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To investigate anesthesia management in patients undergoing right lung surgery after a previous left upper lobectomy (LUL) that may require special precautions since angulation of the left bronchus can hamper correct placement of a left-sided double-lumen tube (DLT), and one-lung ventilation (OLV) depending solely on the left lower lobe may lead to inadequate oxygenation.A retrospective data analysis.Single university hospital.Patients underwent right lung surgery after previous LUL.None.Anesthesia management was investigated in 18 patients who underwent right lung surgery following LUL. All intubation procedures were performed under bronchoscopic guidance to prevent airway trauma. OLV could be achieved with a left-sided DLT in 12 patients, while tubes other than this were required in 6 patients, including a right-sided DLT (n = 3) and a bronchial blocker (n = 3). The presence or absence of remarkable bronchial angulation, characterized by a combination of a wide (140°) angle between the trachea and left main bronchus and a narrow (100°) angle between the left main and lower bronchi critically affected tube selections. The minimum SpO2 during OLV was 90.9±4.1%. In 2 patients, intermittent bilateral ventilation was required to treat desaturation. In all the patients, the scheduled surgery could be completed.Extent of left bronchial angulations had a critical impact on whether or not a left-sided DLT could be used in patients undergoing right lung surgery after LUL.

Postoperative cognitive dysfunction (POCD) has been highlighted over a decade. Although perioperative stroke is obvious central nervous system pathology, POCD is often subtle and unrecognized. No consensus on the definition for POCD has been reached. POCD may be attributed to preoperative, surgical, anesthetic, or adverse perioperative events. POCD often occurs frequently in elderly patients even after minor surgical procedures. POCD may last years after surgery and may impair the patient's social activity including premature departure from the workforce. Although neuroinflammation is suggested as an important predisposing factor, our knowledge on other predisposing factors is limited and effective preventive measure is unknown.

In Japan, it has been thought that pain during labor develops maternal identity and there are cultural and psychological barriers to the use of epidural labor analgesia. The objective of this study was to examine epidemiologic data and psychological data about satisfaction with delivery and maternal identity with epidural labor analgesia.A web-based survey was randomly conducted in 1,000 women (ages, 20-40 years) with children under the age of 3 years. The questionnaire included the basic characteristics of the participants and children, their experiences with delivery and two scales to evaluate satisfaction of delivery and maternal identity.There were a total of 1,030 respondents and 50 (5.0%) respondents reported having epidural labor analgesia. Scores about self-evaluation scales for satisfaction of delivery and maternal identity among women of epidural labor analgesia were not significantly different with those among women of spontaneous delivery.Satisfaction with delivery and maternal identity are not influenced by chosing epidural labor analgesia.

Although the incidence of massive hemorrhage during surgery is low, the prognosis of massive hemorrhage is poor. When we encounter massive hemorrhage, systematic approach is mandatory. Physicians, nurses, and technicians at the scene, staff in the transfusion department, and the staff in the blood center work as a team. Achieving hemostasis by surgical maneuvers and restoration of blood volume to maintain organ perfusion and oxygenation is essential. If the patient requires vasopressors and lack of crossmatched red cell concentrate (RCC), type-specific RCC should be used. When the situation is life-threatening, un-crossmatched type-compatible RCC should be used. To correct coagulopathy, judicious use of blood components such as fresh frozen plasma and platelet concentrates is mandatory. It may require cryoprecipitate, a fibrinogen product, when fibrinogen level is very low. To improve patient’s outcome, understanding of current blood transfusion guidelines and institutional simulation is important.

During thoracoscopic pulmonary lobectomy (TPL) in larger children (15 kg), an endoscopic stapler (ES) and endoscopic clipper (EC) are used during dissection and division of the pulmonary vessels (PVs) and bronchus. However, in smaller children (15 kg), ES/EC cannot be used because of limited space. We report our technique for thoracoscopic dissection and division of the PVs and bronchus in smaller children.Fifteen cases of sequestration/congenital cystic adenomatoid malformation weighing less than 15 kg (range, 8-15 kg; mean, 11 kg) were the subjects for this review. With the patient under single-lung ventilation in the lateral decubitus position, four ports ranging from 5 to 12 mm were placed. After the PVs and bronchus were exposed, thick silk was used to encircle them as a traction suture. By applying traction, the PVs and bronchus could be exposed, and ES/EC were used safely by applying countertraction.All cases had uneventful TPL (upper in 3 patients, middle in 3 patients, and lower in 9 patients). ES/EC were easy to use. Mean operative time was 220 minutes.Our technique allows the PVs and bronchus in children weighing less than 15 kg to be divided safely using ES/EC. We strongly recommend our technique, although simple, be used during TPL in smaller children.

The locus coeruleus (LC) is a noradrenergic brainstem structure that is considered to play a role in promoting arousal. To further clarify the role of LC noradrenergic neurons, we performed an optogenetic assay by injecting AAV-channelrhodopsin-2 (ChR2) into the LC of cre-tyrosine hydrolase (TH) mice. We found here that the specific activation of LC noradrenergic neurons produced a significant increase in wakefulness and a significant decrease in non-rapid eye movement (NREM) sleep during photostimulation. On the other hand, neuropathic pain is believed to significantly interfere with sleep, and inadequate sleep may contribute to the stressful negative consequences of living with pain. In the present study, sciatic nerve ligation, which produced significant thermal hyperalgesia, significantly increased the levels of noradrenaline released in the prefrontal cortex (PFC) by the weak electrical stimulation of neurons in the LC. Under these conditions, the systemic administration of adrenaline α and β inhibitor cocktail at 7 days after sciatic nerve ligation restored the increased wakefulness and decreased NREM sleep to normal levels. These results suggest that neuropathic pain may accelerate neurons in the LC, and its overactivation may be, at least in part, associated with sleep disturbance under neuropathic pain.

