This article describes a short history of the development of the laryngeal mask airway (LMA) and also concretely explains the details of LMA insertion.
  After LMA appeared on the market in 1988, it has been widely accepted as a very useful device for airway maintenance. LMA has now become more frequently used than the tracheal tube in many developed countries for routine elective surgeries. However, because of the lack of basic knowledge and technique, there are still some practitioners who, regrettably, have difficulties with the practical use of LMA and intentionally avoid using it. This article deals with the concepts behind LMA design as well as its history, and discusses the inventor of LMA who suggested a rational insertion technique, and provides practical guidance for inexperienced LMA users.

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  Sevoflurane is widely recognized for its ability to enable rapid emergence from anesthesia. However, it should also be recognized as an agent for rapid anesthesia induction. Previously, halothane was used for slow anesthesia induction, but the possibility of adverse events such as laryngospasm or vomiting were always a concern to anesthesiologists. One-breath induction with sevoflurane is a drastically different concept from slow induction with halothane. Vital capacity induction with a pause at maximum inspiration is recommended because of its ability to induce anesthesia rapidly. Only tens of seconds are required to induce sleep, which is comparable to the onset of intravenous anesthetics, although a good mask fit and manual ventilation are required. Comparison studies have confirmed that sevoflurane induces anesthesia quite rapidly and rarely induces undesirable adverse reactions. Since induction is as rapid as that of intravenous anesthesia, adverse events can be avoided. VIMA (volatile induction and maintenance of anesthesia) can be regarded as “seamless anesthesia” using a single agent for induction and maintenance. The adoption of rapid one-breath anesthesia induction using sevoflurane should enable the avoidance of “halothane trauma” .

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  This article reviewed the relationship between perioperative anesthesia management and long-term outcome of surgical patients. Anesthesia depth, pharmacological preconditioning, beta-blockers, alpha2-agonists, statins, and glucose control have been reported to affect long-term outcomes. Although research in this area has just started, we anesthesiologists should recognize its importance.

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  The number of medical malpractice suits and the severity of criminal actions against physicians have been increasing drastically in recent years. In the face of these social changes, we are now forced to consider what we can do to ameliorate these worsened situations. First, there is a great need to improve and strengthen communication between the medical and legal societies in order to attain mutual understanding. At present, legal professionals are asking for our participation in facilitating their lawsuit processes requiring medical expert opinions. Through our collaborative efforts, we hope to transform the lawsuit arena of accusation into one in which we can discuss together and constructively explore the possible means to provide better medical services for all people in this country in the future.

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  Generally, patients require a detailed preoperative explanation about their upcoming surgery and anesthesia. But there are some patients who do not want a detailed explanation, because they are afraid of hearing it. Therefore, we surveyed the postoperative patients in our hospital to investigate what percent of patients would prefer more preoperative information and how satisfactory the preoperative information we offered was. We interviewed 104 patients and 99 of them answered our questionnaire sincerely. Eighty-one cases preferred the detailed explanation and 3 cases did not because of fear. The others wanted a minimal explanation. Ninety-eight of 99 patients were satisfied with our explanation.
  More patients who underwent endoscopic surgery had anxiety about the anesthesia and surgery than those with non-endoscopic surgery. This finding may have reflected the recent news on TV or in the newspapers about medical mishaps that occur during endoscopic surgery.

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  We asked the doctor and the nurse in the ward related to postoperative epidural analgesia about their knowledge of epidural anesthesia complications and correspondence in perioperative anticoagulant therapy or antiplatelet therapy. It turned out that neither the doctor nor the nurse understand epidural anesthesia complications and correspondence in perioperative anticoagulant therapy or antiplatelet therapy enough. Furthermore, 67% of doctors have removed the epidural catheter in anticoagulant therapy until now. Based on these findings, epidural anesthesia as a whole must be taught to each ward. It is necessary to think of this as a hospital problem. In the future, we have to aim for a safer postoperative epidural analgesia.

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  We experienced 2 patients undergoing thyroplasty, both of whom required laryngeal phonation during the operation to assess optimal vocal cord motion. Dexmedetomidine (DEX) was used as an anesthetic adjuvant. In both cases, anesthesia was induced with 4μg/kg of fentanyl, 5mg of droperidol, and 1.6-1.8μg/kg/hour of DEX for 20 minutes, which was then maintained at 0.2-0.5μg/kg/hour of DEX. The airway was secured using the nasal airway and spontaneous breathing was preserved throughout the surgical procedures. The perioperative courses were uneventful without any respiratory depression, or patient anxiety or discomfort, and both patients obeyed the instructions of the surgeon to phonate without restlessness. DEX has potent sedative, amnesic, and analgesic properties that provide it with a lower respiratory depressive effect. Therefore, we conclude that DEX is useful as an anesthetic adjunct for intraoperative management of patients who must phonate during this type of surgery.

