医師・歯科医師・薬剤師調査のデータに基づき, 年齢, 性別ごとに診療科別医師数の変化を分析した. この結果, 同一世代の医師であっても標榜診療科は年齢, 性別により変化することが明らかとなった. この手法は, 診療科別の医師需給予測に利用可能であると考えられた.
  また, この変化の傾向は, 医師が年齢・性別に応じて生じる動機に適合する診療科を選択するためにみられるものと考察され, 麻酔科においては, 中途からの麻酔科への標榜変更や, 一時臨床を離れた医師の診療復帰が困難である可能性が示唆された. 以上を踏まえて, 女性麻酔科医の雇用の促進に関して提言した.

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Airway stenosis during surgery for oral diseases can result in serious complications, thus making airway management one of the most important aspects of perioperative care. A case of buccal cellulitis, in which airway management was performed using a new type of tracheal cannula, is reported. This new type of tracheal cannula is suitable for patients with physical characteristics, such as obesity and swollen cervical tissues that often result in repeated accidental extubation when using a conventional tracheal cannula. The present patient was a female in her 70’s with chief complaints of pain in the right jaw and difficulty breathing. She was examined at her local dental clinic in February, 201X for pain in the right mandibular first molar; however, her symptoms worsened, and she was subsequently examined in the emergency department of our institution. Her current medical history included angina pectoris and IgA nephropathy treated with hemodialysis. On initial examination, her temperature was 37.7°C, and SpO2 was 94%. Breathing difficulty was evident, and marked swelling was observed from the right buccal area to the neck. Right buccal cellulitis was diagnosed clinically, and she was admitted immediately for incisional drainage under general anesthesia. Tracheostomy was then performed. Following repeated accidental extubations of a conventional tracheal cannula, a new type of tracheal cannula was applied, with which good airway management was subsequently achieved.

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気管チューブ挿管用金属スタイレットは, 気管挿管困難症例において挿管を補助する器具として広く一般に使用されている. 金属スタイレットが挿管操作時に折損しその先端部分が食道に迷入して消化管異物となった症例を経験した. 担当麻酔科医がそれに気づかず, 1週間後に撮影されたレントゲン写真にて上行結腸内の異物として発見された. 異物は翌日の排便時に無事排泄され, 合併症は引き起こされなかった. 金属スタイレットの折損片による事故の予防には, 定期的な器具の点検が重要である. また, 使用者である麻酔科医自身が危機管理の意識をもち使用前後の確認を怠らない必要がある.

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  Robin sequence (RS) is a congenital disease with micrognathia, glossoptosis-caused airway obstruction, and cleft palate as primary symptoms. Pediatric patients with RS are prone to airway obstruction when anesthesia is introduced, and intubation can be difficult because of micrognathia, which is problematic for anesthesia management. We provided general anesthesia management for a glossopexy in a 45-day-old female patient with RS. In this case, mask ventilation after introduction would have been challenging because unless the patient was in the lateral decubitus position during sleep, ventilation would be difficult. Thus, a nasopharyngeal airway was inserted under sedation, and anesthesia was introduced after confirming that the upper airway obstruction had improved. As it was difficult to intubate using a GlideScope^® Cobalt (GS) or a Fiberscope (FB) alone, a narrow field of view of the larynx was secured by performing a two-person technique using both a GS and a FB, making intubation feasible. After fixing the tube, the absence of any breathing problems was confirmed, and the patient’s vital signs remained stable. The operation was then started. The patient’s respiratory and vital signs were stable throughout the operation. Postoperatively, the resting SpO₂ remained in the high 90% range, the patient’s breathing was stable even in the supine position, and no hypoventilation was noted. Furthermore, under the guidance of a nurse, the patient’s mother was able to feed the infant without difficulty. Hence, the patient was discharged on postoperative day 2.

