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Background: Recently several types of head- mounted displays are available for use in the medical field. Because head-mounted display can provide the visualized information without moving direction of eye- sight, ultrasound guided central venous cannulation might be performed more quickly and safer. One of the head-mounted type displays, Near-Eye Display (NED; NED prototype product, JCV Kenwood, Japan) was tested in ultrasound guided central venous cannulation., Methods: Eleven experienced anesthesiologists per- formed central venous cannulation on the training sim- ulator with NED and with control method (without NED). Ultrasound real time image and operating field were recorded by video camera and analyzed to iden- tify procedure time, success rate and incidence of unintentional posterior venous wall penetration., Results: With NED, although time required for cen- tral venous cannulation was similar to the time with standard method (31.3 ± 8.7 sec with control and 30.2 ±7.9 sec with NED, P=0.61), unintentional posterior wall penetration tended to occur less frequently (21% with control and 9% with NED, P=0.17)., Discussions and Conclusions: As NED can help practitioners to have both insertion field and ultra- sound image visible without moving eyesight, NED might be a promising assist device for the ultrasound guided central venous cannulation.

A 31-year-old woman with a left frontal and parietal brain tumor underwent awake craniotomy. Propofol/remifentanil general anesthesia was induced. Following craniotomy, anesthetic administrations ceased. The level of consciousness was sufficient and she was not agitated. However, the patient complained of nausea 70 minutes into the awake phase. Considering the adverse effects of antiemetics and the upcoming surgical strategy, we did not give any medications. Nausea disappeared spontaneously while the operation was suspended. When surgical intervention extended to the left caudate nucleus, involuntary movement, classified as a tremor, with 5-6 Hz frequency, abruptly occurred on her left forearm. The patient showed emotional distress. Tremor appeared on her right forearm and subsequently spread to her lower extremities. Intravenous midazolam and fentanyl could not reduce her psychological stress. Since the tremor disturbed microscopic observation, general anesthesia was induced. Consequently, the tremor disappeared and did not recur. Based on the anatomical ground and the medication status, her involuntary movement was diagnosed as psychogenic tremor. Various factors can induce involuntary movements. In fact, intraoperative management of nausea and vomiting takes priority during awake craniotomy, but we should be reminded that some antiemetics potentially induce involuntary movement that could be caused by surgery around basal ganglia.

Background: From April 2013, Macintosh direct laryngoscopes (DL) were replaced by McGRATH® MAC video laryngoscopes (VL), and VL were distributed in all of our operating rooms and used as routine first choice devices. Purpose of this study was to compare the success rate of the first attempt tracheal intubation by the trainees with VL and DL. Incidence of tracheal intubation related injuries were also assessed., Materials and Methods: We reviewed anesthesia chart database in which tracheal intubations were provided by anesthesia trainees with experience of less than 3 months. Patient demographics, Mallampati classification and tracheal intubation profiles including type of the tracheal tube and devices were recorded., Results and Discussion: The first attempt success rate was 78.6% with DL and 92.8% with VL (P < 0.001). More than 2 repeated trial incidence was 5.2% with DL and 1.3% with VL (P < 0.001). Incidence of mucosal injury was lower with DL than VL., Conclusions: VL notably improved the first success rate of tracheal intubation compared with DL among trainees.

A patient developed acute dystonia following intravenous administration of metocroplamide 20 mg. A 34-year-old woman underwent right hepatectomy, under general anesthesia managed with desflurane, remifentanil, and rocuronium. At the start of surgery, droperidol 1.5 mg was given intravenously for anti-emetic prophylaxis. Operation was completed uneventfully. Intravenous patient-controlled analgesia (i.v.-PCA) with fentanyl, containing droperidol, was selected for postoperative pain management The patient showed a reasonable postoperative course; however, around 15 hours post-operatively, she complained of nausea, although droperidol 2.625 mg had been administrated (maximum dose). Nausea subsequently disappeared following intravenous metocroplamide 20 mg, and i.v.-PCA was terminated. The patient gradually complained of excessive sleepiness. Finally, she showed akinesis and bilateral oculomotor disturbance 140 minutes after metocroplamide administration. However, her vital signs remained stable. Examinations including magnetic resonance imaging, electroencephalogram, and blood test did not show abnormalities. She was diagnosed with acute dystonia. She recovered without medications 300 minutes after the onset of akinesis. She could communicate with her eyes, opening/closing, throughout this episode. The effects of antiemetics acting on different receptors are additive. However, we should remember that coadministration of metocroplamide and butyrophenone induces extrapyramidal signs like acute dystonia. Intraoperative management extending beyond postoperative antiemetic therapy is necessary.

Background: Epidural anesthesia is a useful tool for postoperative pain control. However, inappropriate fixing of the catheter not only hinders the analgesic effect, but could lead to serious accidents as a result of the untoward removal of the epidural catheter., Methods: In our hospital, in order to reduce the removal of catheter, we introduced a new method of fixing by Steri-StripTM from fiscal 2011., Results: We compared 2337 cases of epidural use for general anesthesia in one fiscal year of 2010. In fiscal year 2011, 2500 examples were examined backward., Conclusions: The group using the Steri-Strip, was able to significantly reduce the untoward removal (P = 0.002).

