A growing number of studies in immature animal models have demonstrated degenerative effects of several anesthetics on neuronal structure and brain functions, such as social behaviors, fear conditioning, and spatial reference memory tasks when exposed during the early stages of life. Recently, a population-based, retrospective, birth cohort demonstrated that early (prior to 4 years of age) exposures (multiple, not single) to anesthesia resulted in learning disabilities later in life. This suggests that exposure to anesthesia is a significant risk factor for the later development of learning disabilities in children receiving anesthetics. Another retrospective study demonstrated that behavioral disturbances were more severe in younger patients. These results suggest that the immature brain is more susceptible to anesthetics.
  One of the recent topics in neuroscience is that the major inhibitory neurotransmitter GABA necessarily evokes excitation in immature brain, in contrast to inhibition in adult brain. Such excitatory GABA actions may be involved in neural circuitry development promoted by neuronal proliferation, differentiation, migration, and synaptogenesis. Since GABA_A receptor is a Cl⁻ channel, such a developmental switch of GABA action between inhibition (Cl⁻ influx) and excitation (Cl⁻ efflux) is induced by changes in Cl⁻ gradient produced by cation-chloride cotransporters (NKCC1, a Na⁺, K⁺-2Cl⁻ cotransporter, takes up Cl⁻ and KCC2, a K⁺-Cl⁻ cotransporter, extrudes Cl⁻ out of cells). This suggests that GABA action in human neonates could be excitatory. Therefore, if GABA_A receptor activating drugs are used with intention to augment inhibitory GABA effects, unexpected and deleterious effects could be induced to the immature brain.
  Several animal studies have demonstrated that sevoflurane and isoflurane, which bind to GABA_A receptors, exhibit deleterious effects on neuronal survival and neurogenesis when exposed at early periods of life. These results suggest that anesthetic agents that act on GABA_A receptors could result in cytotoxic effects possibly due to high intracellular Cl⁻ concentrations.
  GABA exhibits tremendous action on the developing brain, such as neurogenesis, migration, synaptogenesis, and excitatory transmission. Therefore, anesthetics or drugs that act on the GABA_A receptor could greatly influence brain development at any stage of development. These findings provide novel insights into the deleterious consequences in children following prenatal or neonatal exposure to GABA-potentiating drugs.

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  Even pediatric anesthesiologists were indifferent to perioperative pain management in children because they might be too concerned about the untoward effects of opioid and believe the myths that neonates and infants do not feel severe pain compared to adults because the nervous system is less developed. A lot of evidence has revealed that even neonates feel as much pain as adults and sometimes showed exaggerated reactions to pain. Since then, it is typical to give potent analgesics and/or to perform regional analgesia not only during surgery but also postoperatively. Patient-controlled analgesia is a very useful and reliable measure, especially for older children, because analgesics can be administered whenever they feel pain.
  Many open surgeries have been converted to laparoscopic surgery, but the procedure has brought many disadvantages to children, and we pediatric anesthesiologists should protect physiologically immature children with accurate anatomical and physiological knowledge. Furthermore, the rule of fasting has been changed to be more patient-friendly, and the prevention of postoperative delirium after sevoflurane anesthesia has been discussed all over the world.

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  A large number of devices similar to the laryngeal mask airway (LMA) have been developed for anesthesiologists. The ProSeal LMA (PLMA) has now become one of the standard tools for maintenance of the airway during general anesthesia. However, the LMA family requires training to be used skillfully. Lectures have therefore been created to facilitate placement of PLMA. From the viewpoint of a recent trend, our clinical studies, intended to be useful in clinical situations, were introduced.

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  Preoperative amino acid infusion was reported to prevent postoperative hypothermia during both general anesthesia and spinal anesthesia, due to nutrient-induced thermogenesis. Amino acid solution was revealed to activate thermogenesis by stimulating muscle protein synthesis via elevated insulin secretion. Valine showed a greater thermic effect of inhibiting perioperative hypothermia than any other single amino acid or amino acid solution. Valine increased thermogenesis by specifically stimulating lipid metabolism in the brown adipose tissue. The thermic effect of Valine was ineffective in the human adult with no brown adipose tissue.

