Hyperglycemia is common in critically ill patients, with approximately 90% of patients treated in an intensive care unit (ICU) developing blood glucose concentrations greater than 110 mg/dl. Recently, the international multicentre NICE-SUGAR study reported increased mortality with this approach and recent meta-analyses do not support adopting intensive glucose control for critically ill patients. While the initial trials in Leuven produced enthusiasm and recommendations for intensive blood glucose control, the results of the NICE-SUGAR study have resulted in the more moderate recommendation to target a blood glucose concentration between 144 and 180 mg/dl.
  As critical care practitioners have paid greater attention to glycemic control, it has become clear that currently used point-of-care measuring systems are not accurate enough to target tight glucose control. Unresolved issues include whether increased blood glucose variability is inherently harmful and whether even moderate hypoglycemia can be tolerated in the quest for tighter blood glucose control. Until another level I evidence is available, clinicians would be well advised to move slowly and abide by the age-old adage to “first, do no harm”.

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  The evaluation of pain is indispensable for the diagnosis of illness and assessment of the treatment outcome. The pain evaluation method must have scientific reliability and validity. In addition, such methods should provide information on the patient to a number of doctors equally, independent of the emotional and physical condition of the patient.
  Evaluation of pain using language, numerical scale and analog scale is done in outpatient care units because it is simple and easy to perform. Another method is the use of medical equipment such as a sensory nerve stimulator, thermograph and pain imaging.
  Because pain is the internal experience of the patient and manifests itself as subjective feeling and sensation, the objective evaluation of pain by clinicians is very difficult. Therefore, we must assess the complaint of pain correctly. In particular, we should understand the difference between subjective and objective evaluations when considering the method. Moreover, it is necessary that we understand and utilize the reliability and performance limitations of medical equipment in pain evaluation.

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  When first learning how to read ECGs, the electromotive force generated by the heart (R wave) can be represented by the vector force, and we analyze the direction of the electrical axis according to Einthoven's triangle. Moreover, Wilson introduced zero potential electrode-merging tree limb lead signals, and developed unipolar chest leads. However, Wilson's zero potential is not a true zero potential, electrically speaking. We must be aware that surface ECGs are essentially the measurement of the voltage difference between indirect and bipolar electrodes. This article summarizes the mechanisms of normal and abnormal surface ECG from the above viewpoints.

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  Monitored Anesthesia Care (MAC) is indicated in all situations during invasive medical procedures. An essential component of MAC is the anesthesia assessment and management of a patient's actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. While MAC may include the administration of the sedatives and/or analgesics often used for Moderate Sedation, the provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. Additionally, a provider's ability to intervene to rescue a patient's airway from any sedation-induced compromise is a prerequisite to the qualifications to provide MAC. Concerning the importance of MAC, it is an unobjectionable issue in Japan. Therefore, we should reach a common understanding of MAC, and educate patients on the need for MAC during invasive medical procedure.

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  “Anesthesia medicine” begins with the medical examination of patient prior to surgery and then the respiratory organs during surgery, continues with circulation management, pain management, and management of the stability of the patient's breathing, blood pressure, and heart rate, and finishes with recovery confirmation.
  Anesthesiologists are responsible for not only taking anesthesia for surgery, but also studying every day to make an effort to ensure safe and comfortable surgeries for patients.
  I talked in this lecture about the current status of, the point at issue with, and the future of anesthesia. Some points that I raised were regional cooperation in the field of anesthesia medicine, the clarification of the roles of business, and postgraduate clinical training in anesthesiology, which was included in the proposal for countermeasures to deal with the lack of anesthesiologists, launched by the Japanese Society of Anesthesiologists.

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  Diagnosis and therapy for chronic non-cancer pain that persists beyond the normal tissue healing time is very difficult, because it has many types of morbidity. Chronic opioid therapy has been effectively used in Japan for relieving this type of pain. However, chronic use of narcotic analgesics exposes the patient to the risk of narcotic dependence, addiction or abuse. We investigated the factors associated with chronic opioid therapy in Japan using questionnaires completed by doctors that treat patients suffering from chronic pain. The results suggested that chronic opioid therapy is an effective method for treating patients with chronic pain. However, this mode of therapy must be limited in patients with chronic non-cancer pain, and careful patient selection, as well as periodic monitoring of their pain and behavior is required.

