Half a century has passed since the first department of anesthesiology in Japan was established at the University of Tokyo. However, this specialty is considered not to meet adequate social acceptance and evaluation yet. One reason is that anesthesiologists are always concerned with the whole body of patients, while patients and surgeons are focused only on the affected region of the body. The visual fields of anesthesiologists are different, obviously, from those of patients and surgeons. In addition, anesthesia is essential to afford a wider margin for “Homeostasis” , which is an indispensable mechanism for life, and anesthetic effects on the mechanism are invisible and difficult for patients to understand. 
Anesthesiologists should do their best to work towards wider and deeper social understanding of their specialty through continuous daily clinical work and vigorous activities within the academic society. The importance of an historical approach to prevent medical accidents and an amendment of the Anesthesiology Society's name are also discussed.

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  It is the mission of anesthetists as experts of airway management to acquire the knowledge and technique of difficult airway management (DAM) . ASA guidelines for management of difficult airways have a systematic strategy and serve as a standard guideline for DAM. I gave an outline of the airway management at the induction of general anesthesia, especially for adult patients, based on ASA and DAS guidelines. In addition, I commented briefly on various airway management tools, including Airway Scope^® designed recently in Japan, and representative methods for DAM.

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  Introduction of remifentanil has dramatically changed the practice of balanced anesthesia. Recent developments in pharmacodynamic and pharmacokinetic analysis of drug interactions give valuable information regarding how opioids and hypnotics should be titrated. Owing to its unique pharmacokinetics with very short and virtually context-insensitive half-time, high opioid concentration can be maintained towards the end of surgery without undue concern for persistent postoperative ventilatory depression. Stable haemodynamics and rapid recovery of spontaneous ventilation are easily achieved. However, intraoperative awareness can occur in paralyzed patients if the dose of the hypnotic is inadequate or if the infusion of remifentanil is inadvertently interrupted. Anesthetists should be aware of a possible risk of difficult or even impossible ventilation due to truncal rigidity and/or vocal cord closure when an airway is maintained by supraglottic devices. The analgesic effect of remifentanil wears off quickly after infusion is terminated. Smooth transition to postoperative analgesia requires proper use of a long-acting opioid, regional/local anesthesia as well as non-steroidal anti-inflammatory drugs. As an NMDA receptor antagonist, low-dose ketamine may prevent postoperative remifentanil-induced hyperalgesia. Maintenance of a secure intravenous route is essential to provide safe and reliable intravenous anesthesia. Routine use of a checklist is recommended to avoid simple errors, such as miscalculation or incorrect setting of the drug infusion rate.

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[Background] Fast recovery from anesthesia is obtainable by remifentanil, and that property is beneficial in neuroanesthesia because early detection of complications after craniotomies is important. However, postoperative analgesia appears to be another problem. To determine the suitable use of supplemental fentanyl, we investigated recovery properties from anesthesia in craniotomies.
[Materials and methods] Seventy-five patients undergoing scheduled neurosurgical procedures were included. Anesthesia was induced and maintained with propofol, remifentanil and vecuronium. Two (RF2) or 3 (RF3) μg/kg of fentanyl was administrated at closure but no fentanyl was administered in group R.
[Results] There were no differences among the groups in duration of anesthesia, amount of bleeding, dose of propofol, dose of remifentanil and recovery time. The frequency of hypertension at extubation was lower in group RF3 (P < 0.01) . Two and 1 patients complained of wound pain in groups R and RF2, respectively, but none in group RF3.
[Conclusion] Threeμg/kg of fentanyl is a suitable supplement in propofol-remifentanil-based anesthesia for neurosurgery.

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  Remifentanil seems to be potentially effective for labor analgesia or anesthesia for cesarean section. During labor, it can provide good levels of analgesia as compared with other opioids in traditional use. Potential disadvantages include maternal sedation and oxygen desaturation. In cesarean section, remifentanil provides maternal hemodynamic stability without prolonged neonatal depression. However, it should be used when adequate facilities for neonatal support are available. Further studies are needed before remifentanil is used routinely for obstetric anesthesia.

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  Dexmedetomidine is an ideal sedative. It also has an analgesic effect that causes almost no respiratory depression, and patients given this drug wake up immediately in response to verbal commands but remain asleep if there is no stimulation. However, fluctuations in blood pressure and individual differences in response to the effects of the drug are so great that many anesthesiologists regard dexmedetomidine as being a difficult sedative to use. This problem could be resolved, however, by an understanding of the pharmacological characteristics and analysis of the pharmacokinetics of dexmedetomidine. In this paper, the causes of the inconvenience that arises when using dexmedetomidine and methods to deal with this inconvenience are discussed, and a method for taking advantage of the ideal characteristics of the drug is described.