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  Anesthesiologists play a crucial role in the ever-changing healthcare environment. It is not too much to say that hospital financial survival depends on whether anesthesiologists and hospital management teams recognize their importance and act strategically. In this article, we discuss hospital management in terms of the role of anesthesiologists, focusing on the following three points: 1) anesthesiologists in the hospital organization, 2) efficient operating room management, and 3) recruiting strategy of anesthesiologists.

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  Recently, the patient's perspective on medical outcomes has become very important in the management of medical practice. It is proposed in this paper to introduce a PDCA cycle and a statistical modeling approach into anesthetic practice on the basis of the Donabedian model. The objects of these introductions are to integrate the elements of anesthetic practices into the systemic form focused on patient-oriented outcomes, and then feedback the accumulated data in order not only to improve the anesthetic management system, but also to visualize the relationship between the patients' outcomes and anesthetic practice elements. In this paper, the author describes the postoperative nausea and vomiting model and the postoperative analgesic management model. It may be useful to incorporate these trials into medical students' understanding of anesthesia and to help improve young anesthesiologist's skills.

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  When establishing a management strategy for an acute hospital, knowledge of Diagnosis Procedure Combination (DPC) is indispensible. This also applies to the surgical as well as anesthesia personnel. In order to increase profit within a DPC system, the use of generic medicine, switching over to outpatient imaging scans, etc., have been highlighted, but an increase in revenue is anticipated through the appropriate coding, which can be also considered as the basis of the DPC system.
  However, the benefits gained by a DPC targeted hospital switching over from a performance system should be invested in the maintenance of the hospital information system within the hospital, and an attitude of active public openness regarding clinical indicators is desired. In particular, continuing to acknowledge not only the DPC data presented currently to the Ministry of Health, Labour, and Welfare, but also the valuable raw data within the hospital, and consideration of the effective utilization of such data, is expected.

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  This article discusses the usefulness, inherent problems and limitations of pulmonary artery catheterization (PAC), an invasive monitoring approach, and minimally invasive monitoring.
  One should be equipped with the knowledge and techniques necessary for PAC in order to enhance its usefulness. It is necessary not only to accurately select patients in whom PAC is indicated and correct interpretation of information obtained by PAC, but also to ensure safety measures to prevent complications. Noninvasive monitoring should be applied to patients who meet the requirements, with the understanding of the characteristics of such method, and with full recognition of its limitations.

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  Pulmonary artery catheter (PAC) is the one of the most common invasive monitors in critical care and intraoperative patients. Regardless of its extensive use, PAC has failed to show strong evidence of demonstrated benefits. The purpose of the clinical use of PAC is early detection of hemodynamic deterioration, and this leads to aggressive therapy with catecholamines, vasodilators and volume expansions, based on obtained PAC data. The important characteristic of PAC is continuous, vigilance monitoring. This is especially important when transesophageal echocardiography (TEE) is not continuously available, such as in postoperative intensive care units. TEE might elucidate every cause of hemodynamic exacerbations, but it is not continuous monitoring. Although specific training in PAC utilization and data interpretation is mandatory, early detection of hemodynamic changes by PAC followed by meticulous investigations with TEE must warrant improvements in patient outcomes.

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  Pulmonary artery catheter (PAC) has been widely used for cardiac output and hemodynamic monitoring. However, the clinical usefulness of the PAC has been seriously questioned, because randomized controlled trials showed that using the PAC did not change mortality but rather increased morbidity. Fortunately, several noninvasive alternative technologies to the PAC have emerged. Cardiac output can be approximated by the indirect Fick method applied to carbon dioxide, called partial carbon dioxide rebreathing technique. When minute ventilation is kept constant during mechanical ventilation, the partial carbon dioxide rebreathing technique can provide reliable monitoring of cardiac output. Analysis of arterial pressure waveform has also been proposed to measure beat-by-beat stroke volume and hence continuously measure cardiac output, called pulse contour analysis. Stroke volume variation derived from this technique is proposed to predict fluid responsiveness.