Monitored Anesthesia Care (MAC) in gastrointestinal endoscopy-treatment has been introduced in Japanese clinical situations recently. Nonetheless, MAC in gastrointestinal endoscopy-examination is not so popular unlike the North American situation because of the lack of trained sedation providers. However, Japan Gastroenterological Endoscopy Society created the "Guidelines for sedation in endoscopic practice"in 2013 under the cooperation of the Japanese Society of Anesthesiologists. These guidelines for sedation in endoscopic practice made MAC more popular for pain relief of the patient, and the establishment of safe sedation system should be provided eventually. In this review article, the guidelines are introduced and discussed for the current clinical practice and for the future.

Both obesity (BMI over 30) and SAS are risks for Supper airway maintenance. We report an obese patient (BMI 33.5) with SAS who underwent awake craniotomy. Weight reduction was instructed 1 month before the operation, and the patient lost enough weight to use intraoperative MRI. Under general anesthesia, surgical pads containing 2% lidocaine with adrenaline were inserted into the nasal cavities. The patient's airway S was secured by i-gel® until dura was opened. A nasal airway was then inserted to confirm the upper airway patency and anesthetics were terminated The patient regained consciousness and started respiration. The i-gel® was removed. The nasal airway was changed to an RAE tracheal tube ; the tube was fixed above the vocal cords under bronchofiberscopic observation. Continuous positive airway pressure (CPAP) via RAE tube was started. Neither coughing nor epistaxis was observed.The RAE tube prevented glossoptosis and did not disturb speech mapping. Emergent endotracheal intubation was easily managed because the tube was close to the glottis. The RAE tube was removed and nasal CP AP was applied overnight Carefully prepared CP AP support via nasal RAE tube was practical in keeping upper airway patency for an obese patient complicated with SAS undergoing awake craniotomy.

Background: Efficacy and safety of sugammadex in reversing neuromuscular block induced by rocuronium or vecuronium were investgated in Japanese patients., Methods: We studied 98 Japanese patients undergoing surgery requiring general anesthesia. Patients were allocated randomly to receive intubation dose of rocuronium or vecuronium. During surgery, patients received additional doses of rocuronium or vecuronium for maintenance of moderate block. At T2 reappearance sugammadex 0-4.0 mg . kg-1 was administered. The neuromuscular block was monitored with acceleromyography using TOF stimuli. Sevoflurane was administered to all treatment groups after intubation., Results: For the rocuronium-induced neuromuscular block, the mean recovery time of the T4/T1 ratio to 0.9 decreased from 82.1 min in the placebo group to 1.8 min in the 4.0 mg . kg-1 sugammadex group. For the vecuronium-induced neuromuscular block, it decreased from 83.2 min in the placebo group to 2.1 min in the sugammadex 4.0 mg . kg-1 group. Plasma concentrations of sugammadex were approximately dose proportional over the dose range of 0.5 to 4.0 mg . kg-1 and independent of the neuromuscular blocking agents used. No clinical evidence of recurarization or residual curarization was observed., Conclusions: The efficacy and safety of sugammadex were confirmed in Japanese surgical patients.

We had a neurosurgical patient who developed apnea during iMRI. She was suspected of obstructive sleep apnea. The tumor had a risk of motor aphasia, and therefore awake craniotomy with iMRI was planned. First, the patient was anesthetized and her airway was secured. After 11 minutes of termination of anesthetics, the patient regained consciousness. The level of consciousness was sufficient. Her respiration was stable with oxygen supply. Anesthetics were not given any more. She gradually became drowsy when the tasks were finished and tumor was removed, although she responded to verbal commands. During the second iMRI, capnogram showed flat line and peripheral oxygen saturation level dropped to 90%. Scanning was urgently stopped and the patient was intubated. The patient recovered without any neurological deficits the day after the surgery although the reason of respiratory arrest is still unknown. Awake craniotomy could be challenging because of unsecured airway with risks of vomitting, epileptic attacks or unstable level of consciousness. It is considered that the patient monitoring becomes more difficult when iMRI is performed because the patient's face cannot be obsereved directly. We should remember that conscious level as well as respiration pattern may change during operation.

Painful diabetic neuropathy is a common, difficult-to-manage complication of diabetes. We report two case of intractable painful diabetic neuropathy which occurred after the rapid lowering of blood sugar level. Although pregabalin, antidepressants, opioid analgetics and various nerve block did not improve their pain, clomipramine dramatically reduced their pain.

We studied the utility of Vigileo monitor for grasping hemodynamics with a patient in a state of anaphylactic shock. The stroke volume variation (SVV) predicts fluid responsiveness of normal cases. In the anaphylactic shock resulting from biased blood distribution, not only blood pressure but also pulse pressure markedly decreased within a couple of minutes. SVV is calculated from the standard deviation of pulse pressure. Therefore the SVV could be overestimated during anaphylactic shock. A former version of Vigileo monitor underestimated the arterial pressure-based cardiac output (APCO) due to the underrating of a single stroke volume (SV) in a range of systemic vascular resistance (SVR) below 800 dyne x sec(-1) x cm(-5). The version 3.02 Vigileo monitor allowed for more accurate estimation of SV because its new algorithm was able to revise the apparently low SVR derived from the arterial waveform characteristics and hence provided more realistic SV and APCO values. It was thus concluded that this ver. 3.02 is useful for anesthetic management of the anaphylactic case.