Several clinical reports on neuropathic pain of various etiologies have shown that it significantly interferes with sleep. Inadequate sleep due to neuropathic pain may contribute to the stressful negative consequences of living with pain. It is generally recognized that melatonin (MT) system in the hypothalmus is crusial for circadian rhythm and sleep-wake transition. However, little, if any, is known about whether neuropathic pain could affect the MT system associated with sleep disturbance. In this study, we investigated the possible changes in circadian rhythm for the expression of MT receptors, especially MT1A and MT1B receptors, in the hypothalamus of mice with sciatic nerve ligation. The samples for real-time RT-PCR assay were prepared at 8:00, 14:00, 20:00, and 2:00 on day 7 after sciatic nerve ligation or sham operation. The mRNA expression of MT1A and MT1B receptors at 2:00 in sciatic nerve-ligated mice, which exhibited thermal hyperalgesia along with an increase in wakefulness and a decrease in nonrapid eye movement sleep, was significantly greater than those in sham-operated mice, whereas the levels of both MT1A and MT1B receptors at 8:00 in sciatic nerve-ligated mice were significantly lower than those in sham-operated mice. These findings suggest that neuropathic pain-like stimuli lead to sleep disturbance in parallel with changes in circadian rhythm for mRNA expression of MT 1A and 1B receptors in the hypothalamus of mice.

While attempting to treat a 71-year-old male patient who had been diagnosed with sciatica from spinal canal stenosis, we discovered his prior cancer metastasizing to the psoas. We initially administered epidural block to him after confirming his prior rectal cancer had not metastasized to lumbar vertebral bones, but the block did not satisfactorily alleviate his pain, and he had difficulty stretching his lower limbs. CT scan to re-examine the cause revealed a metastasized cancer in the psoas. From this experience, we believe malignant psoas syndrome should be considered in addition to metastasis to lumbar vertebral bones, when evaluating lower back to lower limb pain in patients with previous cancer history.

We report the use of ultrasound-guided carotid sinus nerve block for circulatory management during two-stage carotid artery stenting (CAS) in a patient with symptomatic carotid stenosis complicated with decreased cerebral perfusion reserve. The patient was a 70-year-old man with symptoms of ocular ischemia and markedly decreased perfusion of the left cerebral hemisphere observed in single photon emission computed tomography. Ultrasound-guided carotid sinus nerve block was conducted to prevent CAS perioperative circulatory fluctuations caused by carotid sinus reaction (CSR). We did not observe any hemodynamic instability during CAS. There were no complications associated with the nerve block. Although further research is required, the present findings suggest that ultrasoundguided carotid sinus nerve block may safely and effectively prevent CSR in CAS.

We report a case of intraoperative cardiac arrest in a patient with mitochodorial encephalomyopathy undergoing pulmonary wedge resection. The patient is a 50-year-old female who had been diagnosed as progressive external ophthalmoplegia at the age of 44 and underwent resection of mediastinal tumor 11 months before without major events. The patient was found to have lung cancer in the left lung and scheduled for wedge resection. Induction and maintenance of anesthesia using remifentanil and propofol infusion with rocuronium were uneventful until traction and resection of the left bronci when profound hypotension with systolic arterial pressure of 20 mmHg and sinus bradycardia occurred. The rhythm deteriorated to ventricular fibrillation which was refractory to pharmacological therapy including adrenaline (a total dose of 5 mg), lidocaine and nifekalant, and DC shock. The patient was finally stabilized after intraaortic balloon pumping and percutaneous cardiopulmonary support. Although the diagnosis of Takotsubo myopathy was made by echocardiography after surgery, the cause of cardiac arrest was not known.

To assess the impact of stroke volume index (SVI) at the end of esophagectomy upon postoperative renal function. We reviewed medical records of 128 patients undergoing esophagectomy. Intraoperative hemodynamics were monitored with the FloTrac sensor/Vigileo monitor system in addition to standard monitors. Patients were divided into two groups according to SVI at the end of surgery: the normal SVI group (n = 76), with SVI ≥ 35 ml/m2, and the low SVI group (n = 52), with SVI

Although laparoscopic surgery is minimally invasive, it produces stress responses to an extent similar to that of conventional laparotomy. Both epidural anesthesia and remifentanil intravenously (i.v.), combined with general anesthesia, provide stable hemodynamics during laparoscopic surgery. However, it has not been elucidated whether epidural anesthesia and remifentanil are associated with suppression of autonomic and neuroendocrine stress responses. This study aimed to clarify whether thoracic epidural anesthesia (TEA) or remifentanil suppresses stress responses during laparoscopic surgery. We assigned 60 patients undergoing laparoscopic colectomy to three groups anesthetized with 40 % oxygen–air–sevoflurane plus either TEA (TEA group), continuous infusion of remifentanil 0.25 μg/kg/min [low-dose (LD) group], or 1.0 μg/kg/min [high-dose (HD) group] (n = 20 each group). Plasma concentrations of adrenocorticotropic hormone (ACTH), cortisol, antidiuretic hormone (ADH), and catecholamines were measured immediately before anesthesia induction, and 30 and 90 min after the start of pneumoperitoneum. All groups showed no significant changes in hemodynamics during the course of anesthesia. Compared with TEA, both high-dose and low-dose remifentanil significantly suppressed increases in ACTH, ADH, and cortisol during pneumoperitoneum. Plasma adrenaline showed no significant changes during pneumoperitoneum in any group. Compared with TEA, low-dose remifentanil produced significantly higher plasma concentrations of noradrenaline and dopamine during pneumoperitoneum. Notwithstanding similar hemodynamic responses in all groups, only high-dose remifentanil suppressed both sympathetic responses and the hypothalamus–pituitary–adrenal axis. This result indicates that of these three anesthesia regimens, high-dose remifentanil seems most suited for laparoscopic surgery.

