to foresee how this program works in choosing a specialty, however, the perception of a controllable lifestyle accounts for most of the variability in recently changing patterns in the specialty choices of graduating US medical students, and anesthesia is reported to be one of the specialties which offers controllable lifestyle.
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  • Takekazu TERAI
    2006 Volume 26 Issue 7 Pages 627-636
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      Tracheal intubation performed by emergency medical technicians (EMTs) was accepted by the Ministry of Health, Labour and Welfare, and hospital training was started. Twelve EMTs completed training in Osaka Rosai Hospital. However, airway control and face mask ventilation using an anesthesia machine tended not to be performed well. They could not use a laryngoscope well, since they fell into bad habits from prior training using a mannequin for simulation. The rate of success of tracheal intubation was 92±6%, though the level of skill varied among individuals. However, there was not a significant correlation between age and rate of success. As for complications, the incidence of sore throat was 12.5% and of hoarseness, 19.1%. Instructors must understand the importance of training EMTs in tracheal intubation, and should recognize that tracheal intubation training is part of general airway control training. It is important that we assure competence in facemask ventilation first and then carefully teach tracheal intubation techniques to avoid complications.
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Journal Symposium (2)
  • Setsuro OGAWA
    2006 Volume 26 Issue 7 Pages 637
    Published: 2006
    Released on J-STAGE: December 22, 2006
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  • Satoshi HAGIHIRA
    2006 Volume 26 Issue 7 Pages 638-645
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      Many anesthesiologists in Japan seem to misunderstand that the use of fentanyl during anesthesia may lead to a delay in recovery from anesthesia. This idea is apparently incorrect. With the knowledge of the pharmacokinetic and pharmacodynamic features of fentanyl, we can adequately manage the antinociception during anesthesia without any delay in recovery from anesthesia and without respiratory depression. In most cases, more than 1. 5 ng/ml of ESC (effect site concentration) is required to obtain adequate analgesia during surgery. And the incidence of respiratory depression increases when ESC of fentanyl becomes more than 2. 0 ng/ml. We also should have the knowledge of how to use naloxone, the opioid antagonist, in case there is an overdose of fentanyl after the operation is finished. We should know that antinociception during surgery is the key for good anesthesia induction.
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  • Ritsuko MASUDA
    2006 Volume 26 Issue 7 Pages 646-653
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      At present, there are many facilities with anesthesiologists who, as pain management specialists, are trusted and of whom expectations are high. Away from the operating theater, the anesthesiologists is in charge of the long-term management of pain such as cancer pain, acute pain, and chronic non-cancerous pain. There is no question as to the utility of opioids for the first two types of pain. In particular, using patient-controlled analgesia (PCA) to administer opioids to control the breakthrough pain apparent in nociceptive pain has proven to be the most effective anesthetic technique. Also, recent elucidation of the molecular mechanisms underlying chronic pain has promoted wider recognition of the utility of opioids for the treatment of chronic non-cancerous pain. For long-term pain management with opioids to be successful, knowledge of the pharmacology of opioids via the various access routes as well as of possible secondary effects is required, not to mention the countermeasures to be taken. It is also necessary to recognize the kinds of medical accidents that can occur and to decide on how to deal with them. Finally, there is also the requirement of a far-reaching understanding and conception of both the primary disease and the patient's social environment.
