Objective : Acute kidney injury (AKI) is a recognized complication of postoperative cardiovascular surgery. This investigation aimed to identify risk factors for AKI during replacement of descending thoracic aorta (DTA). AKI was diagnosed according to the Acute Kidney Injury Network (AKIN) Criteria, which is defined as the maximum postoperative increase in serum creatinine level from preoperative baseline.
Methods : A retrospective and observational study was performed on 101 patients with replacement of DTA by left heart bypass.
Results : A total of 43 patients (42.6％) developed AKI during the postoperative period.
A logistic regression analysis identified three independent risk factors for AKI : preoperative chronic obstructive pulmonary disease, furosemide used during surgery, and duration of cardiopulmonary bypass. Postoperative AKI increases the risk of postoperative ICU stay and postoperative mechanical ventilation time.
Conclusions : A high incidence of AKI during thoracic aorta surgery was confirmed regardless of deep hypothermic circulatory arrest. A high incidence of AKI during cardiovascular surgery was reconfirmed through this study.

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We performed goal-directed therapy (GDT) with a FloTrac^TM/Vigileo^TM in order to determine its usefulness. In this study, we examined the impact of perioperative management with GDT on renal function and the length of the intensive care unit (ICU) stay. This study focused on pancreatic surgeries. For Group C (n＝24), intraoperative management was provided by measuring mean blood pressure, heart rate, and urine volume as parameters. For Group GDT (n＝23), stroke volume variation and stroke volume index, obtained from the FloTrac^TM/Vigileo^TM sensor, were also used as parameters. The primary endpoints were pre- and postoperative blood urea nitrogen (BUN), creatinine, and length of ICU stay. The length of ICU stay in Group GDT (1.3±0.6 days) was significantly shorter than in the Group C (2.5±2.2 days) (P＝0.043). There were no significant differences in pre- and postoperative BUN or creatinine levels.

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The objective of this retrospective study was to assess the incidence of airway complications when using a size 1 laryngeal mask airway (LMA#1) in ex-premature infants and determine the influence of preoperative pulmonary complications on airway complications during anesthesia. Nineteen ex-premature infants were anesthetized using LMA#1. Five of nineteen infants (26％) experienced airway complications, which included hemoglobin oxygen desaturation (2 of 5), oropharyngeal air leakage (2 of 5), and malposition (1 of 5). Airway complications were not associated with the bronchoscopic view of the glottis via LMA#1. Four of nine infants with and one of ten infants without preoperative pulmonary complications experienced airway complications during anesthesia. A tendency toward higher incidence of airway complications was seen in ex-premature infants with preoperative pulmonary complications. In conclusion, LMA#1 should be used with caution for airway complications in ex-premature infants with preoperative pulmonary complications.

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Sotos syndrome is a hereditary disorder characterized by typical face, early accelerated growth, and developmental delay. We experienced a case of seizure-like movements, and ST-segment depression on electrocardiography (ECG) possibly caused by the induction of anesthesia with sevoflurane in a child with suspected Sotos syndrome. The operation was stopped and the investigation revealed suspected coronary spastic angina in the patient. One year after the first operation, the patient underwent an operation requiring general anesthesia. The induction of anesthesia was achieved rapidly with a barbiturate, and nicorandil was administered continuously during the operation. In the perioperative period, no problems were evident on ECG and there were no neurological adverse effects. In conclusion, anesthesia was successfully induced by avoiding a high concentration of sevoflurane inhalation in a child with suspected Sotos syndrome. Anesthesia in patients with suspected Sotos syndrome requires careful preparation and consideration.

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We report a case of lumbar discectomy under general anesthesia in a pregnant woman in the 13th week of gestation. To avoid miscarriage and premature labor, surgery and anesthesia in pregnant women should be undertaken carefully in the second trimester of pregnancy due to fewer maternal anatomical and physiological changes at that time. In this case, surgery was performed at the end of the first trimester, in the 13th week, because of deteriorating neurologic symptoms, as well as the possible problems associated with adoption of the prone position due to the enlarging uterus. Care should be taken when selecting general anesthetics in pregnant women. In this case, there seemed to be no obvious adverse effects of general anesthesia on the fetus. During anesthetic management for surgery in pregnant women, maintaining utero-placental perfusion and avoiding the use of teratogenic agents are essential to prevent adverse effects.

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A 46-year-old man was admitted to our hospital because of multiple traumas in a motorcycle accident. He presented hypovolemic shock caused by pelvic hemorrhage. After urgent transcatheter arterial embolization to stabilize bleeding from pelvic fracture, his respiratory condition worsened and he needed ventilator support. Chest X-ray showed pulmonary edema caused by mitral regurgitation. He underwent temporary external immobilization of the pelvis following final osteosynthesis. He was discharged, but 22 days later he had dyspnea and was readmitted. Mitral valve repair was planned due to severe mitral regurgitation. Operative findings showed that the anterolateral papillary muscle had torn off from the left ventricular wall. Severe damage to the mitral valve required mitral valve replacement. With careful anesthetic management for acute mitral regurgitation, stable respiratory and hemodynamic condition was maintained throughout the operation. The patient's postoperative course was uneventful and he was discharged on the 11th postoperative day.