Variation in the production of opioid receptors over a 24-h period is considered to contribute to circadian alterations in neuropathic pain. In this study, we investigated the possible changes in the circadian rhythm of mRNA expression for µ-opioid receptor (MOR), κ-opioid receptor (KOR), and adrenaline α2a receptor (α2a) in the periaqueductal gray, frontal cortex, thalamus, and spinal cord following sciatic nerve ligation in mice. In sham-operated mice, the latencies of hind paw-withdrawal in response to thermal stimuli at 14:00 and 20:00 were significantly greater than that at 8:00 and the latency at 2:00 was significantly less than those at 14:00 and 20:00, indicating a "rest" period-dominant circadian rhythm for thermal pain-thresholds. In sciatic nerve-ligated mice, the latencies of hind paw-withdrawal in response to thermal stimuli at 14:00 and 20:00 were significantly less than that at 8:00, and the latency at 2:00 was significantly greater than those at 14:00 and 20:00. A correlative tendency between the time-variation of pain latency and the time-variation of MOR mRNA expression was observed in the periaqueductal gray of sham-operated and sciatic nerve-ligated mice. In contrast, neither mouse showed a strong circadian rhythm for the expressions of KOR and α2a mRNAs in any region. The present data suggest that changes in MOR mRNA expression in the periaqueductal gray may be synchronized with the circadian rhythm for the pain threshold for noxious thermal stimuli. In contrast, neuropathic pain in mice exhibited a negative circadian pattern for the expression of MOR, KOR, and α2a receptors in the frontal cortex, thalamus, and spinal cord.

We reviewed 24 consecutive cases of prenatally or immediately postnatally diagnosed left-sided congenital diaphragmatic hernia (CDH) to evaluate pulmonary artery (PA) size as an indication for thoracoscopic repair (TR). CDH repair is planned once echocardiography confirms improvement in pulmonary hypertension. TR is chosen if cardiopulmonary status is stable more than 10 min in the decubitus position in the neonatal intensive care unit (NICU) under conventional mechanical or high frequency oscillatory ventilation (HFOV) with/without nitric oxide (NO) and the patient appears likely to tolerate manual ventilation during transfer to the operating room. Otherwise open repair (OR) is performed in NICU. Proximal right PA (RPA) and left PA (LPA) diameters measured at birth were assessed with respect to the type of repair. 10/24 had TR and 14/24 had OR. TR cases had significantly larger RPA/LPA diameters (3.52 ± 0.23 vs. 3.10 ± 0.56 mm, p

The present study was conducted to evaluate the efficacy and safety of BLM-240 (desflurane) in comparison to sevoflurane in Japanese patients. A total of 216 patients were enrolled in this randomized comparative study at 15 medical institutions. The patients received either BLM-240 with 50–70 % N2O in O2 (n = 111), BLM-240 with 30 % O2 in air (n = 55), or sevoflurane with 50–70 % N2O in O2 (n = 50). Efficacy was evaluated by an efficacy rate based on an efficacy evaluation criteria and recovery time to extubation from the discontinuation of the anesthetics. Safety was evaluated by incidence of adverse drug reactions (ADR) and other clinical indicators. The efficacy rate of BLM-240 was 98.8 % (164/166 patients), indicating that BLM-240 is effective as an anesthetic. Time from discontinuation of anesthetic delivery to extubation was 9.7 ± 0.6 min in the BLM-240/N2O group and 14.3 ± 0.9 min in the sevoflurane/N2O group, meeting the pre-defined non-inferiority criteria of BLM-240 to sevoflurane. There was no statistically significant difference in the incidence of total ADR between the BLM-240 group (62.0 %) and sevoflurane group (48.0 %). The results indicate that BLM-240 is an effective and safe inhalation anesthetic in Japanese patients.

The purpose of this study was to develop a new tool, the Pain Sleep questionnaire, consisting of 20 items (PS-20) for measuring pain-related sleep disturbances in pain clinic patients, and to examine its reliability and validity.The internal consistency, criterion validity compared with the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36v2), and construct validity of the PS-20 were tested.A total of 125 patients participated in this study. Cronbach's alpha coefficient was 0.969, indicating good internal consistency. The PS-20 score correlated moderately with the physical component summary of SF-36v2 and correlated weakly with the mental component summary of SF-36v2. From the graphical model using the Akaike information criterion and the Categorical principal component analysis, the items were divided into four domains: physical pain, trouble falling asleep, awakened by pain, and general health problems.The PS-20 was shown to be a valid and reliable questionnaire scale for measuring pain-related sleep disturbances among pain clinic patients.

The goals of monitoring are to improve the safety of perioperative care and to improve patient's outcome. Various invasive and non-invasive monitors are currently used. Minimum monitoring standards including blood pressure monitoring, electrocardiogram, pulse oximetry, capnography, temperature monitoring, and neuromuscular monitoring are essential but not enough to achieve the goals. Although emerging technologies have made it possible to monitor cardiac, cerebral and spinal functions in the perioperative period, there is limited evidence that those monitors can improve patient's outcome. We must continue to improve the functions of monitors. The existence of a well-trained competent anesthesiologist at bedside is essential to integrate all the information gained by five senses, the monitors, blood tests and close communication with surgeons on top of deep understanding of the patient's preoperative status.

A 62-year-old woman was treated for schizophrenia for 40 years. When the symptoms had deteriorated and new medications had to be added, CPK rose and she malignant syndrome was suspected. The electroconvulsive therapy (ECT) was proposed because of no improvement of the symptoms. We employed rocuronium bromide instead of suxamethonium considering malignant syndrome. The maintenance of anesthesia was necessary, because the duration of rocuronium bromide is longer than that of suxamethonium chloride. Anesthesia was induced and maintained using target controlled infusion (TCI) of propofol. After ECT was performed, sugammadex sodium 4 mg . kg-1 was administered at 2 post-tetanic counts (PTC) and the patient could come out the operating room safely and speedy. ECT using rocuronium bromide and sugammadex sodium can be performed safely and speedily, when suxamethonium chloride cannot be used.