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  • Hidekazu YUKIOKA
    2006 Volume 26 Issue 7 Pages 654-663
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      Opioids are the most commonly used and effective analgesics administered in intensive care units (ICU) . In ICU patients, effective analgesia may prevent myocardial ischemia and pulmonary complications. Since ICU nurses often underestimate the degree of pain being experienced by a patient and they may administer inadequate doses of analgesics by misguided fears of adverse effects or addiction, education on pain management and analgesia for ICU nurses and the accurate assessment of pain are therefore very important. Pain assessment using a numeric rating scale or the observer-reported face scale is practical in the ICU. During ventilator treatment, pain may be assessed by pain-related behavior and physiological indicators (blood pressure, heart rate) , although pain evaluation is very difficult. In patients undergoing mechanical ventilation, sedation assessment using the Ramsay Scale, Sedation-Agitation Scale or the Richmond Agitation-Sedation Scale is also useful. Opioid administration techniques in the ICU include intramuscular, intravenous and epidural techniques. Epidural opioids are extremely advantageous because of their longer duration of analgesia and lower incidences of both mental status changes and agitation compared with systemic administration of opioids, although epidural analgesia is sometimes contraindicated in critically ill patients. An epidural opioid combined with epidural local anesthetics is more commonly used than an epidural opioid alone. During ventilator treatment, continuous intravenous administration of propofol or midazolam should be performed in addition to opioid administration. Adequate pain relief without adverse effects through the correct use of opioids is needed for ICU patients.
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Journal Symposium (3)
  • Takahiko OKUDA
    2006 Volume 26 Issue 7 Pages 664
    Published: 2006
    Released on J-STAGE: December 22, 2006
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  • Toshihiro YOROZUYA
    2006 Volume 26 Issue 7 Pages 665-670
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      Nitrous oxide has often been used as a basic component of general anesthesia. As the recognition of possible adverse effects and environmental pollution from nitrous oxide have increased remarkably, the use of this important carrier gas has become increasingly limited. Moreover, the development of new volatile and intravenous anesthetics has led to calls for a re-evaluation of the role of nitrous oxide in current anesthetic practice. Nitrous oxide does increase the incidence of postoperative nausea and vomiting, but it seems that use of antiemetics prophylactically prevents this side effect. By enabling reduced doses of more potent anesthetics, nitrous oxide limits other cardiorespiratory side effects as well. The greatest reason for the continued use of nitrous oxide is that it has been reported to reduce the incidence of intraoperative awareness because it has a superior amnesic effect compared with other volatile anesthetics. There are specific contraindications for the use of nitrous oxide, but in the absence of these, it is difficult to justify not using it.
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  • Tetsuhiro SAKAI
    2006 Volume 26 Issue 7 Pages 671-673
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      Which drugs do you use for each patient? How do you use them in each patient?
      The answer to these questions is dependent upon the philosophy of each anesthesiologist. The most important approach for young anesthesiologists in Japan is not to pursue superficial knowledge and limited experiences with nitrous oxide, but to understand and establish a deep historical basis of nitrous oxide.
      The history of nitrous oxide anesthesia in Japan was reviewed and discussed. We have to understand the meaning of ‘Nothing New under the Sun’ deeply again.
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Original Articles
  • Mikiko OHTSUKA, Takashi OKUNO, Kenji MORIMOTO
    2006 Volume 26 Issue 7 Pages 674-678
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      Travelmin® has been widely used for the prevention or treatment of motion sickness. We studied the prophylactic effect of Travelmin® on PONV.
      One hundred twenty adult patients undergoing elective orthopedic surgery were enrolled in this randomized study. All patients had a laryngeal mask airway inserted after receiving propofol. Anesthesia was maintained with sevoflurane, nitrous oxide in oxygen and intravenous pentazocine. Sixty patients allocated to the treatment group received 1ml of Travelmin® subcutaneously at the start of wound closure. We evaluated the incidence of PONV during the following 24 hours.
      The patients' demographics were similar between the two groups. The incidence of PONV was significantly lower in the Travelmin® group than in the control group (10% vs 38 %) . PONV was triggered by motion in 38%.
      Travelmin® is less expensive than other antiemetics, with few adverse effects recorded. We conclude that Travelmin® is a useful prophylactic for PONV.
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Case Reports
  • Hisashi INOUE, Maki YAMADA, Yoshifumi MATSUDA, Keiko SHIMIZU, Takero A ...