Background: The present study evaluated the relationship between the middle ear (ME) pressure increase rate (PIR) and the mastoid size as well as the effect of mastoid size on the incidence of nausea and vomiting during nitrous oxide (N2O) anesthesia., Methods: Twelve healthy male volunteers were recruited. The extent of mastoid pneumatization was measured planimetrically using a mastoid X-ray (Schuller's view). The ears were then divided into a small or large mastoid group according to the median value. The ME pressure was compared just before each increase to 33%, 50%, and 67% N2O. Using the ME pressure curve, the PIR for the first peak of the curve steepness was calculated., Results: Increasing the end-tidal N2O concentration to 50% and 67% in the large mastoid group and to 33%, 50%, and 67% in the small mastoid group significantly increased the ME pressure. The PIR in the ears in the large mastoid group was significantly lower and the incidence of nausea was 33% in the small mastoid group during 33% N2O anesthesia., Conclusions: A higher PIR in the ears and a higher incidence of nausea were observed in the small mastoid group, compared with the large mastoid group.

Bad anesthesia management easily causes mal-temperature situation. Main consequence of it is hypothermia as defined core temperature less than 36 degrees C and the other one is hyperthermia. Usually hyperthermia state have favorable effects on the body; but hypothermia itself does not provide any useful outcome besides one exception. Only confirmed useful exception of hypothermia state is for the post hypoxic brain damage. Other than that, hypothermia may provoke many complications after surgery including higher rate of wound infection, longer duration of hospitalization, more morbid cardiac events, prolongation of drug effects, more postoperative shivering, and delayed post anesthetic recovery. This review article discusses the mal-temperature management during surgery.

We present a case of prolonged hoarseness after tracheal intubation in a 62-year-old woman with bronchial asthma who underwent a pylorogastrectomy under a combination of epidural and general anesthesia. After the induction of anesthesia, the patient was carefully intubated using a 7.5-mm cuffed endotracheal tube without a stylet to avoid causing an asthma attack; the patient was extubated approximately 6 hours after the tracheal intubation. On the first postoperative day, the patient complained of hoarseness, vocal fatigue, and dysphagia. A direct laryngoscopy performed by an otorhinolaryngologist revealed dyskinesia of the left vocal cord and sufficient arytenoid cartilage mobility. The poor vocal fold mobility was probably caused by the force exerted on the left arytenoid by the convex curvature of the endotracheal tube, which had been inserted from the right side of the mouth, or a backward pressure on the thyroid cartilage during intubation. Early treatment is crucial in such cases, since the cricoarytenoid joint can become fibrosed in an unfavorable position. Fortunately, all the symptoms disappeared after one month in the present case. Although the trigger responsible for the spontaneous healing remains unknown, natural recovery might be associated with proper use of the vocal cords.

Arytenoid cartilage dislocation following tracheal intubation is a rare complication. A 48-year-old man underwent an operation for laparoscopic cholecystectomy under general anesthesia. Although no anaesthetic or operative problem had occurred, hoarseness was noticed after the operation, continuing beyond 25 days thereafter. He was referred to a laryngologist. Left anterior arytenoid dislocation was diagnosed using fiberoptic laryngoscopy. About four weeks later, the arytenoid cartilage dislocation resolved spontaneously. Other findings suggest that spontaneous reduction can be expected in many patients with anterior arytenoid dislocation. Patients suffering from arytenoid cartilage dislocation should be observed for several weeks if possible because there exist some reports in the literature describing spontaneous resolution after its dislocation.

We experienced anesthesia of a patient with pheochromocytoma on chronic hemodialysis who developed severe hypotension resistant to vasopressors after induction of general anesthesia. She was presented for spine surgery for destructive arthropathy of the cervical spine. Doxazosin up to 0.5 mg x day(-1) was administered for five days preoperatively for alpha-adrenergic blokade and regular hemodialysis was continued until the day before surgery without change in dry body weight. Blood pressure (BP) was within normal limits preoperatively. After induction of anesthesia with propofol and fentanyl, the patient developed hypotension with systolic BP of 60 mmHg which was resistant to vasopressor treatment with phenylephrine and ephedrine. After 45 minutes of volume replacement and commencement of dopamine and norepinephrine administration via a central venous catheter, BP recovered, and the surgery proceeded without further incident. Hypertension due to pheochromocytoma can be masked by excessive reduction of intravascular volume by preoperative hemodialysis. In a hemodialysed patient harboring pheochromocytoma who undergoes a surgical procedure unrelated to adrenalectomy, preoperative alpha-adrenergic blockade and subsequent intravascular volume expansion by increasing dry weight is required to avoid severe intraoperative hypotension, as for the case of adrenalectomy in the same situation.

