The concept of biomedical designing for all parts of human body, such as bones, muscles, tendons and built-in which are building not only a device but the human body, and air and heat current object analysis of a blood flow in a respiratory tract or a lung, is required for innovative medical designing.
  It is important to closely relate “a doctor's intelligence” with not only experts in techniques but also “human and medical treatment” and “a medical designer's intelligence”, which can imagine the goal of “man and an artifact”, and consider it an “Integrated intelligence”.
  When doctor's creativity is demonstrated freely and medical designers further research and development, an optimal medical environment for man can be improved by imagining next vision creating the goal from there and producing suitable and evolved artifacts.

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  The usefulness of three-dimensional transesophageal echocardiography is discussed. The clinical fellowship program for echocardiography is also described.

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  Management of OPCAB requires close cooperation between anesthesiologists and cardiovascular surgeons. The role of anesthesiologists is indispensable in the intraoperative management of hemodynamic state, arrhythmic control, body position and ventilatory method. Anesthesiologists need to understand the importance of the heart team and have a firm grasp of the patient's morbidity, risk factors, the surgical procedure, and the events that can occur during anesthesia. Furthermore, anesthesiologists must be skilled in the treatment of intraoperative arrhythmia, myocardial ischemia, and the changes in hemodynamic state which occur especially during anastomosis. The control of respiration, circulation, metabolism, body temperature, and pain in the postoperative period are also important for the patient's prognosis.

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  Much scientific evidence has been reported in recent years regarding nutritional management in the perioperative period, and related clinical guidelines have been issued by medical societies. In this overview, current concepts of perioperative management are summarized into 5 points : 1) avoid a fasting period, 2) avoid over-fasting, 3) avoid hyperglycemia, 4) avoid artificial nutrition, and 5) when the gut works, use it. Due to the continuing progress of therapeutic procedures and the introduction of intensive care, nutritionally compromised patients such as the malnourished or overfed can safely undergo surgical treatment. In this regard, anesthesiologists at all times are expected to provide appropriate anesthetic management according to the nutritional condition of each patient in order to contribute to “enhanced recovery after surgery (ERAS).” As members of interdisciplinary teams for perioperative management, anesthesiologists should always be aware of proper perioperative nutritional management.

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  Little is known of perioperative glucose metabolism. Two studies and a case report on glucose and carbohydrate loading conducted in our department and some preceding knowledge are discussed in this article.

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  Since the introduction of the enhanced recovery after surgery (ERAS) protocol, many surgeons and anesthesiologists have shown an interest in postoperative early oral intake. Postoperative nausea, vomiting, and gastrointestinal hypomotility affect oral intake. Concurrently, these factors are also associated with anesthetic techniques. We therefore retrospectively investigated the influence of anesthetic technique on postoperative oral intake. We enrolled 125 consecutive patients who underwent gynecological surgery under general anesthesia with postoperative epidural anesthesia or intravenous patient controlled analgesia (IV-PCA) between January 2011 and December 2011. In comparison with sevoflurane, propofol significantly reduced nausea and vomiting on POD 0 in patients who had undergone gynecological surgery. Moreover, the incidences of bowel sounds and flatus on POD 0 in the epidural anesthesia group were significantly higher than in the IV-PCA group. Propofol and epidural anesthesia might contribute to early oral intake.

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  Bariatric surgery for morbidly obese patients is now increasing around the world as a weight loss surgery. Recently, however, it has been demonstrated that bariatric surgery can ameliorate diabetes in obese patients with type 2 diabetes. Specifically, gastric bypass and biliopancreatic diversion may be effective for the remission of type 2 diabetes. Metabolic surgery is the recently defined name for bariatric surgery in obese patients with type 2 diabetes.
  Japanese type 2 diabetes patients are characterized by impairment of insulin secretion and decreasing insulin sensitivity. Diabetes remission following bariatric surgery is believed to result not only from the effect of weight loss but also from an increase in incretin that works to increase secretion of insulin which is rationalized for Japanese patients' characteristics. Metabolic surgery may become an alternative option for the treatment of Japanese obese patients with type 2 diabetes in the near future.

