This article describes a short history of the development of laryngeal mask airway (LMA) and also concretely explains the details of the LMA insertion technique.
  After LMA appeared on the market in 1988, it has been widely accepted as a very useful device for maintaining airway. LMA has now become more frequently used than the tracheal tube in many developed countries for routine elective surgeries. However, because of the lack of basic knowledge or technique, it is regrettable that there are still some practitioners who have difficulties with the practical use of LMA and intentionally avoid using it. This article deals with the concept behind LMA design, its history and the rational insertion technique, recommended by its inventor, and provides practical guidance for inexperienced LMA users. The newest type of LMA (Supreme LMA) is also briefly described.
  —Finally all I want to say is “Good Luck!!” .—

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  Perioperative anticoagulation therapy is becoming popular, and the modalities of postoperative analgesia are increasing. These circumstances lead to an increased number of cases receiving postoperative IVPCA. Although indication of fentanyl IVPCA is increasing, morphine IVPCA is still the gold standard. This article reviews the history of IVPCA, character of morphine, method and side effects of morphine IVPCA, and also presents the use situation of PCA pomp in Okayama University Hospital and discusses the safety measures and refinements of IVPCA.

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  The optimal analgesic drug for intravenous patient-controlled analgesia (IV PCA) is required to have a rapid onset and a gradual offset of the analgesic effect as well as having no/little effects of postoperative nausea/vomiting (PONV) , dizziness, or constipation. Fentanyl has some advantages of a rapid onset due to high fat-solubility, and of few uncomfortable side effects such as itching, compared to morphine, which is commonly used for IV PCA. It is also necessary to design drug delivery protocols to obtain an adequate level of analgesia during the postoperative period by estimating the adequate effect-site concentration of fentanyl (1-2 ng/ml) calculated with pharmacokinetic simulation analysis. We evaluated postoperative pain management through intravenous fentanyl administration with a disposable PCA device (background: 20μg/hr, bolus: 20μg/push, lock-out time: 10 minutes) on patients under total intravenous anesthesia with multimodal postoperative pain management combined with local anesthetics and non-steroidal anti-inflammatory drugs (NSAIDs) , and found that this IV PCA protocol was effective and satisfactory because of the low incidence of PONV (<30%) and little additional requirement of analgesics (<20%) .

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  Pentazocine is one of the most popular analgesics for postoperative pain control in Japan, but little information is available concerning PCA with pentazocine.
  Intravenous PCA with pentazocine was used to treat postoperative pain after various fracture surgeries. Thirty patients received pentazocine via PCA. The procedure of PCA was as follows: continuous infusion set at 1.0-2.5 mg/h, size of bolus set 5-10 mg with a 10 or 15 minute-lockout interval. Droperidol was added for the prevention of nausea and vomiting.
  Nineteen patients recovered without using any other analgesics ; however, 11 patients used rescue analgesics. PCA bolus could have been given for 7 of these 11 patients properly if this method was well understood among the nursing staff.
  A total of 11 side effects were observed in 8 patients. The most common one was nausea. The dose of continuous infusion was significantly higher in the side-effect group than that of the non-side-effect group.
  Our program of PCA was safe and effective. We should set low-dose continuous infusion to reduce side effects. The guidance for patients, nurses and surgeons is important for more effective PCA therapy.

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  The usefulness of postoperative pain control after abdominal surgery was comparatively studied between two groups, one in which patients received continuous subcutaneous infusion of buprenorphine (Bu-Sc) and another in which patients received continuous epidural infusion of morphine (Mo-Ep) . There was no difference in the analgesic effect, the time of obtundent use and the period without flatus between the Bu-Sc and Mo-Ep branches. The period of urethral catheterization in the Bu-Sc group was significantly shorter than that in the Mo-Ep group. PaCO₂ examined upon the patient's return from the operating room in the Mo-Ep group was higher than that in the Bu-Sc group. Side effects observed in the Bu-Sc group immediately improved by withdrawal of the drug. In conclusion, the continuous subcutaneous infusion of buprenorphine is a useful postoperative pain control method, which can be done safely and simply and offers minimal respiratory depression.

