Spinal cord ischemia during aortic surgery has been thought to result from occlusion of the feeding artery that arises from the segmental artery. This concept has recently been challenged, and it is now believed that occlusion of all the segmental arteries does not result in spinal cord ischemia, if spinal cord perfusion pressure (mean arterial pressure-cerebrospinal fluid pressure) is maintained at a high level, thanks to the presence of a rich collateral network. In this concept, anesthesiologists play a major role by monitoring ischemia and optimizing spinal cord perfusion pressure.
  In this article, I outline the strategies of spinal cord protection under the current concept and the role of anesthesiologists that surgeons expect. In addition, new insights are described for when the collateral blood flow fails to maintain the spinal cord viability. Operative results of my personal experience with thoracoabdominal aortic aneurysm repair are also presented.

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  We recognize that the most famous classification of antiarrhythmic drug is the Sicillian Gambit proposed by the AHA 1991, which was modified to the name J-GAMBIT by the JHA 2002. However, these proposed drug action tables are quite difficult to understand for the non-cardiologist. ECG is essentially the measurement of extracellular voltage and it originates from the voltage difference between the action potentials of subendocardial and subepicardial muscle layers. From that point of view, this article describes the relationship between changes in ECG patterns and antiarrhythmic drug actions.

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  Writing scientific papers is important work and can provide a great contribution to the world we live in. Current anesthesiologists stand on the shoulders of previous scientists, who provided findings that are being used for modern treatments, and have a responsibility to add to their work and contribute to the future world of medical discovery. The basic steps toward publication include performing research, preparing the results, writing a manuscript, and submitting the final proof, followed by editorial review and revising for publication.
  A typical medical manuscript has the following sections: title, authors' names and addresses, abstract, introduction, main body of the text, conclusion/summary, acknowledgments, references, illustrations and figures with captions, and tables. The title should adequately inform the reader about the content of the manuscript without ambiguity, and should be concise as well as comprehensive. The title is important, because most information retrieval services, browser search tools, and databases rely on manuscript titles to prepare their indexes.
  After being written, the entire manuscript should be edited repeatedly to improve the wording and help the reader understand the results presented. Citations and the style of the references are also important matters to consider.
  Scientific misconduct must be avoided, such as gift authorship and redundant publication, and the same material should not be published in different journals. Each paper should also contain some new information. In addition, so-called “fraud”, such as plagiarism and fabrication, must not be done.

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  Lipid emulsion is effective for treating local anesthetic-induced cardiovascular toxicity. Its effect as an antidote was originally proven in experimental animals. Although it has not been proven in clinical experiments, numerous case reports describe its effectiveness for treating both central nervous system and cardiovascular toxicity of local anesthetics. The guidelines for treating local anesthetic toxicity recommend the use of lipid emulsion when cardiovascular toxicity induced by local anesthetics is resistant to conventional therapy. Although no adverse effects have been reported when used with local anesthetics, one patient developed respiratory complications and required long-time mechanical ventilation, possibly caused by the lipid emulsion used for treating toxicity by psychomotor agents.

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  We examined actions of levobupivacaine, the single L isomer of bupivacaine, on action potentials elicited in dorsal root ganglion neurons and excitatory synaptic responses evoked in spinal dorsal horn neurons of rats. Levobupivacaine selectively inhibited the amplitudes of action potentials elicited in Aδ and C afferent fibers, and of monosynaptic Aδ and C fiber-evoked excitatory synaptic currents evoked in substantia gelatinosa (lamina II of the spinal cord) neurons. The anesthetic at the same concentration, however, did not suppress the action potential amplitude and the synaptic response mediated through Aβ afferent fibers. On the other hand, the single R isomer of bupivacaine equally inhibited the action potentials and synaptic responses mediated through Aβ, Aδ and C afferent fibers. These results suggest that the single L isomer, but not the R isomer of bupivacaine, has a selective inhibitory action on noxious transmission from the periphery to the spinal cord.

