The progress in medical electronics has brought about great advances in hemodynamic monitoring. Echocardiography has a proven role in the urgent assessment of unstable patients with suspected cardiac disorders. Applicable technologies in echocardiography include M-mode, B-mode echocardiography and continuous wave, pulsed wave and color Doppler echocardiography. Transthoracic echocardiography (TTE) is available as a diagnostic method or hemodynamic monitoring in critical ill patients. TTE has been advanced as the technologies in medical electronics have been developed. Two-dimensional and pulsed Doppler echocardiographic evaluation of both systolic and diastolic function is necessary for the therapy of patients with severe cardiac dysfunction including myocardial infarction. Combined evaluation using TTE and transesophageal echocardiography (TEE) makes possible an accurate diagnosis in patients with cardiac dysfunction. The use of echocardiographic monitoring together with conventional pressure monitoring, such as the Swan-Ganz catheter, produces precise information on cardiac function.
  With advancing the medical technology in the critical care field, we are now able to evaluate the hemodynamic variables using TTE and TEE.

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[in Japanese]

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  The use of high-fidelity simulators (mannequin-type) is increasing in medical education and also in anesthesia worldwide. Simulation education and training are gradually gaining acceptance. It is also said that they are leading a radical change in healthcare education and contributing to reduced medical errors, resulting in increased patient safety.
  In the early years, simulators were used to practice both basic clinical skills and making diagnoses in anesthesia. In the late 1970's, the concept of crew resource management (CRM) was developed for the training of aviation pilots and crew.
  It was propagated in anesthesia and modified to anesthesia crisis resource management (ACRM) and anaesthetists' non-technical skills (ANTS) to investigate various aspects of human performance in anesthesia and perioperative medicine.
  In this paper, I discuss the history of the simulator, and the concept of CRM, ACRM and ANTS.

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  Brugada syndrome is a hereditary arrhythmogenic disease characterized by coved or saddleback-type ST elevation in the right precordial leads and by ventricular fibrillation (VF) at night. Currently, seven genes for this syndrome have been identified which encode sodium, potassium, or L-type calcium ion channels. The mechanism of the ST elevation and VF has been explained by the repolarization hypothesis, although conduction delay in the right ventricular outflow tract was shown to be essential for the development of ventricular arrhythmias. Antiarrhythmic drugs and anesthetics including propofol and bupivacaine, which block myocardial L-type calcium or sodium channels, induce ST elevation or VF by delaying ventricular conduction. Several long-term prospective studies of Japanese probands revealed that a family history of sudden cardiac death (SCD) at age <45 years and the presence of inferolateral early repolarization were indicators of poor prognosis. The placement of an implantable cardioverter defibrillator is required in patients with a prior history of VF, although two of three risk factors (syncope, family history of SCD, and positive electrophysiologic study results) should be present for implantation in patients with syncope or no symptoms.

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  We experienced a case showing resistance to rocuronium-induced neuromuscular block after reversal with sugammadex. The patient was a 46-year-old woman scheduled for an abdominal simple hysterectomy under general anesthesia. The surgical procedure was performed uneventfully and 4 mg/kg of sugammadex was intravenously administered to reverse residual neuromuscular block of the post-tetanic counts of 3. Sixty seconds after the reversal, a train-of-four (TOF) ratio of 0.9 was observed acceleromyographically at the adductor pollicis muscle. Unfortunately, abdominal hemostasis was needed and therefore general anesthesia was induced with fentanyl, propofol and rocuronium at 0.6 mg/kg iv. Acceleromyography applied at the thumb revealed a marked resistance to rocuronium-induced neuromuscular block and showed a TOF ratio of 0.5 5 minutes after the anesthetic induction. Thereafter, the TOF ratio gradually decreased, but only reached 0.25 10 minutes after the intubation dose of rocuronium. An additional dose of rocuronium at 0.2 mg/kg could not achieve a complete neuromuscular block and TOF counts of 2 were finally observed. It is suggested that the onset and depth of neuromuscular block should be monitored when rocuronium is needed again shortly after reversal with sugammadex.

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  Re-intubation may occasionally be required after neuromuscular blockade reversal by sugammadex. Four adult patients received rocuronium 0.6-1.4 mg/kg at 19, 210, 270 and 360 min after sugammadex administration. For repeat dose timepoints >210 min, onset times of rocuronium were within 2 minutes, except for one patient who received rocuronium 19 min after sugammadex. The duration times of the block in four patients were more than 30 min after repeat dose of rocuronium. It was demonstrated that rapid re-onset of blockade occurred after repeat dose of 0.6-1.4 mg/kg of rocuronium as early as 19 min after sugammadex in re-surgical adult patients.

