Intraoperative awareness (IOA) is defined as a patient unintentionally regaining consciousness during procedures of general anesthesia. IOA is problematic because the recall of dreadful events experienced during surgery may cause post-traumatic stress disorder (PTSD) . Although efficacies of benzodiazepines are a highly discussed subject, they lack evidence in the literature, and there is no established management for prevention of the recall of the events during IOA. Pharmacological aspects of anesthetics should be studied from the viewpoint of amnesia-inducing properties. Synaptic long-term potentiation (LTP) in hippocampal slices, triggered by high frequency stimulation (HFS) , is useful for discovering an effective method to prevent the recall after IOA, because LTP is believed to be a cellular model for learning and memory, and because the advantage in ex vivo studies using brain slices lies in pharmacological application. LTP induction is mediated by activation of NMDA-type glutamate receptors and may be negatively modulated by GABA-A receptors. However, it is difficult to control LTP with NMDA receptor antagonists or with GABA-A receptor modulators once HFS is delivered. Because administration of metabotropic glutamate receptor mGluR antagonists even immediately after HFS inhibits LTP induction, anesthetics inhibiting mGluRs may have potential for the management of IOA

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  The effectiveness of epidural analgesics is well known. Among drugs used for epidural analgesia, morphine, a μ agonist, is most popular. However, μ agonists have a variety of side effects. κ agonists have fewer side effects than μ agonists, and many κ receptors are expressed in the spinal cord. Therefore, epidural κ agonists are appropriate for epidural administration. For analgesia of the face and head innervated by the trigeminal nerve, the effectiveness of cervical epidural κ opioids is evident because the spinal trigeminal nucleus extends into the spinal cord to C1 and C2. On the other hand, epidural NMDA antagonists do not block AMPA receptors that transmit primary afferent nociception. Therefore, epidural NMDA antagonists are inappropriate for epidural analgesia. NMDA antagonists suppress pain-facilitating mechanisms, such as central sensitization, windup, and long-term potentiation, have synergism with opioids, and inhibit opioid tolerance and addiction. Thus, epidural NMDA antagonists may be useful in treatment of chronic spinal pain, and as a supplement for opioids. However, the effect is different from analgesia, and systemic administration of NMDA antagonists may be more beneficial because NMDA antagonists appear to act more effectively for supraspinal mechanisms. About ketamine, the specificity is low, thus ketamine may have various effects, including analgesia (with a lower dose) and anesthesia (with a higher dose) .

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  Spinal analgesia induced by intrathecal and epidural administration of analgesics possesses the advantage of producing maximum analgesic effects and reducing the frequencies of the side effects by systemic absorption of the analgesics. Spinal analgesia has thus been used in various types of pain states including the postoperative pain state. Because it is essential to use a suitable animal model and research design for applying new strategies of relieving postoperative pain in a clinical setting, I will discuss the mechanisms of postoperative pain from findings based on a rat model of incision-induced pain.

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  Regional anesthesia, such as spinal and epidural anesthesia, is used in as many as 30-40% of all anesthesia cases in order to prevent noxious stimuli from the surgical field and to decrease the incidence of complications during the perioperative period. However, a few complications such as spinal cord or nerve damage, spinal epidural hematoma or abscess, and cardiac arrest or anterior spinal artery syndrome have been reported in relation to epidural puncture, catheterization, and drug injections. The author suggests that epidural puncture should therefore be performed in conscious patients in order to prevent spinal cord or nerve damage. In addition, continuous epidural analgesia should be discontinued in order to prevent epidural hematoma during anti-coagulant therapy after surgery, and a standard disinfection technique for the anesthetist's hands and the patient's skin on the back, using an alcohol-containing solution, should be used to prevent epidural infection. A low incidence of complications is important to maintain a high level of epidural anesthesia.