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  Officially approved application of levobupivacaine (Popscaine^TM) in Japan is epidural anesthesia for surgery (0.75% solution) and postoperative pain control (0.25% solution) . As a part of the clinical trial for government approval, we compared the clinical effects of 0.75% levobupivacaine and 0.75% ropivacaine in patients scheduled for surgery of the lower abdomen or lower extremities. Levobupivacaine and ropivacaine were equally effective in terms of clinical efficacy and duration of action. Although we did not encounter severe CNS adverse reactions, levobupivacaine and ropivacaine seem to share a wide margin of safety in cardiovascular and CNS toxicities.

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  Increased plasma concentration of local anesthetics induces central nervous system (CNS) and cardiovascular toxicity, and inhibition of GABAergic inhibitory neurons are involved in this toxicity. An increase in the concentration of local anesthetics in the whole brain is required for inducing CNS toxicity since GABAergic inhibitory neurons are extensively distributed in the brain, and it is not induced by injecting local anesthetics to restricted areas in the brain. General anesthesia inhibits local anesthetic-induced CNS toxicity. Among commonly used agents during anesthesia, sympathetic α₂-adrenergic receptor agonists such as dexmedetomidine, and β₁-adrenergic receptor antagonists such as propranolol increase the threshold plasma concentration for inducing convulsions as well as the dose of local anesthetics for inducing convulsions. These agents increase the concentration of local anesthetics in the brain at the onset of convulsions, suggesting that they did not affect the diffusion of local anesthetics from the blood vessels to the extracellular fluid in the brain. Regarding concentrations of local anesthetics measured by microdialysis using the retrograde calibration technique, the diffusion ratio of levobupivacaine to the extracellular fluid in the brain is much lower than that of lidocaine during intravenous infusion.

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  The role of fiberoptic intubation in difficult airway management (DAM) has been established. Many guidelines for DAM show its importance.
  The fiberoptic intubation technique is found into the American Society of Anesthesiologists difficult airway algorithm in three places: (1) awake fiberoptic intubation in a patient with a suspected or known difficult airway, (2) intubation under general anesthesia in a patient with an unanticipated difficult intubation, and (3) intubation through the laryngeal mask airway or intubating laryngeal mask airway in a patient whose trachea cannot be intubated and whose lungs cannot be ventilated by a face mask.
  Some new effective rigid videolaryngoscopes have recently been introduced for DAM, but fiberoptic intubation has some advantages over these new laryngoscopes. The ‘flexible’ fiberscope is suitable for various difficult airway situations for which these new laryngoscopes are not suitable because of its blade form. Nasal fiberoptic intubation is valuable for patients with extremely limited mouth opening since rigid devices cannot be inserted into the oral cavity. In addition, fiberoptic intubation through the laryngeal mask airway can be effective in cannot intubate-cannot ventilate (CICV) situations.
  The role of the fiberoptic intubation in DAM would be important in the future. The acquisition of these skills are essential for all anesthesiologists, and developing training programs for anesthesia trainees should be established.

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  Airway management has been developed with face mask ventilation and tracheal intubation. A quarter of a century has passed since LMA (Laryngeal Mask Airway) was put on the market. LMA has become indispensable in difficult airway management (DAM). At first, LMA was invented aiming at ease of use and minimal invasiveness. However, usefulness in DAM was gradually recognize with a lot of case reports and clinical studies. These three characteristics of LMA gradually became clear. And LMA evolved from LMA Classic (first generation) to Intubating LMA and LMA ProSeal (second generation), and then to LMA Supreme (third generation).

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  Recently, many video or optical intubation devices have become clinically available. These new laryngoscopes can be divided into two categories, those with an integrated tube guide, and those without. I believe that the laryngoscope with the tube guide will change airway management in the near future, replacing the conventional Macintosh laryngoscope, and will thus alter the difficult airway guidelines. In this manuscript, recent data appearing in published papers are introduced.

