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This article discusses the development of long-acting local anesthetics for postoperative pain management. The use of opioids for pain relief can lead to adverse effects, so researchers have been exploring alternative options. The article explores different strategies, including quaternary lidocaine derivatives, voltage-gated sodium channel antagonists, site-1 sodium channel blockers, and controlled-release local anesthetics. While some of these options have shown promise, there are still limitations and challenges to overcome before they can be widely used in clinical practice. [Extracted from the article]

The COVID-19 pandemic is ongoing as of September 2022. Since January 2020 when the first case was reported in Japan, the medical community faced a variety of problems both domestically and internationally. It is meaningful to review the impact of COVID-19 from an anesthesiologist's perspective to clarify our policy for future infectious disease outbreaks. In this year's Journal of Anesthesia (JA) symposium, five experts who were deeply involved in the COVID-19 response reviewed the past 2.5 years and made recommendations for potential future pandemics. Anesthesiologists are specialists in airway management and their role in intubating patients with COVID-19 has received much attention. However, they have also played an important backup role in intensive care as critical care physicians and must be more involved in critical care in regular (non-pandemic) times to properly fulfill this role. It is especially important for the Japan Society of Anesthesiologists and JA to quickly disseminate accurate information on unknown infectious diseases to the medical community and wider society. Therefore, it is important to promptly publish papers that are quality-assured through peer review. [ABSTRACT FROM AUTHOR]

Purpose: To elucidate the clinical course of patients with coronavirus disease 2019 (COVID-19) treated at a specialized hospital mainly for those with mild and moderate severity during the third wave, and to compare that with the first and second (1st/2nd) waves. Methods: We retrospectively reviewed the severity on admission, treatment, and outcome of a total of 581 patients from September, 2020, to March, 2021, and examined the risk factors for deterioration of respiratory condition, defined as requiring oxygen ≥ 7 L/min for 12 h. Results: The median age was 78 (interquartile range 62−83) years, older than in the 1st/2nd waves (53 years), and 50% of the patients was male. The number of patients classified as mild (peripheral oxygen saturation (SpO2) ≥ 96%), moderate I, II, and severe (requiring admission to the ICU or mechanical ventilation) was 121, 324, 132, and 4, respectively. Favipiravir, ciclesonide, dexamethasone, and/or heparin were administered for treatment. Respiratory condition recovered in 496 (85%) patients. It worsened in 81 patients (14%); 51 (9%) of whom were transferred to tertiary hospitals and 30 (5%) died. Mortality rate increased by fivefold compared during the 1st/2nd waves. Age, male sex, increased body mass index, and C-reactive protein (CRP) on admission were responsible for worsening of the respiratory condition. Conclusion: Patients were older in the third wave compared with the 1st/2nd waves. Respiratory condition recovered in 85%; whereas 5% of the patients died. Old age, male sex, increased body mass index, and CRP would be responsible for worsening of the respiratory condition. [ABSTRACT FROM AUTHOR]

Purpose: To characterize the clinical features and outcome of patients treated at a specialized hospital for coronavirus disease 2019 (COVID-19). Methods: We retrospectively reviewed the symptoms on admission, treatment, and outcome of a total of 300 patients with mild (peripheral oxygen saturation (SpO2) ≥ 96%), moderate I (93% < SpO2 < 96%), moderate II (SpO2 ≤ 93%) and severe (requiring admission to the ICU or mechanical ventilation) COVID-19. Results: Median age was 53 (interquartile range [IQR] 33–72) years and 57% was male. The number of patients with mild, moderate I, II and severe condition was 85, 138, 61 and 16, respectively. Common presenting symptoms were cough (n = 71), loss of taste (42), loss of smell (39), fever ≥ 37.5 °C (36). Dyspnea was observed only 21 cases; 57 reported no symptoms on admission. Favipiravir, ciclesonide, dexamethasone, and heparin were administered in 106, 168, 65, and 38 patients, respectively, but not remdesivir. The median duration of hospitalization was 10 (7–15) days. All patients with mild and moderate I severity were discharged. Among the 77 patients classified as moderate II or severe, 3 were transferred to tertiary hospitals for further treatment on the day of admission. The respiratory condition worsened in 21 patients; 18 required transfer to tertiary hospitals 3 (median) days after admission and 3 died. Conclusion: Respiratory condition recovered in 92%; whereas it worsened in 7% and the mortality rate was 1%. The ratios of male patients, of patients with diabetes mellitus in those with the decreased respiratory condition, were significantly higher than recovered. [ABSTRACT FROM AUTHOR]

