The volatile anesthetics protect the myocardium against ischemia/reperfusion injury when applied both before ischemia (anesthetic preconditioning) and at the onset of reperfusion (anesthetic postconditioning). Mitochondria play a central role in anesthetic pre- and postconditioning. Production of small quantities of reactive oxygen species from mitochondria and mildly acidotic mitochondrial pH induced by anesthetics are triggers for pre- and postconditioning. Furthermore, mitochondria are end effectors for various prosurvival signaling pathways. The activation of prosurvival signaling pathways with anesthetics is responsible for inhibition of mitochondrial permeability transition pore (mPTP) opening. The inhibition of mPTP opening leads to preservation of ATP synthesis, prevention of intracellular calcium accumulation and protection of myocardium.

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  We now know how intravenous anesthetics act but do not understand where and how inhaled anesthetics act.
  Generally two or more drugs are often combined to achieve these end-point-produced interactions labeled as “synergistic”, “additive” or “infra-additive” ; additive interactions suggest a common site of action, and synergistic interactions suggest a different site of action.
  Lately Eger et al. have paid attention to synergy, additivity and infra-additivity in drug interactions. They published two papers about this research.
  First they searched and selected the available data on anesthetic drug interactions for end-points of hypnosis and immobility (MAC) from the entire PubMed database.
  They found that most interactions between drug classes were synergistic, except ketamine, which interacted in either an additive or infra-additive manner. Inhaled anesthetics typically showed synergy with intravenous anesthetics but were additive except in the case of nitrous oxide and isoflurane.
  Next they studied the additivity of MAC for 11 inhaled anesthetic pairs defined by differences in potency for a channel/receptor in rats. They also studied 4 additional pairs that included nitrous oxide because of previous reports suggesting a deviation from additivity for the combination of nitrous oxide and isoflurane. The results showed that all combinations produced additivity, except for the combination of isoflurane with nitrous oxide.
  Such results are consistent with the notion that inhaled anesthetics act on a single site to produce immobility in the face of noxious stimulation.

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  Anesthesiologists are responsible for administering all anesthesia. However, anesthesiologists in Japan cannot be involved in all anesthesia because of the shortage of anesthesiologists. Some solutions to this problem include a perioperative management team and concurrent anesthesiologist-directed anesthesia procedures. Perioperative management team is a team of physician and non-physician anesthesia members and can administer anesthetics by second-person confirmation. Concurrent anesthesia procedures in Japan are defined as simultaneous provision of anesthesia on two patients under one anesthesiologist supervising perioperative management team members. I think these systems can provide safe and high-quality anesthesia.

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  General anesthesia has been performed by not only physicians but also dentists ever since the first introduction of general anesthesia into medical history. At present the total number of cases of general anesthesia in Japan is estimated to be 2 million, of which 15,000 cases would be managed by dentists. Dentists are authorized by the Dental Practitioners' Law to perform general anesthesia. The extent of dental treatment is considered to be the treatment of teeth and the tissues of oral cavity, and the general anesthesia required for dental treatment is assumed to be within this extent. However, if a dentist practices general anesthesia in a medical setting, he or she could be accused of violating the Medical Practitioners' Law. Dentists are permitted to practice general anesthesia in a medical setting on the condition that they comply with the guideline issued by the Ministry of Health, Labour and Welfare concerning on-the-job training of dentists for general anesthesia in medical settings.

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  Recent advancement of ultrasound technology allows anesthesiologists to evaluate airway and respiratory conditions. The author introduces US techniques for 1) evaluation of the airway, 2) Prediction of the difficult intubation, 3) Diagnosis of the pneumothorax after central venous cannulation or nerve block, 4) Confirmation of the tracheal tube placement, and 5) Evaluation of the gastric contents in this article.

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  The American Society of Anesthesiologists published the Practice guidelines for management of the difficult airway in 1993, and revised it in 2003. I expect that the following revised edition will be announced around 2013. I would like to forecast the next algorithm which reflects the progress of the airway management technology for the past ten years.
  At the 2003 revision, the laryngeal mask airway (LMA) came to be used in difficult airway situations, such as difficult mask ventilation and difficult intubation. After that, the LMA and other supraglottic devices became more popular and have grown into an important category of airway management. Thus, these supraglottic devices might play an important role in airway management.
  Mask ventilation is the most primitive and valuable maneuver for oxygenation, however, the strategy for difficult mask ventilation had not completely been described in the 2003 guideline. Recently, a lot of articles about difficult mask ventilation were published, thus, the strategy for difficult mask ventilation will be included.
  The bottom line is that the new algorithm will stress continuing oxygenation by mask or supraglottic devices ventilation instead of tracheal intubation.