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  In the “cannot intubate, cannot ventilate” (CICV) situation, immediate intervention with invasive airway access becomes necessary. While the CICV situation is a rare occurrence, invasive airway access is a fundamental technique required by anesthesiologists. Cricothyrotomy is recommended in emergency situations given that cannula cricothyrotomy with percutaneous transtracheal jet ventilation (TTJV), surgical cricothyrotomy, and percutaneous cricothyrotomy can be performed more safely and quickly than tracheostomy. Various percutaneous cricothyrotomy kits are commercially available. Only a few anesthesiologists in Japan are sufficiently proficient in invasive airway access, underscoring the need to provide anesthesiologists with medical training in emergency invasive airway access.

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  The day surgery unit (DSU) in Kyoto University Hospital was founded as the first facility for ambulatory surgery among the Japanese national university hospitals in January 2000, so as to establish a safe, high-quality and cost-effective management system of ambulatory surgery and to popularize day-case surgery in our country. By the end of 2009, a total of 10,148 patients underwent operations under the supervision of anesthesiologists in the DSU.
  The techniques and procedures in anesthesia and perioperative care in the DSU have been modified and improved year by year. A representative example is day-case hysteroscopy: monitored anesthesia care (MAC) using propofol sedation and paracervical block has led to the shortening of the postanesthesia recovery and discharge times and improved patient's self-assessment of the resumption of normal activity level, compared to the original anesthetic method using sevoflurane. Similarly, thoracic paravertebral block along with MAC brought about a smoother postanesthesia recovery in breast cancer surgery.
  Our experience of over 9 years indicates the significance of the cooperation with nursing, surgical and anesthesia personnel and constant efforts to collect and analyze the perioperative information, especially undesired symptoms that delay postoperative recovery, and patients' demands for establishment of an ambulatory surgery system that is secure and high patient satisfaction.

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  Conventional laryngoscopes are not ideal, as it may often be difficult to see the glottis, even with extension of the patient's head. The Pentax-AWS, a videolaryngoscope, allows one to see the glottis, with the patient's head in the neutral position, and guides a tube into the trachea. The success rate of tracheal intubation using the Pentax-AWS has been shown to be high in patients in whom intubation using the conventional laryngoscope has failed. In the future, the videolaryngoscopes should be the mainstream for tracheal intubation, as they have clear advantages over the conventional laryngoscopes. Nevertheless, our ability to use the conventional laryngoscopes should be maintained, as videolaryngoscopes are not perfect.

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  As older people are now living longer, opportunities for emergency gastrointestinal surgery among elderly people are increasing. We retrospectively evaluated usefulness of Portsmouth modification of Physiologic and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in 36 patients over 90 years old who underwent emergency digestive surgery from April 1, 2006 to March 31, 2009. Area under the curve (AUC) of the receiver operating characteristic curve was defined as a measure of accuracy. The AUC values were 0.887 for the predicted mortality, 0.872 for PS and 0.677 for OSS. These data suggest that PS may be useful to preoperatively predict in-hospital mortality in these patients.

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  The patient was a 55-year-old male with chronic renal failure who was diagnosed, after a detailed clinical examination, with a left kidney tumor. He was therefore scheduled for nephrectomy under sevoflurane general anesthesia with epidural anesthesia. The operation was conducted via celiotomy in the left semi-recumbent position, with the operating table bent to elevate the kidney region. The operation lasted for more than 4.5 hours, however, no sign of malignant hyperthermia was noted intraoperatively. On postoperative day 1, the patient developed a high, persistent fever. Increase in the serum CPK was noted, with the level exceeding 11,000 IU/L on postoperative day 2. The renal failure worsened in severity, necessitating hemodialysis. After administration of dantrolene sodium, the fever subsided and the serum CPK level decreased dramatically. Later, the rate of CICR (Ca-induced Ca release) from the muscle was measured, but this was within normal range. Infection and rhabdomyolysis associated with the body positioning during the prolonged surgery seemed to be responsible for the fever and elevation of the serum CPK levels postsurgery in this patient, although the involvement of malignant hyperthermia could not be ruled out.