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  We report a patient who intraoperatively received sugammadex to antagonize an inadvertent overdose of rocuronium. A 48-year-old man was scheduled for removal of an acoustic tumor. Anesthesia was induced with propofol and remifentanil and maintained with sevoflurane and continuous infusion of remifentanil. Muscle relaxation was achieved with a bolus of rocuronium at 0.7 mg/kg iv, and maintained with continuous infusion of rocuronium. However, rocuronium at 150 mg was inadvertently given in 45 min due to an incorrect infusion pump setting. The neurosurgeon requested reversal of neuromuscular block to confirm the facial nerve 90 minutes after discontinuation of rocuronium. Neostigmine at 2.0 mg failed to reverse the neuromuscular block; thereafter, sugammadex at 2 mg/kg was given intravenously, which increased the train-of-four ratio to 100% in 2 minutes and made the facial nerve able to be confirmed.

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  Sugammadex, a recently developed selective relaxant binding agent, has the potential to transform the practice of anesthesia in patients with myasthenia gravis. Rocuronium was administrated to maintain train-of-four (TOF) counts of 2 until the end of intrathoracic maneuver in myasthenia gravis patients undergoing thymectomy. Intubation dosages of rocuronium were decreased, but maintenance dosages were not that different from non-myasthenic patients. Recovery of the TOF ratio to >90% was attained with 2 mg/kg of sugammadex. We can safely provide adequate muscle relaxation for the duration of surgery using sugammadex administration. However, the TOF ratio during the baseline in the case of fulminant myasthenia gravis was >100%. A TOF ratio of >90% does not always represent adequate muscle function of the pharyngeal or respiratory muscle. In addition, administration of rocuronium and sugammadex might become confusing factors in treating patients with myasthenia gravis. We should use rocuronium with caution for the maintenance of anesthesia.

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  Pamphlets are very important for gaining informed consent for anesthesia. I therefore compared Japanese and German “explanatory pamphlets related to anesthesia”. Based on this, I introduced an “explanatory pamphlet related to anesthesia” in Suita Municipal Hospital. To ensure that patients and their families agreed to anesthesia after understanding it adequately, I adopted the following methodology: 1) The surgeon gave the pamphlet to the patient following the decision to perform surgery, so the patient could read it before admission, 2) After admission, the anesthetist met with the patient, explained anesthesia to him/her, answered questions, and gave the consent form to him/her the day before surgery, and 3) After thinking about it, the patient signed it and gave it to the ward nurse. When I informed patients of the rate of incidents probably due to anesthesia, I worried that more would decline it. However, informing patients of this rate made them understand anesthesia better, and patients no longer disagreed with undergoing anesthesia. Japanese anesthesiologists should consider informing patients of the rate of incidents probably due to anesthesia in each hospital admitted by the Japanese Society of Anesthesiologists, and answer questions from patients not only generally, but specifically and individually as well.

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  In this article, I provide an overview of tort liability (including contractual liability) and explain the main features of the legal theory of medical malpractice cases. Taking the example of unlawfulness, I trace the shifts in the elements of tort liability and discuss the objectivization of the notion of negligence. I then show through some judicial precedents that the standard of care doctrine is playing an important role in medical malpractice cases in our country. There is a tendency towards objectivization in this area as well, and I describe it using the examples of presumption of negligence and presumption of causation. Furthermore, I examine the recent trend of liability for breach of the medical duty to inform, which, according to the dominant view, leads to reparation.

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  Not all medical accidents immediately lead to medical malpractice disputes. Medical malpractice disputes develop due to the breakdown of a trusting relationship between medical providers and patients and their family members.
  Three characteristics of anesthesia accidents include (1) the grave consequences of such accidents, (2) secrecy (closed-door operating room), and (3) society not understanding anesthesia. Therefore, once they occur, anesthesia accidents have a tendency to develop into medical malpractice disputes (criminal or civil cases). Furthermore, in pain clinics, the sequela (i.e., nerve damage) can become a problem. In this paper, we investigated the sequence of events and consequences of past criminal cases and resolved medical dispute cases, providing milestones and strategies for prevention of future medical disputes.

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  Epidural anesthesia is the golden standard technique for postoperative pain control in thoracotomy patients. However, perioperative use of anticoagulant drugs increases the risk of bleeding complications, which limit the application of epidural anesthesia. Thoracic paravertebral block, extrapleural block and intercostal nerve block, which block unilateral intercostal nerves, can also be used in thoracic surgery patients. On the other hand, although opioids and non-steroidal anti-inflammatory drugs are widely applied in patients with coagulopathy, the side effects of opioids often create problems. Multimodal analgesia using these techniques would be useful as an alternative to epidural anesthesia after thoracic surgery.