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  The pain of labor may have significant adverse effects on the mother and fetus. Anxiety and pain during labor may cause hyperventilation, increasing oxygen consumption, and circulating catecholamines. Hyperventilation, in turn, may lead to hypocarbia, uteroplacental vasoconstriction and a leftward shift in the maternal oxyhemoglobin dissociation curve. Coupled with the increased oxygen consumption of the mother, these effects result in decreased delivery of oxygen to the fetus. Those adverse effects on the mother and fetus might be eliminated by proper epidural analgesia. Recent advances, such as the addition of opioids to more dilute local anesthetics, PCEA, CSEA continue to improve patient satisfaction and minimize adverse outcomes.

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  Epidural anesthesia and analgesia are highly specialized techniques performed by anesthesiologists, which can improve patients' postoperative course and prognosis. For maximum benefit, these techniques require careful selection of many parameters specific for each patient, such as the position of the catheter tip, duration of drug administration, and doses of local anesthetics and opioids administered under general anesthesia or while the patient is conscious. Postoperative pain management systems using these techniques should be established at each hospital based on the local conditions at each facility. When good postoperative pain control and safety of patients are achieved, patients report satisfactory results and postoperative management becomes easier for surgeons. Anesthesiologists derive satisfaction from these techniques due to the high level of appreciation from patients and surgeons.

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  The percentage of female doctors among all anesthesiologists is gradually increasing in Japan. The subject of this panel discussion was “What we as female anesthesiologists can do” . Female doctors have intimate contact with society through child-rearing, caring for the elderly, etc. Such experience in practical 1ife supports female doctors in successfully handling informed consent, pediatric anesthesia and terminal care. If we resolve the problem of the work styles of female doctors, the department of anesthesiology would be really suitable for female doctors and a worthwhile profession for male doctors in the near future.

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  The informed consent process depends on the clinician understanding the feelings of patients and their families as well as their medical problems. The ability of anesthesiologists to obtain informed consent thus depends partly on their range of experiences both within and outside the hospital. At present, at least in Japan, female doctors are more likely than male doctors to care for their children or their older parents. These familial experiences provide the female doctor with the opportunity to understand the social and emotional aspects of their patients and their families, an understanding that is particularly useful in the informed consent process. Male doctors also can obtain this understanding by becoming more involved in the daily problems and activities of their own families. Sex discrimination should be resolved by giving women the same rights to work as men and also by allowing men more time to spend with their families.

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  As an anesthesiologist I have experience in performing anesthesia for cesarean section and as a mother I have experienced three cesarean deliveries. From both experiences, I would like to provide some valuable insight to our work and share information from my experiences. My work philosophy changed after my children were born. Previously, the only priority for me had been patient safety. It goes without saying that safety is important, but now, I think that we must manage patients comfortably.
  As an anesthesiologist, I think it is important to achieve patient satisfaction by providing 1) suppression of perioperative anxiety even with premedication, 2) appropriate anesthesia with adequate use of regents, and 3) appropriate postoperative analgesia. The most important and most difficult of all is to provide the appropriate support that meets each patient's needs. All female anesthesiologists have the potential to undergo delivery, cesarean section, and gynecologic operations. We are likely to have first-hand experience with the pain involved in such cases. This makes female anesthesiologists more experienced and possibly more qualified to manage such patients. We should make use of such experiences and we must make an effort to increase the quality of anesthesia for patients.

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  Among working doctors, the probability of female doctors having surgery is high. From the view-point of making use of gender differences in my work, I was fortunate enough to undergo gynecological abdominal surgery twice.
  From this experience, I want to work towards providing better anesthesia and I :
1. Reacknowledged the value of epidural anesthetic, enough fluid therapy and the importance of maintaining gastrointestinal peristalsis in the perioperative management of laparotomy.
2. Experienced the type of anesthesia and medical care I, myself, wanted to have, so from now on I would like to take gender-specific medicine into consideration, while carrying out anesthesia and postoperative medical care.
3. Hope that the number of cases of anesthesia management by anesthesiology specialists to whom I feel I could entrust myself and my family will increase.

