We retrospectively investigated patients who had developed postoperative pulmonary embolism (PE) and were treated at Kyorin University Hospital from 2009 to 2011. We also investigated the degree of patient compliance with the venous thromboembolism prevention guidelines in the hospital. Twenty-two patients developed PE in the postoperative period (8, 7, 2, 2, and 2 patients underwent gastrointestinal, orthopedic, gynecologic, neurologic, and cardiac surgery, respectively; 1 patient was from the emergency department). The incidence was 0.1% (22 cases in the total number of 23,081 cases). One patient died, 1 had prognostic symptoms, while 20 had no prognostic symptoms. Among the patients who developed postoperative PE, 13 did not comply with the guidelines prior to surgery. After diagnosis, the treatment was according to the guidelines except in 1 dead patient. These results suggest that postoperative PE can further be reduced by raising the degree of patient compliance with the guidelines prior to surgery.

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  Catecholamine-secreting glomus tumor at the skull base is very rare. A 31-year-old female with headache and hypertension was diagnosed with catecholamine-secreting glomus tumor. Her plasma norepinephrine level was 21,165 pg/ml, and a tumor 50 mm in diameter was found by MRI in the right cervical venous fossa. An adrenergic alpha-blocker was administered three months before the operation as a preoperative circulation control. The tumor was embolized a week before the operation. Anesthesia was maintained with propofol and remifentanil. During the manipulation of the tumor, a cardiac arrest lasting five seconds occurred, but the patient recovered spontaneously. We also controlled the patient's hypertension with nicardipine, switching to norepinephrine after the tumor was removed. Though her consciousness was clear after the operation, she was moved to the ICU with the respirator due to vagal paralysis. On the third day after the operation, we removed her tracheal tube. We measured plasma catecholamine levels and they were decreasing as the treatments were phased. As a result, we were able to successfully accomplish the anesthesia management of the ectopic pheochromocytoma at the skull base.

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  Difficult removal of epidural catheter is a rare complication of epidural anesthesia. If a catheter is removed with excessive force, it can be broken and left in a patient's body. We report a case in which 3D-CT was useful when removing an epidural catheter was difficult. As epidural catheter was not removed in any direction after surgery, we performed computed tomography and constructed 3-dimensional images from CT. From 3D-CT, we determined that the catheter was fixed in the right intervertebral joint at the Th5/Th6 inter space. We therefore pulled the epidural catheter toward the left side and removed it successfully without breaking it.
  Three dimensional CT is useful to confirm an epidural catheter's position when it is difficult to remove.

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  The left internal thoracic artery (LITA) is commonly used in coronary artery bypass graft surgery (CABG) because of its excellent long-term graft patency and survival rate. Prevalence of severe left subclavian artery stenosis in patients referred for CABG is reportedly 0.2-6.8%. In such cases, LITA graft should be avoided because it can cause coronary-subclavian steal syndrome (CSSS), which leads to myocardial ischemia and dysfunction. Few reports have described the assessment of left subclavian artery stenosis by transesophageal echocardiography (TEE). We report the case of a 70-year-old man who underwent CABG. His severe left subclavian artery stenosis was revealed by TEE examination after induction of anesthesia. Based on that diagnosis, surgeons chose to change the graft vessel from LITA to right internal thoracic artery.

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  A 54-year-old female with myasthenia gravis was scheduled for liver resection. Since she had had bulbar palsy and respiratory distress prior to the surgery, we treated her with immunoadsorption before surgery to improve her symptoms. General anesthesia was induced with propofol and rocuronium and sugammadex was given after the surgery. Twelve hours after extubation, recurrence of dyspnea required intravenous acetylcholinesterase inhibitor. Because the duration of clinical improvement of immunoadsorption is limited, patients with myasthenia gravis must be closely monitored after surgery.

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  A center for perioperative medicine (POM) was opened to patients in April 2011. The Department of Oral Surgery has provided perioperative oral management as part of the POM center team since November 2011. Of the 5,243 patients who visited the POM center in the first year, the anesthesiologists referred 769 patients (14.6%) to the Department of Oral Surgery as outpatients following oral examination by a dental hygienist at the POM center. Management included treatment for loose teeth (313 patients) and treatment for oral infectious diseases (278 patients). After this management, no patients were treated as a result of accidental tooth damage during general anesthesia.
  This system of triaging patients has reduced the number of unnecessary visits to the Department of Oral Surgery's outpatient clinic. As a result, we effectively managed our outpatients while maintaining our participation as a member of the POM center team.

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  Prevention of surgical site infections (SSI) is very important in hospital management. Death due to antibiotic anaphylaxis occurring as a result of treatment of SSI can be prevented by many measures. Some SSI incidents can be analyzed using root cause analysis. SSI can be caused by environmental factors, operator factors, and patient factors. To prevent SSI, it is necessary to understand the theoretical mechanisms of these factors. There are many confounding factors in these areas. It is sometimes difficult to demonstrate that the effects are attributable to a single factor. The verified evidence and theoretically understandable factors should be implemented in a bundle.

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  Pharmacy services in Japan have traditionally consisted of drug dispensing and inventory management. The role of pharmacists in implementing medication safety standards, optimizing drug therapy, and other clinical interventions has not been adequately analyzed in clinical settings such as the operating room (OR). However, only a few hospitals allow the presence of decentralized pharmacy personnel within the OR. The most common reason for not allowing pharmacists in the OR is the small number of pharmacists available. In order to increase the presence of pharmacists in the OR in the future, standard practices for pharmaceutical services in the OR need to be established. Furthermore, the Japanese government should introduce a medical service fee and a medical insurance system that would allow for the presence of pharmacists in the OR.

