Intraoperative transesophageal echocardiography (IOTEE) has been established not only as an essential diagnostic tool in cardiac surgery but also as a useful monitor for cardiac anesthetic management, especially for the evaluation of real-time cardiac function and volume status. A number of studies have supported the efficacy of IOTEE regarding cardiac surgical outcomes, while there are scarce randomized controlled trials as to the usefulness of IOTEE in cardiac anesthesia. Due to frequent misinterpretations and discrepancies of data derived from pulmonary artery catheters by medical staff, anesthesiologists commonly use the IOTEE for hemodynamic management in cardiac anesthesia. IOTEE can also be used for selecting appropriate inotropes and to determine anesthetic strategies at the separation from cardiopulmonary bypass, which include the assessment of diastolic function and the direct inspection of the cardiac performance by communication with cardiac surgeons. Although the IOTEE is easy to use and is a relatively safe device, its proper use is crucial in order to avoid IOTEE-related complications. Integrating information obtained by using IOTEE into the anesthetic practices and sharing it with cardiac surgeons and critical care physicians would improve the care that can be provided to cardiac surgical patients. The skills of cardiac anesthesiologists can be improved by providing them with appropriate training and conducting a suitable certification program.

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  We have started projects to promote medical care, education and research of palliative medicine in Sapporo Medical University School of Medicine. A palliative care section has been established in Sapporo Medical University Hospital Tumor Medical Examination and Treatment Center for managing the physical and mental symptoms of cancer patients. Also, our university is promoting postgraduate education and professional education of palliative care supported by grants from the Ministry of Education, Culture, Sports, Science and Technology of Japan. Moreover, a department of palliative medicine has been established at our university in order to promote the research and education of palliative medicine. Anesthesiologists play an important role in these projects, and efforts are being made to promote and improve palliative medicine by functionally fusing these three projects.

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  Anesthetists can play important roles in palliative care. We, pain clinicians in our anesthesiology department, have made comprehensive contributions to palliative medicine for the last decade, moreover, since the palliative care team (PCT) in our hospital was established in 2007, the pain clinicians have participated in and led this multidisciplinary team. Pain clinicians in our PCT not only take charge in the management of physical symptoms of the patients but also coordinate all the medical professionals treating or caring for the patients and their families. We directly examine and assess the total pain of each patient every day, prescribe drugs necessary for symptom management, and set up infusion pumps. At least one pain clinician is on call every night including weekends and holidays. This type of direct intervention to every referred patient in each ward throughout the hospital has been the consistent policy of our department since the pain clinicians began participating in palliative medicine. Quick responses to the changes in a patient's condition, rapid consultation about any clinical issues involving the patients and caregivers, and high reliability of the activities performed by the team are major advantages in this direct intervention system of our PCT.

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  Anesthesiologists play a very important role in palliative care medicine fields. They are also the members of the palliative care team in our hospital where we are responsible as a kind of consultant but are not involved in actual medical treatment as are attending physicians. We mainly contribute to pain control and maintenance of the general condition of patients.
  However, not that many anesthesiologists or pain clinicians are involved in palliative care of relevant patients, indicating that appropriate countermeasures are required to meet the demand stemming from the current shortage of manpowers. In our institute, electronic health records and closer cooperation with house staff and nurses positively participate in solving the above-stated issues.
  On the other hand, educating students and younger anesthesiologists about palliative care medicine has been proven to be very effective in their understanding of our responsibility through palliative care fields, besides the recognition of the specialization of our procedures and techniques in these patients. If a certain medical institution is suffering from inadequate manpower, it is conceivable that our Consultant-type involvement would play a role as one such valuable measure.

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  Anesthesiologists play various roles in medical centers. These include providing patients with an understanding of palliative medicine through explaining the advantages of such medicine in terms of “a human being supporting another human being” . Other roles of anesthesiologists depend on their technical skills as specialists.
  Such roles include protecting patients from the excruciating pain caused by surgery, while also controlling various types of pain suffered by patients using the many available analgesic methods. Therefore, anesthesiologists play very important roles in the field of palliative medicine, and are an indispensable member of the palliative care team. It is also important for anesthesiologists to attend to patients in the final stages of their lives with compassion and professionalism. Thus, anesthesiologists can use their clinical experiences to make valuable contributions in the palliative care unit.