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  Invasive airway access is positioned as the rescue technique when less-invasive methods fail to manage the difficult airway. JATEC oversees emergency physicians in the ER, and ASA and DAS guidelines oversee anesthesiologists in the operating room. Cricothyroid ligament is a good place for an emergency surgical airway because there are no major blood vessels and nerves. The authors performed cricothyrotomy in a total of 83 cases in ICUs at Fujita Health University and Nagoya University. We are striving to build a system in which the full-time ICU staff members can perform invasive airway access as a medical team responsible for the patients' safety.

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  The number of case reports of epidural hematoma following epidural anesthesia has been increasing. The incidence of epidural hematoma is estimated to be around 1 in 3,000 in some patient populations. The techniques for preventing epidural hematoma include avoiding catheter insertion, limiting the depth of insertion to 5 cm, converting to general anesthesia, and using anticoagulation therapy properly. Patients receiving postoperative epidural infusions should be closely monitored to assess analgesia and anticoagulation statuses. Institutional protocols should also be established to ensure patient safety, and an understanding of the guidelines for peri-operative anticoagulation therapy and the performance of epidural blocks is essential.

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  The main supportive therapy in acute respiratory distress syndrome patients is mechanical ventilation. As with any therapy, mechanical ventilation has side-effects and incorrect ventilator setting could induce ventilator-induced lung injury and bring higher mortality. The open lung approach is the key to treat severe respiratory failure along with the low tidal volume ventilation. This concept consists of two elements, recruitment maneuver and setting adequate positive end expiratory pressure. The author discusses three cases and implementation of the Open lung approach.

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  We experienced a case of delayed awakening due to severe hypoglycemia after the excision of glucagonoma. The patient was a 46-year-old woman with an undiagnosed upper abdominal tumor and glucose intolerance. She was scheduled for tumor excision to confirm the diagnosis under general anesthesia with epidural anesthesia. The tumor was diagnosed as glucagonoma by intraoperative pathological rapid diagnosis. After the operation, she did not awake from the anesthesia, and then blood glucose showed severe hypoglycemia (4 mg/dl). Right after the intravenous administration of dextrose, she recovered from the anesthesia with no neurological complications.
  This case suggests that we must frequently measure blood glucose levels and, especially, take into account of hypoglycemia during the perioperative period in the patient with glucagonoma.

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  A 45-year-old woman underwent abdominal hysterectomy under spinal anesthesia and epidural anesthesia. She did not feel any abnormal sensation (e.g., paresthesia) during the insertion of the needle and epidural catheter. Four ml of 0.5% isobaric bupivacaine was injected intrathecally followed by epidural administration of 5 ml of 2% mepivacaine. The operation was completed with no complications. Continuous epidural infusion of 0.2% ropivacaine was started at a speed of 4 ml/hr immediately after the operation. The patient was able to stand up with support in the next morning but suddenly developed paralysis in the bilateral lower extremities at night on the same day. Although the paralysis gradually improved after the withdrawal of the epidural injection, muscle weakness in the proximal lower extremities was prolonged. An MRI showed no abnormalities in the spinal cord or spinal column. The patient's symptoms gradually improved over the next 12 months. Twenty-four months after the operation, the patient had recovered from almost all paralysis. Neurotoxicity of 0.2% ropivacaine seemed to be the most probable cause of her neurological deficit, because her symptoms occurred after recovering from spinal anesthesia.

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  We retrospectively collected data from 46 severely burned patients who underwent plastic surgery from February 1, 2006 to January 31, 2011. Area under the curve (AUC) of the receiver operating characteristic curve was defined as a measure of accuracy. In-hospital mortality rate was 26% (12/46). The AUC values were 0.88 for Burn Index, 0.85 for Prognostic Burn Index, 0.84 for Total Body Surface Area and 0.84 for White Blood Cell counts. These data suggest that White Blood Cell counts could predict in-hospital mortality accurately as well as Prognostic Burn Index or Total Body Surface Area in severely burned patients. But further studies are needed to validate these promising results.

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  We performed a tracheostomy in a patient who developed right-sided pleural empyema and pneumonia after surgery for esophageal cancer. Although left-sided pneumothorax subsequently occurred, he was successfully treated with differential lung ventilation using a double-lumen endotracheal tube for the tracheostomy. When different pathological conditions exist in each lung, the unaffected lung will be hyperinflated when high-pressure ventilation is applied to improve oxygenation. This, in turn may result in pressure damage. For this reason, each lung should be ventilated under different conditions. However, when using a double-lumen endotracheal tube in tracheostomized patients over long periods, careful attention may be required to ensure the tube is fixed at the right position.