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  Nara Medical University is establishing a perioperative management team based on the recommendation of the Japanese Society of Anesthesiologists. Our team uses an anesthesiologist assistant (AA) system.
  There are four clinical engineers in our institution who have completed a training program for AAs. AAs assist anesthesiologists in their anesthetic practice and maintain anesthetic devices.
  A special educational program is needed for clinical engineers to become AAs because it is necessary to understand physiology, pharmacology, and anesthesiology. Our education program for AAs currently consists of lectures and daily practice, but it will become more sophisticated in the near future.
  AAs' responsibilities are increasing as we introduce new monitoring devices and anesthetic apparatuses in clinical practice, and the number of them should be increased.
  AAs and anesthesiologists enjoy a good relationship and AAs' work can contribute to the improvement of anesthetic practices and medical safety.

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  Fibrinogen is a final substrate in fibrin polymerization. The subsequent firm blood clot is a key factor in secondary hemostasis, and anti-plasmin therapy plays an important role in protecting blood clots from fibrinolysis. Fibrinogen replacement therapy has been widely used to treat critical bleeding. An increase in the minimum level of fibrinogen concentration is consistent with the invention and propagation of thromboelastometry (ROTEM^®) around the world. Cardiovascular surgery with cardiopulmonary bypass has an important pathophysiology of coagulation in consideration with fibrinogen replacement therapy. It would provide a good reference for perioperative critical bleeding and trauma. In view of current hemostatic therapy, we discuss effective hemostasis and appropriate blood transfusion by the combined assessment of fibrinogen concentration and fibrin polymerization (Fuji-san classification). We also consider future perspectives.

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  Plasma substitutes are mainly used to maintain circulating blood volume during massive hemorrhage. These solutions are used to bridge the gap between fluid therapy with crystalloid and that with albumin since plasma substitutes are usually less expensive than albumin while large doses of such synthetic colloids may negatively affect the coagulation system and renal integrity. Since an effective coagulation system depends on the presence of large HES molecule in the circulation, middle-molecular-weight, rapidly degradable hydroxyethyl starch (HES) is generally used for the treatment of massive hemorrhage. Recent randomized controlled trials revealed that middle-molecular-weight, rapidly degradable HES significantly increased the risk of renal injury in critically ill patients. Such studies are characterized by the repetitive administration of HES at the high end of the daily allowable limit. In contrast, better renal effects were reported when middle-molecular-weight, rapidly degradable HES was used for trauma resuscitation. Based on these data, we assume that HES use against massive hemorrhage is safe when used for resuscitative purposes within the allowable limit.

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  The use of epidural anesthesia is declining in frequency because errors in administration may lead to accidents, in particular when administered concomitantly with anticoagulant therapies. However, it is also true that epidural anesthesia is an excellent method for pain relief that shows significant advantages in early ambulation of patients and reducing the length of hospital stays without regard to the postoperative management system. We have created postoperative pain relief procedures for the highest risk patients to take advantage of epidural anesthesia. Anticoagulant therapies are started after removing the epidural catheter, and only one type of anticoagulant is used. A process using a checklist for early detection of spinal epidural hematoma has been established so that nurses can promptly report to senior doctors in contingencies, with a certain level of success. Although postoperative pain relief measures depend on the size and organization of a facility, denying epidural anesthesia is not beneficial to either patients or facilities. Attitudes towards the use of anticoagulants may differ among facilities, but it is necessary to adopt appropriate methods to use epidural anesthesia, IV-PCA, and ultrasound-guided peripheral nerve blocks, considering the advantages and disadvantages of these techniques as well as the circumstances of the facility.

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  Postoperative pain management is important for preventing perioperative complications. We created a novel slow releasing lidocaine sheet (SRLS) with polylactic-co-glycolic acid. The SRLS (30%, w/w) continuously released lidocaine for 1 week in vitro. A single treatment with the SRLS inhibited hyperalgesia and c-fos expression in the spinal cord dorsal horn for 1 week in postoperative pain model rats. And we created injectable slow releasing lidocaine particles (SRLPs) to grind the SRLS. The epidural injection of SRLPs produced prolonged anti-hypersensitivity in a rat model of postoperative pain with no major complications. We planned a phase 1 clinical trial. This study evaluated the efficacy and safety of the SRLS for normal mucous membrane of healthy male volunteers. In the future, we are going to try topical, epidural, and perineural administration of this slow releasing local anesthetic. These techniques can provide safer, easier, more effective postoperative pain management.

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  Many anesthesiologists perform invasive treatments, such as nerve blocking, and non-invasive treatments with analgesics for relief of chronic pain. In recent years, however, invasive treatments are less and less selected due to the progression of drug therapy, especially opioid analgesics, and increasing use of anticoagulants against cardiovascular diseases in patients with pain. Nerve blocking is useful for diagnosis of chronic pain. It is also useful to confirm minor pathological changes associated with pain and support clinical diagnosis of pain. Moreover, malignant diseases are often detected when the expected analgesic effect is not observed after appropriate nerve blocking. Therefore, nerve blocking is a useful method of chronic pain treatment, and anesthesiologists should be well-versed in both invasive and non-invasive treatments. Anesthesiologists should carefully evaluate chronic pain taking into consideration the mental condition of patients as well.

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  The Japanese Association for Medical Simulation conducts workshops on safe sedation and analgesic methods. In order to confirm the knowledge of participants both before and after seminar participation, pre- and post-tests based on the “Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists” developed by the American Society of Anesthesiologists were taken by 47 participants who gave consent among 55 who took part in the seminar. The correct response rate was significantly higher on the post-test than the pre-test, but the correct response rate was <50% on both tests for questions on the importance of capnography. The present seminar may contribute to the practice of safe sedation around the country, but to disseminate even safer sedation, the contents of workshops should be reviewed and workshops should be continuously assessed and revised based on the results in the future.

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