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  The use of prescription opioids for the control of chronic non-cancer pain has become a focus of lively discussion in Japan since the approval of a fentanyl transdermal system for the indication of non-cancer chronic pain was obtained in January 2010. Meanwhile, a large body of evidence and guidelines concerning pharmacotherapy including prescription opioids has been presented in Europe and the United States, wherein the usefulness and methods of use of prescription opioids as second-line and third-line drugs are detailed. Prescription opioids are widely used for the treatment of chronic non-cancer pain, but problems regarding adverse reactions, dependence, liability, etc. have also been pointed out. When properly used in appropriate patients, prescription opioids may become powerful tools for those who have long been suffering from chronic pain. Generation of a guideline for pharmacotherapy including the use of prescription opioids is anticipated in Japan as well.

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  While one therapy is generally ineffective for neuropathic pain, a multidisciplinary treatment is likely to be effective. Various treatments such as a nerve block, minimally invasive surgery, rehabilitation and psychotherapy are necessary, along with pharmacotherapy. Some conditions require opioid prescriptions for patients with chronic pain. Analgesic effects are insufficient with other treatments. A doctor-patient relationship must be established in those not having a psychiatric disorder or drug dependency. After fixing the dosage, it should not be readily increased. It is expected that the chronic pain patient will continue taking opioids throughout life. Therefore, the patients receiving this treatment should be carefully selected.

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[in Japanese]

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  Both Iraq and Afghanistan are conflict countries, but their medical situations are very different. Although Iraq was under U.N. economic sanctions from 1991 to 2004, the human resources necessary for self-recovery of the country are still available, and the medical situation improved dramatically with enough medical supplies after the Iraq war of 2003. Since then the Iraqi economy has also recovered rapidly. The Afghanistan economy, on the other hand, was completely destroyed after the Soviet invasion of Afghanistan in 1979, and all its social infrastructures were also destroyed. Therefore, there is a large deficiency of the human resources needed for the self recovery of the country.
  As for being conflict areas, anesthesia for war surgery is carried out in both countries. Anesthesia for war surgery is a field which gives us deeper insight into not only the fundamentals of anesthesia, but also surrounding areas like postoperative management, or nutritional management.

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  Failure is the only highway to success. It is important for us to analyze the factors of human error in medical practice. The causes of human error are divided as follows: lack of knowledge, lack of technical competence, protocol violation, and multiple factors (Reason's Swiss cheese model). R. Flink and colleagues assert that the anaesthetists' non-technical skills (ANTS), similar to the NOTECHS (non-technical skills) for pilots, contribute to safe and efficient task performance.
  For trainee anesthesiologists, I report in this article my cases of failure in medical practice.

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  My personal experience described here indicates not to cheating the rules of the process of an anesthetic patient's care. Although we have learned that a systemic approach could prevent anesthesiologists from making errors which cause a disaster for a patient, the questions raised, however, might include asking why an individual had specific gaps in their knowledge, experience, ability or performance. As a retired anesthesiologist who has done clinical work without learning any coping strategies, I would insist that a self-assessment for doing routine work seems to impact individual performance. Three events described here contain the key for avoiding specific errors in anesthetic management.

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  Surgical stress activates the descending neuroendocrine system from the hypothalamus through the ascending pathway of the spinal cord on conduction of noxious stimuli, resulting in increase in the release of stress hormones such as adrenocorticotropic hormone (ACTH), growth hormone (GH) and antidiuretic hormone (ADH). Those stress hormones increase cardiovascular response, intraoperative metabolism and blood coagulability, and decrease immune function. Moreover, tissue damage due to surgical insult produces proinflammatory cytokines enhancing the degree of noxious stimuli and neuroendocrine responses. Taking appropriate analgesic measures prevents excessive activation of the neuroendocrine system and axon reflex of noxious stimuli, thereby normalizing immune function and metabolism and attenuating vasodilation and vascular permeability.
  Normalization of the neuroendocrine system via analgesic procedures can avoid hyperglycemia by maintaining endogenous insulin secretion from pancreatic β cells. Insulin activates intracellular Akt, an indispensable phosphorylative enzyme in maintaining homeostasis, in endothelial cells. Both endogenous and exogenous insulin have cytoprotective effects. As exogenous glucose administration stimulates secretion of endogenous insulin for protecting endothelial cell function and suppresses decomposition of fat and skeletal muscle protein for the synthesis of glycogen during surgery, the addition of glucose to intraoperative fluids is considered to be beneficial for preparing for excessive postoperative catabolism. In conclusion, appropriate preemptive and intraoperative analgesia play a significant role in maintaining of homeostasis.

