THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA
Online ISSN : 1349-9149
Print ISSN : 0285-4945
ISSN-L : 0285-4945
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Volume 27, Issue 7
Displaying 1-25 of 25 articles from this issue
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Journal Symposium (1)
  • [title in Japanese]
    Sumio HOKA, Shuji DOHI
    2007 Volume 27 Issue 7 Pages 587
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.587
    JOURNAL FREE ACCESS
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  • Neuroprotection
    Toru GOYAGI
    2007 Volume 27 Issue 7 Pages 588-598
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.588
    JOURNAL FREE ACCESS
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      Anesthesiologists can play an important role in preventing ischemic brain injury during surgery when patients have a crisis of brain ischemia. Even though many neuroprotective agents have been introduced in animal models, they have rarely shown neuroprotective effects in humans. It needs to be understood that many physiological factors affect the prognosis after brain ischemia, because various factors such as hypotension, hyperglycemia, hypoglycemia, hyperthermia, and hypocapnia can worsen ischemic brain conditions. In addition, we need to understand the drugs which affect the ischemic brain conditions. Inhalation anesthetic agents have short- but not long-term neuroprotective effects. Although β-blockers and lidocaine have been demonstrated to be potent neuroprotective agents, further study is needed for clinical use.
      Patients susceptible to brain ischemia should be kept to maintain adequate brain perfusion to exclude the factors that deteriorate the ischemic brain condition. Also, anesthesiologists should select adequate neuroprotective methods.
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  • Spinal Cord Protection for Anesthesiologists
    Hiroki IIDA
    2007 Volume 27 Issue 7 Pages 599-607
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.599
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      For anesthesiologists it is perceived to be important to control spinal cord perfusion pressure to maintain microcirculation of the spinal cord, preventing exacerbation of spinal cord damage. Understanding the characteristics of reactivity of the spinal cord's blood vessels is helpful in maintaining appropriate spinal cord circulation. In addition, it is useful to know that vasoactive drugs administered for maintaining systemic circulation, ischemia-reperfusion, disruption of blood-spinal cord-barrier, or hypothermia could potentially modify spinal cord circulation. Conversely, hypothermia as well as pharmacological spinal cord protection could not adequately overcome the clinical problems with regard to spinal protection. Meanwhile, pre-conditioning is also known to show resistance (ischemia tolerance) to fatal ischemia even in the spinal cord. It is thought that the effect of such internal organ protection is very strong, and the usefulness of introducing it clinically is also expected in conventional spinal cord protection strategies.
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  • Renal Protection Strategy for Ischemic Renal Dysfunction
    Masaaki UEKI
    2007 Volume 27 Issue 7 Pages 608-612
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.608
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      The development of perioperative acute renal failure is associated with a high incidence of morbidity and mortality. Although this incidence varies with different surgical procedures and the definition used for renal failure, we have to understand the etiology of the underlying problem. We must also understand better the renal physiology, the cause of postoperative renal dysfunction and the pathophysiology of acute renal failure.
      A number of possible strategies aimed at alleviating the development of renal dysfunction have been reported. Although commonly used approaches to prevent acute renal failure have included adequate hydration, mannitol, renal doses of dopamine and loop diuretics, successful strategies for performing adequate volume preload, maintaining oxygen delivery and ensuring the appropriate pharmacotherapy are important for providing renal protection.
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Journal Symposium (2)
  • [title in Japanese]
    Tetsutaro ODAGIRI
    2007 Volume 27 Issue 7 Pages 613
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.613
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  • How Does Anesthetic Induction Change?
    Hideki NAKATSUKA, Kenji SATO, Mamoru TAKEUCHI, Kiyoshi MORITA
    2007 Volume 27 Issue 7 Pages 614-619
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.614
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      Vecuronium is currently the first-choice muscle relaxant in Japan. Suxamethonium is no longer widely used because of associated side effects. However, vecuronium does not provide such a rapid onset of action as suxamethonium, despite strategies such as priming or the use of higher doses.
      Rocuronium, which has a faster onset than vecuronium and has been used in the US and Europe for over 10 years, should soon be available in Japan and may replace vecuronium. However, the shorter duration of action of suxamethonium means it may still be used in some patients.
