There are several basic abilities for anesthesiologists during emergency surgical procedures and anesthesia. One of their abilities is technical skill in administering anesthesia. Furthermore, it is important for anesthesiologists to develop communication skills, which consists of intelligence activity from patient or his family according to his medical status or his clinical information and negotiation ability to surgeons, nurses and co-medical stuffs. Emergency surgery fundamentally has a lot of high-risk factors for patients. If an anesthesiologist is faced with emergency surgery, first he should take the time to prepare for anesthesia as soon as possible, and then promptly plan the anesthetic schedule. Next the anesthesiologist should interview the patient or his/her family to determine when his last oral intake was and when event onset occurred. Written or oral informed consent, as permissive as possible, must be obtained from the patient or his family. The anesthesiologist should remain in very close communication with the surgeons during surgery, but he has to understand that their opinions or comments are not always correct. The ability to make decisions is not easily acquired, but general judgement will be developed by learning and clinical experience. Airway management (especially tracheal intubations) is a basic technical skill. Daily clinical training is necessary for anesthesiologists concerning difficult airway management (DAM) . All anesthesiologists should precisely understand the DAM algorism, and then in the operating room the emergency airway management kit or equipment should be commonly prepared. Clinical medical experience is better than education with human high-performance simulator, but the simulator is very useful for anesthesiologists today.

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  It is well known that α₂ agonists have various pharmacological effects, including sedation, analgesia, and sympatholysis. Since these effects are important in anesthetic management, applying α₂ agonists to clinical anesthesia has been expected. Development of dexmedetomidine, a potent and selective α₂ agonist, facilitated a clinical trial of the drug as an anesthetic adjunct in clinical anesthesia. Unfortunately, this clinical trial was interrupted. However, dexmedetomidine was introduced as a postoperative sedative drug, because it provides high-quality sedation. While we can expect that dexmedetomidine has a lot of potential in clinical anesthesia, we should be careful of side effects because of its various pharmacological actions.

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  In 2004, dexmedetomidine was approved for sedation during ventilation and after extubation in the intensive care unit (ICU) . The development of dexmedetomidine is an attempt to improve sedative and analgesic use. One hundred forty consecutive patients who received dexmedetomidine as a sedative between December 2004 and May 2005 in a single institution were reviewed retrospectively. Sedative, hemodynamic, and gastroenterologic effects of dexmedetomidine were assessed. Furthermore, we introduce the possible uses of dexmedetomidine based on our experience and the literature.

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  Surgical hemorrhage-induced death composes 17% of deaths due to critical events in the operating room in Japan. Surgical hemorrhage is not always critical. However, surgical hemorrhage becomes critical in association with multiple co-existing factors: the patient's preoperative condition, surgical decision-making, anesthetic management, transfusion practice and supply of blood products. To reduce these types of incidents, building a high reliability organization and improving the communication between the operating room and the blood supply division are essential.

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  Before revision of the Japanese guidelines for transfusion, anesthesiologists, opinions for transfusion were surveyed. A questionnaire survey was distributed amonged in 958 hospitals registered at the Japanese Society of Anesthesiologists from the end of 2004 through the beginning of 2005, and 56.1% (537 hospitals) were returned. The guidelines for packed red cells were widely accepted. The trigger value of hemoglobin concentration was 7-9 g/dl. Although most of the anesthetists used the coagulation dysfunction as the determining factor for a transfusion of fresh frozen plasma, less than 20% of the hospitals actually inspected coagulopathy. In most hospitals, the critical value for hemorrhage was less than approximately 60% of the bleeding amount recommended by the guideline (critical value in the guidelines: 100% of circulating blood volume) . The guidelines for platelet concentrate transfusions for elective surgery were mostly accepted, but the critical value for cardiopulmonary bypass surgery (3 × 10⁴/μl) was considered to be too excessive. The most prevalent complaint was the inadequacy of the guidelines for rapid massive bleeding. In the near future, the supply of blood products will be more stringently regulated in Japan. Anesthesiologists have to be aware of the guidelines for the appropriate use of transfusion, and the guidelines should be practically reedited.

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  The Blood Transfusion Law is newly established in Japan as of 2003. Under the new law, physicians and co-medical staff have to work hard to establish more appropriate transfusions of blood components for patients according to the guidelines set by the Ministry of Health, Welfare, and Labor in Japan. The type & screen (T&S) , maximal surgical blood order schedule (MSBOS) , and autologous blood transfusion for blood transfusions for surgery are useful tools to accomplish the aims. Furthermore, under the new guidelines, no indication of fresh frozen plasma (FFP) for blood loss of less than 2,000ml during surgery, assists in accomplishing the aims.