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  The FloTrac system is composed of the FloTrac^TM sensor and Vigileo monitor^TM (Edwards Lifesciences, Irvine, CA). The FloTrac system uses arterial pressure-based cardiac output: APCO, which is based on the relationship between pulse pressure and stroke volume. This principle, as well as recent advances in signal processing, has led to the development of a novel system that can continuously measure cardiac output from an arterial pressure waveform that does not require an external calibration reference method. The latest FloTrac system software (Ver. 3.02) shows the highest degree of precision compared to PAC values. Modification of the software, such as assessing differences in systolic/diastolic area and time ratios based on the dicrotic location analysis, has resulted in improved accuracy in measuring cardiac output.
  SVV calculated by the FloTrac system is a useful predictor of increased CO in response to volume expansion (VE), and the FloTrac system is able to track changes in CO induced by VE. The FloTrac system is considered to be useful as a monitoring device in clinical practice.
  In conclusion, our findings suggest that dynamic indices, such as stroke volume variation (SVV), are able to adequately predict the individual response to fluid loading, and can reliably predict fluid responsiveness compared to routinely used static variables of cardiac preload, such as filling pressures (central venous pressure, CVP, and pulmonary artery occlusion pressure, PAOP) in fluid optimization.

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  Transesophageal echocardiography (TEE) has well-established utility in cardiac surgery. TEE is also considered an effective monitor during noncardiac surgery because of its limited invasiveness. We used TEE in laparoscopic surgery and pneumonectomy, which may compromise hemodynamic function. The peak A-wave velocity on transmitral Doppler flow (TMDF) increased because the internal pressure of the thoracic cavity was increased by pneumoperitoneum. The peak E-wave velocity on TMDF decreased because left atrium filling decreased after pneumonectomy. In addition, the atrial septum showed paradoxical motion after pneumonectomy. However, systolic and diastolic functions were not greatly affected during either operative procedure. Although TEE operators need appropriate training, TEE monitoring in noncardiac surgery is useful because of the amount of information recorded and its limited invasiveness.

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  Suppression of the sympathetic nerve activity and stimulation of the vagus nerve in anesthetic management is known to be cardioprotective. However, excessive activation of the vagus nerve may induce hemodynamic collapse. Thus, it is very important to maintain the appropriate balance of activity of the sympathetic and the vagus nerves. It has been well elucidated that there are several signal transduction components in the heart following activation of the sympathetic and the vagus nerves. I suggest that the combination of activation and inhibition of these components by specific pharmacological agents may be a future style of myocardial protection during perioperative management.

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  Stress response is one of the most important host defense mechanisms for insults. Stress-induced hyperglycemia is caused by increased glycolysis and gluconeogenesis, impaired glucose use and decreased insulin secretion. Three sets of data appeared almost simultaneously, thus drawing attention to the control of hyperglycemia. First, high glucose levels resulted in inflammatory and oxidative stress. Second, insulin was found to suppress reactive oxygen species (ROS) generation and activation of the inflammatory process. Third, intensive insulin therapy and glucose control in a critical care setting reduced mortality and morbidity. However, the NICE SUGAR study reported intensive insulin therapy might actually increase mortality. Autophagy is a self-degradative process that is important for balancing sources of energy in response to nutrient deprivation stress. Excessive up-regulated autophagy may induce cell death that is different from apoptosis and necrosis. These observations generated considerable discussion about the wisdom of tight glucose control and nutritional management in critically ill patients.