    2006 Volume 26 Issue 7 Pages 679-682
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      A 7-month-old girl was scheduled to undergo tracheostomy for laryngomalacia. Since the previous surgery revealed that she had a difficult airway, our plan was fiberscopic tracheal intubation through a Soft Seal Laryngeal Mask™ (S-LMA) . A #1.5 S-LMA was cut at the tube part about 10 cm from the tip of the cuff and attached to a 7.5 mm I. D. tracheal tube connector. Anesthesia was induced using oxygen, nitrous oxide and sevoflurane, and then the S-LMA was inserted. The bronchofiberscope was smoothly inserted into the trachea, allowing tracheal intubation while utilizing the bronchofiberscope as a stylet, and removal of the S-LMA following intubation.
      The total length of a cut S-LMA should be about 1 cm longer than the expected depth of the tracheal tube used. The larger the connector used for the cut LMA, the more space you can ensure for fiberoptic procedures, and thus a larger tracheal tube can be inserted.
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  • Yusuke ASAKURA, Naoko KATO, Hiroshi ITO, Kimitoshi NISHIWAKI, Yoshihir ...
    2006 Volume 26 Issue 7 Pages 683-690
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      We report a case with trifascicular block (asymptomatic first degree atrioventricular block with a bifascicular block) complicated with acute respiratory distress syndrome that progressed to complete atrioventricular block during general anesthesia. A 74-year-old male, previously diagnosed as having arteriosclerosis obliterans who underwent aorto-bi-femoral bypass grafting surgery eleven years ago, developed severe dyspnea, and he was diagnosed as having idiopathic interstitial pneumonitis. In spite of corticosteroid therapy, he presented with severe intermittent claudication. His CT-angiography showed total occlusion of the infra-renal abdominal aorta, and he underwent emergent thrombectomy surgery. His preoperative electrocardiogram showed first-degree atrioventricular block with complete right bundle branch block and left anterior hemiblock, but he had experienced no cardiovascular symptoms. Anesthesia was induced with midazolam and vecuronium bromide, and maintained with fentanyl and sevoflurane in oxygen. Just after the operation was started, the ECG abruptly changed from a sinus rhythm to complete atrioventricular block, and his systolic atrial blood pressure decreased to 0mmHg. His heart was responsive to bolus intravenous injection of atropine and epinephrine, and the surgery was completed successfully without any further complications. He was admitted to the intensive care unit post-operatively. The case described here suggests that preoperative insertion of a temporary pacemaker should be considered in a case with trifascicular block complicated by other life-threatening disorders.
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  • Yusuke ASAKURA, Naoko KATO, Yuko SATO, Hiroshi ITO, Yoshihiro FUJIWARA ...
    2006 Volume 26 Issue 7 Pages 691-697
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      Allogeneic red blood cell transfusion should not be dictated, unless the patient's oxygen-carrying capacity is decompensated, and the signs and symptoms requiring blood transfusion have been observed. In cases with chronic normovolemic anemia, an increase of 2, 3-DPG compensates the patient's oxygen delivery capacity by leading the hemoglobin-oxygen dissociation curve shift to right, thereby allowing the unloading of a normal oxygen amount with a lower concentration of hemoglobin, which makes it difficult to assess the appropriate timing for red blood cell transfusion. Here, we describe the efficacy of measuring the oxygen extraction ratio in such a case.
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  • Yutaka YAMAZAKI, Atsushi SAITO, Hiromu TAKAHASHI
    2006 Volume 26 Issue 7 Pages 698-702
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      A woman in her thirties with spina bifida occulta was scheduled for laparoscopic extracorporeal ovarian cystectomy with combined general and epidural anesthesia. After induction of general anesthesia, epidural catheterization was attempted at the level of Th12 to L1 without awareness of her spina bifida occulta. When a 22 gauge needle 32 mm in length was used to anesthetize the route for insertion of a Tuohy's needle, the needle tip was accidentally inserted into the spinal cord. Postoperative magnetic resonance imaging (MRI) revealed a lesion in the conus medullaris and spina bifida occulta from Th11 to L2 without deformities in the lower lumbar and sacral vertebrae. Motor disturbance of her right foot continued. Thermal and pin-prick sensations were lost in her lower limb. Consideration of spina bifida occulta in the lower thoracic to higher lumbar vertebrae in the absence of superficial signs is necessary to attempt epidural blocks.