Recently published case reports relating to anesthesia in patients with coronavirus disease (COVID-19) were reviewed. The diagnosis of COVID-19 was confirmed by positive results of reverse transcriptase polymerase chain reaction test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Numerous reports handled emergency cesarean delivery. Primary symptoms and laboratory data of pregnant women with COVID-19 were similar to those of non-pregnant patients. Although the mortality rate is reported to be high after surgery in patients with COVID-19, cesarean delivery was successfully performed under regional anesthesia in most cases and postoperative course was favorable both in the parents and newborns. There is no direct evidence of vertical mother-to-child transmission of SARS-CoV-2; however, a diagnosis of COVID-19 was made in a newborn two hours after delivery from a pregnant woman with COVID-19, based on the increased immunoglobulin levels and deranged liver function, suggesting that its possibility cannot be completely eliminated. Emergency cerebral shunt reconstruction was performed repeatedly in an eight-month-old boy with COVID-19. The tracheal tube was removed in the operating room after surgery and postoperative course was uneventful. All the procedures should be performed in isolated operating rooms with medical staff with level-3 personal protection to ensure the safety of patients and health care providers. [ABSTRACT FROM AUTHOR]

Keywords: Pharmacodynamics; Pharmacokinetics; Reparalysis; Rocuronium; Sugammadex EN Pharmacodynamics Pharmacokinetics Reparalysis Rocuronium Sugammadex 803 805 3 11/20/20 20201201 NES 201201 Sugammadex is extensively used since its introduction to our country in 2010; however, there is a paucity of data showing its optimal dose for reversal of neuromuscular blockade, particularly shortly after administration of muscle relaxants. Dose of sugammadex for neuromuscular blockade According to the previous studies, sugammadex 2 mg/kg was derived as adequate dose for reversal of moderate neuromuscular blockade by rocuronium and vecuronium. Dose of rocuronium for reparalysis after administration of sugammadex The model by Kashima et al. [[3]] also explained the required dose of rocuronium to provide neuromuscular blockade after reversal by sugammadex. Reversal of profound, high-dose rocuronium-induced neuromuscular blockade by sugammadex at two different time points: an international, multicenter, randomized, dose-finding, safety assessor-blinded, phase II trial. [Extracted from the article]

Background: Ovarian vein thrombosis is a rare complication of pregnancy. The representative complaints of patients with ovarian vein thrombosis are abdominal pain and fever. In some cases, however, fatal pulmonary embolism may develop. We report a case of pulmonary embolism presenting with severe hypotension and loss of consciousness during cesarean section possibly caused by ovarian vein thrombosis. Case presentation: A 25-year-old woman at 38 weeks 4 days of gestation was scheduled for repeat cesarean section. Her past history was unremarkable, and the progress of her pregnancy was uneventful. She did not experience any symptoms indicative of deep vein thrombosis. Cesarean section was performed under spinal anesthesia, and a healthy newborn was delivered. After removal of the placenta, she suddenly developed dyspnea, hypotension, and loss of consciousness with decreased peripheral oxygen saturation. Blood pressure, heart rate, and oxygen saturation recovered after tracheal intubation and mechanical ventilation with oxygen. Postoperative computed tomography revealed no abnormality in the brain or in the pulmonary artery, but a dilated right ovarian vein with thrombi, extending up to the inferior vena cava, was found. A diagnosis of pulmonary embolism caused by ovarian vein thrombosis was made, and heparin was administered. The tracheal tube was removed on the first postoperative day. Her postoperative course was uneventful, and she was discharged with no complications. Conclusion: Fatal pulmonary embolism might be caused by ovarian vein thrombosis during cesarean section. Careful and continuous observation of the patient after delivery and prompt treatment are important. [ABSTRACT FROM AUTHOR]