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  Coronary perfusion is dynamically and precisely regulated by multiple factors to meet substantial need for energy but has limited reserve, which makes cardiac tissues prone to ischemia. Although the major pathophysiology of ischemic cell death was originally recognized as depletion of ATP, various kinds of unexplainable situation such as no-reflow phenomenon, hibernation and stunned myocardium unmasked the injury at reperfusion and enabled us to establish the idea of ischemia-reperfusion injury. Multiple causes such as calcium overload, oxygen radicals as well as protein turnover disorder affect this injury, which lead to apoptotic, oncotic or autophagic cell death. To protect the myocardium, subcellular mechanisms of ischemic pre/postconditioning have been intensively sought, and they are believed to offer clues to potential therapeutic cardioprotection. Some recent clinical studies based on putative mechanisms provide promising results. This review focuses on pathophysiology of ischemia-reperfusion injury, proceedings of research for cardioprotection, and applications for therapeutic strategies, including emerging attempts for intermittent therapy with PDE- III inhibition and PKA-mediated cardioprotection.

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  The analgesic effect of epidural administration of plain ropivacaine was retrospectively assessed in 90 post-operative patients in the intensive care unit (ICU) . After the surgery, 5 ml/hr of 0.2%-ropivacaine was continuously infused, and the rate of cases requiring adjunctive analgesics and the time from the end of surgery to supplemental administration of analgesics were determined. Although, 86 patients complained of no pain at the admission to the ICU and 52 patients were managed without epidural administration of narcotics, 38 patients required adjunctive analgesics during the next 24 hr. The other 34 patients were administered morphine at the admission to the ICU and only 4 patients required additional analgesics, however, 22 patients showed postoperative nausea and vomiting (PONV) . The time from the end of surgery to supplemental administration of analgesics was correlated with only the total dose of fentanyl infused during surgery (coefficient 0.62 min/μg, standard error 1.77, p<0.03) . The incidence of PONV was less in the group administered ropivacaine, however, post-surgical pain management by the epidural administration of plain ropivacaine was difficult and insufficient because the effectiveness of epidural analgesia could not be distinguished from the effect of intraoperative administration of fentanyl. When the analgesic effect of fentanyl administered during anesthesia was diminished, the adjunctive analgesics would be required.

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  In this case report, we presented a anesthetic management in a 60-year-woman who was scheduled for the resection of the granulations in the airway using fiberoptic bronchoscopy-guided laser treatment. This procedure required not only a lower oxygen supply, but also the apnea period for avoiding intratracheal burn during the surgery. We, therefore, planed to achieve total intravenous anesthesia and to apply VV-ECMO for providing sufficient gas exchange throughout the procedure. Two catheters were inserted from the left and the right femoral veins. The former was advanced to place this tip in the right atrium. And the tip of another catheter was placed on the right common iliac vein. Before the surgical procedure, ECMO was started via veno-venous access uneventfully. Although the systemic oxygenation was decreased during the apnea period even under VV-ECMO, increasing cardiac output by cathecholamine infusion could cause the sufficient systemic oxygenation and then all of the procedure was done successfully. The present case suggested that VV-ECMO was useful for maintaining the systemic oxygenation in the anesthetic management for the intraoperative laser surgery in a patient with severe tracheal stenosis.

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  A case of placenta accrete was referred at 32 weeks' gestation. We performed a cesarean hysterectomy by preceded placement of occlusion balloon catheters at bilateral internal iliac arteries. On the day of the operation, under spinal anesthesia, the ureter stent was placed. Both femoral arteries were punctured for placement of balloon occlusion catheters in the angiography room. Under general anesthesia associated with tracheal intubation, cesarean section was performed. After delivered, the occlusion balloons were inflated and, after careful dissection of the uterus and placenta from the bladder, the hysterectomy was completed in the usual fashion. This technique provides satisfactory efficacy for control of profuse bleeding during operation.

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  A 47-year-old male patient (161cm, 40kg) was scheduled for video-assisted thoracotomy. After anesthesia induction, we attempted to intubate a #35 left double lumen bronchial tube. The tube tip was inserted through the glottis, but it was not able to progress, because there appeared strong resistance. A #32 double lumen tube and a 6.5 mm ID single lumen tube were resulted in the same difficulty. The ProSeal type of laryngeal mask #4 was placed and successfully instituted positive pressure ventilation. The surgery was performed while ventilation was interrupted when necessary without any complications. Postoperative examinations revealed a history of tracheostomy for a suicidal attempt several years ago. The surgical scar in the anterior neck at the level of 4-5 tracheal cartilage was confirmed, and the 11 mm of tracheal diverticulum at the level of the previous tracheostomy.