We experienced perioperative management of a patient with Quincke's edema who underwent clipping of ruptured intracranial aneurysm. At the time of presentation, he complained of lip and tongue swelling. We administered dl-chlorpheniramine malate and tranexamic acid perioperatively to prevent further edema. Intraoperatively, we avoided contact of objects to the face and the oral cavity which might have caused mechanical stimuli, and infused albumin to maintain plasma osmotic pressure. The patient was kept intubated postoperatively because of significant tongue edema at the end of the procedure. On postoperative day 1, we extubated the trachea after prophylactic administration of methylpredonisolone. Significant upper airway edema was denied by flexible laryngoscopy. Pathophysiological cause of Quincke's edema is increased permeability of capillary vessels due to vasoactive substances. Aside from anti-histaminergic agents and steroids, tranexamic acid, which reduces production of kinin, is specifically effective for this condition. Although there is a reported case of Quincke's edema, eventually diagnosed after development of postoperative upper airway obstruction, there have been no reports of planned perioperative management of this condition. We demonstrated that Quincke's edema could be managed without life-threatening airway compromise by employing adequate pharmacologic interventions and sensible determination of the timing of extubation.

A 26-year-old G1P0 woman with past history of bronchial asthma underwent emergency cesarean section for non-reassuring fetal status under spinal anesthesia. She had not had surgery before. Thirteen minites after the start of the procedure, she started complaining of flushing and itching of her hands and mouth. We suspected anaphylactic reaction due to cefazolin, but after a thorough work up, it turned out that the symptom was manifestation of latex allergy. She had worked as a dental assistant and, had experienced mouth swelling by touching latex gloves. But she had not recognized it as a symptom of latex allergy. After the discharge from the hospital, she experienced food allergy. It is known that several antigens which cause latex allergy share common structures with defense related proteins of plants. It is to be noticed that, patients sensitized by those defense related proteins by plants intake, may develop latex allergy even though they are not considered to be high risk group from relevant occupational exposure and, co-morbid conditions. We should consider latex allergy as one of the causes of shock during intraoperative period even when the possibility of latex allergy seems scant.

We experienced perioperative management of a woman with large thrombi in femoral veins caused by estrogen producing ovarian tumor. At presentation, serum estradiol level was extremely high. Time constraint due to rapid expansion of the tumor did not allow us a trial of preoperative anti-coagulation. We placed a temporary IVC filter and proceeded with operation. As catastrophic pulmonary embolism could occur even with the presence of a filter, we prepared for institution of cardiopulmonary bypsss and pulmonary embolectomy via full sternotomy. We monitored arterial pressure based-cardiac output for immediate detection of pulmonary embolism. Postoperatively, serum estradiol level declined to normal range by postoperative day 7, and thrombi dissolved with anticoagulation therapy with warfarin and heparin without recurrence. In this case, surgery without preoperative anticoagulation was considered to pose extreme risk of perioperative pulmonary embolism. However, we considered that the thrombi would disolve by the removal of the tumor because estradiol production was the primary cause of thrombi. With above mentioned perioperative approach, the patient was managed uneventfully.

We managed 10 cases of propofol anesthesia with rocuronium, and recorded the time course of the neuromuscular blockade evaluated through accelerometry, as well as the estimated blood concentrations of rocuronium calculated from the administration history with a pharmacokinetic simulation analysis. Rocuronium was injected at 0.6 mg x kg(-1) initially, and the infusion rates were managed in order to maintain a twitch height at 3-10% of the control. The mean estimated rocuronium concentration (1.6 microg x ml(-1)) in our study was similar to the measured blood concentrations at the appropriate neuromuscular blockade that was previously reported. The estimated rocuronium concentrations at the appropriate neuromuscular blockade showed twice the inter-individual difference, and the time from the initial bolus of rocuronium to the spontaneous recovery with a twitch height of 5% showed a good relationship with the estimated rocuronium concentrations at the appropriate neuromuscular blockade. The time to spontaneous recovery with a twitch height of 25% and a reappearance of the fourth response in train-of-four ratio (TOF ratio) nerve stimulation was twenty minutes, even after a five-hour infusion, and was not affected by the length of the infusion. Thus, continuous infusion of rocuronium might be an effective and safe way to maintain appropriate neuromuscular blockade.

Background: Propofol target-controlled infusion (TCI) is now commonly used for the induction and maintenance of anesthesia. In this study, we measured the propofol plasma concentrations of elderly patients to evaluate our hypothesis that propofol TCI is reliable for use in elderly patients., Methods: We measured plasma concentrations of propofol in 10 elderly patients undergoing elective general anesthesia. Propofol TCI was commenced at a target plasma concentration of 3 microg x ml(-1) using a TCI pump. The target concentration was kept at 3 microg x ml(-1) for 2-3 hours. Arterial blood samples were drawn for measurement of the propofol plasma-concentration analysis at 30, 60, 90, 120 and 180 minutes after the induction of anesthesia, and at the emergence from anesthesia., Results: The measured plasma concentrations of propofol were not significantly different from the target plasma concentrations. The mean estimated and measured plasma concentrations at emergence were at about 1 microg x ml(-1), respectively., Conclusions: We concluded that propofol TCI is a reliable method for maintaining anesthesia even in elderly patients, whereas the individual differences of the elderly patients was greater than those obtained from normal patients.