Purpose: We examined the hypothesis that 1 minimum alveolar concentration (MAC) of desflurane and sevoflurane provides different depth of anesthesia. Methods: One hundred and twenty young (20-30 years), middle-aged (31-65 years), and elderly (66-80 years) patients were randomly allocated to receive either desflurane or sevoflurane ( n = 20, each group). General anesthesia was induced with propofol 2 mg/kg bolus and remifentanil 0.25 µg/kg/min, which was stopped after tracheal intubation. Maintenance of anesthesia was started with an end-tidal concentration of desflurane or sevoflurane at age-adjusted 1 MAC and maintained for 10 min, followed by 1-min assessment of bispectral index (BIS), 95% spectral edge frequency (SEF95), and amplitude of the electroencephalogram taken at 10-s intervals. Results: BIS and SEF95 in patients receiving 1 MAC desflurane were significantly lower than those receiving 1 MAC sevoflurane including all age groups [35 (29, 39) vs. 41 (38, 49); 12.53 (10.99, 13.95) Hz vs. 14.42 (12.99, 17.17) Hz median (25, 75 percentile), respectively, P < 0.001 for both]. Both BIS and SEF95 in young patients were lower than in middle-aged and elderly patients receiving either desflurane or sevoflurane ( P < 0.001 for both). There were no differences in amplitude between patients receiving desflurane and sevoflurane. Conclusions: BIS as well as SEF95 were lower in patients receiving 1 MAC desflurane than those receiving 1 MAC sevoflurane, suggesting that desflurane provides higher depth of anesthesia than sevoflurane at 1 MAC. [ABSTRACT FROM AUTHOR]

Numerous studies have implicated the involvement of nonscavenging effect of lipid emulsion for local anesthetic systemic toxicity from the initial stage of research. Partownavid et al. [[11]] demonstrated that free fatty acid oxidation is essential for successful recovery of bupivacaine-induced cardiotoxicity by lipid emulsion in vivo and in mitochondrial suspension. Besides using less-toxic anesthetics such as ropivacaine and levobupivacaine, various techniques, e.g., liposomal bupivacaine and transdermal lidocaine delivery system, have been performed to prolong the effect of local anesthetics and to minimize the required dose [[18]]. [Extracted from the article]

The author comments on the impact of the use of long-acting local anesthetics for both neuraxial and peripheral nerve block in children. Long-acting local anesthetics such as bupivacaine, levobupivacaine and ropivacaine have higher toxic potency than lidocaine. Research on toxicity and pharmacokinetics in children would help avoid adverse effects and improve the quality of anesthesia practice.

PHACE syndrome is a neurocutaneous syndrome characterized by the association of large cutaneous hemangiomas and the cardiac and cerebral vascular anomalies. We report a 6-year-old female with PHACE syndrome presented with left facial hemangiomas, cystic lesion in the cerebral posterior fossa, coarctation of the aorta, aplasia of the left vertebral artery and stenosis of the left internal carotid artery. Surgical repair of the aorta with left heart bypass under beating heart was scheduled. We monitored regional cerebral oxygen saturation (rSO) with infrared spectroscopy in order to detect cerebral hypoperfusion. A decrease of rSO ipsilateral to the cerebrovascular anomalies occurred during anastomosis of the aorta, which was treated by reducing the flow rate of left heart bypass and by increasing the inhalational oxygen concentration. As children with PHACE syndrome are frequently accompanied with cerebrovascular anomalies and at a risk of cerebral hypoperfusion, prevention of cerebral hypoperfusion is crucially important during general anesthesia. [ABSTRACT FROM AUTHOR]

The article discusses the use of intravenous lipid emulsion in the treatment of toxicity caused by lipophilic agents. It is hypothesized that partitioning and enhanced metabolism are possible mechanisms of the antidote effect of lipid emulsion, which is supported by studies on both animal and human subjects. The American Heart Association Advanced Cardiac Life Support (ACLS) released a protocol recommending the use of adrenaline in resuscitating patients for local anesthetic overdose.