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  The detailed mechanisms which cause heart failure have remained unclear. Previous studies demonstrated a correlation between oxidative stress markers and the severity of heart failure, indicating a crucial role of oxidative stress in the pathogenesis of heart failure. Superoxide appears to be one of the reactive oxygen species affecting oxidative stress in the heart. This oxygen-derived free radical is metabolized to hydrogen peroxide via superoxide dismutase (SDO), and hydrogen peroxide is subsequently detoxified into oxygen and water by catalase. It is important to note that superoxide is a precursor of many reactive oxygen species. Recent studies also documented a role of NADPH oxidase in oxidative stress in many organs including the heart. Oxidative stress produced by a relative increase in intracellular levels of superoxide is capable of inducing heart failure as well as cardiac dysfunction, resulting from hypertension, diabetes mellitus, obesity, inflammation and aging. Possible candidates for inhibitors toward cardiac oxidative stress in clinical practice are statins, angiotensin receptor antagonists and/or peroxisome proliferator-activated receptor agonists. However, it is still unclear whether anesthetics can regulate oxidative stress in the heart.

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  Rho-kinase is one of the effectors of the small GTP-binding protein Rho. Rho/Rho-kinase pathway plays an important role in various physiologic functions, such as vascular smooth muscle contraction and proliferation, cell migration, and gene expression. Increased activity of Rho-kinase has been shown to be involved in the pathophysiology of vasospasm in coronary artery and cerebral artery, arteriosclerosis, hypertension, pulmonary hypertension, and ischemia/reperfusion injury in the heart and the brain. Fasudil, a Rho-kinase inhibitor, is clinically available in Japan for the treatment of vasospasm after subarachnoid hemorrhage. Rho-kinase inhibitors have been reported to have protective properties against a wide range of cardiovascular diseases and neurologic diseases including ischemic brain injury and neuropathic pain. Rho-kinase inhibitors may be efficacious therapeutic ways to treat various kinds of diseases.

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  The advantages of intraoperative use of epidural anesthesia combined with general anesthesia include easier anesthetic management and the capability of postoperative pain management. Studies have shown that several harmful responses that occur in the human body from surgical stress as well as related postoperative complications can be prevented by the analgesic and sympathetic nerve block effects of epidural anesthesia. There is an increasing number of patients who cannot receive epidural anesthesia because of anticoagulant administration. On the other hand, some new alternative analgesia methods have been reported recently, such as peripheral nerve blocks. Therefore, it is considered likely that a relatively high quality of perioperative management can be achieved without epidural anesthesia. However, epidural anesthesia has some unique advantages, including a preventive effect on postoperative complications. We believe that it is important to continue the use of epidural anesthesia combined with general anesthesia when indicated.

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  Spontaneous leaks of cerebrospinal fluid (CSF) from the meningeal diverticulum or the root sleeves cause intracranial hypotension ; spontaneous cerebrospinal fluid hypovolemia (SCH). The most typical feature of SCH is an orthostatic headache which is painful in the upright position and is relieved by recumbency. Nausea caused by the irritation of the meninges is often seen and the disorders of visual and hearing functions are also observed. Diffuse dural enhancement is the essential finding in magnetic resonance imaging of SCH. Radioisotope cisternography and CT myelography are used to detect the point of the CSF leakage. An epidural blood patch is necessary for the patient who didn't recover by bed rest and fluid intake for a couple of weeks.
  During a decade in Japan, the presence of “traumatic” cerebrospinal fluid hypovolemia (TCH) has been a matter of debate. Supporters of TCH have declaired that the CSF leakage from the lumbar meninges can occur from trauma such as traffic accidents and can be proved by RI cisternography. We found out that the RI collection at the lumbar spine is not a leakage of CSF but a normal root sleeve without any epidural collection of CSF by CT myelography. We claim that the presence of TCH is suspicious.

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  We, anesthesiologists, have some chance to perform fiberoptic tracheal intubation due to the anticipated difficult airway in elderly patients with chronic rheumatoid arthritis or cervical spondylosis, and so on. Because of their concomitant cardiovascular complications, careful attention should be paid to hemodynamic changes during fiberoptic tracheal intubation. In those patients, we have chosen the anesthetic-induction technique of inhaled high concentration sevoflurane and maintenance under spontaneous breathing during fiberoptic tracheal intubation. Sevoflurane inhalation under spontaneous breathing can provide suppression of the airway reflex with adequate analgesia as well as maintain oxygenation and hemodynamic stability. In this article, we introduce our procedure of fiberoptic tracheal intubation under general anesthesia by inhaled sevoflurane.

