When a significant mismatch between the dose and effect of a drug occurs, the cause should be investigated by separately examining the pharmacokinetics (PK) and pharmacodynamics (PD) . Since such a mismatch is often found for dexmedetomidine (DEX) , it is necessary to understand the PK/PD of DEX. Dose-response relationships exist for the sympatholytic, sedative and analgesic effects of DEX. The expression of the effect of DEX on blood pressure is complicated because of the direct vasoconstriction of peripheral vasculature, which modifies the above effects. The duration of DEX action is relatively long because its distribution volume is comparatively large and metabolic clearance is not large. In order to utilize the various merits of DEX, knowledge of its PK is necessary to prevent any problems that might arise. Since reports on organ-protective effects of DEX have been increasing and various new merits of DEX are expected to be revealed, safe use of DEX with an understanding of its PK/PD is necessary.

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  In Japan, fondaparinux and enoxaparin sodium (low molecular weight heparin, LMWH) have been approved for perioperative thromboprophylaxis. This article discusses the prevention of venous thromboembolism (VTE) using anticoagulants according to the 8th edition of the ACCP guidelines. As a result, fondaparinux and LMWH usage for the prevention of perioperative VTE has increased in Japan.

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  The role of nurses in anticoagulant therapy for prevention of perioperative pulmonary thromboembolism, bleeding wounds and organs other than the wound, prevention and early detection of nerve compression due to epidural catheter is discussed. Thromboembolism is completely preventable if we are not administering anti-coagulation therapy. The early detection of pulmonary thromboembolism is important.

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  Since the mortality rate from pulmonary thromboembolism (PTE) is extremely high, it is important to acquire proficiency in perioperative management of venous thromboembolism (VTE) , which includes deep vein thrombosis (DVT) , the cause of PTE. However, the risk of bleeding is always present after surgery, and we have to pursue blood clot lysis, a conflicting objective under these circumstances. Therefore, surgeons need to perform VTE treatment cautiously, taking both bleeding risk and VTE severity into account.

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  Anticoagulant medication is indicated as the prophylaxis of pulmonary thromboembolism in high- risk patients. In addition to unfractionated heparin, fondaparinux and enoxaparin have been available in Japan. The patients receiving these drugs have a risk of epidural hematoma following epidural anesthesia. Low-dose unfractionated heparin is not contraindicated during epidural anesthesia as long as anesthesia is administered when the effect of heparin is at a minimum. On the other hand, epidural anesthesia should be avoided when fondaparinux or enoxaparin is administered to the patient. Furthermore, the epidural catheter should be withdrawn at least two hours prior to administration of these drugs. Systemic opioid and peripheral nerve block are alternatives to epidural analgesia. Advantage of using opioids is that there is no risk of hemorrhagic complication. Previous studies revealed that the effect of peripheral nerve block for lower extremity surgery is comparable to epidural block.

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  Dexmedetomidine, a highly selective alpha-2-adrenergic agonist, has been introduced into our protocol in tracheal intubated patients requiring sedation. Dexmedetomidine shows benefits as an adjunct to general anesthesia. Effects of dexmedetomidine on intraoperative neurophysiologic monitoring are not yet fully understood. The deterioration of the motor evoked potentials (MEP) signal was found after the completion of loading dose administration of dexmedetomidine during total intravenous anesthesia. The bispectal index (BIS) was also decreased to <30 in these patients. According to several research reports concerned with the relationship between MEP and dexmedetomidine, dexmedetomidine does not change MEP responses under same depth of anesthesia; BIS is recommended to be kept at 40-50 during dexmedetomidine infusion. Intraoperative systemic administration of dexmedetomidine enhanced postoperative analgesic potency after lower abdominal surgery, with an increased time to rescue for the first analgesic medication and a decreased need for postoperative analgesia. The analgesic effect of dexmedetomidine after local administration was reported to also be effective as postoperative analgesia without hemodynamic change. However, the safety concerns about local administration should be clarified before its clinical use.

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  For the reduction of pain and improvement of the quality of life of both patients with cancer and their families, the most important role for the medical practitioner is to relieve the physical pain caused by cancer. The gold standard for the management of cancer pain is the WHO method reported in 1986, and pain relief can be achieved with medication for about 80% of patients. If side effect-control measures are taken and appropriate analgesics for pain intensity and mechanism are prescribed, oral medication can provide sufficient analgesic effects with patient-controlled analgesia without requiring selection of a disease stage and a treatment place.

