Dexmedetomidine (DEX) is currently used as a sedative with or without artificial ventilation in critical care patients in Japan. Originally, DEX had been investigated as an adjunct to general anesthesia in order to decrease the dose of inhaled anesthetics. However, clinical investigation of it as an adjunct to general anesthesia was suspended worldwide. Recently, the unique property of DEX, i.e., the fact that it exhibits almost no respiratory depression, has favored its development as a sedative in monitored anesthesia care (MAC) during surgery. In the United States, DEX was approved in 2009 as a sedative during awake fiberoptic intubation and MAC. In this manuscript, we describe our experiences using DEX as an adjunct to anesthesia during a neurosurgical procedure, as a sedative during awake fiberoptic intubation, in MAC during closure of the head after awake craniotomy, or in MAC during bronchoplastic surgery in a patient with bronchial stenosis. Our experience suggests that DEX is a very useful and safe sedative in patients with spontaneous ventilation without any airway device, especially in the case of airway stenosis. The approval of DEX as a sedative during MAC in Japan is expected.

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  Recently, ultrasound imaging has been used to assist or guide epidural block, and it appears to be a promising alternative to the traditional landmark-based technique. A pre-puncture scout scan allows the operator to determine the optimal puncture point, as well as the trajectory and depth of the needle insertion. Therefore, it may reduce the length of the procedure and improve it by avoiding multiple attempts at needle placement, pain and discomfort to the patient, injury to soft tissue structures that lie in the path of the advancing needle, a failed block, and frustration for the anesthesiologist.
  In January 2008, NICE (National Institute for Health and Clinical Excellence of the United Kingdom) produced the guidance: ultrasound-guided catheterization of the epidural space may be helpful in achieving correct placement.
  Acknowledging the guidance, we have conduct the procedure using the paramedian oblique sagittal view of ultrasound from May 2008. In this article, we describe the pitfall and problems with it, from our 18 months' experience.

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  Recently, Oriental medicine appears to be playing a more important role in the practice of pain clinic. Among the various modalities of its treatment, Kampo (herbal) medicine and acupuncture/moxibustion are the two main strategies which have been utilized for pain patients for centuries. Some Kampo remedies can be prescribed successfully without the deep knowledge and understanding of Oriental medicine, although this is rarely the case in difficult pain problems. In acupuncture, there are also some effective input programs for pain patients which can be performed with limited knowledge and techniques. These are, however, often regarded as symptomatic treatments which often have a merely temporary effect. A complete and systematic acupuncture treatment can only be accomplished when root therapy (radical therapy) is incorporated with the more sophisticated Oriental diagnosis and treatments. For pain problems, diagnosis of “deficiency and fullness”, “Qi, blood, and body fluids”, or “Zang Fu”, based upon classic Chinese literature and textbooks, is especially important and the patients should be treated accordingly.

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  The Anesthesia and Simulation Center was built for education and training by using high-fidelity mannequin-based simulator (HPS) in April, 2007. The Anesthesia and Simulation Center is running as a cooperative facility of twelve affiliated hospitals by the Hyogo Prefectural Government.
  We accept residents, nurses and doctors as trainees working at prefectural hospitals and waive the training fee for them, but residents, medical students and nurses working at hospitals other than the prefectural hospitals must pay the fee. We have adopted anesthesia crisis resource management (ACRM) as a major focus of their training.
  It includes respiratory care, resuscitation and critical incidents during the perioperative period during a 3-day course for residents and a 1-day course for medical students.
  We also describe in this paper the problems now facing the building of a new simulation center in Japan.

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  Our anesthesiology department has been using the High Fidelity Human Patient Simulator (HPS) for medical students and residents since 1999. HPS can provide good simulator-based training to improve the skills and understanding of not only anesthesiologists, but also intensivists. After ten years, our problem is that our HPS is getting old. The importance of simulator-based training has been increasing in the medical field recently, and some other problems urgently need to be solved.

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  Obstetric hemorrhage is the first cause of maternal death. Massive obstetric hemorrhage is highly likely to occur unexpectedly and suddenly, and because the rate of hemorrhage is rapid and disseminated intravascular coagulation is likely to develop early on, treatment measures for hemorrhage may be delayed. Hemorrhagic conditions also differ depending upon whether it occurred at the time of Caesarean section or after vaginal delivery. Moreover, risk for hemorrhage can be expected in some cases but not in other cases. In light of the characteristics of obstetric hemorrhage, we herein report guideline-based measures for the occurrence of obstetric hemorrhage, such as the appropriate selection of anesthesia methods and certain preparatory measures, depending on the different hemorrhagic conditions and causative diseases. We also describe future management of obstetric hemorrhage, including how methods of anesthesia may change with the advent of new strategies such as catheter intervention.

