The sympathetic nervous system is closely linked to autonomic physiological functions, and it also affects pain generation and sustention. Therefore it should be reviewed especially for the treatment of intractable pain. Spinal antinociception, including spinal subarachnoid administration and epidural administration of drugs that directly affect the spinal cord, promises drug sparing, alleviation of side effects and extension of the length of effectiveness. Except for neostigmine, most drugs concomitantly produce suppression of sympathetic nerve activity, however, at least peripheral sympathetic blocking is not involved in alleviation of hyperalgesia. An embedded device that may allow continuous subarachnoid administration of drugs may develop a new treatment for intractable pain. Therefore, disclosing the role of the sympathetic block at the spinal level is valuable.

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  Currently, there is no structured protocol to approach to patients with narrowed airways. Here I mainly discussed the anesthetic management of patients with a huge mediastinal mass and summarized the practical problems to treat mediastinal mass syndrome.
  The first step is the preoperative evaluation, including physical examinations, radiological imaging such as CT or MRI, and pulmonary function test. Mass compression on the airways and/or the great vessels may induce a critical respiratory and/or circulatory insufficiency. We should pay attention to both the airway and great vessels in radiological imaging. Anesthesiologists should confer with cardiac surgeons as well as thoracic surgeons about the surgical procedures and the requirement of extra corporeal cardio-pulmonary support. Anesthesiologists should also consider the possibility of impossible ventilation, what kind of tracheal tube should be used and where the tip of the tracheal tube should be placed.
  In anesthetic management, induction of anesthesia is the first critical point. It might be possible that we cannot ventilate when spontaneous breathing ceases. Titration of the anesthetic is essential. If manual ventilation can not be established, we should stop administration of the anesthetic and PCPS or ECMO should be introduced. After establishing manual ventilation after cessation of spontaneous breathing, a small dose of muscle relaxant can be administered. Some anesthesiologists insists on avoiding the use of a muscle relaxant, but it is not essential. The true essential point is whether spontaneous breathing is remained or not. Even if we are able to establish manual ventilation and can succeed in tracheal intubation, we should not be assured. Catastrophic state may occur at any point during the surgical procedure.
  In conclusion, preoperative assessment of patho-physiological status of patients is the primary step and making a detailed strategy with thoracic surgeons and cardiac surgeons is really important.

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  Neuromuscular blockade is one of the major factors of general anesthesia. In clinical situations, anesthesiologists are requested to provide enough muscle relaxation through surgery, while it is necessary that patients regain muscle power immediately after surgery. Pharmacokinetic and pharmacodynamic knowledge are essential for “better anesthetic practice”. Pharmacokinetic characteristics of muscular relaxants are being water-soluble with small clearance and distribution volumes. Therefore, there is a wide range of individual differences and plasma concentration easily increases, which occasionally causes prolonged neuromuscular blockade. In 2010, sugammadex will be available in Japan, and we have to establish new regimens suitable for a new age of neuromuscular blockade.

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  General anesthesia requires immobilization of the patient. It is possible to immobilize the patient with neuromuscular blocking agents. However, if we administer analgesics and sedative agents, we acheive immobilization of an anesthetized patient without neuromuscular blocking agents. In this article, we consider the proper administration of remifentanil and propofol for total intravenous anesthesia without neuromuscular blocking agents.

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  The number of anesthesiologists who use remifentanil for preventing coughing and body movements during the intraoperative period instead of a neuromuscular blocking agent (NMBA) has increased. From the aspect of safety, using remifentanil instead of NMBA is riskier because it has a very short half-life. Meanwhile, over-administration of NMBA leads to postoperative residual curarization. Pharmacokinetic simulation and proper use of neuromuscular monitoring make anesthesia safer.

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  The effects of neuromuscular blocking agents usually vary among patients and are easily influenced by several factors like the species of the monitored muscle, the patient's age and the anesthetic. By knowing the wide variability of rocuronium-induced neuromuscular block, anesthesiologists should recognize that neuromuscular monitoring during general anesthesia is very important to maintain an optimum neuromuscular block for an individual.

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  Tachyarrhythmia is frequently seen during the course of SIRS and it is sometimes intractable. Sympathetic hypertonia and hyper catecholaminea, in addition to inhibited expression of L-type calcium channel and over-expression of active nitrogen species, account for the pathogenesis of tachyarrhythmia. Combined use of a phosphodiesterase III inhibitor and a β blocker is recommended to construct a treatment strategy.