The direct effects of nitrous oxide on left ventricular contractility and myocardial oxygen consumption (MVO2) in the ischemic isolated rat heart were studied. The rat heart was isolated and perfused by a Langendorf technique. The aortic stump was cannulated and the heart was perfused with Kumpeis solution bubbled with 95% O2 and 5% CO2 (control phase). A latex balloon was inserted into the left ventricle (LV) to measure LV pressures and dP/dt. Coronary flow was measured and MVO2 was calculated. After the control phase, perfusion pressure was decreased to induce global ischemia (ischemic phase). There were four groups of eight hearts each: control, nitrogen, nitrous oxide, and halothane groups. After 15 min of ischemic phase, the perfusion pressure was increased and the gas mixture was changed to the standard gas mixture (reperfusion phase). Nitrous oxide did not further depress myocardial contractility compared with nitrogen in the ischemic phase, and did not alter MVO2 in the ischemic phase compared with nitrogen. Halothane significantly depressed myocardial contractility and decreased MVO2 in the ischemic phase compared with the control.

Kasabach-Merritt syndrome (KMS) is a rare and severe coagulation disorder caused by vascular malformations within or outside the liver. It is characterized by profound thrombocytopenia, microangiopathic hemolytic anemia, and consumption coagulopathy. We successfully managed the anesthesia for a giant hemangioma resection complicated with KMS using FloTrac/Vigileo system. A 78-year-old woman (51 kg, 141 cm) was admitted for giant hemangioma with disseminated intravascular coagulation (DIC). General anesthesia was induced with sevoflurane and remifentanil. Epidural anesthesia was not induced because of coagulopathy. We evaluated arterial pressure-based cardiac output (APCO), stroke volume variation (SVV) as a predictor for fluid responsiveness, systolic blood pressure (SBP), and central venous pressure (CVP) during the operation. Prior to tumor resection, 6,000 ml of fluid was suctioned from the tumor. The increase of SVV and sudden decrease of APCO and SBP were recognized during surgical procedure. The SVV demonstrated marked changes in response to hemorrhage, and it was more sensitive than CVP change during operation. We conclude that SVV is an accurate predictor of intravascular hypovolemia, and it is a useful indicator for assessing the appropriateness and timing of applying fluid for improving circulatory stability during a giant hemoangioma resection.

Pulmonary inflammatory reactions are affected by one-lung ventilation (OLV) and anesthetic agents. However, the effects of anesthetic agents on pulmonary inflammatory reactions may vary. Our previous investigations suggested that inflammatory reactions were more pronounced in the dependent lung during lung resection under general anesthesia with propofol and remifentanil. Therefore, in the present study we attempted to determine the difference in pulmonary inflammatory reaction using either sevoflurane or propofol in both dependent and nondependent lungs during OLV. Forty adult patients undergoing elective lung resection were randomized to receive either propofol (n = 20) or sevoflurane (n = 20) as the main anesthetic agent. Intraoperative analgesia was provided by remifentanil in both groups. Epithelial lining fluid (ELF) was obtained from each lung using a bronchoscopic microsampling method. ELF and plasma levels of inflammatory cytokines were measured using multiplexed bead-based immunoassays before and after OLV. Epithelial lining fluid levels of interleukin (IL)-1β, IL-6, and IL-8 were significantly increased in the dependent lung and the nondependent lung after OLV compared with baseline levels (P

Lidocaine is used clinically for tactile allodynia associated with diabetes-induced neuropathy. Although the analgesic effect of lidocaine through suppression of microglial activation has been implicated in the development of injury-induced neuropathic pain, its mechanism of action in diabetes-induced tactile allodynia has not yet been completely elucidated.To evaluate the effects of lidocaine on microglial response in diabetic neuropathy, streptozotocin (STZ)-injected mice received a continuous infusion of lidocaine (vehicle, 2, or 10%) from day 14 to day 21 after STZ injection. On day 21, microglial accumulation and p38 mitogen-activated protein kinase activation in the dorsal horn were evaluated. In vitro, the effects of lidocaine on cell viability, chemotactic response to monocyte chemotactic protein-1, and induction of proinflammatory mediators were examined in interferon (IFN)-γ-stimulated primary microglial cells.Continuous systemic administration of lidocaine in the early progression of tactile allodynia produced long-lasting analgesic effects in STZ-treated mice. Lidocaine significantly reduced accumulation and p38 phosphorylation of microglial cells in the dorsal horn. In vitro, lidocaine down-regulated IFN-γ-induced gene induction of inducible oxide synthase and interleukin-1β. Pretreatment with lidocaine significantly reduced chemotactic response to monocyte chemotactic protein-1 of IFN-γ-activated microglial cells.Lidocaine alleviates STZ-induced tactile allodynia, possibly by modulating the p38 pathway in spinal microglial cells. Inhibiting microglial activation by lidocaine treatment early in the course of diabetes-induced neuropathy represents a potential therapeutic strategy for tactile allodynia.