Purpose: Despite numerous studies examining the effect of lipid emulsion on bupivacaine-induced cardiac toxicity, few studies have examined its effect on central nervous system (CNS) toxicity of local anesthetics. We investigated the effect of lipid emulsion on the CNS and cardiac toxicity of bupivacaine and levobupivacaine in awake, spontaneously breathing rats. Methods: Male Sprague-Dawley rats were randomly allocated to control-bupivacaine (CB), control-levobupivacaine (CL), lipid-bupivacaine (LB), and lipid-levobupivacaine (LL) groups ( n = 8 in each group). After infusion of saline (CB and CL groups) or 20 % lipid emulsion (LB and LL groups) for 5 min, bupivacaine (CB and LB groups) or levobupivacaine (CL and LL groups) was administered IV at 1 mg/kg/min. Cumulative dose of anesthetics and their plasma concentrations at the onset of convulsions and cardiac arrest were measured. Results: The doses of bupivacaine for inducing convulsions and cardiac arrest in the LB group (8.8 ± 1.7 and 10.2 ± 1.5 mg/kg, respectively) were significantly larger than those in the CB group (5.9 ± 1.1 and 7.1 ± 1.3 mg/kg, respectively, p < 0.001 for both). The doses of levobupivacaine for inducing convulsions and cardiac arrest in the LL group (10.0 ± 2.0 and 13.7 ± 3.6 mg/kg, respectively) were significantly larger than those in the CL group (7.7 ± 1.6 and 9.4 ± 2.4 mg/kg, p = 0.03 and p = 0.02, respectively). Plasma concentrations of bupivacaine at the onset of convulsions and cardiac arrest in the LB group (12.9 ± 2.9 and 41.4 ± 5.2 μg/ml, respectively) were significantly higher than those in the CB group (7.9 ± 1.2 and 21.6 ± 3.3 μg/ml, respectively, p < 0.001 for both). Plasma concentrations of levobupivacaine at the onset of convulsions and cardiac arrest in the LL group (17.5 ± 1.5 and 47.6 ± 6.1 μg/ml, respectively) were significantly higher than in the CL group (10.9 ± 2.2 and 29.2 ± 3.5 μg/ml, respectively, p < 0.001 for both). Conclusions: Lipid emulsion decreased CNS and cardiac toxicity of both bupivacaine and levobupivacaine. [ABSTRACT FROM AUTHOR]

Purpose: We compared the insertion performance of the pediatric size 1.5-3 i-gel airway device with that of the ProSeal laryngeal mask airway (PLMA) in anesthetized children in a prospective, randomized, controlled manner. Methods: We included 134 children, aged 3 months to 15 years, scheduled for elective surgery under general anesthesia. They were randomly divided into the i-gel and the PLMA groups according to the airway device used. The primary outcome variable was oropharyngeal leak pressure. Other outcome variables were ease of insertion, required time for insertion, fiberoptic view, and first-attempt and overall success rates. Results: There were no differences in the ease of insertion, insertion time, or leak pressure between the devices. Fiberoptic view was significantly better with the i-gel than with the PLMA ( P = 0.002). The view was significantly better with the sizes 2, 2.5, and 3 i-gel than with the size 1.5 i-gel ( P = 0.02, 0.004 and 0.002, respectively), and the view was significantly better with the sizes 2.5 and 3 PLMA than with the size 1.5 PLMA ( P = 0.02 and 0.005, respectively). The first-attempt success rates were 94 and 97 % in the i-gel and the PLMA groups, respectively; the success rates including the second attempt were 100 % in both groups. No children developed side effects requiring treatment with either device. Conclusion: Both the pediatric i-gel and the PLMA were successfully inserted in children. The fiberoptic view was better with the i-gel than with the PLMA. [ABSTRACT FROM AUTHOR]