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  Female anesthesiologists are suited to pediatric anesthesia from both mental and physical points of view. Female doctors have the potential to bear children and tend to be more considerate and sensitive. Furthermore, through their experiences of childcare in their private lives, they are used to handling neonates and young children, which gives them a deeper understanding of their needs.
  From a physical point of view, since they tend to have smaller hands than their male counterparts, it is easier for female doctors to gently handle the bodies of these young patients.
  We conducted a questionnaire on whether a need for female anesthesiologists exists and whether female anesthesiologists enjoy pediatric anesthesia or not. We want to discover the ideal model of pediatric anesthesia that female anesthesiologists are aiming for. We are striving on a daily basis to provide tender pediatric anesthesiology care and to do all that we can as female anesthesiologists.

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  I have proved through my experience that female anesthesiologists are appropriate for palliative care. Anesthesiologists are expected to play a greater role as the doctor of the palliative care team than as the doctor of palliative care units in the management of cancer pain. Female anesthesiologists in particular are more suitable in the activities of cooperating with other team members, listening to patients and their families, empathizing with them, and paying attention to their daily lives than male anesthesiologists. Palliative care must be an important part of the activities of anesthesiologists, and anesthesiologists should be the principal member of the palliative care team. Palliative care will be able to expand the activities of anesthesiologists.

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  In guidelines for CPR at ECC (Emergency Cardiovascular Care) 2000, early defibrillation was emphasized, and there were a lot of good data on AED. Whenever people recovered from VF by AED, the total resuscitation rate did not change or become worse. Therefore, there are several changes to the 2005 guidelines. The first major change is that the chest compression ventilation ratio is changed from 15 : 2 to 30 : 2. This change decreases the hands-off time. The second major change is that the respiration time is changed from 2 seconds to 1 second. This change also decreases the hands-off time. The third and final major change is that the series of 3 shocks for VF has been changed to a single shock. This change also decreases the hands-off time and is dependent on the papers that most cases of VF were converted to a normal sinus rhythm or asystole by the first shock during a series of 3 shocks.

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  In recent years, the number of cancer patients and their families desiring palliative home-based care has been increasing. The reasons for the delay in proceeding to home-based care for cancer patients are: 1) Various changes in symptoms and poor pain control, 2) Social factors such as the patient's family being in mid-career and the presence of young children at home, and 3) a lack of communication among medical team members. It is critical for anesthesiologists to communicate with medical team members including nurses, social workers, surgeons, and chemotherapists. The anesthesiologists will be able to contribute to the relief of the patient's pain and anxiety through their techniques and knowledge. I am working towards the growth of palliative home-based care by supporting the patient's fight against cancer and raising awareness of palliative care in the hospital. I would also like anesthesiologists to attain various individual goals as a specialist for pain control.

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  In the past decade, propofol has become the most popular intravenous agent for the induction and maintenance of anesthesia, and also for use as a long-term sedative in the Intensive Care Unit. Various pain reduction methods have been performed via propofol injection, but many patients still have pain. Propofol formulated with long-/medium-chain triglycerides, which was recently introduced in Japan, could clinically achieve painless injection. Propofol infusion syndrome (PRIS) is a rare but highly life-threatening complication of propofol use, characterized by metabolic acidosis, dyslipidemia, rhabdomyolysis, renal failure and cardiac failure. Early warning signs, such as lactic acidosis or Brugada-like changes in electrocardiography, may help to identify, and should lead the immediate cessation of, propofol infusion. The etiology and mechanisms in PRIS are still unclear, but there were PRIS reports considering impairments of oxidation of fatty acid chains and oxidative phosphorylation in the mitochondria. Newly identified gene defects mimicking PRIS may elicit the underlying genetic susceptibility, and low carbohydrate may be a high risk factor, which should be avoided. Due to possibly fatal complication, knowledge of PRIS is essential for all anesthesiologists and intensive care physicians. Recommendations for the limitation of propofol use have been devised by various institutions, and if unexplained metabolic acidosis occurs during the propofol infusion, PRIS should be taken into consideration.