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  Pulse-oximetry is one of the necessary pieces of monitoring equipment in the operating theater and intensive care units worldwide. However, the conventional pulse-oximeter (two wavelengths) can neither detect dyshemoglobin nor correctly determine SpO₂ in the presence of dyshemoglobin. There are two improvements to its function. First, sensitivity and accuracy of photo-signal detection are very important functions of pulse-oximeter with low perfusion state, body movement or pediatric patients. Second, multiple functional (multiple wavelengths) pulse-oximetry can measure several dyshemoglobins and normal hemoglobin, such as carboxyhemoglobin, methemoglobin and total hemoglobin. In the near future, we will be able to rapidly diagnose massive hemorrhage or hypovolemia using non-invasive pulse-oximetry with multiple wavelengths. It is useful to manage the new parameters obtained from pulse-oximetry due to non-invasive analysis of their waveforms (e.g.: perfusion index, PI; and pleth variability index, PVI). Perfusion index (PI) may be reflected in peripheral circulation. Pleth variability index (PVI) also may be useful for judgement of fluid responsibility like the stroke volume variation (SVV) obtained from arterial blood pressure wave form.
  In conclusion, it is suggested that therapeutic and diagnostic values for massive hemorrhage or hypovolemia will expand its indications in peri-operative management of patients with non-invasive and real time monitoring using multiple-wavelength pulse-oximetry.

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  We reviewed the medical records of 39 patients with drug-eluting coronary stents (DES) scheduled to undergo non-cardiac surgery from January, 2007 to December, 2009. The time intervals between stent insertion and surgery were less than one year (16 cases) and more than one year (23 cases). Antiplatelet therapy (aspirin or aspirin and thienopyridine) was continued throughout the perioperative period in 8 cases, while it was interrupted for more than 14 days in 4 cases. In 1 case, 2 months after stent insertion, antiplatelet therapy was interrupted for 7 days. No major artery cardiac events occurred during the hospital stay in any cases, but 1 patient suffered excessive blood loss after surgery. Before surgery, his aspirin and thienopyridine therapy was replaced with heparin injection, which was discontinued 6 hours before the operation and restarted two days after surgery. Surgeons and anesthetists should consider information about the characteristics of coronary artery stents and cooperate with cardiologists in considering perioperative management.

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  The AirwayScope^® (AWS) is a novel tracheal intubation device (a videolaryngoscope combined with a disposable plastic blade) introduced in 2006. This device is now being used in many hospitals; thus, we evaluated the usefulness of AWS. Our evaluation was based on the following three points: 1. comparison of the view of the vocal cords using AWS and a Macintosh-type laryngoscope, 2. intubation time with AWS-inexperienced residents, and 3. usefulness of AWS as a second choice in the case of difficult intubation for one year. Our results revealed that the intubation time with AWS decreases with experiences, and the view fields in difficult intubation cases markedly improved to better than those of the Macintosh-type laryngoscope. In the one-year use of AWS as the second choice in the case of difficult intubation, there were 37 difficult cases (incidence rate of 0.881%), all of which were intubated by AWS without major problems. We suggest that AWS may be added to the difficult airway algorithm, and is a useful device when we encounter a difficult intubation case.