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  Palliative care is total care for people who can no longer be cured.
  The physical pain control that anesthesiologists specialize in is included in palliative care.
  It is important that immediate sharp pain be assessed in palliative care.
  We must choose the direction for use of pain-killer, the painkilling method except the medicine on palliative care.
  In addition, medical cooperation is very important such as outpatient referral system, introduction system, stand-by system, and so on in medical practice for palliative care at home hospice.
  We consider that anesthesiologists can make full use of the technological know-how themselves as a product of palliative care at home hospice.

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  As anticoagulant drugs such as fondaparinux and enoxaparin have become available in Japan, hemorrhagic complication of epidural anesthesia is the focus of attention. Postoperative pain management should include not only epidural block but also various other techniques. Peripheral nerve block has advantages over epidural block for extremity surgery and thoracotomy, because it does not block the contralateral side during surgery and the risk of spinal injury can be avoided. Previous studies demonstrated that peripheral nerve block provides comparable pain relief with epidural block in lower extremity surgery and thoracotomy patients. On the other hand, there are limited data available to compare the efficacy and side effects of the two techniques for abdominal surgery.

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  Inappropriate positioning or inappropriate size of the ProSeal laryngeal mask airway (PLMA) or lateral cuff turning into the airway (lateral cuff-turning) is sometimes shown by endoscopy.
  I investigated the incidences of inappropriate positioning, inappropriate size and lateral cuff-turning in 444 cases in which PLMAs were used, and the following results were obtained:
 1) Inappropriate positioning occurred in 75 cases (17%) , the number of cases with a “deep” or “rather deep” position (50 cases) being twice the number of cases with a “shallow” or “rather shallow” position (25 cases) .
 2) The size was inappropriate in 94 cases (21%) , the number of cases with “small” or “rather small” size (82 cases) being seven times larger than the number of cases with “large” or “rather large” size (12 cases) .
 3) Lateral cuff-turning occurred in 59 cases (13%) , the number of cases with “either” side (39 cases) being twice the number of cases with “both” sides (20 cases) . There also seemed to be a risk of ventilatory failure due to lateral cuff-turning in 21 cases (5%) .
  In conclusion, these abnormalities occurred more frequently than expected, and endoscopy should therefore be routinely performed in cases in which a PLMA is used.

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  We experienced a case of oral mucosa injury caused by the Airtraq^® during tracheal intubation. An anesthesiologist experienced in the use of the Airtraq^® performed tracheal intubation without difficulty. Significant blood-clotting and a laceration in the right palatopharyngeal arch (3×1 cm, width and depth) were found before extubation. The location of the laceration suggested that the oral mucosa was damaged by the tip of the Airtraq^® blade during insertion into the pharyngeal space. We determined that the sharp tip of the Airtraq^® was liable to cause the mucosal injury. Thus, conversion to a blunt tip made of softer material would be safer. Since the manufacturer (PRODOL, Spain) replied to our inquiry that they do not plan to remodel the blade of the Airtraq^® in the immediate future, we have started to routinely attach a silicon cover of surgical osteotome onto the tip of the Airtraq^® to prevent similar injuries. We also emphasize that the standard mid-line insertion technique is critical. Tilting the Airtraq^® while advancing the blade into the oral cavity may cause tissue damage.

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  We report a case of laryngeal web encountered during anesthetic induction. A 60-year-old male with chronic sinusitis was scheduled for endoscopic sinus surgery under general anesthesia. We attempted to insert a 10.8 mm OD endotracheal tube using laryngoscope, but it could not be inserted without some resistance. A laryngeal mask was inserted, and we observed a membranous lesion at the larynx by bronchoscope introduced through the laryngeal mask. The surgeon (otolaryngologist) diagnosed it as being laryngeal web. We decided to continue a general anesthesia using a 8.7 mm OD endotracheal tube, and the operation was undertaken by mutual consent. After surgery the patient did not complain of symptoms associated with airway stenosis. Since the patient had a surgical history, he was suspected as having an acquired laryngeal web.