Pena-Shokeir syndrome is a rare, early lethal disease. It is characterized by fetal growth restriction; craniofacial deformities, for example micrognathia and microcephaly; multiple ankyloses; and pulmonary hypoplasia. For patients with this syndrome, maintenance of airway and control of perioperative respiratory complications are important for anesthetic management. We report 3 pediatric cases of Pena-Shokeir syndrome undergoing tracheostomy and arthrolysis under general anesthesia using sevoflurane, nitrous oxide, fentanyl, and vecuronium bromide. Anesthetic procedures including mask ventilation, tracheal intubation, and extubation were successfully performed without complications during and after surgery. In patients with Pena-Shokeir syndrome, inhalational anesthetics can be safely used for induction and maintenance of anesthesia, although it is important to assume that difficult airway management might be encountered. [ABSTRACT FROM AUTHOR]

Primary tracheal tumors are rare in adults, and careful airway management is required during anesthesia for affected patients. We report the case of a patient with tracheal hemangiomas undergoing nontracheal operation. A 61-year-old woman was scheduled for a lung operation. During preoperative examination, hemangiomas were detected on the tracheal mucosa. As she was asymptomatic and the degree of airway stenosis was small, treatment was not required for the hemangiomas, and left upper lobectomy for lung cancer was scheduled. After induction of general anesthesia, a regular tracheal tube was inserted under fiberoptic bronchoscopy, with care taken to prevent damage to the hemangiomas. An endobronchial blocker was inserted for one-lung ventilation. The operation was performed uneventfully, and the tracheal tube was replaced postoperatively with a laryngeal mask airway while the patient was under deep anesthesia and neuromuscular blockade. The mask was removed after confirming lack of bleeding from the hemangiomas. No hypoxia or other complications occurred during or after the operation. [ABSTRACT FROM AUTHOR]

24-year-old man underwent surgery for a fractured left clavicle and received an interscalene brachial plexus block for intraoperative and postoperative analgesia. After injection of 40 ml 0.5% ropivacaine and confirmation of analgesia, general anesthesia was induced and maintained with propofol. Although the operation was completed uneventfully, the patient was restless and there was limb twitching during emergence from anesthesia. Ropivacaine-induced toxicity was suspected, and a dose of 100 ml 20% lipid emulsion was infused intravenously. The symptoms of toxicity disappeared, and there was full recovery of consciousness within 5 min. Plasma concentrations of total and protein-unbound ropivacaine measured 2 h 20 min after local injection were 1.99 and 0.13 μg/ml, respectively. After infusion of lipid emulsion, the ropivacaine concentrations decreased to 1.72 and 0.05 μg/ml, respectively. The patient had no pain, and neurological examination revealed sensory loss around the clavicle. The patient was discharged without any complications. [ABSTRACT FROM AUTHOR]

To examine the relationships between effect-site concentrations and electroencephalographic parameters after the induction of general anesthesia with midazolam. Twenty-four patients with American Society of Anesthesiologists status I or II were randomly allocated to receive either an intravenous (i.v.) bolus of midazolam 0.2 mg kg−1 (small-dose group, n = 12) or 0.3 mg kg−1 (large-dose group, n = 12) for induction of general anesthesia in a double-blind experimental design. The bispectral index (BIS), 95% spectral edge frequency (SEF95), spectral power density, and plasma concentrations of midazolam were measured for 60 min following the induction of general anesthesia. Plasma and simulated effect-site concentrations of midazolam were significantly higher in the large-dose group than in the small-dose group ( P = 0.005 and <0.001, respectively). There was a correlation between the relative beta ratio and BIS ( r2 = 0.30, P < 0.001; n = 168); however, effect-site concentrations of midazolam showed no association with BIS, relative beta ratio, or SEF95 ( r2 = 0.07, 0.11 and 0.01, respectively; n = 168). The electroencephalographic spectral power density in the beta-band (≥13 and <30 Hz) was significantly increased after induction and was significantly larger in the large-dose group than in the small-dose group ( P = 0.009). Following the induction of general anesthesia with i.v. midazolam 0.2 or 0.3 mg kg−1, the BIS was positively correlated with the relative beta ratio. Despite a rapid decrease in the plasma and effect-site concentrations of midazolam, the average BIS remained >60 for 60 min after induction, reflecting an increased power of the electroencephalographic high-frequency band. [ABSTRACT FROM AUTHOR]

