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Background: Tramadol hydrochloride is a centrally acting analgesic agent with two distinct mechanisms of action, a weak opioid agonist and an inhibitor of monoamine neurotransmitter reuptake, which produces significant analgesic effect synergistically. Though tramadol was approved in 1978 in Japan, it has rarely been used in clinical settings compared to foreign countries, e.g. Germany and USA. The aim of this study is to investigate effectiveness of oral tramadol for chronic non-malignant pain in Japan., Methods: Tramadol was orally administered to patients with refractory non-malignant pain. Effects and adverse effects of tramadol were assessed about one month after the start of the administration., Results: Out of 17 patients using tramadol daily, tramadol was found to be significantly effective in 4 patients (23.5%) and moderately effective in 8 patients (47.1%) from the viewpoint of pain relief as well as improvement of activities of daily livings. Side effects were reported by 7 patients (41.2%), which included nausea, constipation, and dizziness, but none of the side effects were serious., Conclusions: Tramadol is a useful option to treat non-malignant chronic pain, especially considering its very low abuse potential and a more acceptable side effect profile compared to non-steroidal anti-inflammatory drugs and opioids.

Midazolam is a short-acting benzodiazepine commonly used for conscious sedation for a variety of procedures. Severe adverse reactions, including respiratory depression, respiratory arrest, and anaphylactoid reaction, have been described by manufacturers. We report a patient who developed facial edema after iv injection of midazolam during caesarian section. A 26-year-old woman with a history of atopy and pollen allergy was scheduled for caesarian section. Spinal anesthesia was induced with bupivacaine without significant medical problems. Shortly after receiving 2 mg of iv midazolam 15 minutes after delivery for conscious sedation, she developed pruritus and severe facial edema. Airway obstruction did not occur and no specific medical treatment was necessary. However she was not able to open her eyes for 8 hours because of severe eyelid swelling. We should be more careful in administering midazolam which is generally regarded as safe and well tolerated.

Perioperative management including anesthesia may alter long-term outcome of surgical patients. We have reviewed abstracts for meeting and articles published recently concerning effects of anesthetic depth, volatile anesthetic preconditioning, beta-blockers, alpha-agonists, statins, and glucose control on long-term outcome. Although research in this area has just been started, we, anesthesiologists should recognize its importance.