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  In this review, the author provides an overview of the current literature on the effect of different anesthetics and anesthesia technique on the long term outcome of surgical patients. As anesthesiologists, we should have basic knowledge of the immunological effects of commonly used anesthetic drugs and have basic insights regarding the possible consequences of perioperative management on long term outcome.

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  Some papers reported an association between anesthetic depth and long-term mortality. Anesthetic depth was measured with a bispectral index (BIS) monitor. However, the question of the possible causal relationship between deep anesthesia and long-term outcomes remains. Advancing age, comorbidities including malignancy, and intraoperative hypotension are more strongly associated with poor outcomes than cumulative deep hypnotic time.
  The association may be an epiphenomenon, reflecting a poor preoperative condition that predisposes patients to late postoperative mortality.
  Well-controlled randomized trials of a large group of patients are needed to answer this complex question.

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  Anesthetic agents are commonly used for a variety of medical procedures in infants and children, but little is known about their effects on the developing brain.
  Early exposure to general anesthesia causes widespread apoptotic neurodegeneration in the developing mammalian brain and late cognitive impairment. Few well designed studies have evaluated the possible long-term adverse neurologic outcomes of anesthesia and surgery in young children.
  Results from clinical studies have all been analyzed using existing data sets, and these studies produced inconsistent results.
  The pilot study of the Pediatric Anesthesia and Neuro-Development Assessment (PANDA) project recently revealed that there were no differences between 28 sibling pairs after following for 7 years. The pilot study provided useful information and will give us reliable data later.

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  Nicorandil clearly has beneficial effects on the long-term outcomes of patients with ischemic heart disease. However, only a few clinical studies have been conducted to evaluate the effect of this compound on the perioperative outcome of patients. One group examined the effects of nicorandil iv from the commencement of general anesthesia to 15 hrs after coronary reperfusion through levels of markers indicating cardiac injury in patients undergoing off-pump coronary artery bypass surgery. Others conducted a study which evaluated the effects of intraoperative nicorandil iv on cardiovascular events up to the 5th postoperative day in patients undergoing noncardiac surgery. These studies documented slight but significant beneficial effects of nicorandil iv on the outcome of patients. Further studies are needed to clarify the effects of perioperative nicorandil on the long-term outcomes of surgical patients.

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  There has been recent tendency to avoid anesthetic premedication, but this increases the risk of an excessive rise in blood pressure due to mental strain especially for patients with hypertension. A retrospective study was conducted to examine blood pressure, heart rate and percutaneous oxygen saturation when entering an operating room to assess the effect of premedication on blood pressure and heart rate during an operation. Patients without complications and those with complications of essential hypertension were identified according to their anesthesia records and divided into 4 groups depending on the use of premedication. Comparative items were specified as follows : blood pressure, double product, heart rate, and percutaneous oxygen saturation. Systolic blood pressure in patients with hypertension who were administered midazolam as premedication was significantly lower on entering the operating room than in patients who did not receive such premedication. On the other hand, percutaneous oxygen saturation was significantly lower than in non-premedicated patients. Premedication with midazolam is effective to control the excessive rise of blood pressure when entering an operation room but requires attention to low percutaneous oxygen saturation.

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  Background : At our hospital, carotid artery stenting (CAS) is performed under general anesthesia. However, carotid sinus reflex frequently occurs during post-stenting balloon angioplasty (PSBA) under general anesthesia. This study examined the efficacy and safety of the atropine-infusion protocol just before PSBA.
  Protocol : Intravenous atropine (0.5 mg) was rapidly administered just before PSBA for all patients. Another 0.5 mg of intravenous atropine was added if the heart rate (HR) did not increase more than 10%. PSBA was performed after HR increased more than 10%.
  Results : Frequencies of severe bradycardia (HR < 49 bpm, before 100%, after 9.8%), hypotension (systolic blood pressure < 90 mmHg, before 100%, after 9.8%), and use of transcutaneous pacing (before 40%, after 0%) were markedly lower than before adoption of the atropine-infusion protocol.
  Conclusion : This protocol is useful for preventing severe bradycardia and hypotension caused by the carotid sinus reflex.