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  Both the Pentax-AWS^® system (AWS) and Airtraq^® (ATQ) are new rigid indirect laryngoscopes with integrated tube guidance. Not only do they significantly improve the laryngeal view, but they also offer easy intubation.
  They are expected to be a laryngoscope of choice in the next generation.
  The two devices look similar since their blade configuration appears identical. However, there are many differences between the two. Clinical features of these two devices are discussed in this report.

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  We investigated the analgesic effect and side effects of continuous epidural infusion of fentanyl after thoracic surgery. Sixty patients were included in this study. Patients were randomly allocated to four groups. Patients less than 155cm in height were divided into group L1 (2.5μg/ml fentanyl) and group L2 (3.75μg/ml fentanyl) , and patients more than 155cm in height were divided into group H1 (1.66μg/ml fentanyl) and group H2 (2.5μg/ml fentanyl) . Epidural infusion was 4ml/h in patients less than 155cm in height and 6ml/h in patients more than 155cm in height. Pain scores (visual analogue scale: VAS) were assessed at 1, 3, 6, 12, 24 and 48 hrs after surgery. Degrees of satisfaction regarding pain relief and complications during a period of 48 hrs after surgery were compared. Pain scores in the group H1 were significantly higher than those in the other groups at 3, 6 and 12 hrs after surgery. There was more postoperative nausea and vomiting in the group L2 than in the other groups. The average weight in the group L2 was significantly lighter than those in the other groups. In conclusion, weight must be taken into consideration when using continuous epidural infusion of 0.2% ropivacaine with fentanyl.

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  Epidural hematoma is an extremely rare but serious complication of epidural anesthesia. The time between the onset of paraplegia to surgery is critically important for determining the neurologic outcomes of the patients. This is a case report of epidural hematoma that developed after the removal of an epidural catheter in a patient who underwent a partial liver resection. Because a subdermal hematoma was noted at the insertion point of the epidural catheter upon admission to the intensive care unit (ICU) after the surgery, the epidural catheter was removed to stop continuous subdermal bleeding. The platelet count at that time had decreased to 64,000/μl and prothrombin time was prolonged to 53% in activity. Ten hours later, the patient complained of paraplegia in both lower extremities which the ICU doctor on duty attributed to persistent epidural anesthesia. Given that neurologic abnormalities persisted for four hours, an emergency MRI was performed that revealed a posteriorly-placed epidural hematoma extending from T6-T11. Despite emergency laminectomy, the neurologic outcome was poor. This case report highlights the importance of recognizing the potential risks of epidural hematoma following epidural catheter placement and the need for prior communication with anesthesiologists in case clinical coagulopathy occurs.

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  We encountered a case of a 57-year-old woman with acromegalic heart disease who was scheduled to undergo transsphenoidal resection (TSR) of a hypophyseal tumor. Although her preoperative echocardiography showed contraction and dilation disturbance of the heart, her physical activity was assessed as NYHA Class I. Perioperatively, pulmonary artery catheterization was recommended for anesthetic management. However, after considering its indication, we did not use the catheter. Instead, we used impedance cardiography for noninvasive cardiac output measurements as well as central venous pressure monitoring, which resulted in an uneventful perioperative course. We concluded that pulmonary artery catheterization was not indicated for TSR of a hypophyseal tumor in patients with acromegalic heart disease whose physical activity was assessed as being NYHA Class I.

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  In the latest Japanese practical guidelines for the blood component therapy, edited by the Ministry of Health, Labour and Welfare of Japan in 2005, the idea that the compatible red cell transfusion with a different ABO blood group is important for patients with critical massive blood loss was especially underscored. Soon after the revision, we experienced two cases of emergency massive blood transfusion in patients with type-AB blood in whom type-A red cell units were considered to be transfused. Periodical case conference for the urgent blood component therapy is recommended to be held for the education of medical staff. It is also suggested that a brochure of the practical manual that can be easily and quickly utilized for every practitioner should be prepared for better emergency care.

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