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  Postoperative atrial fibrillation (POAF) is the most common complication following cardiac surgery, tending to occur 2 to 4 days after surgery in 30-60% of patients, with a peak incidence on postoperative day 2. POAF is associated with an increased risk of mortality and morbidity due to stroke and heart failure. Preoperative risk factors for POAF include age, enlargement of the left atrium, and hypertrophy of the left ventricle. Intraoperative risk factors for POAF are associated with extracorporeal circulation. Postoperative risk factors for POAF include hypervolemia, electrolyte imbalance, increased afterload, hypotension, and inflammation. Recently, new risk factors related to metabolic syndrome have been identified. POAF can be effectively prevented by administration of beta-blockers, amiodarone, statins, steroids, pacing, and off-pump coronary artery bypass grafting. Beta-blockers and amiodarone are particularly effective and are recommended by guidelines. The treatment of POAF includes rhythm control, rate control, and anticoagulant therapy. When POAF occurs in hemodynamically unstable patients, immediate electrical cardioversion must be performed. For those who are hemodynamically stable, an AV nodal blocking agent should be used to achieve rate control. If POAF does not convert to a sinus rhythm within 24 hours, anticoagulation measures should be initiated, and a rhythm control strategy should be implemented.

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  Despite the recent advance of anesthetic management such as remifentanil, unpredictable arrhythmias remain critical problem during perioperative periods. American College of Cardiology/American Heart Association guidelines for the management of tachycardia certainly helps us even in anesthesia. First, if the patient presents tachyarrhythmia, we should evaluate whether the patient is stable or unstable. Then, if the patient is unstable due to the tachycardia, immediate cardioversion is indicated. If the patient is stable, we should evaluate the ECG, then determine whether the QRS complex is narrow or wide and regular or irregular. A regular, narrow QRS complex tachycardia is presumed to be supraventricular tachycardia and should be treated with ATP. After sinus rhythm conversion, beta-blocker is indicated for preventing recurrence. An irregular narrow QRS complex tachycardia is presumed to be atrial fibrillation and should be treated with beta-blocker in order to control the heart rate. Landiolol hydrochloride, an ultra-short acting beta-blocker, has advantages in this situation. Patients treated with beta-blocker often make an excellent recovery from atrial fibrillation. If the blood pressure deteriorates, landiolol hydrochloride should be discontinued. Landiolol hydrochloride is also effective to treat ventricular tachyarrhythmia with Nifekalant hydrochloride during weaning of the cardiopulmonary bypass in cardiac surgery. In conclusion, anesthesiologists should use beta-blockers appropriately to treat tachyarrhythmia during perioperative periods.

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  Central venipuncture is one of the standard techniques taught to residents during their initial clinical training period. Although ultrasound-guided central venipuncture (US-CVC) has greater clinical efficacy than the conventional landmark technique, US-CVC is still not widely used.
  Establishment of a training system for US-CVC is key to popularizing this technique. Standardization of the US-CVC technique and development of effective training methods are required for developing this system. It is particularly important to train the instructor and to provide tools for training.
  Creating a training system for US-CVC is challenging, but tackling this issue now is important in order to ensure patient safety.

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  We report an endotracheal intubation in the semi-fowler position with the Airway Scope^® (AWS, S-100, HOYA-PENTAX, Tokyo, Japan) for a patient with ankylosing spondylitis (AS). AWS is expected to do the endotracheal intubation more smoothly than the fiberoptic bronchoscopy for patients in the semi-fowler position. We were able to perform endotracheal intubation for a patient in the semi-fowler position with the AWS.

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  We had a case in which a transesophageal echocardiography (TEE) probe migrated into the anterior mediastinum. The patient was a 62-year-old woman who had undergone mitral valve replacement (UMVR) for infectious endcarditis. The procedure was successfully finished. The TEE was inserted without any complications before the surgery and removed at the end of the surgery. However, postoperative bleeding from the ascending aorta was found after the MVR, and an emergency operation for hemostasis was performed. After the hemostatic procedure was completed, we inserted a TEE probe to examine whether aortic dissection had occurred. Insertion of the TEE probe was so difficult that the probe was inserted after a few tries. However, we found that the probe migrated into the anterior mediastinum while TEE was progressing. The oropharynx was perforated, and an operation to close it had to be performed. We considered several possible causes of the perforation. First, the operation was performed in an emergency situation and drapes were covering the patient's face at the time of TEE insertion. Second, the patient had been taking prednisolone over a long period of time which made her tissues fragile.