Background: Propofol target-controlled infusion (TCI) is now commonly used for induction and maintenance of anesthesia. In this study, we measured the propofol plasma concentrations in obese patients in order to test our hypothesis that propofol TCI is reliable for use in obese patients., Methods: We measured plasma concentrations of propofol in 10 obese patients undergoing elective general anesthesia. Propofol TCI was commenced at a target plasma concentration of 4microg x ml(-1) using a TCI pump. The target concentration was kept at 4microg x ml(-1) for at least 3 hours. Arterial blood samples were drawn for measurement of the propofol plasma-concentration analysis at 30, 60, 90, 120 and 180 minutes after the induction of anesthesia, and at the emergence from anesthesia., Results: The measured plasma concentrations of the drug were not significantly different from the target plasma concentrations and they showed no tendency to increase during the 3 hours of anesthesia. The measured plasma concentration at emergence was lower than the estimated value., Conclusions: We conclude that propofol TCI is a reliable method for maintaining anesthesia even in obese patients. At emergence, however, the data suggested that the plasma concentrations might be lower than the estimated values in obese patients.

Background: As we have no information whether target-controlled infusion (TCI) for propofol, using pharmacokinetic parameters obtained without chronic renal failure, is available to estimate the drug concentration, we examined the blood concentration of propofol on the patients with chronic renal failure to evaluate the reliability of TCI of propofol., Methods: Ten patients with chronic renal failure undergoing hemodialysis, from 20 to 60 years of age, were scheduled for living-related renal transplantation. Propofol was administrated with our TCI system at the target blood concentration of 4 microg x ml(-1) for three hours. Blood samples were obtained at 30, 60, 90, 120, and 180 minutes after starting propofol delivery, and at the emergence from anesthesia to measure propofol concentration., Results: There was no tendency of increasing the drug concentration in proportion to the time of propofol infusion. As for the concentration at emergence, mean estimated concentration of propofol was 1.6 mg x ml(-1), showing a good correlation between measured and estimated concentrations., Conclusion: TCI system for propofol provided a good estimation of the blood concentration of propofol in patients with chronic renal failure undergoing living-related renal transplantation.

How to titrate rocuronium under the specific conditions such as hepatic/renal failure, hypothermia, acidosis, and baby/aged, obese, with antibiotics, type of anesthetics, operation site and continuous infusion was discussed.

The rapid onset and offset of the effect of remifentanil are absolutely new and different from fentanyl. The clearance of remifentanil is so rapid and extensive, that it prevents the drug from accumulating in the body tissues. For this reason the context-sensitive half-time of remifentanil is only 3-5 min, irrespective of the duration of infusion; it is thus context-INsensitive. This exciting pharmacokinetic profile gives us an improved titration precision that lets us experience the opioids effects when we need them and to avoid the side effects of residual drug concentrations when the analgesic necessity is reduced or vanished. These clinical advantages would also result in pharmacoeconomic benefits. In the near future, the introduction of reliable delivery systems for remifentanil combined with propofol would provide us with a new concept in intravenous anesthesia, the DOUBLE TCI Anesthesia.

Background: PONV is a complication that reduces a patient's quality of life (QOL). Recently, it was reported that PONV is reduced by preoperative administration of histamine receptor (H1 and H2) inhibitor. In the present study, based on the hypothesis that PONV might be reduced by preoperative administration of H2 blocker, we examined the effect of preoperative administration of H2 blocker only on the incidence of PONV., Methods: Eighty seven patients having regular operations were randomly assigned into two groups; the control (C), and the H2 blocker (F) groups. In the operating room, 20 min after intravenous injection of famotidine 20 mg as H2 blocker, anesthesia was maintened by sevofluorane, oxygen, nitrous oxide, and fentanyl following the induction by fentanyl, propofol, and vecuronium. The frequency and extent of vomiting were observed and the patients were interviewed at postoperative hours 0-6 and 6-12. The incidences between the two groups were examined using the chi-squared test., Results: No significant difference in the appearance of PONV was found between the F group and the C group. In women in the F group, the incidence of vomiting was lower., Conclusions: Preoperative administration of H2 blocker tends to reduce PONV in women.

Background: Intra-operative intraoral moisture was examined using a moisture checker, on the hypothesis that as an operation is prolonged, the intraoral moisture decreases; consequently, intraoral drying level should increase., Methods: This hypothesis was tested on 27 adult patients undergoing a regular operation. The subjects having fasted since 0:00 o'clock of the operation day entered the operating room, where their intraoral moisture was measured using an intraoral moisture checker (Life Co. Ltd., Tokyo) (the unit is % index). Then, propofol administration was started with simulated blood concentration of 4 microg x ml(-1). Anesthesia was induced with vecuronium 1 mg x kg(-1) and fentanyl 1.5 microg x mg(-1). Every hour from anesthesia induction to the end of operation, intraoral moisture was checked. The propofol simulated blood concentration during operation was set to remain at 2-3.5 microg x ml(-1), with fentanyl administered. Statistical analysis was done by two factor factorial ANOVA. P < 0.05 was considered significant., Results and Conclusions: The intraoral moisture during operation under general anesthesia showed no chronologically significant difference.