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  The aim of this study was to examine the effects of different infusion doses of remifentanil on mean arterial pressure (MAP) , heart rate (HR) and electroencephalographic bispectral index (BIS) . Twenty-seven patients who underwent total hysterectomy were studied. They were anesthetized with sevoflurane (end-tidal concentration of 1.0%) combined with a continuous infusion of remifentanil at 0.25 (L group) , 0.625 (M group) or 1.0μg/kg/min (H group) . MAP, HR and BIS were estimated during the first 50 minutes of surgery. MAP and HR in the M and H groups were lower than those in the L group. There were no significant differences found between the M and H groups. Lowest systolic blood pressure and HR during the study were 78 mmHg and 48/min, respectively. BIS remained unaltered, regardless of the remifentanil dose. A does of this opiate between 0.25 and 1.0μg/kg/min in combination with sevoflurane (1.0%) could be safely used during lower abdominal surgery. However, since no difference was found in MAP, HR and BIS between the M and H groups, the infusion rate should be limited to a maximum of 0.625μg/kg/min.

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  We examined the effects of the short-acting beta-1 blocker, landiolol, on hemodynamics during emergence from anesthesia in elderly and middle-aged patients with and without hypertension.  Fifty hypertensive and 50 normotensive elderly and middle-aged patients scheduled for orthopedic or gynecological surgery were selected. Immediately after the end of the surgery and termination of administration of all anesthetics, a landiolol infusion was administered at a rate of 0.125 mg/kg/min for 1 min and then decreased to 0.04 mg/kg/min until extubation. Heart rate and blood pressure were recorded every minute from immediately before the administration of landiolol up to discontinuation of landiolol, and every 5 min from the discontinuation of landiolol to 30 min after termination of the infusion. As a control, nine normotensive middle-aged and 10 normotensive elderly patients were also studied. In addition, eight hypertensive middle-aged and eight normotensive elderly patients were also evaluated with administration of a different landiolol infusion dosage.  In the non-hypertensive group, with landiolol infusion, heart rate of middle-aged patients remained unchanged, while that of elderly patients decreased during emergence from anesthesia and tracheal extubation. In contrast, in the hypertensive group, the heart rate increased in middle-aged patients and remained unchanged in elderly patients with landiolol infusion during emergence and tracheal extubation. With an increase or decrease in landiolol dosage, heart rate remained unchanged during emergence and tracheal extubation in middle-aged hypertensive and elderly normotensive patients.  The present study shows that the chronotropic effect of landiolol is attenuated in middle-aged patients with hypertension during emergence from anesthesia. Anesthesiologists should consider the patient's demographic data, such as age or presence of hypertension, when using landiolol for stabilizing the heart rate during emergence from anesthesia.

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  We reviewed the anesthetic management of thirty-three cases with endotracheal surgery in Saga University Hospital. General anesthesia was performed for all patients. Airway management was mainly performed with LMA Fastrach™, and spontaneous breathing was maintained. Intravenous anesthetics were used for the induction and maintenance of anesthesia, and volatile anesthetics were added conditionally. Various sizes of endotracheal tubes, crycothyroidotomy kits, jet ventilator, and PCPS were prepared to be ready to use in case of an emergency. Throughout surgery, we carefully monitored each patient's respiratory condition. During laser ablation, we kept inspired oxygen concentration at about 40%. When saturation of peripheral oxygen (SpO₂) fell, we asked the surgeons to pause for a minute for ventilatory support. Thirty-two cases were completed without major trouble, but air embolism occurred in one case.

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  Subarachnoid hemorrhage due to rupture of cerebral aneurysm during pregnancy is a rare complication, but, should it occur, the maternal mortality rate is 13-35%. We report anesthetic management in two pregnant women (32 and 33 weeks' gestation) , who underwent Cesarean section and cerebral aneurysm clipping.  Anesthesia was induced with thiopental or propofol, vecuronium or suxamethonium, and fentanyl, and maintained with sevoflurane (<1 MAC) before the delivery. Systolic blood pressure was maintained at 100-140 mmHg and mild hypocapnea was elected. Both newborns did well despite requiring artificial ventilation and surfactant therapy for two days.  After the delivery, anesthesia was maintained with fentanyl, remifentanil for aneurysm clipping, and oxytocin to prevent uterine bleeding. Postoperative courses of both mothers and fetuses were uneventful.  Careful anesthetic consideration for maintaining uterine circulation and avoiding rupture of aneurysm is essential to obtaining satisfactory outcome of both mother and fetus.