Purpose. Although both gabapentin and pregabalin are first-line drugs for neuropathic pain including postherpetic neuralgia (PHN), no report has directly compared the magnitude of pain relief and the incidence of side effects of both drugs. By substituting gabapentin with pregabalin in postherpetic neuralgia therapy, we can compare the two drugs. Methods. In 32 PHN patients being administered gabapentin, without changing the frequency of dosing, the drug was substituted with pregabalin at one-sixth dosage of gabapentin. After 2 weeks, an interview was conducted about the visual analog scale (VAS) pain score, changes in the time of onset of action and duration of action after the substitution of drug and side effects (such as somnolence, dizziness, and peripheral edema). In addition, the dosage was increased while paying careful attention to the side effects (titration) in 22 patients who requested a dosage increase among those whom VAS pain score of ≥25 mm remained even after the substitution. Results. No significant changes were observed in VAS pain scores after the substitution of gabapentin with pregabalin. Regarding the time of onset of action and the duration of action after the substitution, the highest number of patients answered that no change occurred compared with the previous drug, followed by the patients who answered that the time of onset of action became quicker, and the duration of action became longer. The incidence of somnolence and dizziness showed no significant difference before and after the substitution, but peripheral edema showed a significant increase after the substitution. The level of side effects of both drugs was mild, and continued medication was possible. In the patient group where pregabalin dosage was increased, the VAS pain score decreased significantly compared with that before and after increase the dosage (P

A 31-year-old primigravida was admitted for control of twin gestation and delivery. At 36-week gestation, an emergent cesarean section was performed under combined spinal-epidural anesthesia because of progression of PIH. Anesthetic course was uneventful until the operation was finished. An hour later, systolic blood pressure started to decline to reach about 70 mmHg and Sp(O2) about 80%. Pleural effusion was observed in the chest X-ray on post-operative day 1. Echocardiography showed akinesis of the antero-septal wall with ejection fraction (EF) of 47%. Peripartum cardiomyopathy (PPCM) was strongly suspected. HELLP syndrome and DIC were also combined with PPCM, so intensive care was given to her from the 1st POD. Symptoms of heart failure were alleviated by furosemide and carperitide by the 12th POD. The EF increased to 58% on the 11th POD.

Hemorrhage is the leading cause of maternal death. Pregnant woman can tolerate a larger amount of blood loss than non-pregnant woman, but obstetric hemorrhage is characterized by a high incidence of coagulopathy. The Japanese Society of Anesthesiologists and four related academic societies published "Guidelines for management of critical bleeding in obstetrics" in April 2010. The following points are emphasized in these guidelines. Firstly, the trend of the shock index (heart rate/systolic blood pressure) is useful to evaluate the necessity for blood transfusion. Secondly, coagulopathy should be evaluated in a timely manner and treated promptly, when blood loss including amniotic fluid exceeds 2,000 ml. Thirdly, an urgency code for hemorrhage should be introduced to facilitate communication among the related personnel with communication between the delivery/operating room and blood transfusion service. According to a triage tag in disaster medicine, code I or code red is an extreme emergency: overt hemorrhagic shock or evident massive hemorrhage. If code I is declared by the designated commander, transfusion of uncross-matched ABO-identical as well as ABO-compatible, non-identical red blood cells should be considered, if time is short or ABO-identical red blood cells are unavailable. The commander is selected from senior physicians of the anesthesiology or the obstetric department, and is responsible for crisis management. The major problems in crisis management are hesitation to declare an emergency and failure of communication. Declaration of an emergency is also essential for calling supportive medical personnel. To deal rapidly with critical bleeding, hospital actions to be taken should be prepared, and simulation exercise should be performed to correct inappropriate actions prior to an actual crisis. A systematic, not individual, approach is required to save the life of a bleeding pregnant woman.

The annual surveys of critical incidents in Japanese Society of Anesthesiologists (JSA)-certified hospitals in 1999-2002 demonstrated that massive and critical bleeding was the major cause of intraoperative cardiac arrest leading to poor prognosis including death and permanent brain damage. The surveys also suggested that type-specific blood transfusion and emergent O-type blood transfusions were underutilized. Therefore, the JSA and the Japan Society of Transfusion Medicine and Cell Therapy publicized the guidelines for treatment of critical bleeding in 2007. Five academic societies publicized the guidelines for management of critical bleeding in obstetrics in 2010. Each hospital is expected to make institutional emergency blood transfusion guidelines on the basis of the above guidelines in order to decrease the incidence of critical bleeding and to improve the prognosis of the patients with critical bleeding.

The JSA and the Japanese Society of Blood Transfusion and Cell Therapy established "Guidelines for Action Against Intraoperative Critical Hemorrhage" in 2007. This guideline shows practical strategies for managing life-threatening hemorrhage. From 2007 to 2009, we conducted the annual survey with transfusion services of 384 hospitals accredited by the JSA. From the results of these surveys, we proposed some new strategies for managing life-threatening hemorrhage as follows: 1) It is necessary to establish a documentation of institutional procedures for urgent transfusion practices including an emergency code for blood requirement, according to "Guidelines for Action Against Intraoperative Critical Hemorrhage". 2) The simulation exercise according to the documentation of institutional emergency transfusion procedures should be held. 3) On the occurrence of a life-threatening hemorrhage, we should make an appropriate decision to use uncrossmatched ABO-matched blood components and/or ABO-mismatched compatible blood components, to save the patient's life. 4) Though it is well known that the post-transfusion graft versus host disease (PT-GVHD) has poor prognosis and irradiation of blood products is essential for avoiding the PT-GVHD, in some hospitals, non-irradiated blood components were used in situation of critical hemorrhage. We recommend that irradiated blood components should be used if possible in resuscitating a patient with critical hemorrhage.