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Thyroid crisis is a rare life-threatening disorder and its prompt treatment is essential to a complete recovery. We describe a patient with thyroid crisis precipitated by thyroid surgery who survived despite developing multiple organ failure. A 37-year-old woman with Graves' s disease was operated on for long-standing uncontrolled hyperthyroidism. Preoperative examination revealed a marked increase in thyroid hormone levels (FT4 8.82 ng/dL, FT3>30 pg/mL). Total thyroidectomy was uneventfully performed under general anesthesia with carperitide and landiolol given during the operation. On the 1st postoperative day (POD), she developed thyroid crisis characterized by high fever, heart failure and altered mentation, finally leading to cardiac arrest. After successful restoration of sinus rhythm, we progressively started an intensive therapy for hyperthyroidism, congestive heart failure, renal failure, hepatic dysfunction and disseminated intravascular coagulation, but no significant improvement was seen in her condition. On the 2nd POD, her cardiohemodynamics were surprisingly improved by plasma exchange using 40 units of fresh frozen plasma. She gradually recovered from her multiple organ failure and left ICU on the 19th POD. When clinical deterioration occurs despite medical management directed against thyroid crisis after thyroidectomy, plasma exchange may be a useful therapeutic option.

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A 37-year-old woman was scheduled to undergo resection for a massive abdominal tumor. Although there was a risk of massive hemorrhage and other complications, the tumor, which was later diagnosed as uterine myoma, was resected without any major complications. Due to early anticoagulation therapy, postoperative analgesia was performed with continuous wound infiltration of anesthetic and continuous intravenous infusion of fentanyl. When leaving the operating room, the patient did not complain of pain, and postoperative VAS was generally favorable.
Our results suggested that in cases in which epidural anesthesia cannot be carried out, a combination of continuous wound infiltration under anesthesia with 0.2% ropivacaine and continuous infusion of fentanyl could potentially be helpful for post-operative pain management.

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We experienced a case of awake intubation using the novel videolaryngoscope, King Vision^®, in a patient with predicted difficult airway management.
Case : A 71 year-old man with facial deformity and tracheal stenosis due to a history of maxillary cancer resection.
Local anesthetic was sprayed in the patient's pharynx, larynx and trachea before tracheal intubation. King Vision^® channel blade type and endotracheal tube with tube exchanger were used. Visualization of the larynx was easy and the glottis view was adequate. There was no foggy view on the screen due to expiratory vapor. Awake intubation was conducted successfully though difficult airway management was expected. This result indicates that King Vision^® is a suitable device for awake intubation.

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One and half years has already passed since transcatheter aortic valve implantation (TAVI) was approved in symptomatic patients with many comorbidities and in patients who cannot undergo standard surgical aortic valve replacement due to high surgical risk. Over 100,000 TAVI procedures have been performed worldwide, while over 1,000 have been done in Japan. Though many reports have been published, there have been few regarding the Japanese population.
Generally speaking, Japanese body size is smaller than that of Europeans and Americans. Smaller access site vessel and annulus size are more likely to cause serious procedural complications such as aortic dissection and aortic root rupture.
A candidate for TAVI is likely to have many comorbidities, so comprehensive medical care by a number of specialists such as experienced cardiac surgeons, cardiologists, anesthetists, nurses and rehabilitation therapists is essential.
In this paper we would like to assess heart team management, initial treatment results, and future tasks based on our own experience.

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An anesthesiologist tasked with tailoring anesthetic management for pediatric cardiac catheterization should correctly recognize the risk of complications or adverse events related to the procedure for every case and anticipate the effects of the anesthetics on both hemodynamics and respiration. A third factor to consider is the influence of the anesthetics on the conduction system in order to minimize the anesthetic effects on arrhythmia diagnosis and treatment. Anesthesiologists responsible for managing pediatric cardiac catheterization provide either general anesthesia or monitored anesthesia care for most cases. Ideally, an anesthesiologist should discuss the treatment goal and procedure with the surgeon and understand them well before catheterization begins. In this review I will begin by describing the methods for assessing the risk of adverse events related to cardiac catheterization. Next, I will summarize the accumulated knowledge on the adverse effects of various anesthetics on cardiovascular and respiratory systems. Lastly, I will describe the risk of acute left ventricular failure following transcatheter closure of atrial septal defects.