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  We report the current state of blood transfusion in the Obstetric Department at Saitama Medical Center from the blood transfusion service division's viewpoint. Saitama Medical Center hospital has 913 beds and 92 total beds in its integrated perinatal medical center (46 obstetric departments). Through January 2005 to August 2009, they used 2,312 units of red cell components (313 cases), 4,593 units of fresh frozen plasma (220 cases), and 1,725 units of a platelet concentrate (81 cases) at the Obstetric Department. In 24 cases, more than 20 units of red cell components were transfused to each patient. Fourteen cases in 24 massive transfusion cases required urgent transfusion without the crossmatch test. It took an average of 5 minutes and 26 seconds for preparation. The blood transfusion service should be straightening the system that can correspond to urgent, numerous transfusions at any time, although a change is feared in the blood supply situation due to consolidation of the blood center.

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  For critically ill, ventilated patients, protocol-based, light sedation is gaining more and more popularity to minimize the adverse effects of sedatives. A substantial body of clinical data shows that the use of sedation protocols with daily sedation interruption reduces ventilator days and length of ICU stay, along with a potential improvement of long-term survival rates. To maintain a minimum level of sedation, the initial step is to identify and treat any possible causes of patient discomfort including pain, anxiety, and delirium. Of these factors, pain is always the main target. In this review, the concepts, background, validity, clinical regimens, and adverse effects of analgesia-based sedation are discussed.

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  Until recently, our sedative protocols consisted of regimens including mainly propofol, which is a hypnotic based sedation. By using sedative/analgesic indices such as the Ramsay Score, Richmond Agitation-Sedation Scale or face score, the intensivist's supervisory sedative protocols can easily direct the nurse's sedative management. Now, the new concepts of daily interruption of sedation and spontaneous breathing trial tend to change the sedative regimens and weaning from mechanical ventilation. So many patients will undergo propofol and/or dexmedetomidine in combination with fentanyl. In this issue we consider hypnotic/analgesia based sedations, by presenting the role of sedative/analgesic scores associated with ICU management protocols in mechanically ventilated patients.

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  In the past, tracheal intubation was sometimes associated with serious airway complications, such as necrosis of the tracheal membrane and tracheal stenosis. Currently, one major cause of airway obstruction after induction of anesthesia is repeated attempts at tracheal intubation. In addition, even in patients in whom tracheal intubation was easy, injury to the larynx can occur. Therefore, it is necessary to select a tracheal tube which has a less invasive cuff and tracheal tube tip, and which has a higher success rate of intubation. A reinforced tube, the Parker tube, and a tube for the intubating laryngeal tube meet these criteria and thus should be used, particularly in patients with difficult airways, to minimize the airway complications associated with tracheal intubation.

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  We investigated the influence of cervical sympathetic nerve block (CSB) on buccal and palatal mucosa blood flow, cheek surface temperature and thumb perspiration.
  Ten healthy volunteers (aged 26.3±6.3 yr, ht. 171.5±4.9 cm, wt. 70.7±13.2 kg) were given CSB at the transverse process of the C6 vertebra, induced by 6 ml of 1% mepivacaine. The changes in blood flow, perspiration and temperature on the CSB side were measured. The buccal mucosa and palatal mucosa blood flow significantly increased after CSB and continued for approximately 15 min. and 30 min., respectively (P<0.05). The cheek surface temperature increased after CSB and continued for 30 min. (P<0.01). Thumb perspiration after CSB did not change. These results suggest that the CSB at the transverse process of the C6 vertebra may affect the oral and facial area and buccal and palatal mucosa blood flow, and cheek surface temperature may be a good index of the treatment effect.

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  A 37-year-old woman with pregnancy-induced hypertension at 33 weeks of gestation developed severe symptoms of heart failure and was admitted to our hospital. The patient was diagnosed with peripartum cardiomyopathy by echocardiography, which showed severe left ventricular systolic dysfunction (ejection fraction, 29.7%). An emergency cesarean section was performed under general anesthesia. She was managed in an intensive care unit perioperatively. She was extubated successfully the day after the operation. She was given bromocriptine, and left ventricular contractility improved after a month. Early diagnosis and effective treatment reduces the mortality rate and improves the prognosis of peripartum cardiomyopathy. We conclude that anesthesiologists play an important role in perioperative management of peripartum cardiomyopathy.