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  The Pentax-AWS^® (AWS) , combined with PBLADE^® , is a novel tracheal intubation device which allows indirect visualization of the vocal cords without the alignment of the oral and pharyngeal axes required for direct laryngoscopy. Intubation procedure can be monitored on a builtin CCD monitor. The Pentax-AWS^® provides a better laryngeal view than the Macintosh laryngoscope and facilitates easier guided intubation in a larger number of patients. We have had more than 200 intubation cases since its release in July 2006, and the basic features of the AWS are discussed in this literature.

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  The outcome of patients managed with general anesthesia combined with epidural block (11 patients) was compared with that of patients managed with general anesthesia alone (8 patients) during and after abdominal aortic aneurysm repair at our institution. In patients undergoing epidural block, epidural catheters were placed on the day before the operation, and were used for four days after the operation. Epidural block was obtained by 2ml/h continuous infusion of a mixture of 100-400 mcg per day of fentanyl and local anesthetics (0.2% ropivacaine) . Anesthesia during the operation depended on each anesthesiologist in charge, and was not regulated in particular for this study. Results showed tendencies for patients with epidural block to have earlier bowel gas release, and shorter hospital stay compared to patients managed without epidural block (p=0.10) . Patients with epidural block presented a lower white blood cell count immediately after the operation and received smaller amounts of supplemental analgesics after the operation (p<0.05) . Although there have been previous reports on the incidence of epidural hematomas, our results suggested an encouraging postoperative course in the patients managed with epidural block undergoing abdominal aortic aneurysm repair.

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  A 36-year-old male patient with severe ankylosing spondylitis was scheduled for spinal osteotomy and spondylosyndesis in the prone position. Because of the thoracic and lumbar kyphotic deformity and of his limited neck movement, we performed nasal endotracheal intubation with the aid of fiberoptic bronchoscopy under sedation. General anesthesia was maintained with nitrous oxide and sevoflurane. After he was put in the prone position, we performed caudal anesthesia. The patient was discharged with no complications.
  From the viewpoint of the anesthetic management of the patient with ankylosing spondylitis, it was important to evaluate preoperatively the airway management, body position, and complications, especially respiratory dysfunction, and the difficulty of spinal or epidural anesthesia.

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  We present a case of an anesthetic management for balloon aortic valvuloplasty (BAV) in a neonate with critical aortic stenosis immediately after delivery. A 35-year-old, 36-weeks-pregnant woman was referred to our hospital. The fetus was diagnosed as having a severe small annulus with left ventricular dysfunction using fetal echocardiograms. The treatment strategy for avoiding intrauterine fetal death due to fetal cardiac failure was discussed by the obstetricians, the cardiologists and the anesthesiologists.
  According to the strategy, the neonate (heart rate of 102/min. ; SpO₂ 25%) was delivered by cesarean section and was immediately intubated and BAV performed. This procedure was completed in 53 min after the delivery (SpO₂ 93%) . BAV was subsequently performed 4 times for the residual aortic stenosis. Occurrence of significant aortic regurgitation was not observed. The neonate made satisfactory progress and was discharged 4 months later. A carefully worked-out plan and communication in the medical team are essential for successful anesthetic management in newborn neonates with severe congenital heart diseases for which urgent medical treatment should be required.

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  An 83-year-old male was scheduled for a surgical resection of gastric cancer. He underwent uncomplicated general anesthesia in combination with epidural anesthesia (5ml of 0.2% ropivacaine, twice, followed by continuous infusion at 4ml/hr) . At the end of operation, he exhibited lower limb paraplegia and sensory impairment below the level of the umbilicus. The epidural hematoma was negative by an emergency epidurography. MRI revealed an intradural filling defect on the lower thoracic spinal cord extending from Th6 to Th11, consistent with the diagnosis of a spinal arteriovenous malformation (AVM) . Surgery was not indicated because of the complete paralysis of the thoracic spinal cord. A massive dose of methylprednisolone was injected intravenously and therefore rehabilitation was performed. He had no appreciable improvement of either the paraplegia or of the sensory disturbance from therapy. Unfortunately, he died 2 months later because of aggravated cardiac disease and pneumonia.

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