Background: The urine volume and urine specific gravity per unit time during a short operation under volume loading were examined to explore the possibility of urine specific gravity as an indirect index of fluid therapy., Methods: After introducing anesthesia, under volume loading with acetic acid Ringer solution 10 ml x kg(-1) x hr(-1), urine volume and specific gravity per unit time at 30 min intervals from urination to 90 min later and the correlation between the urine volume and urine specific gravity were examined. A chronological increase of urine specific gravity was also confirmed. Therefore, the values of urine specific gravity of each 30 minute intervals were compared using Student's t-test., Results: The urine volume and urine specific gravity per unit time showed no significant negative correlation until after 90 min. Increasing urine specific gravity even under volume loading became significant 90 min after urination., Conclusions: There is a possibility of employing urine specific gravity as an indirect index of fluid therapy.

Background: We reported that recovery from total intravenous anesthesia with propofol was delayed in hepatectomy patients, and the hazard ratio was half against controls. This study was designed to evaluate recovery from sevoflurane anesthesia in patients for hepatectomy., Methods: Sixteen patients receiving hepatectomy and 17 patients receiving other epigastric surgeries (controls) were anesthetized with sevoflurane. Fentanyl was injected repeatedly to insure maintenance of the effect-site concentration of 2.0 ng x ml(-1). Propofol was administered for induction of general anesthesia, and then inhaled sevoflurane was titrated to maintain a Bispectral Index (BIS) value between 40 and 50. The intervals to emergence and extubation after sevoflurane discontinuation, and the predicted fentanyl concentrations were recorded., Results: The amount of sevoflurane and concentration of fentanyl in hepatectomy were similar to those in controls. The extubation time was longer in hepatectomy patients than in control subjects, and the hazard ratio was half against controls., Conclusions: Recovery from anesthesia with sevoflurane was delayed in hepatectomy, and the hazard ratios were half against controls. We speculate that the influence of hepatectomy caused delay of recovery from anesthesia in hepatectomy patients.

A 53-year-old woman developed general fatigue following an upper airway infection, which abruptly progressed to cardiogenic shock showing systolic blood pressure of 60 mmHg. An echocardiography revealed an ejection fraction of 0.11, diffuse severe hypokinesis and left ventricular thrombosis. Fulminant myocarditis was suspected, and intensive care including mechanical ventilation, intraaortic balloon pumping (IABP), catecholamine support and anticoagulation therapy was initiated immediately. Although the cardiac function gradually recovered, she developed a duodenal bleeding on the third therapeutic day. Factors such as low output syndrome, heparinization, steroid pulse therapy and platelet dysfunction due to IABP can enhance the hemorrhagic tendency. Since it was difficult to control bleeding by the endoscopy, blood transfusion was performed, and the operation was planned on the 13rd day when the cardiac function seemed to have recovered enough. The patient was anesthetized with ketamine, propofol and fentanyl. To maintain stable circulation, circulatory parameters such as blood pressure, central venous pressure, and cardiac output were monitored. After a preoperative consultation with the surgeon, the surgical technique had been preoperatively decided to reduce the surgical stress, and then partial duodenosectomy and gastro-jejunum anastomosis was performed. She was discharged on the 38th post operative day without complications. In cases of hemorrhagic disease accompanied by an acute phase of fulminant myocarditis, consultation among surgeons, cardiologists and anesthegiologists should be mandatory to determine the timing of the operation and to decide the degree of surgical invasion.

A 70-year-old woman, who had neither complication nor risk factors of ischemic heart disease, was scheduled for a partial resection of the left lung. After an epidural catheter was placed at the T7-8 interspace, general anesthesia was induced and maintained with propofol and fentanyl. Once stable vital signs had been confirmed, 3 ml of 0.5% ropivacaine was given through the epidural catheter. Bradycardia with hypotension progressively developed and continued despite the intravenous administration of phenylephrine, ephedrine, and atropine. Fourteen minutes after the injection of ropivacaine, the electrocardiogram showed an elevation of the ST segment. One minute later, the heart rhythm changed to a 2:1-type second degree block. Although a bolus of 1 mg epinephrine was injected intravenously, severe hypotension and bradycardia persisted, leading to the complete block and paroxysmal ventricular tachycardia. Continuous infusion of nitroglycerin as well as cardiopulmonary resuscitation was started. The sinus rhythm with normal ST segment was eventually restored with subsequent hemodynamic stability. Intraoperative transesophageal echocardiography indicated a satisfactory cardiac wall motion. Coronary spasm was suspected because of the transient ST segment elevation and the absence of wall motion abnormality after the recovery. The clinical course of the A-V block appearing shortly after ST segment elevation suggested that the right coronary artery, perfusing the A-V node areas, was involved.

Background: Pulse oximetry is insufficient for postoperative respiratory monitoring. It is better to use capnometry for postoperative patients because it is easy to use and useful to monitor patients' breathing. However, capnometry must be improved in its wearability and detection capability. Therefore it is not used often for postoperative patients as a respiratory monitor., Methods: We have examined a side-stream type capnometer and an improved main-stream type capnometer in a post-anesthesia care unit (PACU) to determine which is better as a monitor for detection of breathing. A total of 55 patients participated in this study. Patients wore a device including a main-stream capnometer and a side-stream capnometer. Capnograms were recorded while patients were staying in the PACU., Results: The main-stream system could detect breathing in all the patients, but the side-stream system failed to detect breathing in five patients. The side-stream device showed a warning of "apnea" for five patients, even though these patients were breathing normally., Conclusions: We conclude that the main-stream system is a better monitor of postoperative respiratory condition.