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Regional cerebral oxygen saturation (rSO₂) monitoring by near-infrared spectroscopy is frequently used during cardiovascular surgery to evaluate the adequacy of cerebral perfusion and to avoid neurological and neurocognitive complications. Sudden changes of rSO₂ values and the occurrence of side-to-side differences may indicate impairment of cerebral perfusion and/or brain hypoxia, warning anesthesiologists and/or surgeons to check cerebral perfusion. Although some recent reports show an association between the decline of rSO₂ values during cardiovascular surgery and the development of postoperative cognitive dysfunction, careful interpretation is needed to understand this association. Information showing the usefulness of rSO₂ for detecting and preventing cerebral infarction caused by emboli during cardiovascular surgery is limited. Multi-channel and continuous monitoring of rSO₂ perioperatively might overcome this limitation in evaluating cerebral infarction caused by emboli.

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This article explains the background for inclusion of conventional safe monitoring with near-infrared spectroscopy (NIRS) under anesthesia in the payment system for medical services, and discusses medical fee-related issues concerning NIRS as a cerebral metabolism monitor. The scope of usefulness of NIRS is first presented and guidelines for its use are then summarized.
Until it was included in the payment system for medical services, it was necessary to apply NIRS to Advanced Medical Care A services or as specified in the system for healthcare services provided combining insurance-covered and non-covered services.

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We conducted a survey on the perioperative use of cerebral near-infrared spectropscopy (NIRS) for monitoring cerebral hemodynamics in Japan. Of the hospitals surveyed, 38% responded to the survey. For cardiovascular surgery, NIRS was used in all cases in 38% of hospitals and was not used in 16% of hospitals mostly for economic reasons. For carotid endarterectomy and carotid artery stent, NIRS was used in all cases in 47% and 33% of hospitals, respectively. NIRS was also used in patients with carotid stenosis or occlusion who underwent other types of surgery. NIRS monitoring was efficient in cardiovascular surgery, surgery with cardiopulmonary bypass, carotid endarterectomy and carotid artery stent in most of the responding hospitals. The data indicated that acquisition of support by the medical payment system as well as appropriate use of NIRS is warranted, especially in patients undergoing cardiovascular surgery and carotid artery surgery.

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The author gives a bird's-eye view of palliative care in this article.
Palliative care is defined as an approach that improves the quality of life of patients and their families facing problems associated with life-threatening illnesses through the prevention and relief of suffering by early identification and the correct assessment and treatment of pain and other problems physical, psychosocial and spiritual.
Some shortcomings of WHO cancer pain management are also discussed.

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Anesthesiologists play an active, expert role in perioperative medicine and pain management. In palliative care, they can use their skills to support palliative therapy in other departments as well as manage cancer pain in patients undergoing medical care. For example, to relieve metastatic bone pain, patients who cannot maintain a body position because of pain during radiation therapy are given a continuous epidural block. In order for anesthesiologists to extend their skills into other medical fields, they must grasp the needs of patients by cooperating with the attending doctors, and must inform other departments about the services they are able to provide. Anesthesiologists can definitely contribute to the expansion of cancer treatment and palliative care by using their specialized skills, although some problems such as a shortage of manpower remain to be solved.

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Operative anesthesia given by anesthesiologists is intended to protect patients from operative stress, while palliative care is intended to protect patients from illness-related stress. Regardless of the stage of illness, it is necessary to create environments that allow patients, their families and medical staff to concentrate on providing/receiving treatments and care without anxiety. For anesthesiologists serving as specialists in stress control medicine, there has been an expansion of relevant fields (not confined to the perioperative period) in which their sophisticated skills and support can be provided. The authors will discuss how anesthesiologists should be involved in palliative care, citing intrathecal analgesia as an example.

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The development of innovative therapeutic equipment should be driven by clinical needs and requires close collaboration between medical doctors and technical experts to integrate their knowledge to attain a common goal. During this process, especially with regard to pharmaceutical agents, the approval regulations for the new device, drug, or technology should always be taken into consideration. Such complex objectives require the creation of very specific human resources and the establishment of specialized institutions incorporating experts in various fields.

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Intellivent-ASV (iASV) is the newest ventilation mode provided by Hamilton Medical. It makes a closed-loop system between the ventilator and patients who require oxygenation and ventilation monitoring. We ventilated 22 patients using iASV after cardiac surgery. The closed-loop system of ventilation control is very convenient because patients show increased CO₂ exhalation in the early phase after cardiac surgery. Because of an unstable circulation, anesthesiologists either do not initiate or discontinue automatic oxygenation control system (FIO₂ and PEEP settings) and auto SBT (Quick Wean).
Fully automated weaning after cardiac surgery was successfully achieved with the iASV in about 50% of patients in this study. However, the usefulness of fully automated weaning using iASV in a closed or semi-closed ICU is still not well understood because of the lack of advanced circulatory regulation systems.

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