We examined the hypothesis that remifentanil decreases the bispectral index (BIS) as well as blunts cardiovascular responses to tracheal intubation during anesthesia with midazolam. Sixty patients were randomly allocated to three groups according to the dose of remifentanil—0.1 (S), 0.2 (M), or 0.5 (L) μg kg−1 min−1, respectively. Infusion of remifentanil was started 5 min before the induction of general anesthesia with midazolam 0.2 mg/kg in all groups. Following the administration of vecuronium 0.1 mg/kg, the trachea was intubated 5 min after induction, and the infusion rate of remifentanil was then reduced to 0.05 μg kg−1 min−1 in all groups. Mean arterial blood pressure (MAP), heart rate (HR), BIS, and 95% spectral edge frequency (SEF95) were measured until 10 min after tracheal intubation. Infusion of remifentanil alone before the induction of anesthesia did not affect the hemodynamic or electroencephalographic parameters. MAP was significantly decreased after induction in all groups of patients ( P < 0.01), with no differences among the three groups, while it was significantly increased after tracheal intubation in the patients of groups S and M, but not in those of group L. The HR did not change after induction in any of the groups, but it was also significantly increased after tracheal intubation of group S and M patients, although not in those of group L. The BIS decreased after induction, and both the BIS and SEF95 were significantly lower in group L patients than in those of group S ( P < 0.01). All patients were unconscious after induction, and none complained of intraoperative awareness. In our patient cohort, remifentanil 0.5 μg kg−1 min−1 effectively decreased the BIS after the induction of general anesthesia with midazolam 0.2 mg/kg and suppressed the increase of MAP and HR in response to subsequent laryngoscopy and tracheal intubation. [ABSTRACT FROM AUTHOR]

We investigated cell response, including cell proliferation and expression of heat stress protein and bcl-2, to clarify the influence of low-level [gallium-aluminum-arsenide (Ga-Al-As) diode] laser irradiation on Par-C10 cells derived from the acinar cells of rat parotid glands. Furthermore, we also investigated amylase release and cell death from irradiation in acinar cells from rat parotid glands. The number of Par-C10 cells in the laser-irradiated groups was higher than that in the non-irradiated group at days 5 and 7, and the difference was statistically significant (P < 0.01). Greater expression of heat shock protein (HSP)25 and bcl-2 was seen on days 1 and 3 in the irradiated group. Assay of the released amylase showed no significant difference statistically between the irradiated group and the non-irradiated group. Trypan blue exclusion assay revealed that there was no difference in the ratio of dead to live cells between the irradiated and the non-irradiated groups. These results suggest that low-level laser irradiation promotes cell proliferation and expression of anti-apoptosis proteins in Par-C10 cells, but it does not significantly affect amylase secretion and does not induce rapid cell death in isolated acinar cells from rat parotid glands. [ABSTRACT FROM AUTHOR]

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We have opened an operating room in the perinatal care unit (PNCU), separate from our existing central operating rooms, to be used exclusively for cesarean sections. The purpose is to meet the increasing need for both emergency cesarean sections and non-obstetric surgeries. It is equipped with the same surgical instruments, anesthesia machine, monitoring system, rapid infusion system and airway devices as the central operating rooms. An anesthesiologist and a nurse from the central operating rooms trained the nurses working in the new operating room, and discussed solutions to numerous problems that arose before and after its opening. Currently most of the elective and emergency cesarean sections carried out during the daytime on weekdays are performed in the PNCU operating room. A total of 328 and 347 cesarean sections were performed in our hospital during 2011 and 2012, respectively, of which 192 (55.5 %) and 254 (73.2 %) were performed in the PNCU operating room. The mean occupancy rate of the central operating rooms also increased from 81 % in 2011 to 90 % in 2012. The PNCU operating room was built with the support of motivated personnel and multidisciplinary teamwork, and has been found to be beneficial for both surgeons and anesthesiologists, while it also contributes to hospital revenue. [ABSTRACT FROM AUTHOR]