Post-operative pulmonary complications such as systemic inflammatory response syndrome (SIRS), acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are strongly associated with morbidity and mortality after esophagectomy. Post-operative administration of sivelestat sodium hydrate (sivelestat), a selective inhibitor of neutrophil elastase (NE), has been shown to improve the post-operative clinical course after esophagectomy. This study aimed to evaluate the effect of prophylactic administration of sivelestat on bronchial inflammatory responses. We randomized 24 patients into two groups. One group received 0.2 mg/kg/h sivelestat from the induction of anesthesia to post-operative day 1 (sivelestat group) and the other group received the same amount of physiological saline (control group). Bronchial alveolar epithelial lining fluid (ELF) samples were obtained from both groups at the induction of anesthesia and at the end of surgery. The serum and ELF levels of interleukin (IL)-6 and IL-8 were measured by enzyme-linked immunosorbent assay, and NE activity was spectrophotometrically determined using the same samples. Although IL-6 levels in the ELF significantly increased at the end of surgery compared with the pre-operative levels in both groups, the IL-8 levels and NE activity did not significantly increase at the end of the surgery compared to the corresponding pre-operative values in the sivelestat group. Moreover, IL-8 levels and NE activity in the ELF were significantly reduced at the end of surgery in the sivelestat group compared with corresponding values in the control group. The durations of ALI and ARDS were apparently shorter in the sivelestat group and the duration of SIRS was significantly shorter in the sivelestat group compared to the control group. We demonstrated that prophylactic use of sivelestat mitigated bronchial inflammation by suppressing NE activity and IL-8 levels in the ELF and shortened the duration of SIRS after transthoracic esophagectomy.

We reported on a 66-year-old male who developed a severe obstruction of a portion of the intermedistinal trachea as a result of tracheostomy and endotracheal intubation following surgery for hepatoma. He had the endotracheal intubation for 42 days. After the tracheal hole closed, he had no respiratory symptoms for about 2 months. He complained of difficulty in breathing, and his symptoms progressed rapidly. Endoscopy revealed endotracheal stenosis, with the narrowest part being 3-4mm in diameter. The stenotic portion was in the intermediastinal space. During open mediastinal surgery, an annular excision was performed, three tracheal cartilages were cut and an end-to-end anastomosis was performed. As intubation through the stenotic part was impossible, the incubate tube was kept just above the oral side of the stenotic portion, and, during the operation, anesthetic control was maintained under spontaneous respiration. The postoperative couse was satisfactory, and the patient could stand up 20 days after the operation

We reviewed 26 consecutive cases of congenital diaphragmatic hernia (CDH) prospectively to establish selection criteria for successful thoracoscopic CDH repair (TR). Five preoperative deaths were excluded, leaving 21 subjects. TR was only considered once pulmonary hypertension (PH) improved on echocardiography, and if cardiopulmonary status was stable in the decubitus position in the neonatal intensive care unit (NICU) under conventional mechanical or high-frequency oscillatory ventilation (HFOV) with/without nitric oxide (NO) for at least 10 min as a marker for tolerating surgery and manual ventilation was possible for transfer to the operating room. All other patients had open repair (OR). 8/21 had TR and 13/21 had OR. There were significant differences between TR and OR for prenatal diagnosis (37.5 vs. 84.6%, p

Background The objective of this study was to demonstrate the feasibility of a bar code-based identification system for the pre-transfusion check at the bedside in the setting of pre-operative autologous blood donation (PABD). Materials and methods Between July 2003 and December 2008 we determined the compliance rate and causes of failure of electronic bedside checking for PABD transfusion. Results A total of 5627 (9% of all transfusions) PABD units were administered without a single mistransfusion. The overall rate of compliance with electronic checking was 99%. Conclusions The bar code-based identification system was applicable to the pre-transfusion check for PABD transfusion.

A 44-year-old man underwent radical thymectomy for malignant thymoma 5 years ago. He subsequently underwent right extrapleural pneumonectomy because a right pleural metastatic lesion had developed. The operation was completed uneventfully. Immediately after arrival at the intensive care unit, the patient appeared restless and in pain. His heart rate increased to 140 bpm and then abruptly decreased to 20–30 bpm concomitant with profound systolic hypotension of 30–40 mmHg. Chest X-ray showed that the heart was shifted into the right thorax. Emergent re-thoracotomy was performed and the heart was found to be malrotated and herniated from an upper defect of the pericardial patch in the right thoracic cavity. The heart was returned to the pericardium and the defect was covered with a pericardial patch. The blood pressure and heart rate became stable. He was transferred to the surgical ward from the intensive care unit on the first postoperative day. The rest of the course was uneventful and the patient was discharged on the seventh postoperative day. The incidence of cardiac herniation after extrapleural pneumonectomy following chemotherapy for malignant pleural mesothelioma has been reported to be around 3%. The risk of cardiac herniation should always be considered, especially after extrapleural pneumonectomy.

We report on technical modifications we developed for thoracoscopic esophagoesophagostomy in patients with esophageal atresia. They are: (1) placing stay sutures along the edges of the atretic esophagi and exteriorizing them through the thoracic wall to expose the luminal surfaces of the esophagi nicely and relieve tension on the anastomosis; (2) leaving 1/5 of the length of the distal and proximal ends of the atretic esophagi intact before placing the stay sutures, to avoid retraction of the mucosa into the lumen; (3) making the diameter of the proximal esophagus 1.5-2 times larger than the diameter of the distal esophagus to make the shape of the anastomosis more streamlined without notching.

A 35-year-old primigravida with twin gestation was admitted for elective cesarean section. She had no preoperative systemic diseases including heart disease. At 37 weeks of gestation, elective cesarean section was performed under combined spinal-epidural anesthesia. Anesthetic course was uneventful until the delivery when the patient started to cough and complained of dyspnea. At the same time, Spo2 started to decline to reach 95% despite the oxygen supplement. Pleural effusion was observed on the chest X-ray on postoperative day 2. An echocardiography showed diffuse hypokinesis of the left ventricle with ejection fraction (EF) of 36%. Peripartum cardiomyopathy was strongly suspected. Symptoms of heart failure were alleviated by water restriction and furosemide by the 9th POD. The EF increased to 50% on the 15th POD.

