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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., Author(s): Kanji Uchida [sup.1], Osamu Nishida [sup.2], Hiroshi Morimatsu [sup.3], Takahisa Goto [sup.4], Yutaka Oda [sup.5], Takashi Asai [sup.6] Author Affiliations: (1) grid.26999.3d, 0000 0001 2151 536X, Department of Anesthesiology, [...]

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., Author(s): Yutaka Oda [sup.1] Author Affiliations: (1) Department of Anesthesiology, Osaka City Juso Hospital, , 2-12-27, Nonaka-kita, Yodogawa-ku, 532-0034, Osaka, Japan Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is highly [...]

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 (SpO.sub.2) [greater than or equal to] 96%), moderate I (93% < SpO.sub.2 < 96%), moderate II (SpO.sub.2 [less than or equal to] 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 [greater than or equal to] 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., Author(s): Yutaka Oda [sup.1], Satoshi Shiraishi [sup.2], Motoko Shimada [sup.1], Osamu Kurai [sup.3] Author Affiliations: (1) Department of Anesthesiology, Osaka City Juso Hospital, , 2-12-27 Nonaka-kita, Yodogawa-ku, 532-0034, Osaka, Japan [...]

Author(s): Yutaka Oda [sup.1] Author Affiliations: (1) Department of Anesthesiology, Osaka City Juso Hospital, , 2-12-27, Nonaka-kita, Yodogawa-ku, 533-0034, Osaka, Japan Sugammadex is extensively used since its introduction to our [...]

Author(s): Yutaka Oda [sup.1] Author Affiliations: (Aff1) Department of Anesthesiology, Osaka City Juso Hospital, , 2-12-27, Nonaka-kita, Yodogawa-ku, 532-0034, Osaka, Japan Introduction 'Practical guide for the management of systemic toxicity [...]

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 [micro]g/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., Author(s): Shinya Kanazawa [sup.1] , Yutaka Oda [sup.1] , Chika Maeda [sup.1] , Ryu Okutani [sup.1] Author Affiliations: (Aff1) 0000 0004 1764 9308, grid.416948.6, Department of Anesthesiology, Osaka City General [...]

Author(s): Yutaka Oda[sup.1] Author Affiliations: (1) Department of Anesthesiology, Osaka City General Hospital, 2-13-22, Miyakojima-hondori, Miyakojima-ku, 534-0021, OsakaJapan Introduction With the development of ultrasound-guided regional anesthetic techniques, peripheral nerve block [...]

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 (rS[O.sub.2]) with infrared spectroscopy in order to detect cerebral hypoperfusion. A decrease of rS[O.sub.2] 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. Keywords Coarctation of the aorta * Dandy-Walker syndrome * Left heart bypass * PHACE syndrome * Regional cerebral oxygen saturation, Introduction PHACE syndrome (1) is a coined acronym consisting of the initial letters of the following features: posterior fossa brain malformations, hemangiomas on face, anomaly of the cerebral arteries, coarctation [...]

Background It has been nearly 15 years since the effectiveness of intravenous lipid emulsion in resuscitation from bupivacaine-induced cardiac arrest was reported by Weinberg et al. [1]. Despite the outstanding [...]

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 [+ or -] 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 [+ or -] 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 [+ or -] 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. Keywords Bupivacaine * Levobupivacaine * Central nervous system toxicity * Cardiac toxicity * Lipid emulsion, Introduction The effect of lipid emulsion on local-anesthetic-induced cardiac toxicity has been extensively studied [1]. Most of those studies employed anesthetized, mechanically ventilated animal models [2-4]. One reason for this [...]

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. Keywords Airway * Device * Intubation * i-gel * ProSeal laryngeal mask airway * Pediatrics, Introduction The pediatric i-gel (Intersurgical, Wokingham, Berkshire, UK) is a new single-use, latex-free supraglottic airway device for children [1]. It is a smaller model of the i-gel device used in [...]