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  A 55-year-old female visited the emergency unit because of a bronchial asthmatic attack and abdominal pain. Though the bronchial asthmatic attack was not well-controlled even after treatment with steroid, an emergent operation for a strangulated umbilical hernia was scheduled. We underwent spinal anesthesia combined with epidural anesthesia, and used continuous infusion of ketamine as a bronchodilator and sub-analgesic, and propofol to reduce the stress during the surgery. After 2.0 ml of 2% lidocaine was injected through the epidural catheter, 1.7 ml of 0.5% hyperbaric bupivacaine was injected for spinal anesthesia, and analgesia up to Th8 was obtained. During the surgery, the bronchial asthmatic attack was well-controlled. About two hours after the beginning of spinal anesthesia, the patient woke up and complained of wound pain. But an additional injection of ketamine and local anesthetic through the epidural catheter were effective for the pain. Though the appropriate dosage of ketamine remains to be elucidated, our anesthetic management was useful for the patient with a bronchial asthmatic attack.

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  Numerous compact and high-performance video devices in airway management have recently become commercially available.
  It is the anesthesiologist's inventive approaches that integrate visual information from these various equipments to put easy-to-use device designs together in contrast to the manufacturer's efforts.
  In this report, we introduce a novel system of fiberoptic intubation employing a new video laryngoscope named COOPDECH^® VIDEOLARYNGOSCOPE PORTABLE, equipped with a CCD camera and LCD monitor, with a conventional video bronchoscope.
  We configure our video system by projecting a laryngoscopic image as a small display window on a bronchoscopic display, which we refer to as a “picture in picture” function. The “picture in picture” of our video system enabled us to provide simultaneous visualization of not only laryngoscopic but bronchoscopic views.
  With this system, practitioner, assistant and trainer can share integrated visual information from these two devices during fiberoptic intubation simultaneously.
  Thus, the design of the multiviewing system device can contribute to the improvement of safety and educational efficiency on fiberoptic intubation.

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  Forty adult patients scheduled for orthopedic surgery of the spine under total intravenous anesthesia were studied. They were anesthetized with propofol and remifentanil. Remifentanl 5 mg was solved with normal saline 16.7×50/body weight (kg) ml, and was contained in a disposable injector, Syrinjector 60^®. Remifentanil was administered continuously at 0.5, 0.3, or 0.2μg/kg/min using the disposable injector. Propofol was given continuously using a target-controlled-infusion device. The speed of the administration of remifentanil was selected based on the arterial blood pressure or heart rate of the patients studied. The anesthetic course was uneventful in all patients. However, lead pipe rigidity due to the administration of remifentanil occurred in 55% of patients during induction of anesthesia. Mean arterial blood pressure decreased to a value of less than 65 mmHg in 85% of patients. It is concluded that total intravenous anesthesia can easily and safely be performed using a disposable injector in which remifentanil is contained.

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[in Japanese]

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  We have previously reported the utility of the Pentax-AWS Airwayscope^® (AWS) as an intubation device during chest compressions at one institution. To validate and generalize the utility of AWS, we investigated tracheal intubation time during cardiopulmonary resuscitation (CPR) in manikins using Macintosh laryngoscope (McL) or AWS in 34 difficult airway management (DAM) workshop students and task forces from various institutions. In the McL trial, time to secure the airway was significantly longer in a chest-compression situation than in a non-chest compression situation (15.0±3.3 sec vs 20.7±10.2 sec, P‹0.01). In the AWS group, significant differences between chest compression or non-chest compression were not observed. The success rate of the tracheal intubation in McL was significantly lower than that of AWS (P‹0.01). AWS training may lead to the emergent intubation in the situation of CPR.

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  There are several advantages to using portable disposable infusing devices (Syrinjector^®). First, the initial costs of introducing their devices are very low and are paid by health insurance in Japan. Second, their mechanism is so simple that it is easy to educate medical staff members and patients on management of their devices. Therefore, misapplication of them is rare and it is not necessary to collect their waste devices. There are some disadvantages of portable disposable infusing devices, such as they have no recording or alarm systems. It is not variable to fine infusing dose in comparison with electric mechanical pumps. However, Syrinjector^® in particular has the advantages that its residual volume can be accurately and its button easily pushed for patient-controlled analgesia. Syrinjector^® has also the disadvantage of having a small reserved volume, but it has the advantage of having a light weight load on the patient.

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  There are several advantages to using portable disposable infusing devices (Baxter Infuser PCA). First, the initial costs of introducing their devices are very low and are paid by health insurance in Japan. Second, their mechanism is so simple that it is easy to educate medical staff members and patients on management of their devices. Therefore, misapplication of them is rare and it is not necessary to collect their waste devices. There are some disadvantages of portable disposable infusing devices, such as they have no recording or alarm systems. It is not variable to fine infusing dose in comparison with electric mechanical pumps. However, Baxter Infuser PCA has the advantage of being able to administer drug to a patient for a long period of time, especially over five days. Its disadvantages are that it is difficult to visually check its residual volume correctly and for the patient to push its PCA button on his or her own.

