When an emergency intracranial hematoma removal operation was performed for brain contusion in a patient who had hypertension and diabetes, cardiac arrest developed due to complete atrioventricular block. Although 1.0 mg of atropine intravenous injection was ineffective, pacing was initiated immediately and was successful since the pad for pacing and defibrillation was placed before the operation. Although it is not taken into consideration in an emergency, there are guidelines for a permanent pacemaker thicket standard over a two branch and a three-branch block, but there are no guidelines for temporary pacemaker insertion, and guidelines in an emergency are required.

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  Unintended intrathecal cannulation is a dangerous complication of internal jugular venipuncture which has been reported in both pediatric and adult patients using both the anatomic landmark and ultrasound-guided techniques. Many possible causes have been considered in the literature, but there is no consensus about the actual mechanism. We hypothesize the importance of three factors in the occurrence of this complication, including : 1) rotating the head excessively to the contralateral side, 2) directing the needle medially, and 3) deep insertion of the needle. These three factors are based on the anatomy of the neck and central veins. The mechanism of this complication in previous reports may be explained by some combination of these factors. This hypothesis may serve as a challenge to prevent this rare but serious complication.

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  New surgical techniques and advances in diagnosis and medical therapies have significantly lowered mortality rates for children and adolescents with complex congenital heart disease (CHD). However, children with CHD are at increased risk of developmental disorders or disabilities and developmental delays caused by both biological and environmental risk factors. Biological risk factors include underlying syndromes and genetic/developmental disorders, the circulatory abnormalities specific to the heart defect, and the medical and surgical therapies required. Biological risk factors are modified by environmental risk and protective factors at home, school, and work.
  Among pediatric patients with complex CHD, there is a distinctive pattern of neurodevelopmental and behavioral impairment characterized by mild cognitive impairment, impaired social interaction, and impairments in core communication skills, including pragmatic language, as well as inattention, impulsive behavior, and impaired executive function. Many school-aged survivors of infant cardiac surgery require habilitative services including tutoring, special education, and physical, occupational, and speech therapy. With early identification of developmental delays, children have the best chance of reaching their full potential. Periodic developmental screening and reevaluation throughout childhood may enhance identification of significant deficits, allowing for appropriate therapies and education to enhance later academic, behavioral, psychosocial, and adaptive functioning.

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  There are various problems which are solved by Operations Research in the management of operating rooms in hospitals, such as the scheduling of operating rooms and shift work scheduling of anesthesiologists and nurses in charge of the operating rooms. In this paper, we introduce a support system for shift work scheduling of anesthesiologists developed through joint research by the Department of Anesthesiology of Aichi Medical University and our research group. We focus on the development of the design of the system by which the anesthesiologist in charge of scheduling utilizes his knowledge and experience to make good schedules. The system is in trial use at the Department of Anesthesiology of Aichi Medical University.

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  The National Disaster Medical System (NDMS) was developed in Japan following the Great Hanshin-Awaji Earthquake of 1995. The Japanese government has been setting up Japanese DMAT and the Broad Transportation System. In the Higashi Nihon Earthquake and Tsunami Disaster of 2011, 383 DMATs throughout the country were activated and this major disaster certified the availability of the system. On the other hand, problems in the subacute and chronic phases of disasters were generally recognized.

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  The concept of Enhanced Recovery After Surgery (ERAS) was established by the European Society for Parenteral and Enteral nutrition and is now spreading worldwide. Although favorable effects of ERAS in reducing postoperative complications and shortening hospital stays have been found in meta-analyses, some adverse effects may occur because of the implementation of individual protocols without sufficient grasp of basic ERAS principles. For successful dissemination of ERAS, the Japanese Society for Surgical Metabolism and Nutrition started a campaign named ESSENSE for the pleasant, prompt, and satisfactory recovery of patients after surgery. ESSENSE is an acronym for ESsential Strategy for Early Normalization after Surgery with Patient's Excellent Satisfaction. The expected results of this project include a decrease in physical responses against surgical stress, early restoration of physical activity, self-reliance with regard to nutrient intake, increased motivation for recovery, and reduction of anxiety. Surgeons are expected to cooperate with anesthesiologists especially to decrease the physical responses of patients against surgical stress, and good communication between the two teams with regard to the sharing of the results of the campaign are expected to enhance patient recovery after surgery.

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  Enhanced recovery after surgery (ERAS) protocols are designed to improve patient recovery, reduce postoperative complications, increase safety, shorten hospital stays, and reduce health care costs. In Europe, many reports have described not only improved medical efficacy due to enhancing patient recovery but also the associated important economic benefits of shortening hospital stays when ERAS protocols are used. In Japan, ERAS protocols are increasingly utilized, primarily to improve patient care, but the potential economic benefits of ERAS protocols have not attracted major interest. This article describes how our hospital introduced an ERAS program, and reports the shortening of hospital stays and the economic benefits resulting from its implementation. Differences in Japanese culture, lifestyle and health care systems across Japan could lead to challenges in the widespread use of ERAS protocols unless they are customized to fit each local medical situation.