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  Anesthesia for thymectomy in myasthenia gravis (MG) is challenging. Video-assisted thoracoscopic thymectomy (VATT) presents a new approach to thymectomy. It provides less postoperative pain, shortened hospital stay and better cosmetic results by minimizing chest wall trauma. But that needs insertion of a double lumen tube (DLT) and deep anesthesia. Furthermore, patients with MG exhibit increased sensitivity to non-depolarizing muscle relaxants.  We report two cases of myasthenic patients who underwent VATT and one lung ventilation with DLT. Anesthetic managements were successfully done with total intravenous anesthesia (TIVA) with remifentanil and propofol and thoracic epidural anesthesia, without using neuromuscular blocking agents. The patients also showed good postoperative courses with little postoperative pain.  Our experiences show that the combination of TIVA with remifentanil and propofol without using neuromuscular blocking agents and thoracic epidural anesthesia should be an effective technique for VATT providing satisfactory intra/post operative conditions.

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  We managed two patients for emergency mitral valve replacement with infective endocarditis and neurological complications under general anesthesia.  The first patient was a 54-years-old man with infective endocarditis and intracranial hemorrhage. The second patient was a 52-years-old man with infective endocarditis and severe cerebral infarction. General anesthesia was maintained by total intravenous anesthesia with propofol and fentanyl. Bispectral Index was monitored to assess the hypnotic state and to detect cerebral ischemia during the surgery.  To prevent cerebral hypoperfusion during cardio pulmonary bypass, we maintained the blood pressure at around 50-60 mmHg, and maintained PaCO₂ at around 36-46 mmHg. And to reduce the risk of platelet dysfunction associated with cardiopulmonary bypass, we selected a new hydrophilic polymer coating (X-coating) system. After the surgery, further neurological complications were not observed in either patient.

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  The Datura genus includes a group of plants containing tropane belladonna anticholinergic alkaloids that can cause food poisoning. We report a case of Datura poisoning that was initially misdiagnosed as mushroom poisoning.  A married couple complaining of general fatigue after eating noodles with mushrooms was transferred to our emergency room. Both patients showed hallucinations, confusion, tachycardia and papillary mydriasis. As mushroom food poisoning was suspected, they were admitted to the intensive care unit in our hospital. The tachycardia and confusion disappeared nine hours after the food intake, but intense thirst remained.  A few days later, it was discovered that the mushrooms they ate turned out to be nonpoisonous. We reinvestigated the case, and knew that they had also eaten Datura metel roots that were mistaken for a burdock root.  In conclusion, we need to consider Datura poisoning when a case of food poisoning accompanies typical anticholinergic signs and symptoms.

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  Resuscitation rate may be improved if the tracheal intubation during CPR can be enforced promptly and safely without interruption of chest compressions. We investigated the time for tracheal intubation during CPR in manikin using Macintosh laryngoscope (McL) or Pentax-Airway Scope^® (AWS) in 18 anesthesia initial trainee doctors. In the McL trial, time to secure the airway was significantly longer during chest compressions than during non-chest compression times (14.9±4.0 sec vs 22.7±6.5 sec, respectively, P<0.01) . In the AWS trial, no significant difference between the time during chest compression and non-chest compression was recognized (13.3±3.8 sec vs 14.5±3.4 sec) . The success rate of the tracheal intubation in the McL trial was 55.5%, though all intubation was successful in the AWS group. AWS training during anesthesia training may lead to the emergent intubation during cardiopulmonary resuscitation.

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  Epiduroscopy has been designated as an advanced medical treatment by the Ministry of Health, Labour and Welfare, and it is indicated in lumbar disc herniation, spinal canal stenosis, and failed back surgery syndrome (FBSS) .  In many cases, this treatment is effective in relieving pain, particularly that arising due to adhesions around nerve roots that can be observed by performing epiduroscopy and nerve roots block works.  It is thought that irrigating the inflamed tissue with saline might be effective for lumbar disc herniation, irrigation and exfoliation irrigation. Exfoliation improves the blood flow to the cauda equina and adhesiotomy mitigates FBSS.