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  The aim of this study was to examine intubating conditions with 0.5 mg/kg rocuronium after anesthetic induction with 1μg/kg/min remifentanil, 1 mg/kg lidocaine and 2 mg/kg propofol, in adult patients who had been scheduled for laryngomicrosurgery. Twenty-five patients were randomly assigned to the groups treated with or without rocuronium. The patients were intubated tracheally and the intubating conditions were evaluated. Intubating conditions after rocuronium were all graded excellent. In contrast, inadequate conditions for safe and easy tracheal intubation were observed in the group not receiving rocuronium. For short-duration surgeries, 0.5 mg/kg rocuronium is appropriate to perform safe tracheal intubation 2 minutes after administration of rocuronium, however, induction with remifentanil, lidocaine and propofol provides a even safer intubating conditions.

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  A 38-year-old woman with cardiac failure was scheduled for an urgent appendectomy. She was classified as NYHA class IV and her cardiac ejection fraction was 14%. Antiplatelet drug and anticoagulant had been administered just before surgery. She received a transversus abdominis plane block with 30 ml of 0.75% ropivacaine and was given fentanyl intravenously. Hemodymamic status was stable during the surgery and no analgesic agent was needed. An ultrasound-guided transversus abdominis plane block with a small dose of intravenous fentanyl is suggested to be useful for anesthetic management in patients with severe cardiac failure.

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  A 21-year-old man diagnosed with thoracic spine tumor was scheduled for resection of the thoracic tumor and posterior thoracic spinal fixation. This operation had to be performed on one-lung ventilation in a prone position. We used a four-point support frame to maintain dynamic compliance and used rigid head pin fixation to secure the working space. Hypoxemia during one-lung ventilation was treated using continuous positive airway pressure in the non-ventilated lung. An understanding of respiratory physiology is essential for one-lung ventilation in a prone position and management of disturbances in ventilation-perfusion matching caused by hypoxic pulmonary vasoconstriction.

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  A 76-year-old man underwent insertion of bare metal stents into his right coronary artery (segment 2) and left anterior descending coronary artery (segment 7). The patient was scheduled for resection of meningioma 108 days after the coronary intervention. Aspirin and clopidogrel were discontinued 18 days before the surgery. The surgery was successfully performed and there were no intraoperative signs of myocardial ischemia.
  We did not resume the antiplatelet therapy immediately after the operation because of the persistence of postoperative bleeding. At 16 hours after operation, his electrocardiogram showed bradycardia and atrioventricular block, and both troponin T and CPK-MB in plasma were elevated. The patient was diagnosed as having acute coronary syndrome.
  Although no definite guidelines for perioperative antiplatelet therapy in cases undergoing neurosurgery exist in Japan, the therapy should be restarted as soon as possible after surgery.

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  We report 3 adult cases that presented with extremely severe emergence delirium after a short period of general anesthesia with concomitant use of low dosages of remifentanil over relatively short periods. In all 3 cases, severe emergence delirium continued for 30 minutes or more. This created risks for the staff as well as the patients themselves, and many staff members were required. We have to take the possibility that remifentanil administration causes emergence delirium into consideration.

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  We report a case of unanticipated difficult airway with lingual tonsil hyperplasia in which intubation with fiberoptic bronchoscope (BFS) under Pentax-AWS Airwayscope (AWS) observation was effective. A 33-year-old man was scheduled to undergo submucous resection surgery for deviation of nasal septum. After propofol and fentanyl administration, we encountered upper airway obstruction which was alleviated by oropharyngeal airway insertion with spontaneous breathing. We could not intubate orally with a Macintosh laryngoscope or under BFS. With AWS, we were able to observe hyperplasia of the epiglottis but not set the target mark to the glottis. Under AWS observation, we could perform tracheal intubation with BFS.
  We conclude that AWS using the BFS procedure is useful for patients with difficult airway which is impossible to secure the airway with AWS or BFS alone.

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