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Short Communications
  • Eita OKUNO, Tsutomu SHIMABUKURO
    2006 Volume 26 Issue 7 Pages 703-705
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      A 27-year-old female complained of pain upon opening her mouth, and the surgical arthroscope and arthrocentesis of the temporomandibular joint (TMJ) was scheduled. Under general anesthesia, nasotracheal intubation was performed. The surgery consisted of examination and the release of adhesions of both TMJ with lactated Ringer's solution. Just after the surgery, we noticed edema in her cheeks, submandibular regions, and neck due to fluid extravasation as a complication of TMJ pumping. Endotracheal intubation and artificial ventilation were performed for 3 hours after surgery until the fluid was absorbed. We should be aware of this complication in arthroscope or arthrocentesis because it can cause severe airway obstruction.
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Educational Articles
  • Mayumi TAKASAKI
    2006 Volume 26 Issue 7 Pages 706-710
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      Spina bifida occulta shows a minor bony defect in the spinous process and laminae by radiographical examination, with no neurological deficit. Spinal bifida is usually observed in the lumbo-sacral region, with or without cutaneous manifestations such as a lipoma, a skin dimple, or a pileous skin, sometimes including low-placed conus medullaris descending into the sacrum, and rarely observed in the thoraco-lumbar region, with no cutaneous manifestations. Attempted epidural puncture at the level of the lesion with no sense of the spinous process may result in dural tap and spinal cord injury because of the absence of the epidural space. When epidural or spinal anesthesia is indicated, spinal anesthesia may be preferable following some reports of clinical practice.
      Epidural puncture is performed in anesthetized adults in England, however, the German Society for Anesthesiology and Intensive Care Medicine has developed guidelines stating that general anesthesia is an absolute contraindication to placement of a thoracic epidural catheter in adult patients. According to the authorities on epidural anesthesia, it is not recommended to perform epidural puncture on anesthetized adults, in order to avoid spinal cord injury.
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Journal Symposium (4)
  • Shinobu YAMAGUCHI, Motoyasu TAKENAKA, Naokazu FUKUOKA, Shigeaki TANAHA ...
    2006 Volume 26 Issue 7 Pages 713-717
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      Our outpatient clinic was requested by a doctor at the other branch to insert and place a central venous catheter in two patients. The first patient had pancytopenia which worsened over several weeks and wasn't treated for it. The second patient had a blood test and her platelet count fell as compared to the prior 7 days, but her chief physician did not notice it. It was determined that there was a great risk of a fatal complication and the catheterizations were postponed. We may have caused a serious medical accident if we had not confirmed their data in advance, so we reported these cases as examples of safe medical practice. A discussion was held in a risk management committee, and, as a result, a general standard in our hospital was implemented.
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  • Koji ISHII, Sungsum CHO, Tetsuya HARA, Koji SUMIKAWA
    2006 Volume 26 Issue 7 Pages 718-721
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      We standardized the way to order that a patient fast before surgery in our hospital in 2003. However, there were cases in which the order to fast wasn't adhered to, so we standardized the way of confirming that the patient fasts, too. After implementing these standardizations, we had a patient who vomited during the induction of anesthesia and developed aspiration pneumonia, although he fasted sufficiently before the surgery. The patient was a boy with inguinal hernia. The operation was canceled and he was transferred to the intensive care unit, where he recovered without any complications. We explained to his family his status, treatment plan, and possible complications, and we also explained that the ordering and confirmation of fasting was most certainly done. The quick treatment and honest explanation after the accident enabled us to avoid trouble with the patient's family. It is very important to standardize the way of ordering and confirming of necessary procedures like fasting before surgery.