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  Most persons retiring from managerial posts should prepare for handling affairs on their own before retirement. They cannot rely on their secretary for help after retirement.
  It is important for us to continue to be interested in learning even after retiring. We should not retire from every branch of knowledge. I still subscribe to major academic journals. People believe that you are still an expert in medicine. You are expected to have up-to-date knowledge of medicine. Being specialized in medicine for longevity, we are very ignorant about many fields outside of medicine. We need cultural exchange with many persons. The older we grow, the more interested we are in everything.

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  A new concept of electrocardiogram is proposed for the interpretation of normal and pathological propagation of cardiac action potential. Recording of electrocardiogram is essentially the measurement of extracellular voltage, and it originates from the voltage difference between action potentials of subendocardial and subepicardial muscle layers. The activation of Purkinje cells has quite an important role in the formation of normal electrocardiogram. This article describes the relationship between voltage-dependent ion channels and the effects of electrocardiogram.

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  Dental treatment and dental local anesthesia may cause intense anxiety or fear in patients due to the pain associated with the procedure. In addition, these procedures may induce various complications, particularly among elderly individuals and in patients with medical conditions. Psychosedation (conscious sedation) , a method of patient care that alleviates anxiety and fear while maintaining consciousness, has been used for over 30 years to enable safer treatment for these patients in Japan. Psychosedation is largely classified into nitrous oxide inhalation sedation, in which ≤30% nitrous oxide and ≥70% oxygen are concomitantly inhaled through a nasal mask, and intravenous sedation, in which drugs such as anxiolytic agents, anesthetics, and sedatives are intravenously administered. These methods are becoming more commonly used in procedures outside of general dentistry, such as in oral implant surgery and during extraction of impacted teeth.
  This presentation focuses on the usefulness of sedation methods in outpatient dental treatment with a review of their historical background and the characteristics of these methods, in addition to a literature review.

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  Internal jugular venipuncture has been performed by the ultrasound-guidance with a short-axis approach. We reviewed past records on the utility of the approach and on complications. Intern and resident doctors (n=18) had learned the method following the manual, and then trained with a simulator. After that, they tried it in the clinical setting. If the venipuncture was difficult to perform, staff doctors took turns.
  The number of the patients was 203 (age: 64±13years old, height: 158±9cm, weight: 58±11kg) . The success rate on the first try was 91%. The average number of venipunctures was 1.1±0.5. The total success rate of the venipuncture was 99%. Unintended arterial puncture happened in two cases (1%) and the injured artery was repaired surgically.
  Ultrasound-guided internal jugular venipuncture had a high success rate with appropriate training, but the unintended arterial puncture was not able to avoided. Further problems still remain in the training methods to avoid complications.

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  Recent evidence has indicated that women wake up earlier than men under propofol anesthesia, but the women examined in the previous reports were mainly premenopausal. We compared gender differences in elderly (60-79 years of age) patients.
  Sixty patients (female ; n=30 and male ; n=30) undergoing abdominal surgery were analyzed retrospectively. Induction and maintenance of anesthesia was performed by propofol infusion using a target-controlled infusion system titrated based on a bispectral index (BIS) value between 40-60, and administered along with intravenous vecuronium, buprenorphine and 0.375% epidural ropivacaine. Propofol infusion was stopped at the end of surgery.
  There were no significant differences in age (females, 70.9years ; males, 70.6years) , duration of anesthesia (females, 217min ; males, 218min) , propofol consumption (females, 6.1mg/kg/h ; males, 6.0mg/kg/h) , vecuronium (females, 0.07mg/kg/h ; males, 0.08mg/kg/h) , buprenorphine (females, 2.54μg/kg ; males, 2.33μg/kg) or 0.375% ropivacaine (females, 22.3ml ; males, 22.8ml) administered. There were no significant differences in predicted target propofol concentration (females, 2.29μg/ml ; males, 2.28μg/ml) or BIS value (females, 58 ; males, 54) at the end of surgery. Eye-opening time (females, 11.2±4.7min ; males, 12.4±5.8min) and predicted target propofol concentration on awakening (females, 1.36μg/ml ; males, 1.39μg/ml) did not differ significantly by gender.
  The women did not wake up significantly faster than the men in elderly patients. We suspect that sex hormones contribute to the significantly earlier recovery of premenopausal women.