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  Subcutaneous emphysema and pneumomediastinum are rare complications associated with oral and maxillofacial surgery. A 78-year-old man underwent a dental operation under general anesthesia wherein an air turbine drill was used to section his mandibular third molar for extraction. After the operation, he developed a massive subcutaneous emphysema from his cheeks and neck to his chest wall. Neck and chest computed tomography was used to diagnose pneumomediastinum. He was given antibiotics and was discharged on the 13th day. Most cases of this type found in the literature have been due to molar extraction and high-speed dental drills. When patients are exposed to these risks, dentists should be alert to the consequences of such procedures, and the anesthesiologist must anticipate such rare complications as cardiac tamponade, pneumothorax, mediastinitis, and airway obstruction.

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  We used dexmedetomidine for intraoperative management of 5 patients during percutaneous endoscopic lumbar discectomy (PELD). To avoid nerve injury, it is essential that the patient maintain consciousness during PELD. We used dexmedetomidine (DEX) as a sedative. The dosage of DEX was adjusted according to the patient's sedation status. For 2 patients, we used pharmacokinetic (PK)/pharmacodynamic (PD) simulations of DEX and attempted to maintain the DEX plasma concentration at 1.0-1.5 ng/ml. The DEX dosage commonly used in intensive care units is not sufficient for use during surgery. In the case of our patients, the sedation status was favorable for surgery. None of the patients had nerve injury. Although SpO₂ decreased slightly, hemodynamic stability was preserved. Therefore, we conclude that DEX is suitable for use as a sedative agent during PELD.

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  During fiber-optic bronchoscopy (FOB)-guided intubation, we sometimes found it difficult to insert a tracheal tube into the trachea. If we forced to the tube in, we could damage the bronchoscope. To solve this problem, we suggested the strategy using a guide wire and the tube exchanger. We advanced the FOB into the trachea and inserted a guide wire (0.038 inch Radiforcus, TERUMO INC., Tokyo, Japan). Then we withdrew the FOB, and advanced the tube exchanger over the guide wire. Finally, we advanced a tracheal tube into the trachea over the tube exchanger. Because the tube exchanger is harder than the FOB, it is easier to advance a tracheal tube. This method also could avoid damaging the FOB. In this way, we didn't have to fit the size of the FOB to a tracheal tube. It is a rather more complicated way than the traditional one, which is intubating a tracheal tube directly following FOB, but it seems to be safer and more secure. Furthermore, this strategy can be applicable when intubating a double-lumen endobronchial tube. We recommended our method in FOB-guided intubation to prevent FOB damage.

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  The prognosis of cannot intubate, cannot ventilate (CICV) cases depends on whether oxygenation in emergency airway management is successful or not. A laryngeal mask or Airway Scope^® cannot be used for obstruction of the upper airway by swelling of the oral cavity and the cervical region, and cricothyroid membrane puncture/cricothyrotomy (CTT) and bronchofiberscope (BF) insertion are also difficult. High frequency jet ventilation through a suction catheter placed in the pharyngeal cavity (pharyngeal HFJV) is useful for oxygenation until the airway is secured in such patients. Effective oxygenation can be obtained employing pharyngeal HFJV applied through an aspiration tube inserted into the pharynx nasally or orally until the airway is secured by BF or CTT. Barotraumas, such as abdominal distention and pneumothorax, are considered to be complications, for which the position of the aspiration tube and setting of HFJV should be carefully established. It is important to always have HFJV available for emergency airway management.

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  This report describes the therapeutic strategy for treating lumbar disk hernia (LDH) and lumbar canal stenosis (LCS). Determining an appropriate treatment strategy requires knowledge of the natural course of the disease, the limitations of conservative therapy and the absolute indications for surgery. Conservative treatment with drug therapy, physical therapy, or a nerve block is an effective treatment option for both diseases.
  Patients that present with a posterior lumbar apophyseal ring with hernia during adolescence, cartilage endplate with hernia in the elderly and cauda equine type in the lumbar canal stenosis do not normally respond to conservative treatments, and often require surgical intervention. Surgery may be indicated in patients that do not respond to conservative therapy within 1-3 months. Surgery is also indicated in patients with acute cauda equina syndrome, rapid progressing paralysis, and excruciating pain. Epiduroscopy is a valuable modality to assess and diagnose the patient's condition. However, there are only limited data on the efficacy, invasiveness and the cost-effectiveness of epiduroscopy for both diseases.