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  When providing postoperative analgesia for patients receiving antithrombotic therapy, we should have thorough knowledges of the type and doses of antithrombotic medications, and the diseases they are prescribed for. After taking all kinds of risks the patient may suffer into consideration, we should determine how we deal with antithrombotic therapy during the perioperative period. Upper abdominal surgery is frequently associated with severe postoperative pain. Thus, postoperative pain management should be facilitated via a context-sensitive approach. This approach tries to optimize postoperative analgesia by timely utilization of all kinds of analgesic tools after considering the pathophysiological and biochemical contexts regarding the type of surgery, rehabilitation protocols and pain. As the regional anesthesia technique can provide effective analgesia without affecting the physiological functions of the patient, it can play a major role in context-sensitive analgesia for patients receiving antithrombotic therapy.

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  Neuraxial analgesia for obstetric and gynecologic open abdominal surgery is often unacceptable in patients receiving antithrombotic therapy. Although optimized pain relief and early mobilization is a prerequisite for thromboprophylaxis, analgesia solely using opioid analgesics may delay postoperative recovery because of the side effects. Multimodal balanced analgesia, the use of a combination of non-opioid analgesics, local infiltration analgesia/regional block and intravenous patient controlled analgesia (IV-PCA) with an opioid, is recommended for reducing opioid consumption and improving analgesia. Planning of context-sensitive pain management including constant patient monitoring through pre-, intra- and post-operative and post-discharge stages is vital.

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  Lower extremity joint replacement is conducted to help reduce pain and improve both mobility and quality of life. However, the surgical procedures themselves also produce severe postoperative pain, which may result in postoperative complications and chronic pain. Thus, improved analgesia and physical therapy in the immediate postoperative period should be implemented to obtain improved surgical outcomes. Recently, due to the concern regarding neuraxial hematoma and bilateral motor block, peripheral nerve blocks have gained popularity and have been replacing epidural analgesia, which was once considered the technique of choice. In this paper, postoperative management with a multimodal regimen in which peripheral nerve blocks are centered is discussed.

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  Heart failure (HF) management tools at present can be simply divided into 2 groups: ‘visible’ treatments and ‘invisible’ treatments. Visible treatments mean the tools that promptly relieve visible signs and symptoms. On the other hand, invisible treatments improve long-term prognosis.
  Since HF is characteristic in term of a progressive disorder, earlier intervention is more effective in improving prognosis. It is necessary, in addition, to be conscious of the concept of ‘invisible’ treatment in the acute phase using ‘visible’ treatment. Speculating that HF prognosis may improve by modestly inhibiting hyperactivated sympathetic tones during exacerbation, it has been demonstrated that early administration of beta-blocker prior to relieved decompensation improved prognosis. The concept of acute HF management, taking into consideration the long-term prognosis, must be recognized by anesthesiologists.

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  Breast reconstruction with tissue expander and implant after mastectomy was performed as an ambulatory surgery.
  For one year, about 400 patients underwent surgery under the supervision of anesthesiologists in the Breast Surgery Clinic (BSC).
  We present our anesthesia care in BSC and investigated side effects after the operation from April to November, 2007. The subjects were rated as I -II in ASA. Seventy-five patients underwent breast expansion and 106 patients underwent exchange breast implant. Postoperative pain was observed in 79.5% of the patients after these procedures. Postoperative nausea and vomiting were seen in 19.8% of all patients. Patients who underwent the expander procedure had postoperative pain more than the patients who underwent implant operation. Patients who underwent the implant exchange procedure had headache attended with sit down position compared with supine position.
  We have to predict side effects from surgery to make ambulatory anesthesia successful.

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  Living-donor liver transplantation (LDLT) patients have a risk of massive blood loss during the surgery because of coagulopathy due to liver failure, portal hypertension, and surgical procedure. We investigated retrospectively the relationship between hemoglobin, platelet count, or coagulation tests and blood loss or transfusion volume during the perioperative period in 40 cases of LDLT. Preoperative hemoglobin (Hb) and activated partial thromboplastin time (APTT) showed significant association with intraoperative blood loss. Hb, prothrombin time (PT-INR), APTT showed significant association with intraoperative red blood cell transfusion. On the other hand, postoperative coagulation tests showed no significant association with postoperative red blood cell transfusion. The results show that preoperative Hb, PT and APTT could be predictors of intraoperative blood loss and red blood cell transfusion.

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  A 74-year-old female was diagnosed with hepatocellular carcinoma with tumor thrombus extending into the right atrium. She was scheduled to undergo hepatectomy and tumor thrombus removal with cardiopulmonary bypass.
  Starting cardiopulmonary bypass before attempting to resect her liver would reduce the risk of pulmonary embolism from tumor fragments, whereas concomitant heparin use might increase bleeding. After putting in the cigarette suture to enable starting the cardiopulmonary bypass at any time, hepatectomy was done before in this case.
  The operation was able to be finished safely while observing the tumor by echocardiography.

