In recent years, although it has been possible to maintain a stable anesthetic depth by using pharmacokinetic and pharmacodynamic analysis, it has not been feasible in the case of neuromuscular blocking agents.
  It is difficult to control the effect of vecuronium because its metabolite, 3-desacetyl vecuronium, has a neuromuscular blocking action. On the other hand, rocuronium does not produce such a metabolite.
  Hence, when administering rocuronium, a single-drug pharmacokinetic model may be effective in maintaining an appropriate level of neuromuscular block.
  The appropriate neuromuscular level of a drug can be easily maintained if we consider the combination of pharmacodynamics and pharmacokinetics of neuromuscular blocking agents.

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  Train of four stimuli (TOF) is the standard of monitoring for neuromuscular blockade. Many drugs are known to alter the neuromuscular junction and the nicotinic acetylcholine receptor. Rocuronium, which has been in clinical use since 2007, shows more rapid onset than other non-depolarizing muscle relaxants. Reversal of muscle relaxant means that inhibition of acetylcholinesterase, by the administration of an anti-acetylcholinesterase, allows acetylcholine released into the synapse to remain available to bind to the acetylcholine receptor. In the near future, a new type of reversal agent, a γ-cyclodextrin (Sugammadex) , will effectively decrease the plasma concentration of available non-depolarizing neuromuscular blocking agents with a steroidal structure. This compound is water-soluble and has a hydrophobic cavity that can encapsulate steroidal neuromuscular blocking drugs, especially rocuronium. There are a lot of factors to alter neuromuscular junction, for example, which are interaction of neuromuscular blocking agents, volatile anesthetics, antibiotics, local anesthetics, diuretics, anti-convulsants, lithium, electrolytes and body temperature. The new non-depolarizing neuromuscular blocking agent, gantacurium, has a rapid onset of effect and an ultra-short duration of action.

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  When neuromuscular block is monitored, the influence of neuromuscular or muscular disorder on neuromuscular monitor information should be considered. In myasthenia gravis and Lambert-Eaton syndrome, neuromuscular diseases, the actions of non-depolarizing neuromuscular blockers are reinforced due to dysfunction of neuromuscular transmission. Actions of the neuromuscular blockers are often enhanced in Duchenne-type muscular dystrophy and myotonic dystrophy, myopathys, and sepsis, all of which impair not only the function of muscle fibers, but also that of neuromuscular junctions. Weak or prolonged twitch tension and dysfunctions of excitation-contraction coupling also make neuromuscular monitor information inaccurate.

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  Pain is a subjective sensation that is difficult to measure and/or assess. Methods of pain intensity measurement that have been presented in the past, including the visual analogue scale (VAS) , are all subjective. A device for quantitative analysis of perception and pain sensation has now been devised which quantitatively assesses a patient's pain by replacing it with another sensation that does not accompany pain. This device will enable a more objective measurement of pain intensity as well as a comparison and evaluation of pain intensities among different patients or that of a patient over a long period of time. Presented is a part of our clinical data in comparison with VAS.

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  Since many institutions are now equipped with ultrasonic diagnostic equipment, the use of ultrasound (US) is recommended for central venous catheterization in order to reduce complications. The use of US has many benefits for the patient and enhances the safety of the procedure. The knacks and pitfalls of central venous catheterization using US are described in this article with the hope that the information presented will lead to more widespread use of US for central venous catheterization and will be useful for acquiring skills in US-guided central venous catheterization.

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  Awake craniotomy for epilepsy surgery is not a new. Nowadays, it has become increasingly popular for the optimal excision of brain tumors located in eloquent areas, such as speech, motor and sensory areas. In order to minimize postoperative neurological deficits, awake craniotomy with intraoperative monitoring cortical mapping can be employed. Awake craniotomy is useful to avoid neurological deficits and maintain the quality of the patient's life after neurosurgical procedures. However, anesthetic management for awake craniotomy requires particular attention to airway management, taking measures to deal with complications, and caring about the anxiety of patients. Before surgery, the patient must be carefully evaluated, and appropriately prepared. In the operating room it is essential for the anesthetist to handle monitoring, communicate with the patient, surgeons, and nurses, and judge the situation accurately.

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  Intubation with the Pentax-AWS Airway scope (AWS) during application of manual in-line neck stabilization (MILNS) was evaluated in 60 ASA I-III patients scheduled for elective surgery. Application of MILNS worsened the laryngeal view with the conventional Macintosh laryngoscope, whereas the AWS improved the view. The entire laryngeal view with the AWS was converted into Cormack grade 1, and intubation was successful on the first attempt. Average time to place the tube was 27 sec, and most of the time (19 sec) was spent inserting the blade. Intubation difficulty scale was 0 in all cases, which indicates that intubation was very easy. Although the MILNS maneuver restricts mouth opening and neck extension, the AWS can provide easy intubation condition. We conclude that the AWS can be a useful device for patient with suspected cervical injury such as blunt facial trauma.

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  A patient with angina pectoris suffered an acute renal failure that was induced by a contrast medium used for coronary angiography. The patient had orthopnea, but he could not be placed in the supine or head-down tilt position because of congestive heart failure. Using ultrasound guidance, we safely performed internal jugular venipuncture and achieved venous access for continuous hemodiafiltration in the 45° head-up tilt position, which was employed considering the risk of air embolism.
  Ultrasound guidance may be useful for internal jugular venipuncture in patients who cannot be placed in a head-down tilt position. For patient safety, ultrasound-guided central venipuncture should be considered when the puncture is challenging.

