Clinical application of the PGA-C tube began in Japan in 2002. This article involves a brief summary of the clinical results and the concept of ‘in situ tissue engineering’ and field theory, which is the background of this novel therapy. A clinical trial of the PGA-C tube for neuropathic pain is also discussed in this article.
  In situ tissue engineering was first proposed in Japan in 2000 as a new concept in which, a defected tissue is fabricated not in the incubator but in the body. A peripheral nerve has strong potential to regenerate, so if an adequate ‘field’ for regeneration is provided in our body, it recovers easily. The PGA-C tube is a bio-absorbable tube stuffed with collagen. The collagen with a structure of multilayed thin films provides an adequate scaffold for tissue regeneration.
  To date, over 300 PGA-C tubes have been used, and surprisingly good results have been obtained after the peripheral nerve repair. Interestingly, the PGA-C tube is effective for patients who suffered from neuropathic pain. Thus this new device, the PGA-C tube, might be promising for further clinical application.

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  After the Great East Japan Earthquake, deciding to start scheduled surgery was a major challenge. We distributed a questionnaire survey on operating room management to 16 medium-sized hospitals in Iwate prefecture. The survey questions concerned the following : the starting times of emergency and scheduled surgery, the reasons for these starting times, damage to hospitals and/or operating rooms, lack of materials and medicine and necessary prerequisites for starting scheduled surgery. Thereafter, we considered the requirements for resuming surgery after the occurrence of a large-scale disaster. Answers were received from 11 hospitals. Only one hospital sustained damage to the building. Emergent surgery was started at an early stage at 6 hospitals, while there were significant differences in starting times of scheduled surgery among the hospitals. The restarting of planned operations was influenced by gasoline storage and the distribution of lifelines. Restoring lifelines enables the early resumption of emergency surgery. Resumption of scheduled operations requires the restoration of lifelines and distribution systems. Important points were the awareness of medical staff and cooperation within the region. Furthermore, we believe that administrative intervention was necessary for early resumption of scheduled surgery.

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  If an earthquake occurs during surgery, it is first necessary to promptly conclude the surgery upon securing the safety of yourself, the patient, and others around you, and to protect the life of the patient. However, this is not possible if the operating room becomes damaged or lifelines such as electricity and medical gas are lost. It is therefore necessary to ensure an earthquake-resistant environment on an everyday basis, establish backup systems for lifelines, create manuals for disasters, and perform simulations of situations in which an earthquake actually occurs during surgery.

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  In the Great East Japan Earthquake, a number of hospitals suffered serious damage due to inadequate earthquake resistance. In order for hospitals to continue operating during a disaster, the following points are necessary. First, hospital buildings must adequately resist earthquake shaking. Second, electricity, water, and gas supplies must be maintained. Third, communications systems such as the Internet and cell phone and satellite networks must remain operational, and medical gas delivery systems, drug supplies, and general-use medical materials must be continuously available. Fourth, the most important factor is that medical staff survive and be able to carry out their duties. Along with infrastructure, a proper human response is needed. Training for major disasters and management training should be conducted. Training at both departmental and institutional levels can provide an accurate picture of how the hospital will function during a disaster. Disaster training should also be conducted with operating room staff, including anesthesiologists and surgeons. The participants should read aloud and compare their respective disaster manuals.

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  Background:
  We conducted yearly disaster drills in operating rooms from 2007 to 2012. In 2006, we created a disaster manual for the operating room, but we could not determine how useful the manual would be. Hence, we decided to use the manual in actual training in order to improve it.
  Methods:
  In 2007, we used a simulation-based desktop exercise for the first time and improved the disaster manual. In 2008, we trained again using the revised manual. We added action cards and status reports in every operating room. In 2009 and 2010, we again conducted simulation-based training for emergency situations in operating rooms. In 2011, we conducted simulation-based training for earthquakes. In 2012, we conducted simulation-based training for power outages.
  Results:
  ·We improved the disaster manual for the operating room by using it in simulation-based training.
  ·Simulation-based training improved communication between staff.
  ·We could mentally and physically prepare for a disaster by performing simulations.
  ·We recommend small groups for this training program because extensive training is difficult to conduct with larger groups.
  Conclusion:
  Simulation-based training in the operating room is an effective way to prepare for disasters and improve manuals.

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  The Tokai region is considered to be at high risk for mega-earthquakes. If an earthquake occurrs, extensive damage is expected, while the region would be isolated without any support from outside. By reducing the risk of unexpected events such as those which occurred after the Great East Japan Earthquake, we may be able to reduce damage at the hospital. In this article, we discuss education and disaster measures for operating room staff including anesthesiologists at our institution.

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  Today, drug therapy for multiple pain is possible, analgesics diverse, different mechanisms, efficacy, effectiveness, so also affect drug interactions and side effects, and be familiar with relevant aspects of clinically it is important to choose the drug considering both sides of side, and the analgesic effect is essential, is shown on the need to monitor the problem of drug-related drug interactions and a plurality of drug metabolism in the individual the implementation of pain treatment, it is necessary to construct systematic system.

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  Although anesthesiologists are becoming increasingly involved in palliative care, a variety of needs emerge during the treatment period, including symptom alleviation, support for decision-making, and terminal care. While anesthetic techniques are useful for alleviating pain, these techniques alone are not sufficient in cases where suffering takes many forms. Assessment of the situation is necessary in order to provide appropriate palliative care. Use of checksheets based on the Japanese version of the M.D. Anderson Symptom Inventory (MDASI-J) and prognostic prediction during the terminal phase using the Palliative Prognostic Index (PPI) are useful for assessment. It is important to first clarify problems and share them among experts.