      Sugammadex is able to rapidly and completely reverse rocuronium-induced muscle relaxation with a novel mechanism of action. Once sugammadex is introduced, the combination of a high dose of rocuronium with sugammadex allows rapid onset and reversal as needed. As such, the use of suxamethonium may no longer be an issue. Unlike cholinesterase inhibitors, sugammadex also allows recovery from deep blocks which may change how muscle relaxants are used.
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  • How to Use Rocuronium during Anesthetic Maintenance
    Yoshifumi KOTAKE
    2007 Volume 27 Issue 7 Pages 620-630
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.620
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      Neuromuscular blocking agents (NMBA) can provide muscle relaxation during surgical procedures independent of the anesthetic depth. In this respect, NMBA remains an important adjunct for anesthesiologists to provide optimal surgical conditions and patient safety. Rocuronium will finally be available in Japan this autumn. The duration of rocuronium is almost identical to that of vecuronium. Therefore, major changes in the current practice of NMBA administration during surgery may not be necessary even when rocuronium is available. Furthermore, rocuronium undergoes limited metabolism, as the metabolites lack neuromuscular blocking activity and are eliminated via hepatic excretion. These favorable characteristics may contribute to the reduced risk of prolonged neuromuscular blockade after prolonged use in patients with hepatic and renal dysfunction, compared to the currently used vecuronium or pancuronium.
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  • Future Trends in Antagonism of Neuromuscular Block
    Takahiro SUZUKI
    2007 Volume 27 Issue 7 Pages 631-638
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.631
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      Sugammadex, synthesized as a selective relaxant binding agent for rocuronium, should be an “history-making” drug in clinical anesthesia. The sugammadex molecule encapsulates the lipophilic steroid rings of rocuronium and forms a 1: 1 host-guest complex. In addition, negatively-charged carboxyl groups around the perimeter of cyclic sugammadex easily attract the positively-charged quaternary nitrogen of rocuronium. Even in a profound block induced by rocuronium, adequate reversal can be obtained within 1-2 min after a bolus administration of sugammadex. No specific side effects and recurrence have been seen. Sugammadex should make it easier to treat patients with a difficult airway and decrease postoperative respiratory complications caused by residual neuromuscular block. In the near future, the rocuronium-sugammadex combination will reliably contribute to patient safety.
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Journal Symposium (3)
  • [title in Japanese]
    Toshiya KOITABASHI
    2007 Volume 27 Issue 7 Pages 639
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.639
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  • Significance of TIVA/TCI Education in Anesthesiology Training from the Standpoint of the Community Hospital
    Tsutomu SHICHINO
    2007 Volume 27 Issue 7 Pages 640-644
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.640
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      TIVA/TCI education for residents in their first year is considered to be significant due to the high expectations placed on developing the residents' interest in Anesthesia. Step-by-step instruction will help residents to learn more smoothly. On the other hand, TIVA/TCI education with limited full-time attending anesthesiologists compels the advisors to do too much.
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  • The Significance of TIVA/TCI in the Training Program for Residents at University Hospitals
    Yasuhiro MORIMOTO, Kohji UTADA
    2007 Volume 27 Issue 7 Pages 645-651
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.645
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      The training program for residents is important for attracting more residents to university hospitals. The survey on the training program for residents by the Ministry of Health, Labour and Welfare revealed that the degree of satisfaction was higher in teaching hospitals than university hospitals. The main difference between them was programs for primary care.
      In the resident training program, the residents can learn the basic skills in airway and circulation management in the Anesthesiology Department. Moreover, with the training for total intravenous anesthesia (TIVA) and target controlled infusion of propofol (TCI) , they can acquire knowledge about the basic pharmacokinetics of intravenous anesthetics that also can be readily applied to sedation and pain relief outside the operation theater. This could remind residents of the importance of Anesthesiology in primary care at university hospitals.
      The questionnaire survey about the current status in TIVA in Japan revealed that about 1/3 of anesthesiologists are mostly practicing TIVA. The anesthesiologists who choose TIVA tend to use TCI infusion of propofol, EEG monitor and simulation program of fentanyl blood concentration. Understanding and extended use of these devices seems useful in the training program for residents.
      We believe that facilitating to teach TIVA/TCI is the major cue for the residents training program at university hospitals.