Background: The purpose of this study was to investigate the interaction of anesthetic agents with Org 9426 (rocuronium bromide) infused continuously. The effect of intubation dose of Org 9426 on its infusion rate was also investigated., Methods: Total of 38 Japanese patients were randomly allocated either to receive intubation dose of 0.6 or 0.9 mg x kg(-1) of Org 9426. These patient groups were anesthetized with either sevoflurane or propofol. Infusion of Org 9426 was started with the initial infusion rate of 7 microg x kg(-1) x min(-1) when T1 reappeared after the intubation dose. The infusion rate was adjusted to keep the height of T1 between 3-10% of the control value., Results: The rates of infusion 90 min after the start of infusion were 3.4, 7.5, 3.9 and 7.7 microg x kg(-1) x min(-1) for the 0.6 mg x kg(-1)-sevoflurane, 0.6 mg x kg(-1) propofol, 0.9 mg x kg(-1)-sevoflurane and 0.9 mg x kg(-1) propofol groups, respectively. Sevoflurane significantly reduced the infusion rate with both intubation doses. The mean infusion rates of 0.9 mg x kg(-1) groups were slower than those of 0.6 mg x kg(-1) groups up to 60 min after the start of infusion. Mean clearance of Org 9426 during infusion was not different between sevoflurane and propofol anesthesia., Conclusions: Patients receiving sevoflurane anesthesia required a markedly lower Org9426 infusion rate compared with patients receiving propofol anesthesia.

Background: The purpose of this randomized, multi-center phase III trial was to investigate the influence of sevoflurane and propofol on the neuromuscular blocking effects and pharmacokinetic parameters of Org 9426 (rocuronium bromide) in Japanese population., Methods: Thirty-nine adult Japanese patients participated in this randomized, multi-center study. Neuromuscular function was monitored continuously with TOF-Watch SX (Organon NV, Netherlands) after anesthetic induction with propofol. These subjects randomly received either 0.6 mg x kg(-1) or 0.9 mg x kg(-1) of rocuronium for endotracheal intubation. These two groups were further divided to two anesthetic regiments : sevoflurane group and propofol group. The difference in onset and recovery of rocuronium-induced neuromuscular block was statistically analyzed with two-way ANOVA., Results: Mean duration for maximal block was 76 seconds and 66 seconds, respectively. The duration between Org 9426 administration and 25% recovery of first twitch response was significantly prolonged in patients given 0.9 mg x kg(-1) of Org 9426. Sevoflurane also significantly increased this duration. However, the serum concentration of Org 9426 was not statistically different between the four study groups., Conclusions: The duration of Org 9426-induced neuromuscular blockade was significantly increased under sevoflurane anesthesia compared to propofol anesthesia. This difference may be attributed to pharmacodynamic change.

We report anesthetic management of a 5-year-old girl for corpus callosotomy indicated for the treatment of intractable epilepsy. The procedure mandated intraoperative monitoring of evoked potentials and electrocorticogram. During the first half of the surgery until the corpus callosum was exposed, anesthesia was maintained with continuous infusion of propofol. Motor and somatosensory evoked potentials were monitored and diagnosed as intact throughout the procedure, with no epileptic activity observed in 32-lead electrocorticogram. Then propofol infusion was replaced with the inhalation of sevoflurane, 2.0% in air/oxygen mixture, which induced epileptic spike-and-wave activities, synchronized between the hemispheres, in electrocorticogram. After the completion of corpus callosotomy, we observed interhemispheric desynchronization of epileptic activities indicating successful surgical intervention. The patient emerged from anesthesia uneventfully with no neurological deficits, and thereafter with decreased incidence of generalized epileptic episodes. We suggest that such switch of anesthetic agents between propofol and sevoflurane should be helpful in intraoperative electrophysiological monitoring for ascertaining both functional preservation and successful intervention during epileptic surgery.

Background: The purpose of this study was to examine pharmacodynamics, pharmacokinetics and safety of Org 9426 (rocuronium bromide) in Japanese patients., Methods: Seventy-eight patients anesthetized with thiopental, droperidol, fentanyl and nitrous oxide, were randomized to receive either a single dose of Org 9426 0.3 mg x kg(-1), 0.6 mg x kg(-1) or 0.9 mg x kg(-1). Contraction of the adductor pollicis to the ulnar nerve stimulation (0.1 Hz) was measured by acceleromyography. Blood was sampled over 6 hr and pharmacokinetic variables were calculated by plasma concentrations of Org 9426., Results: Onset times for patients receiving 0.3 mg x kg(-1), 0.6 mg x kg(-1) or 0.9 mg x kg(-1) were 271.5 s, 140.0s and 125.4s, respectively. There was a dose-dependent increase in clinical durations until 25% recovery of twitch height (17.4 min in 0.3 mg x kg(-1) group, 37.2 min in 0.6 mg x kg(-1) and 60.4 min in 0.9 mg x kg(-1) group). Pharmacokinetic study revealed that elimination half life, steady state volume of distribution and plasma clearance of Org 9426 were 48-76 min, 146-181 ml x kg(-1), and 3.8-4.5 ml x min(-1) x kg(-1), respectively. No adverse effects were found except a case of local erythema on a forearm., Conclusions: The efficacy of neuromuscular block, stable pharmacokinetic behavior and excellent safety of Org 9426 were also confirmed in Japanese surgical patients.

