We compared the degree of head extension during laryngoscopy with the McGrath^® laryngoscope and AirwayScope^®. Fifty patients without cervical spine abnormality were randomized into two groups who received laryngoscopies with the McGrath^® laryngoscope or AirwayScope^®. Each patient who wore goggles mounted with a goniometer lay supine with the head in the neutral position. After general anesthesia and muscle relaxation, an experienced anesthesiologist obtained the best glottic view using one of the two laryngoscopes, and change in the angle of goggles (head extension angle) during laryngoscopy was measured. In addition, we compared the head extension angle with extension angle of the cervical spine between the occiput and the fourth cervical vertebra(C0-4) measured radiologically in 6 healthy volunteers. Head extension angles with the McGrath^® laryngoscope and AirwayScope^® were 9.9 ± 2.8°and 6.6 ± 2.8°, respectively (P < 0.0001). There was a strong relationship between head extension angle and C0-4 extension angle measured radiologically in the volunteers (r = 0.94, P < 0.0001). Both the McGrath^® laryngoscope and AirwayScope^® may be a reasonable technique of choice for intubation when minimal cervical spine movement is indispensable.

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  Patients requiring major lower extremity amputation may be afflicted with severe comorbidities that increase the risk of postoperative mortality. The aim of this retrospective pilot study was to identify the risk factors of hospital mortality following major lower extremity amputations in patients with significant comorbidities such as diabetes mellitus (DM) or severe atherosclerosis obliterans (ASO). The study population consisted of 36 patients with DM and/or ASO who underwent either above knee (n = 15) or below knee amputation (n = 21). Demographic and clinical data, perioperative data, postoperative complications, and mortality were recorded from medical and anesthetic records. Thirty-day postoperative mortality was 8.3% (n = 3) and total hospital mortality was 30.6% (n = 11). All hospital deaths occurred within 1 year. Low preoperative serum albumin and postoperative blood transfusions were independent risk factors of hospital mortality (P < 0.05). In conclusion, the patients with ASO and DM are at high risk of hospital mortality following lower extremity amputation, particularly in cases with preoperative hypoalbuminemia or cases requiring postoperative blood transfusion. Because of the small sample size, further prospective studies are needed to confirm our findings.

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  The case is a 32 year old woman with twin pregnancy. The first child was delivered by absorptive delivery. However, because of sudden and significant fetus bradycardia at the time of the second child's delivery, an urgent cesarean operation was performed. We delivered the second child under general anesthesia with rapid sequence induction. The operation was completed without bleeding tendency or significant pulmonary-ciruculatory failure. After she breathed spontaneously, she showed no responses to verbal commands. In response to her delayed awaking, we performed an artery blood gas analysis and blood examination and found significant metabolic acidosis, decreased platelet count and coagulation disorder. She entered the intensive care unit with suspected disseminated intravascular coagulation syndrome by amniotic fluid embolism. Later, we were led to a diagnosis of clinical amniotic fluid embolism. It was difficult to doubt amniotic fluid embolism until we performed a blood examination. The onset style of amniotic fluid embolism varies, and it is always necessary to take it into consideration as a differential diagnosis in obstetric anesthesia.

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  A case report of Paget's disease of bone (PDB) with high-output heart failure monitored by arterial pressure based cardiac output (APCO) and central venous oxygen saturation (ScvO₂). PDB is a metabolic bone disease characterized by increased and disorganized bone turnover and in rare cases is complicated by high-output heart failure.
  We report a case of PDB with heart failure in a 52-year-old man monitored by APCO and ScvO₂. Changes in APCO and ScvO₂ values were closely related to change in serum level of alkaline phosphatase (ALP), an index of clinical severity of PDB. We suspected that the cause of the heart failure was arteriovenous shunting in bone tissues due to PDB. APCO and ScvO₂ seemed to be very helpful for estimating and controlling the hemodynamics in this case.

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  Studies have shown that tramadol hydrochloride/acetaminophen (T/A) tablets are associated with a high incidence of adverse events leading to discontinuation when administered at the generally prescribed dose of 4 tablets/day. We aimed to assess the incidence of adverse events and discontinuation in patients who received T/A tablets for chronic non-cancer pain. Reducing the initial dose of T/A tablets may lead to a decreased incidence of adverse events and discontinuation.

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  Hypoxia caused by respiratory suppression is common in post-anesthetic patients. However, a pulse oximeter is deemed insufficient for preventing postoperative hypoxia. We used an acoustic respiratory monitoring device (Rad-87) to evaluate respiratory status after general anesthesia. Respiratory depression was defined as a respiratory rate less than or equal to 8/minute for more than 120 seconds, while desaturation was defined as SpO₂ less than or equal to 90%. Respiratory monitoring was feasible in 742 of 806 patients (92%). Of the 742 patients, respiratory depression was noted in 24 (3.2%) and desaturation in 207 (27.9%). These results indicate that postoperative respiratory monitoring is feasible and may provide a key aid in postoperative safety management.