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  • A Meaning to Teach TIVA/TCI to Anesthesia Residents
    —A Current Condition to Perform TIVA or Use TCI—
    Toshiya KOITABASHI
    2007 Volume 27 Issue 7 Pages 652-657
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.652
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      I investigated the current conditions surrounding the clinical use of propofol for TIVA/TCI. The survey revealed that TIVA was performed in more than 50% of patients undergoing open-thoracic or cardiac surgery, although this incidence differed depending on the operative procedure. Factors often indicated by anesthesiologists as reasons for hesitating to perform TIVA were: (1) adjustment is easier with volatile anesthesia ; and (2) the anesthesiologist is more familiar with volatile anesthesia. Experience with cases of delayed awakening from anesthesia was another reason for hesitating to choose TIVA.
      According to the tutorial guidelines for anesthesiology residents of the Japanese Society of Anesthesiologists, the goal of using TIVA with propofol is acquiring the skills to perform total intravenous anesthesia with propofol. Training in propofol TIVA/TCI thus appears to be necessary for anesthesiology residents. This paper presents the current status of TIVA/TCI tutorials at our facility and discusses the anticipated effects of this type of tutorial.
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Educational Articles
  • Combined Spinal Epidural Anesthesia
    Reiko TAKAHASHI
    2007 Volume 27 Issue 7 Pages 658-664
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.658
    JOURNAL FREE ACCESS
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      Combined spinal epidural anesthesia (CSEA) offers the advantages of both spinal and epidural anesthesia: rapid onset and deep level of anesthesia, flexibility and postoperative analgesia. The disadvantage relating to single segment technique is the high incidence of failure, the risk of catheter migration, and drug transfer from the epidural space to the cerebrospinal fluid. The principal concern regarding the double segment technique is that the patient suffers twice as much pain. The mechanism of extended spinal anesthesia by epidural injection is largely the epidural volume effect. I hope CSEA is established as a more reliable method of regional anesthesia.
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  • The Role of Anesthesiologists in Management of a Patient with Circulatory Support Systems in the Perioperative State
    Chol KIM
    2007 Volume 27 Issue 7 Pages 665-674
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.665
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      As main circulatory support systems, the Intra-Aortic Balloon Pumping (IABP) , the Percutaneous CardioPulmonary Support (PCPS) , and the Left or Right Ventricular Assisted Devices are available in operating rooms. In particular, IABP and PCPS are important devices for anesthesiologists to be skilled and experienced with since they are used often in the perioperative state. IABP increases coronary flow by diastolic augmentation, and decreases afterload of the left side of the heart by systolic unloading, while PCPS assists the systemic circulatory flow with a closed circuit consisting of a centrifugal pump and an artificial lung. Each of them can be applied individually, but it is better to use them in combination with each other to obtain the maximum desired effects on systemic circulation and oxygenation of patients. Also, adequate monitoring is required for good and safe handling of these devices. The role of anesthesiologists in managing a patient with circulatory support systems in the perioperative state is to stabilize circulation, preserve systemic oxygenation, and manage risk and safety. Described here are the mechanisms and points of note for each system to accomplish this role of anesthesiologists.
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Review Articles
  • Neuraxial Anesthesia Related Morphological Phenomenon in Spinal Canal
    Tetsuo TAKIGUCHI, Shigeki YAMAGUCHI, Toshimitsu KITAJIMA
    2007 Volume 27 Issue 7 Pages 675-683
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.675
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      It is necessary to pay attention to morphological information of the spinal canal, while performing the epidural and spinal anesthesia. In this report, we showed morphological changes in the spinal canal using myelography, magnetic resonance image, as follows: 1) the subarachnoid space is markedly compressed from the dorsal side by epidural injection, 2) the subarachnoid space is compressed from the ventral side by the engorged vein in pregnant women, 3) the spinal cord and cauda equina dynamically move in the subarachnoid space just by changing positions, and 4) the dynamical movement of the cauda equina in adults was more obvious than that in children. For safe and effective epidural and/or spinal anesthesia, it is very important to know about those events in the spinal canal.