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  We report four cases of Denver shunt system application for intractable ascites caused by severe liver cirrhosis. Despite high-level risks, such as delayed emergence from anesthesia and a hypovolemic state caused by a deficiency of protein, general anesthesia has the advantage of immobilizing patients for hours. One of the cases was maintained with the infusion of propofol, and emergence from anesthesia was more delayed than in the other cases maintained with sevoflurane. The laryngeal mask airway (LMA) was used in three cases, and a tracheal tube in one case. The patients using the LMA maintained spontaneous respiration safely without vomiting or aspiration. Despite checking the endotoxin concentration and treatment with gabexate mesylate, in one case, severe disseminated intravascular coagulation (DIC) occurred just one day after the operation. We should take each patient's condition into consideration, and choose the optimal method of anesthetic management.

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  General anesthesia is usually administered for patients undergoing lumbar spine surgery. But in the case of patients who are predicted to have severe adverse events associated with general anesthesia because of their systemic diseases, another method should be considered. We have experienced two cases of spinal anesthesia for lumbar spine surgery.
  The first patient was diagnosed as having lumbar canal stenosis with idiopathic interstitial pneumonia. The second patient was diagnosed as having lumbar disk hernia with a family history of malignant hyperthermia. Spinal anesthesia was performed with 0.5% isobaric bupivacaine in the both patients, and the block level was Th4 in the first patient, and Th6 in the second patient. Severe hypotension was observed in the both patients, and mild nausea was observed in second patient. But hypoventilation or an irregular respiratory pattern were not observed during the operation.
  In the management of spinal anesthesia for lumbar spine surgery, preventing adverse events such as severe hypotension, nausea, and hypoventilation is very important.

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  A 65-year-old man with dilated cardiomyopathy (NYHA functional class II) underwent tympanoplasty under general anesthesia. Preoperative transthoracic echocardiography showed that the ejection fraction was 33%. Arterial pulse contour analysis using FloTrac^TM/Vigileo^TM was started before induction of anesthesia. The baseline value of the cardiac index was 3.9l/min/m² and that of the stroke-volume variation (SVV) was 11%. Anesthesia was induced with midazolam and fentanyl. After the initiation of the operation, the blood pressure and BIS value increased. Therefore, propofol infusion was carefully initiated. Unexpectedly, the cardiac index decreased to 1.3l/min/m², and the SVV increased to 18%. We performed fluid therapy using FloTrac^TM/Vigileo^TM, and the blood pressure and cardiac index improved. In patients with dilated cardiomyopathy, anesthetic agents may cause severe circulatory disturbances. Therefore, selection of the appropriate drugs and dose adjustment based on adequate monitoring are very important.

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  In nephrectomy for renal cancer with tumor thrombus in the inferior vena cava, we should pay attention to the release of tumor embolus or development of air embolism during the operative procedure. To avoid such fatal complications, we should continuously observe changes in the shape of tumor thrombi and we must rapidly respond to changes in circulatory dynamics. Here we report 3 cases of nephrectomy for renal cancer with tumor thrombus. We could successfully manage all cases without any complications by using partial extracorporeal circulatory support. In these cases, transesophageal echocardiography and monitoring of the pulmonary artery pressure and right ventricular pressure by the pulmonary artery catheter were very useful.

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  Advances in anesthesiology have greatly improved patient safety during the perioperative period, and have ushered in dramatic changes in methods of pain relief after surgery. The most important factors that have influenced improvements in postoperative pain management are related to innovations in equipment and drugs, but equally important has been the spread of postoperative anticoagulation therapy. The result of these changes has been increasingly sophisticated methods of pain control, including patient-controlled analgesia. This article reviews the history of postoperative pain management and the role of PCA.

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  As anesthetic drugs become short-acting, postoperative pain control upon prompt awakening has become essential. For the spread of patient-controlled analgesia (PCA) which is ideal for postoperative pain control, we start a perioperative pain control team on a small scale and make it bigger. In addition, we hold a periodic meeting to share directions on how to use PCA instruments. We make a manual and an emergency anesthesiologist call system for support for insufficient analgesia, side effects and alarms. It reduces anxiety about PCA and offers effective analgesia that we can explain to the patient with a pamphlet and real PCA instruments.