In Japan, emergency blood transfusion practices including ABO-compatible, different blood group transfusion and uncross-matched, ABO-identical blood group transfusion are very limited possibly due to adherence to identical blood transfusion as well as fear of hemolytic reactions due to anti-A, anti-B, anti-RhD and unexpected antibodies. Purpose of the study is to examine the incidence of hemolytic reactions due to compatible, ABO-different blood group transfusion.We conducted a questionnaire survey regarding emergency compatible, different blood group transfusion in the operating theater in hospitals with more than 500 beds among those with an accredited Department of Anesthesiology regarded as regional hospitals. Of 384 institutions, 247 responded to the questionnaire. During the year 2006, compatible, ABO-different blood group transfusion was reported in 112 patients from 32 hospitals, among which 105 patients in 26 hospitals were available for further analysis.Compatible red cell concentrate (RCC), fresh frozen plasma (FFP), and platelet concentrate (PC) were transfused in 23, 10, and 83 patients, respectively. Total amount of compatible RCC, FFP, and PC were 232, 162, and 1,679 units, respectively. In patients who were transfused with compatible RCC, two patients had unexpected antibodies. Overall mortality rate within the 30th post-operative day was 23%. In 80 patients, in whom only PCs were used as compatible blood products, blood loss was 86 +/- 85 ml x kg(-1), 65% of patients underwent cardiovascular surgery, and mortality was 11%, implying that compatible PC was transfused mainly to avoid hemorrhagic diathesis in cardiovascular patients. In 64 patients with blood type of A, B, or AB, who underwent compatible PC transfusion, type O PC, incompatible blood products, were transfused in 9 patients. In 21 patients, in whom only RCCs were used as compatible blood products, blood loss was 206 +/- 224 ml x kg(-1), and mortality was 57%. Therefore, compatible RCCs were transfused mainly to avoid life-threatening events. Uncross-matched, ABO-identical RCC transfusion was performed only in 29% of patients among these 21 patients. Transfusion-related hemolytic reactions were not reported in all 104 patients available for this analysis.Although the patient number was small, the finding that there were no hemolytic reactions might promote emergency blood transfusion practices in Japan. High mortality rate and a low rate of uncross-matched, ABO-identical RCC transfusion in patients with compatible RCC transfusion suggest that promoting emergency blood transfusion practices might reduce mortality rate due to massive hemorrhage in the operating theater.

Parents sometimes deny their children blood transfusion because of their religious beliefs. The Japanese Joint Committee on the Refusal of Blood Transfusion on Religious Grounds asserts that the health and life of every child younger than 15 years should be guarded by the collective efforts of health, welfare, and advocacy institutions when a parent or guardian seeks to withhold transfusion therapy. Patients 18 years or older should receive treatment without transfusion after signing and submitting a "Certificate of Refusal Blood Transfusion and Exemption from Liability." For a patient younger than 18 years, but 15 years or older, essential transfusion can be performed if the patient or at least one guardian consents. Without patient's or guardian's consent, guidelines for patients 18 years or older shall apply. Health care providers should offer the best possible care that is consistent with a patient's age and competency.

Herpes zoster causes acute pain and sometimes leads to postherpetic neuralgia (PHN). The previously reported risk factors of PHN such as old age, allodynia, paresthesia and so on are not based on evidence. Although nerve block is useful to relieve acute pain and recommended for prevention of PHN, evidence is scanty.The patients with herpes zoster within 3 months after the onset were studied. The patient underwent nerve blocks and proper medical treatment, and were followed for up to one year. The risk factors of PHN were assessed. We evaluated whether nerve block prevented PHN.A total of 144 consecutive patients were studied. Twenty seven % of patients suffered PHN. Old age (65 y. o) and hypesthesia were confirmed to be the risk factors of PHN, whereas the intensity of acute pain was not. Patients who underwent nerve block within 1 month after the onset were less likely to suffer from PHN compared with patients of delayed nerve blocks.Old age, hypesthesia and delayed nerve blocks were the risk factors of PHN. Nerve blocks in the early phase of herpes zoster may be useful to prevent PHN, particularly in the younger patients.

Annual surveys conducted by the Japanese Society of Anesthesiologists repeatedly show that hemorrhage is the leading cause of life-threatening events in the operating room.We performed a questionnaire survey regarding the present status of critical hemorrhage/ blood transfusion occurring in the operating room on an institutional scale and individual blood transfusion management in cases of massive hemorrhage (or = 5,000 ml) in hospitals withor = 500 beds and those with an accredited Department of Anesthesiology regarded as regional hospitals.Of 384 institutions, 247 responded to the questionnaire (response rate: 64%), and 692,241 cases managed by anesthesiologists in 2006 were registered. There were 2,657 cases of massive hemorrhage above the circulating blood volume in the operating room, and 404 of them were critical. Thus, the number of cases of massive hemorrhage was 6.6 times that of cases of critical events due to hemorrhage. In the survey of individual cases of massive hemorrhage (or = 5,000 ml), 1,257 cases were registered in 2006, of whom 196 cases (15.6%) died within 30 post-operative days and 160 cases (12.7%) had some sequelae. The amount of transfused red blood cell concentrate was 25.2 +/- 24.2 units. The amount of red blood cell concentrates stocked for emergency was 12.7 +/- 10.1 units for blood group A, 9.7 +/- 7.3 units for group B, 11.9 +/- 9.6 group AB, and 11.3 +/- 11.0 for group O. Therefore, for those other than group O cases, 21-46 units of red blood cell concentrates seemed to be available in the hospital. The survey of individual cases showed uncross-matched, same blood group transfusion and compatible, different blood group transfusion were performed in only 8.2% and 4.3%, respectively. The lowest hemoglobin concentration was below 5 g x dl(-1) in 16.7% of the cases, but uncross-matched, same blood group transfusion was performed only in 19.0% and compatible, different blood group red cell concentrate transfusion in 5.2%. Even in cases who required cardiac massage, uncross-matched, same blood group transfusion was performed only in 17.1% and compatible, different blood group red cell concentrate transfusion in 8.5%. Intraoperative blood salvage was performed in only 5.7% in cases who underwent non-cardiac surgery. The "Guidelines for the Management of Critical Hemorrhage" proposed in 2007 or the manuals for in-hospital emergency blood transfusion were insufficiently recognized, even by anesthesiologists, and rarely known by surgeons. There were no such manuals in more than 60% of the institutions.Undertransfusion may occur in 16.7-28.3% of cases of massive hemorrhage in the operating room, and the rate of emergency blood transfusion was much lower than this percentage. To avoid operation-associated deaths from hemorrhage, the improvement of hospital systems for emergency blood transfusion, including the active use of intraoperative blood salvage, should be promoted.