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  73歳，男性．重症僧帽弁閉鎖不全症（僧帽弁逆流症）を合併したアドレナリン優位型褐色細胞腫に対し，腹腔鏡下右副腎摘出術を施行した．麻酔導入後，PreSep oximetry catheter^TMとFloTrac^TMを用いて，心係数と中心静脈酸素飽和度（ScvO₂）の測定を開始した．腫瘍周囲の手術操作の間，血圧と全身血管抵抗（SVRI）が急激に上昇したために，フェントラミンを投与した．腫瘍摘出後，血圧と心係数を維持するためにドブタミンを使用した．これらのモニターを指標にした循環管理を行うことで，僧帽弁閉鎖不全症を合併した褐色細胞腫の麻酔を安全に行うことができた．

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Purpose ; The thoracic bioimpedance method (TBI) is thought to be useful to measure cardiac output continuously and non-invasively. In this study, the usefulness of TBI using BioZ.com^TM (CardioDynamics International Corp.) in cardiac surgery was examined in comparison with continuous thermodilution methods (CCO) using Vigilance^TM (Edwards Lifesciences LLC).
Methods; Cardiac output was continuously measured by both TBI and CCO in 10 patients (ASA risk II) undergoing elective coronary artery bypass grafting. Data were collected (1) after intubation but before incision; (2) after surgery; and (3)12hrs after surgery, when hemodynamics were stable.
Results; Cardiac output measured by TBI and CCO were ranging (1) 1.7to 2.3l·min^-1·kg^-1 and 1.0 to 2.7 l·min^-1·kg^-1, (2) 1.1 to 3.1l·min^-1·kg^-1 and 1.9 to 4.0l·min^-1·kg^-1, (3) 1.7 to 3.1l·min^-1·kg^-1 and 2.3 to 3.9l·min^-1·kg^-1, respectively. And, correlations between cardiac output measured by TBI (Y) and CCO (X) were (1)y=0.891+0.408x;r=0.366, (2) y=0.771+0.478x;r=0.559, and (3)y=0.592+1. 057x;r=0.573.
Conclusions; In cardiac surgery, TBI might be useless to measure cardiac output because it did not have a good correlation with CCO.

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ビリルビン吸着では血漿分離器の性能限界や溶血の発生およびフィブリン析出により，治療効果が得られないことがある。今回，選択的血漿分離器Evacure EC-4A（川澄化学工業製）を用いて，安定したビリルビン吸着ができた症例を経験したので報告する。70歳代女性の多臓器不全に対して，一次膜に選択的血漿分離器EC-4Aを用いてビリルビン吸着を施行し，総ビリルビン（T-Bil），フィブリノーゲン（Fib），血小板（Plt）の変動を経時的に評価した。治療回数は7回（血漿処理量：30L/回）で，治療後のT-Bil低下率は平均53.6％であった。Fib，Pltの変動はそれぞれ−22％から＋22％，−15％から＋31％であった。EC-4Aを用いることで，安定したビリルビン吸着が可能であった。

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  Multiple myeloma (MM) is a neoplastic proliferation of plasma cells characterized by the production of a large amount of abnormal immunoglobulin. Complications include renal impairment, hyperviscosity syndrome, amyloidosis, hypercalcemia, fractures, anemia, hemorrhagic tendency, and susceptibility to infection. We report the general anesthetic management of a patient with multiple myeloma undergoing a sequestrectomy for the treatment of medication-related osteonecrosis of the jaw (MRONJ).

  An 85-year-old woman (weight, 47.7 kg ; height, 148 cm) had a 4-year history of multiple myeloma. She had multiple myeloma-related complications including moderate renal impairment, anemia, and susceptibility to infection, and had received several immuno-pharmacotherapies. To prevent multiple myeloma-related destructive bony lesions, she was medicated with intravenous zoledronic acid for 14 months, which led to the development of MRONJ. She was scheduled to undergo a mandibular sequestrectomy under general anesthesia. Anesthesia was induced with propofol and remifentanil, and a lower dosage of rocuronium (20 mg) was administered incrementally under neuromuscular monitoring before tracheal intubation. The anesthesia was maintained with desflurane and remifentanil. To avoid acute kidney failure, low-dose carperitide was administered continuously. Because the effect of rocuronium was prolonged until the end of the surgery, sugammadex was administered to reverse the effect. Low-dose unfractionated heparin was injected subcutaneously to prevent deep vein thrombosis, which could have been induced by multiple myeloma-related hyperviscosity syndrome.

  Because bisphosphonates are the standard of care for the prevention of multiple myeloma-related destructive bone disease, the number of patients requiring surgical treatment for MRONJ is likely to increase. Since the symptoms of multiple myeloma vary among patients, appropriate perioperative management for each complication is required.