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  Several cases of successful treatment of rocuronium-induced anaphylaxis with sugammadex have recently been reported. Since sugammadex is fast and easy to use in the operating room, it can be proposed as one of the therapeutic choices for rocuronium-induced anaphylaxis. On the other hand, the need for muscle relaxation should be taken into consideration. We experienced a case of laryngospasm after treatment with sugammadex for rocuronium-induced anaphylaxis. Based on this case, we discuss issues pertaining to the use of sugammadex for the treatment of rocuronium-induced anaphylaxis.

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  We experienced a complete atrioventricular block which occurred in an elderly woman undergoing spinal anesthesia when dexmedetomidine was administrated.
  Dexmedetomidine was stopped immediately, and infusion of atropine and ephedrine resulted in rapid improvement, so neither her general condition nor prognosis was affected. Her cardiac functions were investigated post-operatively, but since no organic disorder was found to have caused the complete atrioventricular block, dexmedetomidine was strongly suspected.
  When infusing dexmedetomidine to a patient under spinal anesthesia, it is necessary to monitor the patient's condition and be prepared to carry out emergency measures promptly.

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  Neuroblastoma secretes catecholamines which induce uncontrollable hypertension, tachycardia and arrhythmia. Intraoperative hemodynamic instability is uncommon in neuroblastoma. However, some case reports have described severe intraoperative hypertension during the manipulation of the tumor. We report on the anesthetic management of a 5-month-old infant who presented with severe intraoperative hypertension though he did not show severe hypertension preoperatively. We encountered frequent hypertensive attacks and needed to administer bolus and continuous infusion of vasodilators after the induction. It is difficult to predict from preoperative findings which patients with neuroblastoma will experience intraoperative hypertension. Even though intraoperative hemodynamic instability due to neuroblastoma is uncommon, anesthesiologists should prepare for it through measures such as invasive arterial blood pressure monitoring and administering vasodilators before the operation.

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  We report the usefulness of a transversus abdominis plane block for pain management during peritoneal dialysis catheter surgery in a patient with ischemic heart disease. A 91-year old male diagnosed with renal disease 10 years ago experienced a decrease in renal function, which required immediate dialysis. However, the patient had an ischemic heart attack, and a peritoneal dialysis catheter placement was scheduled prior to cardiac catheterization and treatment.
  With the patient awake, an ultrasound-guided transversus abdominis plane block was performed. Mild pain was experienced during fascial, muscle and peritoneal incision, and it was controlled by local infiltrative anesthesia. Hemodynamics were stable and the patient did not feel pain during the surgery. The transversus abdominis plane block is a useful anesthetic procedure for surgery of the abdominal wall in patients with poor general condition.

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  An intraosseous needle placement (IO) practice seminar was held during the 32nd annual meeting of the Japanese Society of Reanimatology under the joint sponsorship of the Japanese Association for Medical Simulation and IMI Corporation. In a 20-40 minutes session following a 20 min review of IO, participants practiced needling on chicken bone and dummy tibia and humerus using manual needle placement and an EZ-IO^® system. Participants also practiced various methods of confirming IO including point-of-care color Doppler ultrasound confirmation of IO (the Doppler method), which was newly introduced to Japan.
  The EZ-IO^® system enables immediate vascular access to the central circulation of children and adults. The Doppler method enables participants to objectively recognize needle misplacements. The hesitance on IO needle placement among the participants will be mitigated by the widespread use of the Doppler method in Japan.

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[in Japanese]

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