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  We report intrapleural misplacement of an epidural catheter in an obese patient. A 71-year-old woman 147cm tall and weighing 58kg was scheduled for video-assisted thoracoscopic esophagectomy under sevoflurane-fentanyl anesthesia combined with intended epidural anesthesia. A catheter was intended to be inserted through the T6-T7 interspace via a paramedian approach using a loss of resistance technique. The misplaced catheter was found with thoracoscopy. It was caused by unintended puncture of the visceral pleura by a Tuohy needle. The catheter was removed and the postoperative course was uneventful. Ten other patients with intrathoracically misinserted epidural catheter were reported in the literature. Close review of the reports showed that the misplacement was found in 10 patients during thoracic surgery or thoracoscopy. Among the 8 patients whose body mass index was calculated, six showed body mass index of 25kg/m² or over. As X-ray examination demonstrated frequent intrathoracic misplacement of an epidural catheter, the incidence of undiagnosed misplacement of an epidural catheter seems higher than generally thought.

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  We experienced a case in which the endotracheal tube was damaged during maxillo-mandibular osteotomy. The patient was a 16-year-old male with an oblique facial cleft. After induction of general anesthesia, the trachea was intubated nasotracheally for airway management. During the maxillo-osteotomy, the surgeon noticed that he had accidentally damaged the endotracheal tube with the bone chisel. Since severe bleeding and edema were observed in the operative field, we thought that it would be dangerous to exchange the endotracheal tube at that time, but we decided that the surgery could be continued because the level of mechanical ventilation was acceptable. After surgery, a small crack of 7 mm was found in the endotracheal tube using bronchial fiberscopy. After repair of the endotracheal tube by wrapping the crack with tape, the patient was transferred to the intensive care unit.

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  A 38-year-old schizophrenic woman who had been medicated with several antipsychotic drugs underwent an emergent hemostatic operation two days after left mastectomy. The anesthesia was maintained with propofol 2.8 to 3.0mcg/ml (administered by target controlled infusion system) and fentanyl 4.8μg/kg in total. The patient showed “arousal reaction” such as body movement and eye-opening when a total of 7mg etilefrine was intravenously administered for 8 minutes to raise her blood pressure to determine the point of surgical bleeding.
  Etilefrine has both beta and alpha adrenergic effects. The beta action, which increases hepatic blood flow with an increase of cardiac output, potentially decreases propofol concentration. This mechanism is presumed to be most closely related to the “arousal reaction” during total intravenous anesthesia in this case. In addition, since schizophrenic patients tend to show an increase in blood brain barrier permeability, etilefrine potentially stimulates central nervous alpha-1 receptors, which play an important role in awaking action.
  A higher than normal dosage of sympathomimetic drugs is often prescribed for schizophrenic patients medicated with antipsychotic drugs to improve their intraoperative hypotension. Since such patients potentially display the “arousal reaction” during surgery, a monitor which assesses anesthetic depth, such as BIS™ , should be used in the anesthetic management.

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  Recently, tumor resection under awake craniotomy using intravenous anesthesia has become a mainstream surgical method in the field of neurosurgery. Awake craniotomy seeks to preserve the motor or speech areas in a patient whose tumor is located close to these areas. On the other hand, general anesthesia using sevoflurane, which has the potential to induce epileptic seizure, is commonly performed for the resection of epileptic foci. We report two cases of epilepsy patients with brain tumors close to the motor and speech areas who underwent tumor resection under awake craniotomy using propofol and resection of the epileptic focus under general anesthesia using sevoflurane, simultaneously. We used different methods of anesthesia and maintenance of airway for each operative procedure serially and were able to perform smooth and safe anesthesia management using various devices.

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  A 64-year-old female with spinocerebellar degeneration underwent laryngotracheal separation surgery. The patient developed transient upper airway obstruction because both the right and left vocal cords were fixed to the midline. A small percutaneous tracheal tube for suction of sputum was placed in the trachea. Anesthesia was induced with target controlled infusion of propofol and maintained with propofol and fentanyl. The effect of vecuronium was monitored by the train-of-four ratio of the intact muscle. There was no upper airway obstruction during the induction of anesthesia and the vocal cords showed a normal appearance. However, tracheal intubation was performed with a reinforced tracheal tube (6.0mm ID) that was smaller than the one we first attempted to use. Patients with spinocerebellar degeneration need careful perioperative management to prevent upper airway obstruction, and the use of a smaller endotracheal tube is necessary.