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  Two patients suffering from chronic intractable pain were treated with intravenous patient-controlled analgesia (PCA) with fentanyl. During the course of the PCA therapy, the pain was not relieved sufficiently when the patients had a relatively long infusion line for PCA which was connected to a continuous intravenous infusion line. Side effects associated with fentanyl, such as drowsiness, were also observed. We then connected the PCA system to the most proximal part of the continuous intravenous infusion line in order to obtain a rapid onset of fentanyl action with administration of a single bolus injection. This improved the pain relief and decreased the side effects. Hence, we believe that the length of the infusion line may be an important factor in determining the adequacy of pain control during PCA with fentanyl.

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  A 67-year-old female patient was scheduled for colectomy. Subclavian vein catheter was inserted under local anesthesia one week before the operation. The postinsertion chest X-ray film did not detect a pneumothorax, and the patient did not complain of chest pain or respiratory distress. Anesthesia was induced with propofol and maintained with nitrous oxide/sevoflurane and epidural anesthesia. During the surgery, airway pressure was almost normal, and the value of pulse oximetry was almost stable at around 97%. After extubation, the value of the pulse oximetry decreased remarkably and became 89%. Right pneumothorax was found on a chest X-ray, and at thoracic drainage tube was inserted. In a patient with subclavian vein catheterization, even if the catheter was inserted a week ago, it is necessary to take care not to overlook intraoperative delayed pneumothorax due to positive pressure ventilation and administration of nitrous oxide.

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  We examined the postoperative respiratory complications of eight patients with myotonic dystrophy (MD) and analyzed the risk factors for these complications. Two patients suffered from postoperative respiratory complications which needed long-term mechanical ventilation, one patient suffered from aspiration pneumonia, and the other patient from respiratory failure due to respiratory muscle weakness. These two patients complained of difficulty in standing and dysphagia which is indicative of advanced MD, and hypercapnea preoperatively, and underwent open heart surgery. The other six patients with no postoperative respiratory complications underwent less invasive, non-open heart surgery, and the MD of most of these patients was at an early stage. This study shows that special precautions to avoid postoperative respiratory complications are mandatory for patients with advanced MD who undergo major surgery, especially open heart surgery.

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  This is a report of a middle-aged female patient on hemodialysis (for diabetic nephropathy) suffering from a severe burning pain in the anus. The pain was regarded as an unpleasantness following manipulation to remove rock-hard stool. Proctoscopically, a herpes zoster-like lesion was observed in the right side of the anal canal, innervated by the 5th sacral nerve. The lesion was of tiny vesicular papules which bled easily and was diagnosed as either herpes zoster or herpes simplex. The dose of the antiviral drug was halved due to renal failure. Prostaglandin E1 ointment was added. An antidepressant was started in the early phase. The skin lesion healed and the pain disappeared 33 days later. Complement fixation titers for both herpes zoster virus and herpes simplex virus were 16 times 180 days later. Herpes zoster or herpes simplex should be considered in the case of pain in the anus. For visual diagnosis, it is mandatory to observe the anus as far as the dentate line.

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  Pain after rotator cuff repair is one of the major factors preventing the expansion of joint motion range during postoperative rehabilitation, and thus early expansion of joint motion range is largely affected by postoperative pain control. In this study, we examined the analgesic effects of continuous postoperative brachial plexus block (0.1% ropivacaine, 6 ml/h) and the postoperative range of joint motion in 15 patients who underwent arthroscopic rotator cuff repair. The median VAS was 2.3 cm at rest on the day after surgery, and 4.4 cm at the maximum elevation of the shoulder joint, which decreased thereafter. Passive joint motion range of 120° was achieved on postoperative days (POD) 6.8. The passive joint motion range was 140° on POD 10, and the spontaneous joint motion range was 136° on POD 90. Continuous brachial plexus block decreased postoperative pain, enabling expansion of the range of joint motion.

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  Perioperative bleeding is a major factor for adverse events. Recently, blood transfusion as intervention for hemorrhage has also been reported to be associated with the pathogenesis of adverse events. Prompt and adequate amount of fluid infusion/blood transfusion management and avoidance of unnecessary transfusion for intraoperative bleeding would improve the prognosis of surgical patients. Traditionally, anesthesiologists measured perioperative hemoglobin (Hb) concentration to estimate the degree of anemia and oxygen delivery in surgical patients. When massive intraoperative bleeding occurs, it is necessary to measure Hb concentration and detect the circulating blood volume deficit to maintain the oxygen supply to tissues. Recently, continuous monitoring of total hemoglobin (SpHb) and Pleth Variability Index (PVI), which is a new fluid-responsiveness measurement, are now possible with a Pulse CO-Oximeter developed by Masimo. Here, I describe the reliability of SpHb monitoring, and the effectiveness and limits of the simultaneous monitoring of SpHb and PVI on perioperative circulatory management.