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  PCA (patient-controlled analgesia) can provide rapid-onset analgesia. PCA can also reduce the cost of postoperative pain management. These are the merits of postoperative pain management by using PCA. However, PCA involves complicated operation and maintenance techniques. Intensive education is also required for patients. Because the equipment is heavy, it is not easy to handle. Patients with consciousness disorders cannot use PCA. These are the downsides of PCA.
  In our hospital, the Acute Pain Service (APS) team plays an active part in overcoming these shortcomings of PCA systems. For example, the APS team educates patients before and after the operation. The APS team also educates the medical staff, nurses, and other co-medical staff of our hospital so that they can efficiently operate PCA systems. To lighten the burden imposed on the medical and co-medical staff, who are required to perform complicated operations and maintenance of PCA systems, our APS team recommends using the disposable PCA pump.

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  Intraoperative administration of opioids is important for postoperative pain management by using patient-controlled analgesia (PCA) . For successful postoperative pain management, the effect-site concentrations of opioids such as morphine and fentanyl have to reach minimum effective analgesic concentration (MEAC) before the patient wakes up from general anesthesia.
  Postoperative MEAC of morphine is estimated to be 30 ng/ml. To maintain the effect-site concentration of morphine at 30 ng/ml at the end of general anesthesia, 0.2 mg/kg of morphine should be administered approximately 30 minutes before the end of general anesthesia.
  The postoperative MEAC of fentanyl is estimated to be 1 ng/ml. The effect-site concentration of fentanyl can be maintained at approximately 1 ng/ml by intraoperative loading administration of fentanyl, i.e., 3 injections of 2μg/kg of fentanyl at 30-minute intervals and continuous administration of 0.5μg/kg/hr of fentanyl, 3 hours before the end of general anesthesia.

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  We present the indications and contraindications of the patient-controlled analgesia (PCA) system and intravenous PCA (IV-PCA). PCA is contraindicated in patients who cannot comprehend PCA, refuse to use PCA, or cannot operate the PCA device. Indication of IV-PCA depends on the type of surgery, duration of postoperative pain, and the start of oral intake. In other words, patients who can understand the PCA system and require parenteral opioids for their moderate to severe pain during the first few postoperative days are good candidates for postoperative IV-PCA, even young children. Furthermore, IV-PCA is a good choice for patients who are contraindicated for postoperative epidural analgesia such as the patient refusing, deformities of the spine, abnormal coagulation status, and perioperative aggressive anti-thrombic therapy. On the other hand, adverse events related to intravenous opioids, especially respiratory depression, must always be kept in mind. Improving postoperative analgesia and also avoiding adverse events related to opioids, multimodal analgesia consisted with opioid, nonsteroidal anti-inflammatory drug and neural blockade is rational choice for postoperative analgesia.

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  We present the indications of patient-controlled epidural analgesia (PCEA) for postoperative analgesia. In postoperative epidural analgesia, it is known that the addition of patient-controlled analgesia (PCA) provided similar analgesia with less drug consumption compared to continuous epidural infusion alone. Therefore, PCEA should be applied in postoperative epidural analgesia whenever the PCA system is not contraindicated. The major advantages of epidural analgesia over IV-PCA, such as providing superior analgesia upon movement, reducing postoperative pulmonary complications, and hastening the return of gastrointestinal function, are attractive after major thoracic, abdominal, hip or knee surgeries. On the other hand, postoperative epidural analgesia could potentially cause extremely rare but catastrophic central nervous system complications, and a recent increase in patients requiring perioperative anticoagulation therapy restricts the indication of postoperative epidural analgesia. Accordingly, coagulation status in surgical patients and pharmacological prophylaxis of venous thromboembolism should always be taken into consideration for PCEA.

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