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  Sevoflurane and Desflurane, the most widely used volatile anesthetics, are both fluorinated alkyl ethers. Unlike predecessors in this category, they do not contain chlorine atoms and therefore do not destroy ozone layer in the stratosphere. However, they are greenhouse gases which absorb infrared radiation from the Earth. In particular, desflurane is chemically stable and stays for a considerable time in the atmosphere. The Global Warming Potentials in 20 years of these agents are several thousand times higher than that of carbon dioxide. Although the amount of these inhalation agents used in each surgical case may be negligible compared to industrial/agricultural output of nitrous oxide, more widespread use of minimal/low flow technique can significantly reduce consumption of anesthetics, contributing to environmental protection. End-tidal Control (EtC) is a newly installed function of Aisys^TM anesthetic workstation (GE Healthcare, Helsinki, Finland). In the EtC mode, anesthetists set the desired end-tidal concentrations of oxygen and anesthetic agents (etO₂/etAA). The machine attains and maintains these targets within the specified time period by automatically adjusting fresh gas flow (FGF), delivered oxygen concentration as well as output of vaporizer. Fresh gas flow can be reduced to a minimum value of 0.5 litres/minute. Concentrations of volatile agents can be rapidly changed by simultaneously adjusting both FGF and inspired anesthetic concentration. EtC can be considered as an “effect-site target-controlled inhalation” of oxygen and volatile anesthetics, which makes it possible to easily administer minimal/low flow inhalation anesthesia without risk of hypoxemia.

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  In order to determine propofol concentration in human plasma, we developed a simple and reliable method which is performed with a combination of deproteinization by acetic acid/acetonitrile and high-performance liquid chromatography with fluorescence detection (HPLC-FLD). It was demonstrated that good linearity, recovery, precision and accuracy of this method met each criteria. It was confirmed that the long-term stability in human plasma at -20°C was stable for 6 months. Additionally, we suggest that our method is sensitive without much sample volume and effective in reducing the risk of accidental exposure for experimenters. These results suggest that this method is a useful measurement system for a clinical study using propofol.

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  Posterior reversible encephalopathy syndrome（PRES）is characterized by visual disturbance, seizures and mental disorder, as well as radiologic findings of focal reversible vasogenic edema that mainly involves the occipital lobes. The etiological cause of PRES is thought to be hypertensive encephalopathy with dysregulation of the cerebral vasculature.
  Our report is about a 63-year-old woman with hypertension who developed bilateral blindness after total aortic arch replacement. No intraoperative complications occurred, except elevated selective cerebral perfusion pressure up to 110 mmHg. After surgery, she was delirious and her blood pressure was high enough to require a continuous infusion of calcium channel blockers. On the first postoperative day, bilateral visual loss was noted after extubation. A CT showed multiple low density lesions in her bilateral occipital lobes. However, her vision improved dramatically over the following days and the lesions decreased by the seventh postoperative day.
  She was diagnosed with PRES, but follow-up neuroimaging showed a small persistent occipital lesion and residual left homonymous hemianopia.
  The condition of PRES is not always reversible. This case suggests that the possibility of PRES should be considered during the initial stage if bilateral blindness is observed postoperatively. Diffusion-weighted MRI can distinguish vasogenic edema in PRES from early infarction. Prompt differentiation from acute ischemic stroke and treatment with antihypertensives are important to prevent progression to irreversible brain damage and cerebral infarction.

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  A 30-year-old man with cervical spinal tumor, having tracheal stenosis and brachiocephalic artery compression was scheduled for resection of the cervical tumor and posterior cervical-thoracic spinal fixation. This operation had to be performed in a prone position. We expected that tracheal stenosis would lead to fatal ventilator insufficiency and brachiocephalic artery stenosis to cerebral ischemia. Therefore we first scheduled for partial removal of the suprasternal region to avoid these problems. We evaluated the anatomical positional relations of the trachea and artery by 3D-computed tomography. General anesthesia was induced under spontaneous ventilation and tracheal intubation was performed. Tracheal tube was inserted beyond the tracheal stenosis and cerebral blood flow was evaluated with rSO₂. The operation was finished without respiratory or circulatory complications. After 159 days, tracheal stenosis and brachiocephalic artery compression were improved and secondary operation was performed without any complications.

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  A 57 years old woman was scheduled for colon resection under general anesthesia combined with epidural anesthesia. When epidural anesthesia was attempted via Th11/12, cerebrospinal fluid was dripping from the Tuohy needle. Epidural anesthesia was performed again at Th 10/11, then general anesthesia and the operation were performed.
  Since a headache in the upright position occurred on postoperative day 1, she was diagnosed as PDPH. Epidural blood patch (EBP) was contraindicated, because fondaparinux had been administered. Pregabalin was administered orally from postoperative day 3, and the headache greatly improved. On postoperative day 8, administration of pregabalin was interrupted and the headache was aggravated. It was relieved again after restarting pregabalin. In such cases where EBP is contraindicated, the administration of pregabalin may be very useful and as a conservative therapy against PDPH.

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  A 41-year-old female with an unusually located hyoid bone underwent mastectomy. A previous computed tomography scan revealed that her hyoid bone was located anterior to the thyroid cartilage. She had no symptoms suggestive of upper airway obstruction or swallowing disorder preoperatively. During induction of anesthesia, mask ventilation with jaw lift maneuver was easy and Airway Scope^® provided a good view of vocal cords. Subsequent tracheal intubation was performed easily. At the end of anesthesia, the tracheal tube was extubated after the patient became fully awake. Postoperative course was uneventful.

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