Here we report on a postoperative living-donor liver transplantation (LDLT) patient who received nightly infusions of dexmedetomidine (DEX), a specific α2-adrenergic receptor agonist, to treat agitation and insomnia during an intensive care unit stay. The infusion rate was adjusted according to the Ramsay sedation score. The actual plasma concentrations were higher than the values predicted by RugLoop software package simulation 9 h after the DEX infusion. However, all of the measurements were within the therapeutic range for DEX. Thus, DEX infusion could be safely used in the postoperative LDLT patient by employing a simple consciousness scale. [ABSTRACT FROM AUTHOR]

To optimize the properties of titanium for use in dentistry, alloying is necessary. This study reports on the characterization of some titanium alloys for grindability, wear, and corrosion resistance. Improvements in grindability and wear seemed to occur with the presence of the eutectoid in the alloy. [ABSTRACT FROM AUTHOR]

An introduction is presented in which editor discusses various articles within the issue on topics including continuous infusion rate of rocuronium, appropriateness of applying pharmacokinetic parameters and prediction of plasma concentration.

Recently, Ryu et al. [[1]] demonstrated that both bispectral index (BIS) and surgical pleth index (SPI) during anesthesia with desflurane were lower than those with sevoflurane at age-corrected 1 minimum alveolar concentration (MAC). Desflurane reduces intraoperative remifentanil requirements more than sevoflurane: comparison using surgical pleth index-guided analgesia. Bispectral index, Desflurane, Sevoflurane, Surgical pleth index. [Extracted from the article]

Rapid sequence spinal anesthesia is a recently developed technique for the most urgent, category-1 cesarean section. To successfully perform this technique, it is important to multi-disciplinarily discuss with all staffs related to delivery, make a local protocol in each hospital and simulate the procedure with them. Owing to the above preparation, we were able to perform the technique smoothly also in the real patient. Considering possible benefits of rapid sequence spinal anesthesia, we should prepare enough before we use it in the actual clinical situations. [ABSTRACT FROM AUTHOR]

Background: Although various agents are used during anesthesia for surgical resection of pheochromocytoma, application of desflurane has rarely been reported. We report the use of desflurane in a case receiving resection of extra-adrenal pheochromocytoma.Case presentation: A 51-year-old female was transferred to our hospital for sustained hypertension. A diagnosis of extra-adrenal pheochromocytoma was made based on increased plasma catecholamine levels and radiographic findings. Surgical resection was planned after controlling blood pressure. General anesthesia was induced with propofol and fentanyl, followed by maintenance with desflurane 4.3% and remifentanil 0.2-0.4 μg/kg/min. Blood pressure and heart rate were stable during induction, tracheal intubation, and tumor manipulation. Blood pressure abruptly decreased to 62/40 mmHg after removal of the tumor, which was treated with noradrenaline. The surgery was completed uneventfully and the postoperative course was also uneventful.Conclusion: Desflurane was safely used in combination with remifentanil during anesthesia for resection of extra-adrenal pheochromocytoma. [ABSTRACT FROM AUTHOR]

An introduction is presented wherein the editors discuss several articles published within the issue including one on the introduction of the modified enhanced recovery after surgery (ERAS) protocol in a Japanese hospital by Dr. Hideki Taniguchi, one on the effects of intraoperative analgesia with peripheral nerve block by Dr. M. Kitayama, and one on a review on several peripheral nerve block by Dr. Shibata.

A letter to the editor is presented about a case of an intraoperative ventricular tachycardia during hepatectomy in a 65-year-old man.