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  A 20-year-old male underwent bimaxillary orthognathic surgery. After extubation, his upper airway was obstructed, so a nasal airway was immediately established and assisted ventilation was performed. The oxygenation was not sufficient even after his airway was established and a chest X-ray showed bilateral diffuse infiltration. We diagnosed it as negative pressure pulmonary edema (NPPE) due to upper airway obstruction. We re-intubated and ventilated with positive end-expiratory pressure (PEEP) , and on the next day, oxygenation and chest X-ray improved. His pharyngeal airway size was decreased compared with the pre-operative size on a lateral cephalogram taken one week later.
  Previous studies have shown a correlation between the amount of mandibular setback and the decrease in pharyngeal airway size. Upper airway obstruction may occur after mandibular setback surgery due to narrowing of the pharyngeal airway and mucosal edema following surgical procedures. Therefore, it is necessary to evaluate the pharyngeal airway size on a lateral cephalogram before surgery. In cases with a narrow pre-operative pharyngeal airway, suspected obstructive sleep apnea or significant mandibular setback, we must take care to prevent post-operative airway obstruction.

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  Fifty-one patients undergoing orthopaedic surgery for over 4 hours received combined spinal-epidural anesthesia with continuous propofol infusions. In spinal anesthesia, 2% lidocaine and 0.4% tetracaine added to epinephrine were injected and in epidural anesthesia ropivacaine was injected. Mean epidural additional time was 2 hours 57 minutes. Mean systolic blood pressure was 98 mmHg and changes in blood pressure were minimal. We concluded that combined spinal-epidural anesthesia with propofol infusion provided reliable anesthesia for over 4 hours in orthopaedic surgery.

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  Nasotracheal intubation using a Macintosh laryngoscope requires skill. The Airway Scope (AWS) system provides indirect visualization of the larynx utilizing a color liquid crystal display (LCD) monitor, while the Intlock blade facilitates oral intubation. We made a slit at the base of the guide groove of the blade to guide the tip of a tracheal tube into the groove on the blade during nasotracheal intubation. We clinically assessed the feasibility of the device in patients requiring nasotracheal intubation. All patients were classified as Grade I using the Cormack & Lehane classification on visualization with the LCD monitor. In most cases, the tip of the tracheal tube was able to pass from the pharynx to the groove through the slit, allowing confirmation of proper endotracheal tube placement with the LCD monitor. Although several limitations still exist with this device, the modified Intlock blade with AWS facilitates visible laryngoscopy and enables secure nasotracheal intubation.

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  We report a case of double-lumen tube intubation under spontaneous breathing for intractable pneumothorax with bilateral multiple bulla. An 80-year-old man with bilateral multiple bulla in the lung developed spontaneous pneumothorax and underwent bulla resection under general anesthesia. Epidural catheter was placed at Th5/6. Under propofol sedation, double-lumen tube was intubated under lidocaine regional anesthesia with Pentax-AWS Airway Scope^®. We conducted one lung ventilation under spontaneous breathing during the surgery. The patient was extubated in the operation room, and was discharged from the hospital on the eighth postoperative day without any complications. One lung ventilation preserving spontaneous breathing was considered to be effective in preventing rupture of bulla in the patient with multiple bulla.

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  Higher concentration ropivacaine (7.5 to 10 mg/ml) is mainly used for epidural anesthesia alone or in combination with general anesthesia in major abdominal surgery. Recently, it is increasingly used for ultrasound-guided regional anesthesia. Particularly rectus sheath block and transversus abdominis plane block are available for intra- and postoperative analgesia to inhibit somatic pain.
  On the other hand, lower concentration ropivacaine (1 to 2 mg/ml) does not cause motor nerve blockade but provides good postoperative analgesia when used in combination with low-dose opioids when it is continuously infused to the epidural space. Patient-controlled epidural analgesia is superior to continuous epidural infusion in terms of patient satisfaction and sparing effect of supplemental analgesic.