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  Local analgesia is used to perform epiduroscopic adhesiolysis. In this report, we administered analgesics or sedatives in the area where pain was experienced. First, we inserted an endoscope 0.9 mm in diameter in the epidural space using a video-guided catheter. We confirmed the position of the endoscope tip by radioscopy and advanced it while observing the epidural space. Adipose tissue was then exfoliated using the tip of the video-guided catheter. For patients with nerve root symptoms, we also performed radiculoplasty. Following adhesiolysis, we injected contrast into the epidural space to confirm exfoliation. Once confirmed, we injected a mixture of local analgesics and steroids. We also found that epidural catheter insertion and injection of local anesthetic and steroid from the sacrum hiatus to the head side, or from the head side of the surgical site to the tail side, allowed for a more effective epiduroscopic adhesiolysis.

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  Complications in epiduroscopy are classified in the following three major categories: procedural complications, drug-induced cases and infections.  First, cerebrospinal pressure is elevated, because a large quantity of physiologic saline is injected into the epidural space during percutaneous epiduroscopic adhenolysis. Therefore, some complications such as headache, cervicodynia, convulsions and visual impairment have been reported frequently.  Second, allergic and anaphylactic reactions to local anesthetics and radiocontrast agent must be considered. Also, we have to know that such drugs can be occasionally injected into blood or cerebrospinal fluid.  Third, it is important that we do epiduroscopic adhenolysis under sterile conditions and keep the postoperative wound clean to prevent perioperative infection.  To provide an extra margin of safety in epiduroscopy, it is necessary to have full knowledge about the complications and accidental symptoms, and to understand the treatment and prevention methods for them.

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  Epiduroscopy (Spinal canal endoscopy) is a diagnostic and treatment method for intractable lower back and leg pain. This method is characterized by: (1) minimal invasiveness, (2) macroscopic observation of the epidural space, (3) irrigation, washing, and lysis of adhesion under direct vision, (4) accurate drug administration to the pathological lesion, and (5) adequate extension of epidural block after this method. This method has been used for the diagnosis and treatment of intractable lower back and leg pain in various countries, and its usefulness has been reported in patients with lumbar intervertebral disc herniation, lumbar spinal canal stenosis, or failed back surgery syndrome. This method may become increasingly more important as a diagnostic and treatment method for intractable lower back and leg pain.

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  We had 137 cases of patients treated with epiduroscopy with chronic low back pain and lower limb pain during 2002 to 2008. The efficacy and complications of epiduroscopy were investigated retrospectively. Significant pain reduction was observed in 62% of the patients who received the epiduroscopy. We experienced four cases of sensory disturbance in anterior thigh, two cases of muscular weakness in legs, and two cases of prolonged headache after surgery. All of these complications disappeared within three weeks. There were no other severe complications such as retinal hemorrhage or subarachnoidal hemorrhage during or after operation.  Furthermore, we discuss epiduroscopy, epidurography, the posture of the patient during the procedure, the anesthesia and the epiduroscopy techniques which we cultivated through our experiences.

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  Dr. Igarashi of Jichi Medical University introduced epidural endoscope (Epiduroscopy) to Japan about 10 years ago. Since then, through trial and error on multiple cases, we have made satisfactory improvement on the methods and techniques to achieve better outcomes.  Here, we will discuss the improvement of the Epiduroscopy techniques and postoperative care in comparison to the earlier period.

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  The expenses to perform epiduroscopy are not covered by health insurance in most hospitals, and this procedure is not commonly performed. Although the procedure of epiduroscopy is well-established, there are a few differences in the methods among hospitals.  Centesis is induced when a 14G epidural needle is inserted into the relatively inaccessible sacral hiatus. Using an all-purpose sheath, similar to the one used for cardiac catheterization, overcomes the difficulties (such as being turned up) of using one particular kind of sheath.  Relatively high amounts of saline is required for epiduroscopy, and adhesiotomy can be easily performed in many cases. In addition, radiculoplasty is performed without difficulty. The important factor to be considered is the pressure of the saline, and not its volume.

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