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Case Reports
  • Five Cases of Severe Hypotension upon Red Blood Cell Transfusion through a Potassium Adsorption Filter
    Mai HIRAISHI, Michiya OHKURO, Toshiyuki TOBITA, Hiroshi BABA
    2007 Volume 27 Issue 7 Pages 684-688
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.684
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      We report five cases of intraoperative severe hypotension likely related to red blood cell transfusion through a potassium adsorption filter. The severe hypotension occurred either immediately after the start of red blood cell transfusion or during rapid transfusion through the potassium adsorption filter, and was easily reversed with vasopressive agents. It is unclear whether the use of the filter was the primary cause of the severe hypotension, because the filter was often used in patients in whom hemodynamic conditions were unstable, i. e. , those with massive bleeding or those undergoing a liver transplant. Hypotension due to blood transfusion through a white cell-reduction filter and conventional blood filter has been reported. Hypotension in these patients may have been caused by some vasodilative substance produced by contact with the potassium adsorption filter.
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  • A Case of Converting a Laparoscopic Procedure to an Open One Due to Subcutaneous Emphysema and Hypercarbia during Cholecystectomy
    Masako MAYUMI, Shigehito SATO
    2007 Volume 27 Issue 7 Pages 689-692
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.689
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      An 82-year-old patient developed subcutaneous emphysema and hypercarbia without pneumothorax during laparoscopic cholecystectomy. EtCO2 reached 75 mmHg after 60 minutes of pneumoperitoneum. At this time, severe massive subcutaneous emphysema from the anterior thorax to the head and neck was observed. Arterial blood gas analyses revealed pH 7.03, PaCO2 111 mmHg, PaO2 148 mmHg, and BE -5 mmol/L. Pneumoperitoneum was terminated, and the surgical procedure was changed to open abdominal surgery. PaCO2 decreased gradually and returned to normal, and the postoperative course was uneventful.
      It is necessary to pay attention to possible hypercarbia and subcutaneous emphysema associated with pneumoperitoneum during laparoscopic surgery.
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Journal Symposium (4)
  • [title in Japanese]
    Atsuko KIUCHI
    2007 Volume 27 Issue 7 Pages 695
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.695
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  • Autopsy in a Medical Malpractice, and the Future of a Model Enterprise
    Noriaki IKEDA
    2007 Volume 27 Issue 7 Pages 696-703
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.696
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      Now, death by medical malpractice is considered to be a serious matter in society, so the post-mortem examination is essential to determine the cause of death. Judicial autopsy has disadvantages for both the bereaved family and the clinician, because the conclusions are not presented. We have some alternative ideas, such as forensic autopsy and a new system to determine the cause of death. Consent autopsy, which is a kind of forensic autopsy, is performed by classes in the forensic department, with the consent of the bereaved family, and the conclusions are disclosed. It functions almost identically as the pathological autopsy, but is performed by forensics department. The new system which is pushed ahead by the Ministry of Health, Labour and Welfare searches for the cause of death via medical malpractice by third party.
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  • Medical Accident and Criminal Case
    Sadato GOTO
    2007 Volume 27 Issue 7 Pages 704-712
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.704
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      Interventions of police officers in clinical departments, which is supported by some and rejected by others, will increase in frequency. In response to accusation and notification on article 21 of the Medical Practitioners Law, the police officer rushes into an investigation of the case. Criminal investigation has a search with the consent of the witness and compulsory investigation is accompanied by arrest or the seizure of documents. It is prosecuted by judgment of criminal investigation. In this process, the defendant has the right to remain silent, the right to ask for a lawyer, and the obligation to accept the questioning of the police.
      The criminal case: I present the case in which a patient died of total spinal block by epidural anesthesia.
      To defend yourself, the most important thing is not to make falsifications, not to join the flats, and not to incorrectly present one's actions. Honesty is the greatest defense.
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  • What to Do When an Accident Occurs in Your Hospital?
    Kazumasa EHARA
    2007 Volume 27 Issue 7 Pages 713-718
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.713
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      The most important concepts to defend against medical malpractice are 1) explaining honestly to a patient's family about a medical accident at early stage, 2) maintaining accountability by fair investigation, and 3) prevention of recurrence. In our hospital various reformations have been undertaken since 2000 by organizing medical safety control and the risk-management system against medical accidents. A lot of problems are related to Article 21 of the Medical Practitioners Law, and criminal punishment is pointed out. Although the number of criminal and a civil actions have increased and become more severe for health professionals, taking responsibility for one's actions will also protect medical professionals and institutions, and will help lead to reform of the health care system.