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  The Japanese Society of Anesthesiologists (JSA) and the Japan Society of Transfusion Medicine and Cell Therapy published “Guidelines for Management of Critical Hemorrhage” in 2007. A report by the JSA suggested that the incidence of critical hemorrhage has declined and that mortality has decreased since then. Recent evidence has made it necessary to revise the guidelines. One of the concerns is how to supply fibrinogen in active bleeding patients. It may be necessary to increase fibrinogen levels to more than 150 mg/dl in the case of critical hemorrhage. The use of cryoprecipitate and fibrinogen concentrates in addition to fresh frozen plasma, the introduction of massive transfusion protocol (MTP), and the use of cell salvage in obstetric hemorrhage have been discussed. The revision of the guidelines will be published in a few years.

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  Remimazolam, a novel imidazobenzodiazepine, is a carboxylic acid ester that is rapidly degraded to inactive metabolites by tissue esterases. Clinical phase I and II trials for Japanese approval of remimazolam were performed at Hamamatsu University Hospital. The elimination half-life of remimazolam following a single bolus injection was found to be between 39 and 53 min. A bolus injection of 0.2 mg/kg remimazolam rendered all participants unconscious. The average rates of remimazolam infusion required to maintain general anesthesia in adult and elderly patients were 1.02 and 0.72 mg/kg/h, respectively. Heart rate and arterial blood pressure remained stable during anesthesia with remimazolam. Remimazolam surpasses propofol in terms of water solubility, specific antagonist availability, and hemodynamic stability, and represents a promising next-generation intravenous hypnotic agent.

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  Motor evoked potential (MEP) monitoring is one of the most reliable measures for detecting spinal cord ischemia during descending thoracic and thoracoabdominal aortic aneurysmal surgery. Although MEP monitoring can help to determine the segmental arteries that should be reattached, it often shows false positive results, which may be due to a variety of factors including the use of anesthetic agents, body temperature, cardiopulmonary bypass, age, perioperative neurologic function, the muscle selected for recording, operating time, and obesity. Among these factors, we regard anesthetic agents, body temperature, and cardiopulmonary bypass as the most important contributors to false-positive results because cardiopulmonary bypass with low body temperature can change the pharmacodynamics and pharmacokinetics of anesthetic agents. Titration of the dose of these agents should decrease the false-positive rate. Establishing guidelines for MEP monitoring during aortic aneurysmal surgery that include the optimal dosing regimen for anesthetic agents would be beneficial.

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  Intraoperative monitoring of motor evoked potential (MEP) has been used to prevent postoperative motor deficit, and its clinical importance increases in patients who undergo surgeries of the brain or spinal cord.
  However, MEP is easily affected by anesthetics and muscle relaxants, which can make it difficult to interpret changes in MEP. Specialized doctors or medical technologists contribute to MEP monitoring at most hospitals, but in our institution MEP monitoring can commonly be done by anesthesiologists. In this paper, we describe the clinical pitfalls of and tips for MEP monitoring during neurosurgery as well as basic information on anatomy and physiology.

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  Postoperative visual dysfunction is a devastating complication affecting quality of life. Intraoperative visual evoked potential (VEP) has been proposed to monitor the functional integrity of visual function during neurosurgical procedures, in which the optic pathway is at risk of injury. Recent advances in techniques including a new light-stimulating device consisting of high-luminosity LEDs and induction of electroretinography to ascertain the arrival of the stimulus at the retina have provided better conditions for stable VEP recording under general anesthesia. On the other hand, the use of propofol anesthesia is important for successful VEP recordings because inhaled anesthetics have a suppressive effect on VEP waveform. VEP monitoring may allow us to intraoperatively detect reversible damage to the visual pathway and enable us to prevent permanent problems.

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  Regional cerebral oxygen saturation measured by near infrared spectroscopy has often been used clinically due to its non-invasiveness and continuous measurement. However, rSO₂ values have a wide individual variation compared to SpO₂ measured by pulse oximeter. We need to consider why there is a wide variation individually and what kind of errors rSO₂ is associated with. Further, we would like to discuss the usefulness of rSO₂ in the future.