The purpose of this study was to examine whether nitrous oxide increases the inflammatory reaction in the airway in patients undergoing minor surgery.Twenty patients were divided into two groups at random. The patients were anesthetized by either sevoflurane with air (Group A: n=10) or sevoflurane with nitrous oxide (Group G: n=10). In addition, all patients were mechanically ventilated. Epithelial lining fluid (ELF) specimens were obtained by bronchoscopic microsampling method at both the beginning and end of surgery. The concentrations of interleukin (IL)-6 and IL-8 in the ELF were measured by enzyme immunometric assay(ELISA).Significant differences were observed in the IL-8 concentrations in the ELF of the G group at the end of surgery in comparison with those seen at the beginning of surgery in the G group (P0.05), and at the end of surgery in the A group (P0.05). The IL-6 levels were not measured in either group.The pulmonary immunologic function changed progressively during anesthesia, surgery and positive pressure mechanical ventilation. The data from this study suggest that the immune ability of the lung may possibly change due to the administration of nitrous oxide. As a result, our findings suggest that the postoperative inflammatory reaction in the lung may increase when sevoflurane plus nitrous oxide are used during general anesthesia.

Cardiac anesthesia carries high risk because of the patient's cardiac and coexisting diseases and rapid and complex hemodynamic changes during surgery. We should be ready to treat hemodynamic changes which may rapidly deteriorate into a vicious cycle. Many potent drugs and life-support devices are used. The drugs should be properly labeled to avoid drug error. Prefilled drug syringes and ready-to-use bags are helpful to avoid mixture error. Syringe and infusion pumps should be properly set. All the infusion systems should be checked in a systematical way. Blood management including blood transfusion and coagulation is important. Heparin-induced thrombocytopenia (HIT) may cause thrombosis. Heparin and heparin-coated catheter should be avoided in patients with HIT. Causes of bleeding tendency should be sort out and treated accordingly. Protamine reactions including hypotension and pulmonary hypertension can be catastrophic. Lastly, intimate communication between surgeons, anesthesiologists, medical engineers, and nurses is essential to perform cardiac surgery safely.

Atrial fibrillation (AF) is a frequent complication after coronary artery bypass surgery. Postoperative AF can lead to thromboembolic events, prolonged hospital stay, and increased costs. Recent reports have shown that an elevated plasma brain natriuretic peptide (BNP) level is associated with AF. The purpose of this prospective study was to test the hypothesis that preoperative BNP level is a predictor of postoperative AF following off-pump coronary artery bypass surgery (OPCAB). One hundred and fifty patients without a history of AF undergoing elective isolated OPCAB were enrolled. Plasma BNP level was measured preoperatively. Heart rate and rhythm were continuously monitored during the first 72 h after surgery. Twenty-six patients (17.3%) exhibited postoperative AF. This proportion is similar to those reported in earlier studies. Univariate analysis demonstrated that age (odds ratio [OR], 1.060; 95% confidence interval [CI], 1.008 to 1.114; P = 0.023), previous myocardial infarction (MI; OR, 2.628; 95% CI, 1.031 to 6.697; P = 0.043), and BNP level (OR, 7.336; 95% CI, 2.401 to 22.409 / log BNP level; P < 0.001) were accurate predictors of postoperative AF. Stepwise multivariate regression analysis indicated age (OR, 1.059; 95% CI, 1.002 to 1.120; P = 0.043) and BNP level (OR, 6.272; 95% CI, 1.980 to 19.861/log BNP level; P = 0.002) as the only independent predictors of postoperative AF. Preoperative BNP level is an independent predictor of postoperative AF following OPCAB. Our findings permit us to stratify the risk of AF and to plan prophylactic strategies in high-risk patients.

We compared the effects of nitrous oxide (N2O) plus isoflurane with equianesthetic isoflurane alone on the L-type calcium current (I(Ca,L)), and also investigated their modulation of beta-adrenoceptor stimulation.I(Ca,L) was recorded from enzymatically isolated rabbit ventricular myocytes using the whole-cell patch clamp technique. Ventricular myocytes were exposed to prepluses of -40 mV from a holding potential of -80 mV and then to +50 mV in 10 mV increments and thereafter the depolarization pulses that acquire peak currents were applied every 10 seconds. The changes in I(Ca,L) were measured in exposure to experimental gases of 1 MAC:1) 0.5% isoflurane and N2O:O2 (2:1) (I-N20) and 2) 1.15% isoflurane and N2:O2,(2:1) (I-N2).I-N2O and I-N2 depressed the peak I(Ca,L) by 15.6 +/- 9.2 and 14.6 +/- 8.1%, respectively. In the presence of 1 microM isoproterenol or 10 microM forskolin, the depression by I-N20 was significantly suppressed, but not by I-N2.The results show that I-N2O and I-N2 depressed I(Ca,L) to a similar degree without beta-adrenoceptor stimulation. The depression by I-N2O, however, was modulated by beta-adrenoceptor stimulation. Beta-adrenoceptor stimulation was thus found to modulate the effect of N2O combined with isoflurane rather than equianesthetic isoflurane alone.