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  We present a 40-year-old woman with Jacobson's neuralgia (otic type glossopharyngeal neuralgia) . The pain had been controlled for a while using oral ketamine and topical dibucaine instillation for the tympanic membrane. However, the otalgia worsened after we abandoned prescribing oral ketamine, so she went to another hospital seeking other therapeutic possibilities including surgery. Sixteen months later, she suffered from multiple gastric ulcers due to the anticonvulsant, antidepressant, muscle relaxant, migraine drug, and nonsteroidal anti-inflammatory drugs. Her activities of daily living were disturbed by dizziness and drowsiness caused by the medication. She decided not to seek further pain relief and stopped taking the above drugs. Now she is in a comparative remission status with occasional 50 mg gabapentin, topical mepivacaine instillation, and physical therapy.
  Jacobson's neuralgia is difficult not only to diagnose but also to treat. Patients require support both physically and mentally.

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  Foreign body aspiration in children is a relatively common occurrence. However, the anesthetic management of foreign body removal may cause a variety of complications.
  The following is a report on a case in which bilateral tension pneumothorax developed during the removal of a foreign body.
  The patient was an 18-month-old boy and his history and preoperative x-ray confirmed that he had aspirated a peanut into his left bronchi. Removal of the wedged peanut was planned to be done under general anesthesia. After the insertion of a laryngeal mask airway (LMA) , a bronchoscope was injected through the LMA. Jet ventilation (JV) through a suction channel of the bronchoscope was employed to maintain the patient's ventilation. After several attempts to retrieve the peanut with a Fogarty catheter, hypotension and bradycardia occurred abruptly. SpO₂ dropped to 40% simultaneously. Manual ventilation through the LMA was impossible. Pneumothorax was suspected and a catheter was immediately inserted into the left chest wall to deflate the air. An x-ray was taken and it showed the collapse of the bilateral lungs. After a catheter was inserted into the right chest wall, the ventilation was promptly restored. The removal of the foreign body was successfully performed two days later with PCPS on site.
  We think the occurrence was caused by positive pressure ventilation which included JV—which may lead to air trappings. The risk of barotraumas and pneumothorax associated with positive pressure ventilation during the removal of foreign bodies should be kept in mind.

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  We describe a case of pulmonary thromboembolism during spinal surgery. An 80-year-old woman with deep vein thrombus underwent spinal surgery under general anesthesia in the prone position. When the wound was sutured, her blood pressure suddenly decreased and pulseless electrical activity developed, which did not respond to epinephrine. Just after the postural change from the prone position to the spine position, her blood pressure went up. Pulmonary embolism and femoral vein thrombus were revealed by postoperative examination. Anticoagulant therapy with heparin and placement of inferior vena cava filter were performed. We conclude that preoperative thrombolytic therapy might be very important for spinal surgery in the prone position with deep vein thrombus.

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  We report a patient with low serum levels of pseudo-cholinesterase. A seventy-four-year old female was scheduled for cholecystectomy. She had no history of surgery or anesthesia, and had been diagnosed with malignant anemia and hypertensive heart disease. Abnormally low levels of serum pseudo-cholinesterase were seen in her laboratory data. Nevertheless, the low levels of serum pseudo-cholinesterase, she did not produce any symptoms. Therefore she was not treated by her family doctor.
  Anesthesia was maintained by general anesthesia in conjunction with thoracic epidural anesthesia without using depolarizing muscle relaxant and local anesthetics with ester binding structure, and the surgery and anesthesia were performed without any problem.

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  We conducted a questionnaire about preoperative use of herbal medications for surgical patients. Herbal medications were used in 7% of the patients, and none of them discontinued herbal medications in the preoperative period. There were no perioperative complications related to the use of herbal medications, while in Europe and the United States many complications have been reported. In the future, in Japan too we have to recognize the risk of using herbal medications in the preoperative period and it may be important to examine whether preoperative discontinuation of herbal medicines is necessary.