Background: Incidence and intensity of pain on intravenous injection of propofol were assessed with emulsion of long-chain/medium-chain triglycerides (LCT/MCT, 50: 50) and only long-chain triglycerides (LCT, 100) in patients undergoing different elective surgical interventions in this prospective, randomized, cross over and double-blinded study., Methods: 1) Forty six patients were assigned to two groups. One group received 0.2 mg x kg(-1) LCT/ MCT propofol prior to LCT propofol administration. The other group received 0.2 mg x kg(-1) LCT propofol prior to LCT/MCT propofol administration. Pain elicited upon questioning was assessed with each injection in the two groups. Patients were asked to grade the pain as VAS of 0 to 100 mm. 2) Fifty one patients were randomly assigned to two groups. One group received 0.4 mg x kg(-1) LCT propofol. The other group received 0.4 mg x kg(-1) LCT/MCT propofol. Patients were asked to grade the pain as VAS of 0 to 100 mm., Results: Pain of LCT propofol injection was stronger than LCT/MCT propofol. As incidence of 0.4 mg x kg(-1) propofol injection, VAS on LCT/MCT propofol and LCT propofol gave score as 0 and 23.5 (P=0.0019)., Conclusions: Propofol with emulsion of long- and medium-chain triglycerides appears to reduce the injection pain than with emulsion of only long-chain triglycerides.

Background: Liver dysfunction has major impacts on the pharmacokinetics and pharmacodynamics of anesthetics. This study was designed to evaluate propofol concentrations during and at the end of total intravenous anesthesia (TIVA) for hepatectomy., Methods: Fifty patients receiving hepatectomy (n = 25) or other epigastric surgeries (controls, n = 25) were anesthetized with TIVA. Fentanyl was injected repeatedly to insure maintenance of the effect-site concentration in the 2.0 to 2.5 ng x ml(-1) range with off line computer similation program. Propofol was administered with target-controlled infusion at the initial target concentration of 3.0 mcg x kg(-1), and then titrated to maintain bispectral index (BIS) values between 40 and 50. The intervals after propofol discontinuation to emergence and extubation and the predicted propofol and fentanyl concentrations were recorded. Propofol concentrations at emergence were measured with blood sample in eight cases., Results: The propofol dose in hepatectomy patients as well as both measured and predicted concentrations of propofol at extubation, were lower than in control patients. The extubation time was longer in hepatectomy than in control subjects., Conclusions: Recovery from TIVA is delayed in hepatectomy patients. We speculate that this is attributable to altered pharmacodynamics in these patients.

Background: Adequate preoperative evaluation with sufficient informed consent from patients will lead to safe perioperative anesthetic managements. We started outpatient preoperative evaluation from October, 2002., Methods: We investigated 1137 elective cases operated during one year after starting outpatient examination. They were compared with 1083 cases under the previous system. On requests from surgeons we examined the patients and obtained informed consents. Additional examinations and medications were ordered if necessary for adequate preoperative management., Results: Eight hundred and twenty-three cases (72.4%) of 1137 elective operative cases visited our outpatient booth and 86.8% of them visited before admission for the surgery. Patients classified into ASA-PS II-III, 550 cases (66.9%), and their major complications were cardiovascular and pulmonary diseases. Two hundred and ninety seven cases (36.1%) required additional examinations following adequate preoperative management by another consultants. After the introduction of this system, the number of postponing or cancellation of operation after hospitalization was only 1.3% of elective operations. Furthermore the number of patients admitted on the day and the day before the operation significantly increased compared with those under the previous system (27.9 - 45.2%)., Conclusions: Our preoperative consulting system will decrease average length of hospital stay and improve the quality control of patients before surgery.

Background: There are some reports on the incidence of awareness during general anesthesia that is usually stable at the maintenance period. The aim of this study is to evaluate the incidence of awareness during the induction period of general anesthesia in which the effects of anesthetics are unstable., Methods: The research-nurses interviewed the patients, who had undergone general anesthesia, on the awareness during anesthesia within a week after operation. The patients were excluded from the study if they were in deep sedation or unconscious because of the medical reasons. We defined the induction period from the administration of hypnotic drugs to the tracheal intubation., Results: Seven cases with ages from 20 s to 70 s out of 1922 cases were identified as the residual awareness cases during the induction period. Six cases were managed with low concentrations of inhalation anesthetics after injection of intravenous hypnotics. The incidence was lower, but not significant, if they were managed with total intravenous technique. The BIS values were above 60 in all these cases if the monitor was attached., Conclusions: The incidence of awareness during the induction was 0.36%. We have to pay more attention to the disappearance of the hypnotic effect at the induction period.