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  Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual (WHO : 2002). To meet the needs of such patients and their families, palliative care teams (PCT) consist of interdisciplinary medical professionals including physicians, nurses, pharmacologists, medical social workers, rehabilitation professionals, dieticians, clinical psychologists, dentists and dental hygienists. According to registration of PCT in Japan by the Japanese Society for Palliative Medicine, there are currently more than 480 PCT in this country. The role of rehabilitation professionals as members of PCT is the same objectives according to the definition of palliative care above, but different by means of that.

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  Kampo, a Japanese form of herbal medicine, uses natural biological products to treat patients. The practitioner of Kampo medicine considers its effects on the entire body, making it a form of holistic medical care. In psycho-oncology, psychiatrists obtain information from patients about their living environment, eating habits, personal tastes, lifestyle, family life, and interpersonal relations, and then treat each patient in a highly individualized manner. In this regard, Kampo and psycho-oncology are similar. Practitioners must understand the fear, anxiety, and depressed mood experienced by cancer patients and treat them while relieving their digestive symptoms to avoid the harmful effects of malnutrition. It is therefore important that cancer patients be treated for anxiety and depressed mood with Kampo medicines frequently used to improve digestive symptoms, such as Rikkunshito (including iced Rikkunshito), Hangekobokuto, Bukuryoin with Hangekobokuto, Kososan, Hochuekkito, and Juzentaihoto, along with formulations from the bupleurum root drug group for anxiety and depressed mood and formulations from the kuoketsu drug group for oketsu (stagnant blood), as indicated by the patients' state.

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  Japanese traditional (Kampo) medicine supplements modern medicine in the treatment of symptoms such as general fatigue and appetite loss. Kampo medicine is established as a form of holistic medicine whose examination method itself is thought to have a therapeutic effect. Kampo formula therapy can be used easily for cancer patients because it is covered by the national health insurance system in Japan. When it is difficult for patients to take Kampo formula, acupuncture is a good alternative. Recently, many clinical studies have been done to establish the efficacy of acupuncture in palliative care. We demonstrated the efficacy of Contact Needle Therapy (CNT) for chemotherapy-induced peripheral neuropathy. In order to establish evidence for Kampo medicine, high quality randomized controlled trials are needed.

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  Emergence agitation (EA) following general anesthesia in children is an evolving problem because it can injure both the patient and the caregiver and decrease the parent's satisfaction. Risk factors for emergence agitation include age, preoperative anxiety, the character of the patient, pain, the operative procedure, and the anesthetics used. Maintenance of anesthesia with sevoflurane is a major risk factor for EA, whereas propofol maintenance allows for calm wake-up, smooth and rapid recovery profile, and few postoperative side effects. Perioperative medications including opioids, midazolam, alpha-2 agonists, ketamine, and non-steroidal anti-inflammatory drugs are effective for avoiding EA. Anesthesiologists should prevent EA following pediatric anesthesia by considering the risk factors and appropriate selection of anesthetics.

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  Newborn babies present with a diverse variety of conditions which are typically influenced by gestational age at birth and by congenital comorbidities. Perioperative management should be individualized to their medical conditions. It is well known that neonates respond to pain and that exaggerated stress response will adversely affect surgical outcomes. Recently, various animal studies have indicated that many types of anesthetics are potentially neurotoxic to the developing brain. Although the neurotoxic effects of anesthetics on the human brain require further study, the current trend in neonatal anesthesia favors minimizing hypnotics and using ultra-short acting opioids instead. New anesthesia-related medications and equipment have also enabled the extubation of neonates in the operating room.

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  In pediatric cases undergoing internal jugular vein (IJV) catheterization, the blood vessel course should be confirmed before puncture by ultrasonographic imaging. Practitioners may occasionally penetrate the posterior IJV wall during puncture, which may result in inadvertent puncture of the arteries behind the IJV and lead to intra-arterial catheter placement. The arteries behind the IJV can occasionally be palpated. However, confirming the presence of arteries around target veins using Doppler color-flow imaging before puncture is vital. The vertebral, subclavian, transverse cervical, and inferior thyroid arteries, as well as the thyrocervical trunk, along with the common carotid artery, are occasionally present just behind the IJV in pediatric cases. Its observation requires knowledge of anatomy.
  Practitioners should become accustomed to identifying the needle tip, the IJV, and these arteries simultaneously using real-time ultrasonographic guidance. Images of the needle tip near or at the anterior IJV wall should be continuously captured to avoid inadvertent puncture. We can obtain two bright echoic enhancements, reflected from the needle tip, particularly in the inner portion of the vein. Thus, the arteries around the IJV including the common carotid artery should be carefully identified to ensure safe central catheter placement in pediatric cases.

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  Ultrasonic technology has proved useful in intraoperative examinations because it allows the exact anatomy and pathophysiology of patient to be defined immediately. Intra-cranial bleeding and ischemia can be assessed using sonography of the head. This assessment is important for surgical management with premature neonates to prevent neurogical complications. Cardiac valve function and ventricular filling can also be evaluated by transesophageal echocardiography (TEE). TEE probes are available which can be inserted into small infants. If a TEE probe is to be inserted, however, monitor ventilation carefully because its passage may compromise ventilation in small patients.