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  It is sometimes difficult to manage FBSS (Failed Back Surgery Syndrome) due to three factors: 1) the possibility of the change in pathogenesis between the pre-operative and post-operative phases, 2) the relatively lower diagnostic value compared with pre-operative image findings, and 3) the determination of failed back surgery is made by the patient, not by the clinician. In this paper, management for FBSS was described simply.
  Another topic was the difference between the patients who received epiduroscopy in the pain clinic and those who underwent spine surgery in the orthopaedic department. From the results, there seemed to be differences between the two groups in regards to the magnitude of pain and disability.

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  Epiduroscopy / spinal canal endoscopy is a new, minimally invasive diagnostic and therapeutic modality. In this paper, we first describe the effectiveness of epiduroscopy for low back and leg pain. Epiduroscopy reduced low back and leg pain in patients with lumbar disk herniation, degenerative lumbar spinal stenosis, and failed back surgery syndrome, particularly those with radiculopathy. We then presented two patients, suffering from cauda equina tumor or epidural abscess, who received orthopedic surgery combined with the use of epiduroscopy. In these two patients, the use of epiduroscopy allowed a less invasive operative procedure by the single-level or two-level laminectomy. Epiduroscopy may be useful not only for low back pain and leg pain, but also for strategic treatment of cauda equina tumors and epidural abscess.

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  At our hospital, epiduroscopy is indicated for pain refractory to nerve block and pharmacotherapy, pain that is temporarily relieved by nerve root block, and adhesions demonstrated by sacral epidurography. In 23 patients who obtained sufficient abrasion during epiduroscopy, sacral epidurography was randomly performed between postoperative days 2 and 14. Re-adhesions began forming on postoperative day 3 in early patients and had occurred in approximately 30% of our patients by 2 weeks after surgery. However, there was no observable difference in postoperative analgesic effects between patients with and without re-adhesions. Epiduroscopy may be associated with not only physical abrasion effects on the epidural space, but also the cleansing effect of physiological saline, local drug effects, and so on.

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  A multi-institutional, prospective, clinical study was performed to investigate the efficacy and complications of epiduroscopy in patients with intractable low back and leg pain. Japanese Orthopedic Association (JOA) score (0-29, 29=best), the Japanese version of the Roland-Morris Disability Questionnaire (JRMDQ) score (0-24, 24=worst), and 100-mm visual analogue scale (VAS) for leg pain, leg numbness, low back pain and dissatisfaction with ADL were recorded before and 1, 3 and 6 months after epiduroscopy.
  All scores significantly improved 1, 3 and 6 months after epiduroscopy in patients with or without history of back surgery. Patients without history of back surgery achieved significantly better improvement in JOA scores and VAS scores than those with history of back surgery. 37% of patients reported transient headache/neck pain during epiduroscopy, 4% of patients complained of wound pain and 1-2% complained of or experienced motor disorder in the lower extremities, bladder and bowel dysfunction (BBD), headache or elevated blood pressure on a temporary basis after epiduroscopy. Neither severe nor permanent complications were observed.

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  Today, as the number of aged people increases, the number of patients who visit a pain clinic complaining of low back pain and leg pain has been rising sharply. Having acquired information from the media, many of them wish to undergo epiduroscopy.
  Recently, we had two cases of epiduroscopy for patients over 85-years of age. Both of them mainly complained of low back pain and numbness in both feet. A lumbar vertebrae MRI showed lumbar spinal canal stenosis in both cases. Both patients received caudal epidural block and phototherapy as outpatients. During their surgeries, both showed strong adhesion requiring aggressive adhesiotomy. Although one case experienced pain and the other weakness in the legs postoperatively, and both took a long time to recover, both found their low back pain relieved and were highly satisfied.
  It was considered important to adequately explain the surgery, determine indication taking into account their symptoms, pathology, etc., and carefully perform the operation.

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  The treatment of intractable low back and leg pain using an epiduroscope was approved as a highly advanced medical technology in 2004. We conducted a questionnaire survey involving 26 institutions which perform epiduroscopy about the current situation regarding epiduroscopic treatment. Epiduroscopic treatment is provided in only 10 institutions at present, and is not covered by health insurance. The number of cases was larger in advanced than non-advanced medical centers. In addition, a difference in the medical costs was observed in non-advanced medical centers, with the average being approximately 160,000 yen. For anesthesia, local anesthesia plus sedation were prevalent. It is considered that the accumulation of evidence in multi-center studies on the effects of epiduroscopic treatment, and subsequent availability of health insurance coverage for it, may facilitate the development of such treatment in the future.

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