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  Medical education for the middle grade students has mainly been performed by classroom lectures. However, the format of these lectures does not lead to a strong understanding of clinical practice and training in medical procedures. On the other hand, despite the advantages of hands on practical lectures, they are limited by the availability of few medical simulators and instructors. In our curriculum, we are able to provide practical lectures on airway management for the middle grade students. This is achieved by the availability of many simulators for tracheal intubation and by implementing the methods of a Yanegawara-type education in which the 4th grade students teach the 3rd grade students. Based on the students' feedback, they preferred the practical lectures over the oral lectures. Thus, the curriculum of medical school education should include more practical lectures.

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  Intestinal mucosa is anatomically vulnerable to any type of oxygen deficit because of its low oxygen tension, right-angle branching of microvessels and countercurrent blood supply. In the event of loss of its barrier function, the gut becomes a significant portal for the entry of microorganisms and/or toxins into the systemic circulation, inducing the release of pro-inflammatory mediators and subsequent development of multiple organ dysfunction syndrome. While it has become a therapeutic goal to preserve the functional integrity of the gut in critically ill patients, few approaches to date appear to be clinically relevant in preventing the progression of gut mucosal injury. We have summarized the recent concept of gut barrier dysfunction and bacterial translocation, with focus on the potential roles of epidural anesthesia and analgesia.

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  When performing spinal and/or epidural anesthesia, it is important to understanding morphological changes in the spinal canal including the subarachnoid space and epidural space. Therefore, we have investigated those using myelography, epidurography, discography, cadaver and magnetic resonance imaging. In this article, we described epidural volume effects, morphological changes by pregnancy, obesity and aging, the relationship between the cauda equina and position, and differences in the cauda equina between adults and children.

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  Levobupivacaine is a levoisomer of bupivacaine, a long-acting, amide-type local anesthetic. This stereoisomer has less central nervous system and cardiovascular toxicity than racemic bupivacaine (bupivacaine) , as shown by the larger dose required to induce central nervous system and cardiovascular toxicity such as convulsions, hypotension and cardiac arrest. Its threshold plasma concentration for inducing those symptoms is also higher than bupivacaine. Central nervous system and cardiovascular toxicity of levobupivacaine is similar to those of ropivacaine. In an experiment using awake, spontaneously breathing rats, plasma concentrations of bupivacaine and levobupivacaine after intravenous infusion are superimposable, suggesting that the pharmacokinetics of the two stereoisomers of bupivacaine are similar. A microdialysis study has shown that the concentrations of bupivacaine in the cerebral extracellular fluid are higher than levobupivacaine, suggesting that those might be responsible for the higher central nervous system toxicity of bupivacaine.

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  I discuss here the efficacy of epidural analgesia for postoperative pain management. Epidural analgesia has been reported to be useful for postoperative pain management in patients who have undergone abdominal surgery with medium to high risk. Levobupivacaine, which was recently introduced into clinical practice in Japan, has a long duration of action and a lower affinity for motor nerves than that of bupivacaine. Therefore, I evaluated the efficacy of epidural infusion of levobupivacaine on postoperative pain management in patients who underwent abdominal surgery. Six ml/hr of continuous epidural infusion of 0.25% levobupivacaine showed adequate analgesia without any motor blockage for postoperative pain management in patients who underwent upper abdominal surgery. Epidural infusion of 0.25% levobupivacaine may be useful for postoperative pain management in patients who have undergone upper abdominal surgery.

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  Epidural catheter-related infection is a rare but a serious complication of epidural anesthesia/block. It can cause permanent paraplegia and even death if treatment is delayed. Physicians doing epidural anesthesia/block should always have the possibility of epidural catheter-related infection in mind. Prevention of epidural catheter-related infection is of paramount importance. Strict adherence to the standard precaution of infection control is mandatory when an epidural catheter is inserted. The most effective antiseptic solution available at present is 0.5% chlorhexidine in 80% alcohol, used to prepare the skin before the procedure. Frequent observation of the puncture site through a translucent covering and less frequent dressing changes are recommended to prevent epidural catheter-related infections. When epidural block with an epidural catheter is needed for longer treatment of patients with pain, a covering containing chlorhexidine is recommended. When epidural catheter-related infection occurs and causes paraplegia, an emergency decompression of the epidural space should be done as soon as possible to prevent permanent paraplegia.