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  Epidural analgesia has been considered the gold standard for pain relief during and after various kinds of thoracic and abdominal surgical procedures. However, recent increases in the numbers of patients receiving minimally invasive surgical procedures and prophylactic anticoagulation therapy has led to the development of several new kinds of ultrasound-guided truncal blocks. These are relatively easy to perform and have therefore enjoyed a surge in popularity. However, since the analgesic effects obtained are limited in extent and duration, the selection of an appropriate approach is important and the development of continuous techniques is required. This paper describes the anatomy of thoracic and abdominal walls, procedures for each technique, and the benefits and problems associated with truncal blocks.

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  The supraclavicular approach of brachial plexus block provides complete anesthesia/analgesia without opioid supplementation for most surgical procedures of upper extremity distal to mid-humerus. Since it often spares supraclavicular and axillary nerves, the interscalene approach is recommended for shoulder or proximal arm procedures. Addition of a superficial cervical plexus block should be considered because the interscalene approach alone sometimes provides incomplete analgesia. The infraclavicular approach is a good candidate for an indwelling continuous perineural catheter because it enables stable catheter placement and causes less patient discomfort. The axillary approach is a good choice for an ambulatory distal upper limb surgery because it poses no risk of delayed-onset pneumothorax after discharge home.

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  Total knee arthroplasty (TKA) and uni knee arthroplasty (UKA), one of the most popular orthopedic surgeries, are increasing year by year in Japan. There are various approaches to knee arthroplasty and postoperative rehabilitation. Therefore, the most suitable combination of peripheral nerve blocks, which is well known as a good analgesic procedure for knee surgery, depends on the type of surgery and rehabilitation.
  Continuous femoral nerve block (CFNB) provides much better postoperative analgesia and range of motion, but it also leads to muscle weakness of the quadriceps. Recently, adductor canal block and local infiltration analgesia have been reported as alternative analgesia for CFNB by some investigators. These may be acceptable methods for the rehabilitation oriented early ambulation.
  It is crucial for anesthesiologists to recognize which combination of analgesia is best for each patient.

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  Third generation hydroxyethyl starch 6%HES130/0.4/9 (Voluven^®) went onto the market in Japan in October 2013, while the European Medicines Agency had recommended suspending marketing authorizations for HES in Europe in June 2013. This recommendation was based on clinical studies which found that patients with severe sepsis treated with HES were at a greater risk of kidney injury requiring dialysis. The recommendation was finally withdrawn in December 2013 in response to new positive findings for colloid solutions published thereafter and the statement of the chairman of the European Society of Anesthesiologists supporting HES usage during surgery. In this article, the general characteristics, renal function, and hemostasis-coagulation problems of 6%HES130/0.4 during surgery are discussed.

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  In aviation, navigation aids play a crucial role in preventing fatal crashes of aircraft. An anesthetist's job is in a sense similar to that of a pilot, and knowledge of drug interactions is essential to appropriately provide balanced anesthesia. However, many anesthetists regard pharmacokinetics (PK) and pharmacodynamics (PD) as boring, difficult subjects with no relevance to clinical practice. SmartPilot View^TM (Dräger Medical GmbH, Lübeck, Germany) is a “navigation tool” which visualizes PK/PD as an easily understood two-dimensional graph. Measured concentrations of volatile anesthetics are exported from anesthetic machines (Primus^TM, Apollo^TM, Perseus^TM) to SmartPilot View^TM, while predicted concentrations of propofol and opioids are calculated based on “history” of drug infusion and a PK model of each agent. Time course of balanced anesthesia can be depicted as a path of a dot on xy plane when concentrations of analgesics and hypnotics are plotted as x and y coordinates, respectively. By superimposing an isobologram which shows probability of somatic/sympathetic responses to various stimuli (calling patient's name, laryngoscopy, surgical incision) on this xy plane, temporal change of pharmacodynamic effects is easily appreciated. Not only past and present drug concentrations but also “future” concentrations in the next 15 minutes can be predicted. SmartPilot View^TM is a valuable pharmacological aid and supports the “safe flight” of balanced anesthesia.

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  According to the Japanese Society of Anesthesiologists Closed Claims Project, about 30% of medical disputes involve problems in the airways causing death and serious sequelae in many cases. Currently, a variety of video laryngoscopes have become available for the resolution of such cases. The McGRATH^® MAC, a new video laryngoscope, enables visible laryngoscopy to be performed both under indirect vision through its camera and direct vision through actual laryngoscopy. Since the shape of its blade is similar to those of traditional laryngoscopes, anesthesiologists are not required to undergo special training. Herein, we illustrate the points required for intubation with double-lumen endotracheal tube (DLT) using the McGRATH^® MAC in addition to describing its usefulness in normal tracheal intubation.

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