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. Keywords Pena-Shokeir syndrome * Cerebro-oculo-facio-skeletal syndrome * Anesthetic management * Pediatric * Airway, Introduction Pena-Shokeir syndrome is an inherited disorder characterized by intrauterine growth restriction, craniofacial deformities, multiple ankyloses, and pulmonary hypoplasia [1-3]. Another phenotype referred to as cerebro-oculofacio-skeletal syndrome [4], has similar [...]

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. Keywords Tracheal tumor * Hemangioma * One-lung ventilation * Endobronchial blocker, Introduction Primary tumors of the trachea are rare, and affected individuals are often asymptomatic despite the high level of malignancy [1]. These tumors are commonly discovered during a health checkup [...]

A 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 [micro]g/ml, respectively. After infusion of lipid emulsion, the ropivacaine concentrations decreased to 1.72 and 0.05 [micro]g/ml, respectively. The patient had no pain, and neurological examination revealed sensory loss around the clavicle. The patient was discharged without any complications. Keywords Local anesthetic * Ropivacaine * Toxicity * Peripheral nerve block * Lipid emulsion, Introduction After the first report of successful treatment of local anesthetic-induced toxicity by use of lipid emulsion [1], its use has increased so widely that it has become almost a [...]

Purpose To examine the relationships between effect-site concentrations and electroencephalographic parameters after the induction of general anesthesia with midazolam. Methods 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.sup.-1] (small-dose group, n = 12) or 0.3 mg [kg.sup.-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. Results 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 Conclusion Following the induction of general anesthesia with i.v. midazolam 0.2 or 0.3 mg [kg.sup.-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. Keywords Bispectral index * Electroencephalogram * Midazolam * Relative beta ratio * Spectral edge frequency, Introduction Midazolam is used for sedation and general anesthesia [1]. During anesthesia, monitoring of the depth of anesthesia is required in order to maintain an adequate level of anesthesia and [...]

Purpose We examined the hypothesis that remifentanil decreases the bispectral index (BIS) as well as blunts cardiovascular responses to tracheal intubation during anesthesia with midazolam. Methods Sixty patients were randomly allocated to three groups according to the dose of remifentanil-0.1 (S), 0.2 (M), or 0.5 (L) [micro]g [kg.sup.-1] [min.sup.-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 [micro]g [kg.sup.-1] [min.sup.-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. Results 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. Conclusion In our patient cohort, remifentanil 0.5 [micro]g [kg.sup.-1] [min.sup.-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. Keywords Bispectral index * Electroencephalogram * Midazolam * Remifentanil * Spectral edge frequency, Introduction Remifentanil is a short-acting opioid commonly used in combination with intravenous and volatile anesthetics for the induction and maintenance of general anesthesia. It is known to be effective in [...]

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. Keywords Cesarean section * Operating room * Perinatal care unit * Occupancy rate, Introduction In North America and in several European countries, obstetric surgery is routinely performed in an operating room with special facilities such as a delivery suite and perinatal care unit [...]

Author(s): Yutaka Oda [sup.1] Author Affiliations: (1) Department of Anesthesiology, Osaka City Juso Hospital, 2-12-27, Nonaka-kita, Yodogawa-ku, 533-0034, Osaka, Japan Rocuronium has become the neuromuscular blocking agent of first choice [...]

Author(s): Yutaka Oda [sup.1] , Shinya Kanazawa [sup.2] , Motoko Shimada [sup.1] Author Affiliations: (Aff1) Department of Anesthesiology, Osaka City Juso Hospital, , 2-12-27, Nonaka-kita, Yodogawa-ku, 533-0034, Osaka, Japan (Aff2) [...]

We, the chairpersons, chose 'Enhanced Recovery After Surgery' as a topic of the 2013 Journal of Anesthesia symposium held on May 23, 2013. After reviewing all the manuscripts assigned to [...]

To the Editor: Institutional Review Board approval and informed concent were exempted because no ethical problem was involved in this case report. After the operation, informed consent for publication was [...]