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  International Association for the Study of Pain defines pain as “An unpleasant sensory and emotional tissue damage, or described in terms of such damage”. This means that pain is a completely subjective sensation. Therefore, it is very difficult to evaluate this sensation quantitatively. We must, however, try to evaluate pain in the clinical field because the evaluation of pain is indispensable for the diagnosis of diseases and the selection of treatments. Some methods to evaluate pain such as pain scales, pain questionnaire, devices for the measurement of the degree of pain, and drug-challenge test with pharmacological analysis of pain are described in this article.

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  In recent years, there have been several reports of the usefulness of perfusion index (PI), and pleth variability index (PVI), measured with a pulse oximeter manufactured by Masimo Corporation, in the evaluation of the peripherally circulating blood volume and management of transfusions. In the present study, we tested and confirmed that it was possible to evaluate autonomic inhibition under general anesthesia by observing pulsatile components in the measurement sites (observation of PI). Furthermore, we examined whether the PVI obtained from respiratory variations in PI is useful as an index of fluid responsiveness, in comparison with the preceding arterial pressure wave-derived cardiac output (APCO).

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  The observations of the epidural space and the treatments for epidural adhesion by epiduroscopy have been widely developed. The indications of epiduroscopy have become more prevalent for the treatment of low back pain and melosalgia due to lumbar disc hernia, spondylosis deformans, failed back syndrome, and spondylolisthesis. The methods of epiduroscopy and the outcome of our results are introduced. In the future, the indications for epiduroscopy, elucidation of the analgesic mechanisms of pain and survey of the long-term prognosis for patients with intractable, chronic lumbar pain who have received epiduroscopy should be investigated in multiple facilities.

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  Epiduroscopy is a new technique for the treatment of chronic low back pain. A historical review of the medical literature shows that clinicians have been working with various types of spinal canal endoscopes for more than 60 years, with varying degrees of success. Today, epiduroscopy/spinal canal endoscopy could be an option for pain management of intractable low back pain.

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  Fifteen years has passed already since the introduction of epiduroscopy. Its therapeutic efficacy has been estimated and confirmed in many countries and facilities. In this article, we retraced the several technical improvements in epiduroscopy research organization in Japan, some of which are the positioning of the patient, irrigation speed of the intra-epidural space by the saline, pain reduction mechanism and so on. We also list several problems to solve in the future such as clear visualization by the introduction of the disposal glass fiber tip, cervical or thoracic level visualization, prevention of radiation-induced diseases in the surgeon and so on.

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  We have 144 cases of epiduroscopy used to treat patients with chronic low back pain and lower limb pain during 2002 to 2009. The efficacy rate of the first 58 cases was 56.9% and that of the last 86 cases was 60.5%. The efficacy rate has not improved with the number of experience. Such a low effectiveness rate may be due to the complex problem of chronic low back pain patient. Therefore, it is necessary to explain the effectiveness for each case as much as possible, to prevent the patient from having too-high expectations before the operation. For the consideration of the indication of epiduroscopy and the efficacy in each case, we present three failed cases.

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  We started performing treatments with the epidural endoscope in 2005, and accumulated cases using the technique. Employing epiduroscopy, we have treated patients with spinal canal stenosis, lumbar disc herniation, FBSS, and adhesive arachnoiditis secondary to epidural abscess or epidural hematoma. For cases with nerve root symptoms of intractable low back pain and leg pain where adhesiolysis was successful with epiduroscopy, long-term effects were observed. However, in patients with recurrent adhesion or in whom adhesiolysis was impossible, the current epiduroscopy technique was ineffective, since the diameter of the scope is small with a narrow visual field, and only blunt ablation can be carried out. Outside Japan, an improved technique using a large diameter scope and forceps to excise connective tissue was reported. If such a technique can be used safely in epiduroscopy, an improved treatment effect would be realized.

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  We opened our clinic specializing in spinal procedures in April of 2007 and we mainly operate using Minimally Invasive Spine Surgery (MISS) for lumbar hernia and spinal canal stenosis. With the increase in the number of operations and as a result of many examinations done by our spine surgeons, we began performing surgeries using epiduroscopy as intermediate positioning of operative therapy. We employ a conservative approach to therapy for cases that end up ineligible for operations due to discrepancies in specific cases, such as physical, neurological or imaging findings among patients with intractable lumbago (lower back pain) and melosalgia (pain in legs), spinal canal stenosis in some discs, and cases which are not high-risk, such as MISS. While this differs from primary indications for epidural endoscope procedures, after enough informed consent, we performed this method 67 times (LCS: 52 cases; FBSS: 15 cases; Men-27 cases, Women-40 cases). Afterwards, we conducted a study on VAS JOA score and patient satisfaction improvement factors based on both questionnaires we created and several examples from major cases of our epiduroscopy procedures.

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