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  We described the case of a pregnant woman who was diagnosed as having primary pulmonary hypertension during her pregnancy. She had been given supplemental oxygen and prostaglandin I2 right after the diagnosis. Her general condition improved and the elective cesarean section was planned at 29 weeks and 2 days of pregnancy under general anesthesia. Pulmonary artery catheter was inserted to the day before the operation. High FiO2 and PGI2 were maintained during the operation. Her perioperative course was stable and the pulmonary hypertension did not worsen. It is important to have a collaboration among specialists to manage such critically ill parturients.

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  We currently use a combination of propofol and dexmedetomidine as sedative agents during mechanical ventilation. This practice may attenuate undesirable cardiovascular effects while maintaining adequate sedation and prompt wakening. In this retrospective analysis, the dosage of each agent and estimated blood concentration were reported in 13 postsurgical cardiac patients. During mechanical ventilation, the dosage of propofol and dexmedetomidine, titrated to achieve a score of 5 on the Ramsay sedation scale, were 1.83±0.73 mg/kg/hr and 0.25±0.11μg/kg/hr, respectively. The corresponding plasma concentration were 0.98±0.42μg/ml and 0.34±0.17 ng/ml. During weaning from mechanical ventilation, the dosage and plasma concentration of propofol were 1.30±0.64 mg/kg/hr and 0.43±0.11μg/ml, respectively, while the dosage and plasma concentration of dexmedetomidine were almost identical to those of the pre-weaning period. In conclusion, the coadministration of propofol and dexmedetomidine enables us to reduce the dosage of each drug while maintaining adequate sedation.

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  Pharmacokinetic-pharmacodynamic models of propofol have been widely used to estimate the response of the Bispectral Index (BIS) . The pharmacokinetic parameters, utilized in these models, were obtained from intermittent blood samples obtained from a limited number of subjects, and are not guaranteed to be ideal for the estimation of the BIS. Moreover, these models have not taken adequate consideration of a delay in the BIS response. In this paper, parameters of a pharmacokinetic-pharmacodynamic model and the delay were identified from measurements of infusion rate and the BIS during surgery. The identified parameters decrease the estimation error of the BIS response compared with the standard parameters. The importance of adequate consideration of the delay is also suggested.

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  Refemitanil is an ultra-short-acting opioid analgesic. It is metabolized by non-specific esterase in the blood and tissues, and therefore metabolism of it does not depend on liver/kidney function. If the dose of remifentanil were calculated by total body weight, extremely obese patients would receive an overdose. Since remifentanil is a short-acting agent, we should take care of postoperative analgesia.

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  TCI (target-controlled infusion) and anesthetic management based on effect-site concentration are now widely used. Remifentanil, which was released this year, has many advantages for anesthetic management based on pharmacokinetics because it has rapid onset, is short-acting, and does not accumulate. Since the effect-site concentration of remifentanil becomes fixed during continuous infusion, TCI is frequently accomplished without conscious effort. Both lean body mass and age affect effect-site concentration based on pharmacokinetics and these effects will therefore be explained in this paper with the presentation of concrete cases and using the results of pharmacokinetic simulation. The advantages and downsides of remifentanil will also be outlined, and an infusion method resembling TCI and TCI will be introduced.

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  Remifentanil is a potent μ-opioid receptor agonist, and its onset and duration of action are very short. Its action disappears very quickly after ceasing infusion, and it is therefore thought to be useful in anesthetic management for day surgery. Because its plasma concentration can be easily controlled, remifentanil is suitable for awake intubation and insertion of a laryngeal mask airway. For these reasons, remifentanil is thought to be useful for the anesthetic management of orthopedic surgery.

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  Remifentanil is a very short-acting opioid and a suitable alternative to fentanyl for neurosurgical anesthesia. It should allow quick neurological recovery. Remifentanil has minimal effect upon the cerebrovascular response to changes in cerebral perfusion pressure and intraoperative monitoring. The recovery time is shorter with remifentanil and also allows better intraoperative hemodynamic control. These characteristics make remifentanil the ideal opioid for neurosurgical anesthesia. The short duration of action of remifentanil requires a transitional method of analgesia to ensure a smooth and painless emergence from anesthesia. Care for post-operative analgesia should also be taken into account.

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