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  Epidural anesthesia and analgesia has become popular because there is a lot of evidence that proves the benefits of epidural anesthesia. However, the recent spread of antiplatelet drugs and anticoagulation therapy is starting to influence the choice of anesthetic or postoperative analgesic method, because the prevention of perioperative venous thromboembolism may lead to increase incidences of epidural hematoma. Although these circumstances may decrease the indication of epidural anesthesia and analgesia, epidural anesthesia and analgesia still have more beneficial evidence compared to other methods. The author outlines the benefits and risks regarding not only epidural anesthesia but also perioperative anticoagulation therapy.

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  Because the use of thoracic epidural anesthesia has raised concerns about asthmatic attacks resulting from sympathetic blockade, epidural anesthesia is contraindicated in patients with bronchial asthma. Even though epidural anesthesia is known to decrease sympathetic nerve activity, animal studies have shown that it has no effect on the inspiratory pressure induced with methacholine. Furthermore, there have been many reports on asthmatic patients who experienced relief or whose symptoms and signs did not change with thoracic sympathetic blockade. Tracheal hyperreactivity is now considered to be the cause of asthma; this means that tracheal intubation is the main factor responsible for inducing bronchoconstriction in patients with bronchial asthma. In patients with increased bronchial reactivity, thoracic epidural anesthesia did not show an increase in tracheal reactivity, but on inhalation bronchial challenge with acetylcholine, attenuation of tracheal activity was observed. Intravenous administration of bupivacaine attenuated bronchial reactivity and intravenous administration of lidocaine suppressed the cough reflex in a dose-dependent manner. These results indicate that the systemic effects of local anesthetics override any possible negative effects of sympathetic blockade. Although more studies are warranted, epidural anesthesia should be made available to patients with bronchial asthma.

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  Retained fragment of epidural catheter within a patient is a rare complication. Since the retained fragment rarely causes neurological symptoms, it is not necessary to remove it. However, the management for the entrapped catheter depends on whether there are neurological symptoms, the patient's age, the site and the length of the retained catheter. Some case reports have indicated that neurological symptoms occurred several years after epidural catheterization. A neurological examination including CT scan should be conducted periodically. The retention of a fragment of epidural catheter is caused by the catheter breaking upon insertion, chronic compression or stretching within a epidural space, and the result of difficulty withdrawing the catheter due to looping around a spinal nerve root, forming a knot. Careful attention is needed to manage the epidural catheter at the time of insertion and removal. Anesthetists should learn the proper techniques of epidural anesthesia.

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  At present, no well-defined criteria are available about the dose of local anesthetics to be used for epidural anesthesia in combination with general anesthesia. When epidural anesthesia is performed, the size of the area to be anesthetized and the depth of the anesthesia depend on the dose at which the local anesthetic is administered. However, there is no established method for evaluating the effect of epidural anesthesia combined with general anesthesia. This is the reason that, as stated above, no criteria are available. The extent and magnitude of noxious intraoperative stimuli vary widely. If the goal of epidural anesthesia applied during general anesthesia is to block noxious stimuli, epidural anesthesia should be administered over a sufficiently large area and to an adequate depth to deal with operative stress. The use of a local anesthetic at a high dose is expected to suppress reactions associated with operative stress. Continuing epidural pain relief, primarily using local anesthetics, can favorably affect control of perioperative complications and improve the long-term prognosis.

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  A secret of safe and certified epidural analgesia is to know the complications related to its procedures. You have to insert a needle and catheter into the epidural space certainly and inject adequate local anesthetics skillfully. After the block takes effect, you cannot leave the patient, and must monitor him or her for a while.
  The certification of the epidural space is unreliable, except for the hanging-drop method, and you need a closed observation for a out-patients.
  For cases of epidural analgesia with general anesthesia, you have to perform epidural analgesia under awake conditions, and you may introduce general anesthesia after a test block. When you neglect to perform a test block, you have to handle the situation as you would intrathecal spinal analgesia.

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