Visual evoked potential (VEP) is used to monitor the integrity of the optic pathway. In this study, we evaluated the reliability of intraoperative VEP monitoring to detect visual dysfunction during neurosurgery that poses a risk of postoperative visual dysfunction (POVD). Anesthesia was maintained by total intravenous anesthesia using propofol. Significant change in VEP was defined as a more than 50% decrease compared to control VEP. Control VEP was recorded successfully in 113 of 118 cases. Significant VEP changes were observed in 20 cases during the operation. Of the 20 cases with intraoperative significant VEP change, 16 cases had temporary change and 4 cases had continuous change until the end of the operation. There was no case with POVD. The specificity of intraoperative VEP monitoring was 96.5%. The sensitivity was not calculated. The results of this study showed the feasibility of VEP monitoring during neurosurgery that poses a risk of POVD.

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A 45-year-old female taking steroid and methotrexate with dyspnea and weight loss was admitted to our hospital. She was given a diagnosis of miliary tuberculosis with septic shock and respiratory failure and was administered antituberculosis chemotherapy and methylprednisolone. Because her dyspnea worsened, she was intubated on the 12th hospital day and placed on ECMO on the 15th hospital day. Eight days later, her respiratory status improved and she was weaned from ECMO. As a result of treatment and nutritional rehabilitation, she was discharged on foot on the 108th hospital day.

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We report the preoperative and anesthetic management of a patient with obstructive hypertrophic cardiomyopathy. Preoperatively, the patient was diagnosed with severe obstructive cardiomyopathy and started on beta blockers (bisoprolol fumarate, oral tablets 2.5 mg/day). Eight days later, echocardiography revealed that the left ventricular outflow tract obstruction had been relieved. On the ninth day after beta blocker induction, orthopedic surgery was performed. There were no serious problems during anesthetic management or postoperative recovery.

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We removed a tracheobronchial foreign body using a flexible bronchoscope under airway management by supraglottic airway device (SAD). The procedure was performed safely under spontaneous breathing. Airway management by SAD permits spontaneous breathing, thereby preventing poor oxygenation during the procedure or pushing the foreign body into the bronchi. Additionally, it allows passage of a thicker bronchoscope compared with airway management by intubation. However, laryngospasm can occur when using an SAD for airway management, making ventilation difficult, so it is important to properly manage airway control when using an SAD. We conclude that the choice of airway management by SAD was approprite in this case and that preparation for difficult ventilation was important in achieving successful removal of this tracheobronchial foreign body.

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We compared early recovery times with desflurane (DES) anesthesia and sevoflurane (SEV) anesthesia using continuous infusion of remifentanil (CIR). Eighty patients (ASA I-II) who underwent otorhinological surgery were randomly allocated to either DES (n = 40) or SEV group (n = 40). Anesthesia was induced with propofol, remifentanil, and rocuronium. Tracheal intubation was performed and anesthesia was maintained with remifentanil and 0.6 MAC DES or SEV. Toward the end of surgery, CIR rate was fixed at 0.02 µg/kg/min. After a 20-min equilibration period, DES or SEV was discontinued, and the patient’s name was called out loudly every 20 s. Upon eye opening, the patient was considered awake and time after DES or SEV discontinuation was defined as T1. If the patient was able to obey commands, the tracheal tube was then extubated ; this time was defined as T2. T1 values of DES and SEV were 266 ± 105 s and 346 ± 157 s, respectively, while T2 values were 331 ± 108 s and 411 ± 154 s, respectively. T1 and T2 were significantly shorter in the DES group than in the SEV group (p < 0.01). The difference between T1 and T2 were 65.3 ± 28.9 s in the DES group and 65.4 ± 22.6 s, in the SEV group. There was no significance between them. Even during CIR, DES anesthesia was associated with quicker recovery time than SEV anesthesia.

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Regional anesthesia is preferable to general anesthesia for cesarean section, but it is often difficult in morbidly obese parturients undergoing cesarean section. We report three cases of parturients with morbid obesity (body mass index > 45 kg/m²) undergoing cesarean section under neuraxial anesthesia. Although lumbar spinous process was palpable in no parturients, epidural and/or spinal anesthesia was successfully performed with no complications after confirming spinous process, interspinous ligament and spinal dura mater by ultrasound images. Ultrasonography is useful for neuraxial anesthesia in obese parturients.