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  • Fumiaki ABE, Akihiko NONAKA
    2006 Volume 26 Issue 7 Pages 722-726
    Published: 2006
    Released on J-STAGE: December 22, 2006
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      There is much in the literature about how to communicate with a patient refusing blood transfusion. The judgment passed down by the Supreme Court in 2000 was very important for the medical profession in treating a Jehovah's Witnesses patient. We were attentively reading the judgments of the Supreme Court and the Tokyo High Court which decided the original judgment, and investigated the points of changing a means of treatment for the patient refusing blood transfusion. Consequently we understood that it was respected to agree with refusal of blood transfusion for any reasons as the result of the sufficient discussion, and the policies on blood transfusion adopted by each hospital must be made clear to the patient at the beginning of medical treatment. The main points of this problem remain mostly unchanged but we need to manage them more strictly for blood transfusion.
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  • Masaki KUME, Fumimasa TAMAKI, Miyuki WAKABAYASHI
    2006 Volume 26 Issue 7 Pages 727-729
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      Based on our experience of two cases of sponges left inside the patient after surgery, the manual to prevent leaving instruments and sponges inside the patient has been revised. Sponges, towels, and all other materials placed in the operation field must contain a radio-opaque marker and only X ray-detectable items shall be placed in the surgical wound. An inventory of instruments and sponges shall be recorded in the clinical chart. It has been decided that a radiograph of every patient who undergoes an open-cavity operation must be taken.
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  • Riko KIUCHI, Tadahiko ISHIYAMA, Katsumi OKUYAMA, Satoshi KASHIMOTO
    2006 Volume 26 Issue 7 Pages 730-733
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      Inadvertent tracheobronchial intubation of a nasogastric tube sometimes occurs and it may cause several complications including pneumothorax, pneumonia, pulmonary hemorrhage and bronchopleural fistula. We experienced a case of intrabronchial malpositioning of a nasogastric tube in a 79-year-old patient who was scheduled to undergo coronary artery bypass graft surgery (CABG) . The nasogastric tube was inserted after completion of CABG because of concerns about the nasal bleeding caused by the intraoperative use of heparin. No change in waveform of the capnogram was observed during the insertion, but gastric juice was not obtained by sucking on the tube. Inadvertent tube placement was not suspected, and the patient was transferred to the intensive care unit. Nasogastric tube malpositioning in the right bronchus was confirmed by chest radiography. There were no complications caused by bronchial placement of the nasogastric tube. Radiographic detection is an effective method of assuring accurate nasogastric tube placement, but observation of the waveform of the capnogram may not be. After this incident, we created an insertion manual for nasogastric tubes in an attempt to verify proper placement.
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  • Fumihiko SHIMADA, Shuichi NOSAKA
    2006 Volume 26 Issue 7 Pages 734-741
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      In recent years, medical lawsuits over anesthesia have been increasing. We reviewed the medicolegal problems of anesthesia records. We collected anesthesia records from several anesthesia teaching hospitals, and compared and discussed the medicolegal problems of each of them. We also discussed the medicolegal problems of electronic anesthesia records, because the number of hospitals that use electronic medical records has become increasing in recent years. Generally, preanesthesia records are satisfactory. But records of accidents in anesthesia and of postanesthesia are not satisfactory. So we hope to improve this from now.
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  • Atsuko KIUCHI, Yoko MATSUMURA, Miyaji KYAKUNO, Shuichi NOSAKA, Shoichi ...
    2006 Volume 26 Issue 7 Pages 742-749
    Published: 2006
    Released on J-STAGE: December 22, 2006
    JOURNAL FREE ACCESS
      We evaluated recent judicial precedents of accountability. Lost cases due to accountability violations have increased. The Supreme Court clarified the following: 1. When a surgical technique is changed to another one that has not been explained to the patient, the wishes of the patient must be confirmed. 2. When the surgical technique is a procedure performed considerably often, even if not common, an explanation is necessary. 3. In cosmetic surgery, a stricter explanation is required. 4. Not only the general explanation of the surgery but also explaining to individual patients is required. 5. Under certain conditions, the right to self-determination, such as the patient's religious beliefs, is given priority over the view of the value of life. Though a reasonable patient decision concept was conventionally adopted, there have been some judicial precedents adopting the concrete patient theory.
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