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Cornelia de Lange症候群の4歳女児に対する腹腔鏡下噴門形成術の麻酔管理を経験した. 麻酔管理上, 挿管困難と不慮の横隔膜損傷が問題となった. 挿管困難に対しては, 細径の気管支ファイバースコープを使用して経鼻挿管を行った. 術中に横隔膜を損傷し, 気胸を合併したため呼吸管理に難渋し, 気腹を中止した. 本症候群のような先天異常症候群では, 腹腔鏡下手術中の気胸は気腹圧の影響によって, とくに重篤になりやすい. 重篤な疾患を合併した小児のハイリスクな症例に対して腹腔鏡下手術を行う場合には十分な注意が必要であり, 安易に行ってはならない.

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症例は76歳，男性．盲腸癌に対する右半結腸切除術の3カ月後に腹痛発作で入院した．腹部単純Ｘ線，腹部CT検査，腹部エコー検査で，腹腔内に線状金属陰影を認めた．腹部症状が悪化し，Ｘ線下に開腹手術を施行したところ，小腸を突き破る長さ7cmの金属片を確認した．摘出した金属片をただちに調査し金属スタイレットの先端部分であると断定した．先の手術の麻酔導入時に食道挿管されており，その時に金属疲労した先端部分が折損し食道内に進んだものと推察された．術後経過は順調で術後10日目に退院した．現在術後3年半が経過したが，合併症なく外来通院中である．

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  Nasotracheal intubation is frequently selected for oral surgical procedures. We experienced a case with pressure sores formed form a nasotracheal tube in which the sores cicatrized, causing nostril stenosis. The patient was a 59-year-old man who had undergone bilateral temporomandibular joint (TMJ) mobilization and bilateral coronoidectomy for bilateral TMJ ankyloses. The anesthesia time was 12 hours. Upon extubation, pressure sores with reddening were observed on the nare. An ointment was applied, and the patient was discharged from the hospital. Three months later at a regular checkup after oral surgery, the patient complained of nostril stenosis. The patient was referred to the Department of Plastic Surgery and a nasal prosthesis was inserted ; widening of the nasal cavity was subsequently observed 1 month later.

  Factors affecting pressure sore formation include long operations, a male gender, pressure on the nare exerted by the intubation tube, and skin humidity. In addition to these factors, the patient had a history of diabetes mellitus and atopic eczema, which might have increased the risk of pressure sore formation and delayed healing. Tube fixation or dressing applications can be useful for preventing sore formation from the exertion of pressure on the nare. Furthermore, the Department of Plastic Surgery or Otolaryngology should be consulted promptly when sore formation is observed upon extubation to prevent the development of severe conditions.

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We experienced a case of ambulatory anesthesia for a 13-year-old boy with 47XXY Klinefelter's syndrome and systemic lupus erythematosus. He visited the Department of Pediatric Dentistry in our hospital complaining of toothache. He underwent dental treatment under general anesthesia.
The previous year, he had visited the Department of Pediatrics because of fever, and thrombocytopenia was found. A detailed examination was therefore performed and revealed that his chromosomal type is 47XXY. Additionally, he was diagnosed with systemic lupus erythematosus, since he had antinuclear antibody, anti-DNA ds antibody, anti-sm antibody, and PA IgG. He took prednisolone 5mg every day.
In the preoperative examination, the platelet count was 12.8 × 10⁴/micro-L. PT-INR was 1.32 and APTT was 57.5 seconds. Hemorrhagic diathesis, however, was not observed clearly.
Anesthesia was induced with intravenous midazolam and fentanyl and maintained with inhalation of sevoflurane and intravenous fentanyl. No severe complication occurred.
A patient with Klinefelter's syndrome is often complicated with autoimmune diseases, so it is important to pay attention to the patient's condition.

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The hard laser is now widely used in the oral and maxillofacial region because itshemostatic ability and imploved visualization of the operative field facilitate a presice op-eration. Another important advantage of the hard laser is that some operations can be donewithout anesthesia. In this paper, six cases of epulis excised by the hard laser without anes-thesiaare presented.
A CO² laser (one type of hard laser) was used with a continuous wave, power setting of 2 to 4 watts. All lesions could be excised completely, and no patients felt pain during laserirradiation. The operation was successful without using surgical packs, and there was nopostoperative discomfort. There has been no evidence of recurrence after operation.

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