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  Both BIS^® and aepEX^® are popular anesthetic depth monitors, but the mechanisms by which they obtain indices are different. BIS^® index is calculated not by simple frequency analysis of spontaneous brain waves, but by combination of four components of processed brain wave analyses and databases. However the details of the algorithm that produces the BIS^® index has not been published. aepEX^® index reflects the length of curves of auditory evoked potentials between 0 and 144 ms from the auditory stimulus. aepEX^® contains mid-latency potentials, so it may be possible that aepEX^® can monitor consciousness more accurately. Further studies are necessary to compare these two monitors directly.

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  Kagoshima University has put in place a program aimed at helping female doctors resume work after giving birth. The program is supported by the university, its affiliated hospital, and each department of the hospital. The hospital has introduced a short-time employment option for doctors, in an effort to help female staff return to work after giving birth.
  Efforts by each hospital department include a major training system change enabling doctors to receive enough training to gain anesthesiologist and other qualifications, a change that makes it easier for doctors to handle both work and child-rearing. The university aims to increase the number of staff by introducing a work-sharing system and a new status of permanent workers with shorter working hours, and to train medical staff to help revitalize community medicine.

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  A survey conducted by the Japanese Society of Anesthesiologists showed that during the past 10 years the proportion of women among its members has increased from 27% to 35%, and the proportion of women councilors has risen from 3.9% to 6.7%. However, the conditions of full-time employment remain inadequate for female physicians. Therefore, many female physicians in their 30s or older do not work as anesthesiologists. Recent rapid progress in surgical techniques in Japan has led to increases in the number of patients who undergo surgery, but increasing the number of female physicians remains a very serious challenge. To support female anesthesiologists and their vital roles in surgical diagnosis and treatment, return-to-work assistance programs have been developed. It is important to educate and encourage young female physicians to strive to continuously improve their own careers and improve working conditions so that female anesthesiologists can continue to work.

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  With the recent increase in female doctors, institutional and workplace reforms have been discussed to alleviate the hardships they face in juggling work and family or climbing the career ladder to a management or supervisory position. It is becoming easier for female doctors to work because of the introduction of in-house nurseries and short work shifts at hospitals nationwide. We need to further improve the working environment for female doctors to help them work in a new manner by maintaining work-life balance and have a clear career design. Female doctors themselves should not take the improved working environment for granted. They need to work hard to win the understanding and support of others and create a comfortable workplace.

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  Although laws and regulations supporting female physicians with children have progressed and there are now many more facilities offering such support, the backgrounds of and the environment surrounding female anesthesiologists who utilize the existing child care system vary significantly, and not everyone fits into one box. Opinions about work-life balance differ from person to person, and while I believe that everyone should lead their life as they see fit, I believe that female physicians with children wouldn't feel they had to give up work so readily if they reminded themselves of why they decided to become a physician in the first place and of the support they received at that time. As a third-generation female anesthesiologist, and looking back at my past, I discuss here the merits of utilizing female physicians with children and their secrets of how to succeed in the hope that this will lead to successful fourth-generation female physicians.

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  Trigeminal neuralgia (TN) is a common cause of facial pain. If the initial medication is not tolerated because of side effects, nerve blockade therapy must be considered. The goals of interventional pain therapy for TN are to relieve pain and discontinue, carbamazepine. The pain specialist must be skilled, not only in the technical aspects of how to accomplish a selected neural blockade technique, but also in its indications and contraindications as well as appropriate intraoperative management. Efforts should be made to minimize patient discomfort during the procedure through the systemic use of propofol. The approach to identify correct needle placement is to gently probe the nerve with the tip of the needle. Fluoroscopy, CT, and ultrasound are useful aids for the accurate placement of the trigeminal nerve block. Patients with a more dense sensory loss from the procedures tend to have a lower rate of recurrence, but they are subject to greater complications from dysesthesia and analgesia.

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  One of the most common conditions we treat at our pain clinic is locomotive pain induced by spinal disease. As many cases of spinal disease can be effectively managed with a nerve block and a patient's response to a nerve block can provide a clue to their diagnosis, it is essential for physicians who treat pain to learn how to perform various types of nerve block to treat locomotive pain caused by spinal disease. In this report, we describe the essential regional anatomy and practical techniques for performing lumbar nerve root blocks and facet blocks, which are particularly commonly used for pain treatment. We also outline the principles of how radiofrequency (RF) and pulsed radiofrequency (P-RF) work for pain relief and present results of RF treatment at the medial branch of the spinal nerve (facet rhizotomy) for patients at our facilities who underwent lumbar surgery or had a spinal compression fracture.

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  We often treat patients with pain by using local anesthetic blocks of trigger points. Trigger point injection of local anesthetics can be easy and safe. It is important to be aware of the possible adverse effects of trigger point injection and practice myofascial examination techniques carefully.

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[in Japanese]

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