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  Ropivacaine is a relatively recently introduced amide local anesthetic drug that is structurally similar to bupivacaine. Ropivacaine has less toxicity on the cardiovascular and central nervous systems and less effect on motor function than bupivacaine when used in equivalent analgesic doses. In the gynecological and urological surgeries, ropivacaine is effective in the meaning of the early mobilization and ambulation. However, more devices that don't cause motor block are necessary to obtain sufficient postoperative pain relief.

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  Recently, ropivacaine has become popular in intra- and postoperative epidural anesthesia because there are a lot of benefits in the clinical setting. Ropivacaine has longer anesthetic effects than lidocaine and mepivacaine, and causes less cardiovascular and central nervous toxicity than bupivacaine. In addition, ropivacaine has been proven to cause a strong differential nerve block that is useful in the assessment of postoperative motor functions. Epidural ropivacaine is superior in perioperative analgesia for orthopedic surgery.

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  Thirty-five patients (24 adult and 11 pediatric) who underwent orthopedic surgery of the upper extremities were retrospectively evaluated on its safety, efficacy and patient satisfaction. Nerve block procedures consisted of 13 interscalenes, 10 supraclaviculars, 7 infraclaviculars, 3 axillars and 2 of selective terminal branch cases. Total amount of local anesthetics (0.75% ropivacaine and 1% lidocaine in a 1: 1 mixture) were 30.5+/-7.9 ml for the adult cases and 17.3+/-8.8 ml for the pediatric cases, respectively. Combined with monitored anesthesia care, ultrasound guided nerve block provides satisfactory anesthesia and with few complications. In majority of patients, this method was accepted favorably. This preliminary study warrants further evaluation in various age groups and surgical procedures.

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  Recent advances in ultrasound technology allow direct visualization of nerves and other surrounding structures and have increased the interest in performing many kinds of peripheral nerve block of the lower extremities. Peripheral nerve block of the lower extremities can be a good choice for anesthesia and/or analgesia during lower limb surgery. We provide an outline of peripheral nerve blocks of the lower extremities with ropivacaine performed at our hospital.

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  Ropivacaine has been extensively investigated for use in neuraxial anesthesia/analgesia in cesarean section and labor analgesia. It has an excellent safety profile for both mother and neonate. However, its weak motor blockade has not been shown to result in decreased instrumental delivery rate when used for labor analgesia. Less cardiotoxicity of ropivacaine is most useful when used for epidural anesthesia for cesarean section.

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  Ropivacaine has several properties that produce differential nerve blockade with less motor blocking, along with reduced cardiovascular and neurological adverse effects. Thus it is considered useful for regional anesthesia in adults as well as older and younger children. However, in Japan ropivacaine is limited for clinical use in children, because clinical trials have not been conducted, even though a number of studies have reported its clinical efficacy and safety in children. In addition, the pharmacokinetic parameters have been calculated for several different age groups. Ropivacaine is commonly used in a concentration of 0.2% at a maximal dosage of 3 mg/kg for a single caudal or lumbar epidural block, or 0.4 mg/kg/h for continuous epidural infusion. For peripheral nerve block, 0.2-0.5% ropivacaine up to 3 mg/kg is recommended. Neonates and young infants have anatomical and pharmacodynamic properties that cause extensive infiltration of local anesthetics, and often achieve high plasma concentrations of unbound ropivacaine. In such young children, the total dosage should be reduced. Ropivacaine is usually administered under sedation or general anesthesia, and thus safety guidelines should be followed to prevent toxicity and complications when used for regional anesthesia in children.

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  It is known that ropivacaine produces a differential block for sensory and motor nerves. It has a greater effect on sensory than motor nerves. It also has lower cardio-toxic and central nerve toxic potential than bupivacaine. The safety margin before the onset of toxic side effects is higher than any other local anesthetic. Because of these advantages, using ropivacaine, we can perform a treatment with both lower motor blockade and higher sensory blockade. Ropivacaine is an agent which has been improving treatment of pain in many ways.

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  The factors and mechanisms of major adverse events during postoperative epidural analgesia are described. Countermeasures against the adverse events are also discussed. Consistent patient management throughout the perioperative period could balance postoperative epidural analgesia with ropivacaine against the adverse events.

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