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  • The Breakage of an Epidural Catheter inside a Patient
    Satoki INOUE, Noriyuki SASAOKA, Masahiro TAKAHASHI, Hitoshi FURUYA
    2007 Volume 27 Issue 7 Pages 719-722
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.719
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      We had a case of an epidural catheter breaking off inside a patient. Prior to induction of general anesthesia, epidural catheterization was performed. At that time, the epidural catheter accidentally broke off inside the patient. After obtaining informed consent and inducing general anesthesia, we tried to remove the broken piece of the epidural catheter (12.5cm) with a minor incision but failed. We recommended that the patient to leave it as is and follow up later because it did not cause any neurologic symptoms at that time. She agreed to our proposal. Since then, the patient has not shown any symptoms. However, she has since claimed that she was not informed of the possibility that the epidural catheter could break off inside her and that she is very worried that her health could be affected at any time by the piece of the epidural catheter that is still inside her. Consequently, we gave her a monetary compensation according to the out-of court settlement between her and our institute.
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  • A Case in Which the Incorrect Insertion in the Vertebral Artery Became Clear Four Days after Inserting the Central Venous Catheter
    Osamu YOSHITOMI, Sungsum CHO, Takuji MAEKAWA, Tetsuya HARA, Tetsuji MA ...
    2007 Volume 27 Issue 7 Pages 723-727
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.723
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      Insertion of central venous catheters (CVC) is an essential treatment in modern critical care. Despite the utility of CVC, insertion and placement of CVC is often associated with mechanical, infectious, and thromboembolic complications. Recently, accidents associated with CVC have been reported. We had a case in which the incorrect insertion in the vertebral artery became clear four days after inserting CVC. The patient recovered without any neurological complications. Mechanical complications such as accidental arterial puncture and drug injection can contribute to endangering life. Therefore, it is absolutely necessary to standardize the way of confirming the correct insertion and placement of CVC. Moreover, it is very important that we acquire the correct knowledge about complications associated with insertion and placement of CVC.
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  • Detection and Prevention of Incidents Related to Drugs
    Riko KIUCHI, Tadahiko ISHIYAMA, Takeshi OGUCHI, Satoshi KASHIMOTO, Tak ...
    2007 Volume 27 Issue 7 Pages 728-731
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.728
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      Incident reports have been a major source of information in the development of errors in clinical anesthesia. In the past eight years, 276 incidents were reported in our department. Errors associated with drugs and ventilation accounted for 46% of all incidents. We therefore summarized and highlighted drug-related incidents, which occurred from January 1999 to August 2006. We also evaluated the preventive strategies for drug mishaps. Because administration of the wrong drug was the major factor in drug-related incidents, we introduced labels that were pasted on the syringes. Afterwards, incidents associated with drugs decreased but did not decline to zero. We then made the drug-handling manual. In the manual, when anesthesiologists want to administer a drug, they have to consult their supervisor as to whether the drug is appropriate. After introducing the manual, inadvertent drug mishaps decreased and only one case was reported in 2006. Using labeled syringes is not sufficient for preventing wrong drug administration. Checking drugs by more than 2 anesthesiologists should be an efficient strategy for minimizing drug-related mishaps.
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  • A Facial Injury during Surgery in the Prone Position
    Ryota AOI, Shuichi NOSAKA
    2007 Volume 27 Issue 7 Pages 732-735
    Published: 2007
    Released on J-STAGE: December 07, 2007
    DOIhttps://doi.org/10.2199/jjsca.27.732
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      In one case a patient's face was damaged when she had plastic surgery in the prone position at our hospital. The injury was caused by sticking tape to her face.
      We apologized and explained the reason for the injury after her surgery, and unwillingly accepted our explanations. We planned some way of preventing similar injuries to the patient's skin, such as applying and removing tape slowly, before and after the surgery.
      We need to explain to our patients the possibilities of damaging their skin before surgeries. That is a good way to prevent severe problems, such as law suits.
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