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  We report a case of a 51-year-old man who developed subcutaneous and mediastinal emphysema following microlaryngo surgery under mechanical controlled ventilation. While anesthesia was maintained, insertion of the direct laryngoscope caused hemodynamic instabilities including hypertension and tachycardia, which were refractory to intravenous beta blockade and Ca channel blockade. On day 2 he began to exhibit obvious symptoms of his emphysema and conservative therapy was continued. We suggest that the hemodynamic instabilities are related to the emphysema that was caused during direct laryngoscopy.

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  A 52-year-old man was scheduled to undergo redo replacement of the aortic valve and ascending aorta. He had undergone successful aortic valve replacement in 1977.
  During weaning from cardiopulmonary bypass (CPB), however, an increase in pulmonary artery pressure from 20 to 40 mmHg suddenly occurred. Transesophageal echocardiography (TEE) revealed an intra-cardiac abnormal mass in the left atria which was not recognized during the surgery. Although TEE did not show severe mitral regurgitation, the mass grew gradually. After CPB was restarted, the surgeon incised the right atria and found a hematoma in the endocardium of the atrial septum, which seemed to be contributing to dissection of atrial septum caused by the endocardial hematoma. After the hematoma was removed, TEE confirmed no residual hematoma in the left atria and the hemodynamics became stable. It seems to be important to perform TEE examination before weaning from CPB and share the findings with the surgeon.

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  A 73-year-old male, who was taking ticlopidine and aspirin after coronary stent placement, presents with inguinal hernia. All antiplatelet agents were stopped 15 days prior to the operation. Heparin infusion (500 U/hr) was continued until 5 hours before surgery. In order to evaluate platelet procoagulant activity for the feasibility of spinal anesthesia, we used the modified-thrombelastography which measures platelet-mediated facilitation of clotting in the presence of argatroban. Impaired platelet function was confirmed on thrombelastography (TEG) and thus the surgery was performed under general anesthesia. The surgeons noticed diffuse oozing from the surgical wound. Residual antiplatelet effects may be observed even after 2 weeks' cessation of thienopyridines in some patients. Individualized monitoring of platelet function may be indicated especially if patients take both thienopyridines and aspirin.

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  We present an anesthesia case of a 37-year-old male patient with von Hippel-Lindau syndrome who was complicated with uncontrolled pheochromocytoma and cerebellar hemangioblastoma. On the fifth day after admission, because the patient showed clinical signs of high intracranial pressure, emergency surgery was decided. First, under general anesthesia, pheochromocytectomy was performed and then hemangioblastoma were removed on the same day. We initially were able to successfully control the patient's blood pressure with high dose remifentanil (1.0 μg/kg/min) and vasodilators. Following pheochromocytectomy, we lowered the dose of remifentanil (0.2-0.3 μg/kg/min) and the patient's blood pressure was able to be maintained in the normal range perioperatively. In conclusion, we found that a high dose of remifentanil can adequately control hemodynamics in patients with uncontrolled pheochromocytoma.

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  A 30-year-old woman in the 20th gestational week developed right-sided spontaneous pneumothorax. Chest tube drainage was performed, but air leakage continued. At the 24th gestation, video-assisted thoracoscopic bullectomy was performed. General anesthesia was induced with thiopental, vecuronium and fentanyl and, maintained with sevoflurane. Endobronchial intubation with a 32Fr double-lumen tube was successful. After changing to the left lateral position, epidural catheter was placed and mepivacaine 2% was administered. During one-lung ventilation, SpO₂ remained 100% but end-tidal CO₂ was elevated to 66 mmHg. Ephedrine 15 mg was required to maintain systolic blood pressure above 100 mmHg. After the surgery, continuous injection of levobupivacaine 0.18% was started through the catheter. When patient complained of pain, 3 ml bolus injection was administered. In our case, one-lung ventilation led to hypercapnia, but avoided prolonged fetal acidosis by returning to bilateral lung ventilation.

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  We devised a simple method for placement of a double-lumen tube (DLT) using an Airway Scope^® (AWS) that does not require special instruments.
  In all 41 of our patients scheduled for differential lung ventilation, we successfully placed a DLT during the first attempt at intubation. The time required for intubation was 28.2 ± 6.7 sec in the first 10 patients and 22.7 ± 5.6 sec in the following 31 patients, indicating a significant improvement in procedural time (P < 0.05).
  The important points with this procedure are that (1) a DLT made by Phycon was used, (2) the stylet was advanced near the tip, (3) it was then set to the disposable blade while it remained at an approximately right-angle curve, and (4) it was not withdrawn until it had completely passed the glottis. In the placement of a DLT, which is considered to be more difficult than placement of a single-lumen tube, this simple intubation method using an AWS appears to be useful.

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