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  Foreign-body inhalation is an extremely serious hazard for children: it is sometimes fatal. A treatment method and ventilatory technique must be chosen according to the foreign body's characteristics. We report a case of sasage-bean aspiration in a one-year-old patient.
  We chose to use a flexible bronchoscope because sasage-beans have a hard shell and do not fragment easily. After administration of thiopental, a muscle relaxant was administered and controlled ventilation was instituted. We removed the bean by aspiration through a flexible bronchoscope. The patient was discharged from the hospital without aspiration pneumonia.
  According to the literature, spontaneous ventilation is preferred because positive-pressure ventilation might dislodge the foreign body and move it distally into the bronchial tree. However, the spontaneous ventilation technique requires deep anesthesia that is sufficient to prevent patient movement and coughing during the procedure. For that reason, we adopted controlled ventilation instead of spontaneous ventilation.

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  We report three families with malignant hyperthermia (MH) . [Family A] A 35-year-old man was scheduled for osteosynthesis of humerus fracture. He had a past history of MH and had been treated with dantrolene in a prior surgery at a university hospital. The operation was maintained with total intravenous anesthesia (TIVA) , and he showed no MH symptoms perioperatively. In the patient and his father, the calcium induced calcium release (CICR) rate with skinned muscle fibers showed a significant acceleration and the same mutation in the ryanodine receptor gene (RYR1) was also detected after surgery. The family-specific mutation of RYR1 was also detected in the younger brother and his son. Though patient's niece (5-years-old) did not receive MH test, she was maintained with TIVA for inguinal hernia repair surgery without showing MH symptoms perioperatively. [Family B] A 66-year-old man was scheduled for lumbar laminectomy. He had a past history of MH in a prior surgery. Anesthesia was safely maintained with combination of spinal and epidural anesthesia. In both the patient and his son, CICR rate was accelerated. [Family C] A 75 year-old man was scheduled for sigmoidectomy. As for his family history, his second son died due to MH. Although CICR rate did not show a significant acceleration in the patient, anesthesia was maintained with TIVA. In his wife, first son and daughter, CICR rate showed significant acceleration. In conclusion, families with a diathesis of MH need a definitive diagnosis due to the measurement of CICR rate and/or the detection of a RYR1 mutation, and anesthesia should be maintained with TIVA or local anesthetics in these patients.

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  We compared intravenous patient-controlled fentanyl (IVPCA: P group) with continuous epidural ropivacaine (E group) for postoperative pain control in gynecologic patients. There were no difference between the two groups in pain control and the incidence of side effects, but the consumption of supplementary analgesics during the first 24 hours was significantly lower in the P group than in the E group (P < 0.05) . We conclude that IVPCA by fentanyl may be superior to continuous epidural ropivacaine in the management of postoperative pain.

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  GABA is the principal inhibitory neurotransmitter in the central nerve system. It mediates fast synaptic inhibition by interaction with the GABA_A receptor. GABA_A receptors are ligand-gated ion channels that are modulated by a large number of anesthetics. Over the past decade, in addition to conventional forms of transient synaptic responses that underlie phasic conductances, a tonic conductance has been identified in several brain regions. Tonic inhibition of this type refers to the continuous activation of high affinity, slowly desensitizing GABA_A receptors by low concentrations of ambient GABA. For many years, enhancement of fast synaptic inhibition was widely thought to be the primary mechanism underlying the actions of many anesthetics. Recently, attention has turned to tonic inhibition, as this conductance has more sensitivity to anesthetic actions than phasic inhibition. Here we summarize several recent discoveries related to the effects of anesthetics on GABA_A receptors.

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  According to the idea of the gate control theory, spinal cord stimulation (SCS) would be efficient in suppressing both acute and chronic pain of a nociceptive nature. This is, however, a paradox because SCS is preferentially effective for neuropathic and ischemic forms of pain. Experiments on animal models of neuropathy have demonstrated that SCS inhibits hyperexcitability of wide dynamic range (WDR) cells in the dorsal horn. SCS also induces release of GABA in the dorsal horn, with a subsequent decrease of the interstitial glutamate concentration. Neuropathic pain, especially that following peripheral nerve injury, is regarded by many to be the prime indication for SCS, with the best chances of obtaining satisfactory and long-lasting pain relief. The most common indication for SCS is chronic intractable neuropathic pain due to failed back surgery syndrome (FBSS) . Neuropathic pain due to complex regional pain syndrome (CRPS) is another common indication. It should be emphasized that the primary indication for SCS in conditions of PVD is ischemic pain. For each condition, SCS is considered as a pain management therapy only after conventional pain therapies, including pharmacological and non-pharmacological treatments, if applicable, have been attempted and have failed. The main advantages of SCS are its minimal invasiveness and reversibility, as well as some convincing studies justifying its use.

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  The application of ultrasonography to regional anesthesia has been recently developed. Although ultrasound visualization of the spinal column and the surrounding structure is limited, ultrasonography provides important information when performing pediatric epidural anesthesia. Adequate knowledge of a high-resolution ultrasound system and understanding of sonographic anatomy is essential to performing ultrasound-guided nerve blocks. Prepuncture ultrasound confirmation of the puncture point, guidance into the epidural space and depth into the epidural space are useful benefits. Furthermore, real-time ultrasound confirmation of epidural drug spread and insertion of a catheter can be performed. Ultrasound guidance offers safer implementation of epidural anesthesia.

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