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  Intravenous patient-controlled analgesia (IV-PCA) has efficacy as a substitute for epidural anesthesia. CADD Legacy^® (Smiths Medical, St. Paul, MN, USA) is a medical device used for IV-PCA. It is easy-to-use and safe for patients. Its features and usage, as well as its advantages and disadvantages, are described.

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  Patient-controlled analgesia (PCA) is increasingly spreading in Japan to improve the quality of postoperative analgesia or analgesia for cancer pain. PCA is provided using either a mechanical infusion pump or a disposable infusion pump. Gemstar PCA pump is a new mechanical infusion pump provided by Hospira Japan Co., Ltd. and has two administration modes that include one regimen for PCA and seven regimens for various clinical settings including PCA. These pumps have improved upon the weak points of previous mechanical PCA pumps, thereby being suitable for Japanese users, who are not accustomed to dealing with mechanical PCA pumps. Although the Gemstar PCA pump has its drawback, such as its memory size and its portability, it is expected to be used effectively in broad clinical fields including the area of pain control.

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  It is an important approach for the improvement of safety in the practice of patient-controlled analgesia (PCA) for postoperative analgesia or treating cancer pain to observe the patients carefully and to confirm the accurate set-up and operation of the PCA pump. Acute pain service providers have to reconfirm whether the PCA pump is connected correctly with the prescribed catheter and to find out the adverse effects elicited by PCA during patient rounds. At the same time, the quality of analgesia also has to be evaluated. In particular, default information of the PCA pump and detailed information on the drugs used should be described in the medical charts for preventing an insufficient dose or an overdose of drug which decreases the quality of analgesia and increases the incidence of adverse effects.

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  Postoperative pain management is moving away from epidural analgesia towards increasing use of IV-PCA in Japan to avoid the risks associated with the former IV-PCA, in which a narcotic is continuously injected. It was originally devised to prevent an excessive dose of a single bolus injection of a long-acting analgesic like morphine. Using IV-PCA, the dose of narcotic can be individually adjusted to be optimal for each patient. IV-PCA is, therefore, expected to become ever more widely used in the future. In this article, I review the fundamental principles of IV-PCA, as well as how to employ it with frequently-used opioids, and give examples of actual cases of opioid administration.

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  IV-PCA can control postoperative pain effectively because opioid concentrations in the blood can be increased quickly. Control of postoperative pain with IV-PCA is prompt. IV-PCA has been widely used to treat postoperative pain. Patients' satisfaction with IV-PCA is high. Recent increasing demand of prophylactic postoperative anticoagulation has further increased the role of IV-PCA in postoperative pain control. Proper settings of IV-PCA are mandatory for a safe method of postoperative pain control. However, the side effects of opioids hinder effective postoperative pain control with IV-PCA. Some side effects can lead to severe complications. Early recognition, treatment, and prevention of side effects of opioids are important. We describe the side effects of opioids used for IV-PCA and their treatments.

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  Treatment of postoperative pain with IV-PCA using opioids is on the rise. However, there are some surgeons, nurses, and pharmacists who hesitate to use IV-PCA with opioids. PCA pumps have so many hidden functions that prompt resolution of malfunctions of the PCA pump is not easy on occasion. Problems with IV-PCA are various and include drugs, pumps, patients, and medical staff members. It is important to have knowledge about frequent problems related to IV-PCA and to create strategies to manage them in advance. We describe the problems with IV-PCA and their management.

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  Management of postoperative pain is very important for the recovery of patients after surgical operation, and it affects the outcome. Recently several studies revealed that epidural analgesia is useful for postoperative pain management. The techniques of drug administration into the epidural space include a single injection, continuous infusion and patient-controlled epidural analgesia (PCEA). In these, PCEA provides better pain relief than others. It is well known that the combination with a local anesthetic and an opioid is most effective for pain relief without the side effects. Drug selection of a local anesthetic or an opioid is necessary to understand their characteristics. Ropivacaine, levobupivacaine or bupivacaine are choices as the local anesthetic, and morphine or fentanyl as the opioid. Further research is needed for the choice of optimal drugs.

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  Patient-controlled epidural analgesia (PCEA) is a strong strategy for postoperative pain control in the clinical practice. However, adverse or side effects of PCEA which are relatively frequent sometimes leave patients dissatisfied. Those side effects include nausea/vomiting, itchiness, drowsiness, respiratory depression, hypotension, etc. We should pay attention to treat those side effects, which could be important in the safety and quality of postoperative pain management.

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  Although many studies have shown the advantages of postoperative pain management, life threat as well as side effects might be caused. Main side effects caused by patient-controlled epidural analgesia (PCEA) include epidural hematoma, epidural abscess, migratation into the subdural space and human errors. In this chapter, the measures taken against those side effects are described.

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