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  A 65-years-old woman, who had suffered from mixed connective tissue disease (MCTD), had back pain and numbness, and the symptoms expanded to her left limbs. From the MRI study and neurological findings, she was diagnosed as having MCTD-related myelitis. Three months after she first experienced such pain, we began to prescribe gabapentin 400 mg/day orally and gradually increased the dosage to 2,000 mg/day within 2 weeks. Two weeks after the initiation of our treatment, her pain was alleviated considerably, the visual analogue scale score improved from 7 to 3, and the Japanese version of the Neuropathic Pain Symptom Inventory (NPSI) score improved from 38 to 15 as well. Thus we truly succeeded in treating neuropathic pain rapidly due to the gradual increase of gabapentin in the short term. Furthermore, we suggest that NPSI is useful for evaluating the severity of neuropathic pain and the analgesic effects of its treatments.

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  The patient was a 57-year-old male. He was unconscious and a necrotic lesion was detected in his right leg. Because of the laboratory findings and clinical features, he was diagnosed as having severe diabetic ketoacidosis.
  Above-the-knee amputation was scheduled to control bacteremia. Anesthesia was maintained with ketamine, fentanyl, and propofol under his own airway without tracheal intubation. During perioperative management, we encountered the following five problems; 1) the method of anesthetic management, 2) adequate correction of severe metabolic acidosis, 3) estimation of pain in the patient with diabetic neuropathy, 4) unconsciousness and systemic convulsion, and 5) cardiac arrest and refractory arrhythmia. However, because of the intensive care, he recovered.

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  A thymectomy is generally selected as standard treatment for myasthenia gravis (MG). We provided anesthesia management twice for the same patient during operations that differed in regard to the degree of surgical invasiveness, anesthesia technique, and severity of MG symptoms. A 60-year-old male with MG underwent excision of a thymoma, and then required another surgery 10 months later for a metastatic thymoma. Prior to both operations, we were unable to predict the necessity of postoperative respiratory management based on the severity of MG symptoms, and concluded that the severity of surgical invasion was the most important factor. For MG patients undergoing a thymectomy, it is important to consider postoperative management by assessing the severity of both the surgical invasion and disease symptoms.

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  The patient was a 67-year-old female with a history of right lower extremity fracture and cast immobilization for 15 days prior to admission, who was diagnosed with cecal cancer. She underwent ileocecal resection uneventfully. On postoperative day 2, she developed dyspnea and then suffered cardiopulmonary arrest when she was trying to walk for postoperative ambulation. The patient immediately showed return of spontaneous circulation upon initiation of cardiopulmonary resuscitation (CPR). Pulmonary angiography revealed bilateral occlusion of the pulmonary arteries, consistent with the diagnosis of acute pulmonary thromboembolism. Catheter thromboembolectomy was performed. After intensive care including CPR and percutaneous cardiopulmonary support (PCPS), the patient recovered with no severe complications. It is important to be aware that perioperative patients with cast immobilization are at a high risk of developing thromboembolism.

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  In March 2009, we created the “Nagoya City University (NCU) anesthetic panic card”, and security measures have been taken for life-threatening events during anesthesia. On these cards, simple treatments for crises are written, and the cards are attached to the anesthesia machines. Eight months after installation, we conducted a questionnaire study of the panic card in 26 anesthesiologists and 44 nurses in the operating room, and evaluated its usefulness. Cases of life-threatening events were rare, and determination of the usefulness of the card was difficult. However, the results of this study suggest that a sense of security is possible with the card, and it helps in administering anesthesia with confidence. The panic card can contribute to improving the safety of anesthesia.

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  Imparting effective training for central venipuncture to residents during their initial clinical training is important to ensure patient safety.
  In the past, we have held training courses for ultrasound-guided central venipuncture in seminars for residents (JJSCA 28: 956-960, 2008; JJSCA 30: 460-464, 2010). The training course has been reviewed and improved to achieve good performance of the procedure. We recently developed an instruction manual describing the method of teaching the central venipuncture technique. In addition, in the training course, the target vein to be punctured is confined to the internal jugular vein. The training course was improved, which resulted in a high success rate of a perfect puncture.
  To ensure the safe performance of a central venipuncture, it is important to develop an effective training program. We expect the training course to serve as a good guide for ultrasound-guided internal jugular venipuncture.

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