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  It is difficult to communicate with patients with serious mental and physical handicaps. General anesthesia is often required for dental treatment in these patients. However, these patients often have physical deformities and gastro-intestinal and respiratory diseases. Moreover, they often have been taking several drugs including antiepileptics, anticonvulsants and/or major or minor tranquilizers. Therefore, we often experience difficulties in airway, respiratory, and circulatory management. We present our management using dexmedetomidine (DEX) , an α2 adrenergic agonist, and propofol and local anesthetics, which provide satisfactory sedation and analgesia without causing respiratory depression.

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  Jehovah's Witnesses love life and do whatever is reasonable in order to prolong it. For this reason, they seek out quality health care and accept the vast majority of medical treatments. However, for Bible-based religious reasons, Jehovah's Witnesses do not accept allogeneic blood transfusion. Instead, they request non-blood alternatives. We will discuss the ethical, medical, and legal aspects concerning this position of Jehovah's Witnesses. The treatment for minors often becomes an issue. When a patient is a mature minor, his wishes should be respected. In the case of a minor patient lacking decision-making capacity, the wishes of the parents should be respected as much as possible.

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  We surveyed the institutions to which councilors of Japanese Society of Pediatric Anesthesiology belong on their response to pediatric Jehovah's Witness patients or pediatric patients whose parent (s) is/are Jehovah's Witness member (s) . Sixty-three percent of the respondents have guidelines to deal with this religious group and many of them have specific rules regarding pediatric patients. However, these rules, including the age until which a patient is considered to be a child and conditions for accepting Jehovah's Witness patients, vary according to the institution. In addition, many institutions replied that they would resort to blood transfusion if the patient's parent (s) refuse (s) to do so, whereas some institutions said they would not give the transfusion in such cases. Many respondents asked for the development of a legal system or response to deal with those cases. It is important to improve the environment so that pediatric Jehovah's Witness patients do not have disadvantages and physicians can practice with a sense of security.

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  In medical care for the Jehovah's Witness patients (JWs) who refuse primary blood component, informed consent is very important. Jichi Medical University Hospital has recently revised the medical care guidelines for JWs who refuse primary blood components. In these guidelines, JWs' religious conviction underlying blood refusal should be respected as far as no life-threatening condition exists. But once life-threatening exsanguinations occur, lifesaving blood transfusions should be given until the patient is relieved from the imminent danger of death. JWs should be informed fairly about these guidelines before receiving medical care, and a private and confidential meeting with treating physicians should be arranged so they have an opportunity to speak for themselves and decide by themselves, free from religious pressure and in the absence of family members who are also JWs.

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  Blood transfusion and other medical treatments require, in principle, approval from patients. Generally, medical treatment without a patient's approval is illegal and ethically inappropriate. Patients need to be competent in order to approve medical treatment. Competence is a necessary (although not a sufficient) condition for patients, approval to be legally and ethically effective.
  The legal and ethical rules about who approves and disallows a blood transfusion are quite simple and clear. If a patient is competent, he/she is the one who judges, or makes the decision to receive a blood transfusion by him-/herself. In this case no one else can make the proxy decision, representing him/her, and doctors cannot conduct medical treatment against the decision of a competent patient.
  If a patient is not competent, someone else needs to make the proxy decision, representing him/her. Doctors need, in principle, to follow the decision made by the proxy decision-maker. The proxy decision-maker is not supposed to make a decision that goes against the patient's interest. When doctors give a blood transfusion to a patient who is not competent, even though the person in his/her parental authority refuses it, it is a legal and appropriate action as long as the blood transfusion is beneficial to the patient or at least as long as the blood transfusion does not work against the patient.
  Accordingly, if a patient who is 15 years old or over but under 18 and is competent refuses a blood transfusion, doctors cannot conduct a blood transfusion against the decision of the patient. If a person in parental authority with respect to a patient who is under 15 and is not competent refuses the patient's blood transfusion, and if the refusal of a blood transfusion works against the patient, the person's proxy decision to refuse the blood transfusion is legally and ethically ineffective and it is legal and ethically appropriate for doctors to conduct the blood transfusion against the proxy decision of the person in parental authority. Here, there is no logical necessity of finding another person to represent the person in parental authority.

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