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We report a case of differential lung ventilation in a patient with tracheobronchial anomaly that was undiagnosed pre-operatively. A 24-year old man was presented for video-assisted thoracic surgery of biopsy and resection of a left posterior mediastinal tumor.
After induction of general anesthesia, we tried left bronchial intubation with a 37 Fr double lumen tube two times without bronchoscopic guidance, but we failed to obtain adequate positioning of the DLT. On the third attempt, we inserted the bronchoscope into the left lumen of the DLT and tried to guide the tip of the left lumen to the left main bronchus. From this procedure, we obtained bronchoscopic views showing three lumens arising at the height of the tracheal carina. With this finding and re-evaluation of thoracic CT images, we diagnosed a tracheal bronchus where the right upper bronchus arises at the tracheal carina level. The left main bronchus was intubated under bronchoscopic guidance and successful one lung ventilation was performed.
The following two points are emphasized in the discussion ; 1) thorough preoperative evaluation of thoracic CT images should have been made to rule out tracheobronchial anomaly. 2) Bronchoscopic guidance should have been utilized for bronchial intubation from the beginning of the procedure.

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In animal models, neuronal apoptosis was induced by several anesthetics in the developing brain and this interruption could cause deficits in brain function in adulthood including social deficits. Recent research has revealed that exposure of the infant rhesus macaque brain to isoflurane causes widespread neuroapoptosis. However, inadequate human data exist to affirm the possibility that similar effects occur in human children. Previous studies showed many potential mechanisms of neuroapoptosis in immature animal brains but there are no promising therapeutic strategies to mitigate neurotoxicity. The purpose of this article is to discuss anesthesia-related neurotoxicity and the possible therapeutic applicability of molecular hydrogen as an antioxidant.

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SmartTots (Strategies for Mitigating Anesthesia-Related Neurotoxicity in Tots) is a public-private partnership (PPP) between the International Anesthesia Research Society (IARS) and FDA (Food and Drug Administration) to assess the neurodevelopmental safety of anesthetic drugs in infants and children. The author reports on the “SmartTots Workshop 2014” held in Washington DC in June 2014. SmartTots supports multi-institutional joint research including the PANDA study, the MASK study, and the GAS study. Unfortunately, none of these studies have been completed yet, and it may take several years to obtain the results. SmartTots also supports some experimental studies including CO (Carbon Monoxide) study. CO is known as an ROS (Reactive Oxygen Species) scavenger which can prevent injury from neuronal apoptosis in the developing brain. SmartTots focuses on the clinical application of CO inhalation.
In the workshop, we revised “Consensus Statements” as “Surgeries and procedures requiring anesthetic and sedative drugs that could reasonably be delayed or postponed because of the potential risk to the developing brain of infants, toddlers, and preschool children.”, however, this revision has not been endorsed by any major academic societies such as American Society of Anesthesiologists (ASA), Society for Pediatric Anesthesia (SPA), or American Academy of Pediatrics (AAP).

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According to the 2013 National Survey of the Japanese Society of Hospital Pharmacists (JSHP), 30.4% of hospitals reported that pharmacists were involved in perioperative medication management and 16.4% reported that pharmacists were involved in postoperative medication management in the ICU. In addition to medication distribution, useful pharmaceutical perioperative services performed in several facilities included providing drug information for dealing with emergency situations, management of antimicrobial drug use for surgical site infection (SSI), prevention of venous thromboembolism, dealing with postoperative nausea and vomiting (PONV) and postoperative pain, and assessment of nutrition status. Although few reports of pharmacist activities during operations were found, several incidents and accidents caused by doctors administering medication during operations have been reported, which has made it necessary to seriously consider interventions by pharmacists as an option.
There is a growing need for pharmacists to learn not only about anesthetic agents but to have a general knowledge of surgery including operating methods and amounts of intraoperative blood loss and to be actively involved in selecting and preparing operating medications during emergency situations.

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[in Japanese]

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The introduction of the Anesthesia Care Team (ACT) has been advancing around the world. Its mission is to ensure and achieve a safe and secure peri-anesthesia medical provision system, and here in Japan, the “Perioperative Management Team Certification System” was started from April 2014. This can be considered a huge advancement for medical staffs who are active in the field of peri-operative care.
This paper will introduce the related discussions and their backgrounds in Japan, as well as include examples of practical education activities from other countries, in order to describe the ideal form of the ACT in our country.

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During cardiac surgery, there are major disturbances in coagulation systems caused by perioperative hemodilutional changes. Conversely, procoagulant activity and inflammation are increased postoperatively because of physiological stress responses. Thus, perioperative monitoring of coagulation markers may be required for differential diagnosis of hemorrhage and to decrease perioperative thrombotic complications. Dilutional coagulopathy which is followed by hemorrhage is often refractory at the end of cardiopulmonary bypass. Understanding the limitations of coagulation tests with plasma samples in central laboratory is important for applying these tests to perioperative hemostatic management. Recently, Point-of-care devices (e.g. prothrombin times, fibrinogen concentrations, rotational thromboelastometry, etc.) are increasingly being used in clinical practice, especially in patients undergoing cardiac surgery. The combination of several hemostatic/coagulation tests is the key to establish optimal hemostatic strategies in cardiac surgery.

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In past years, epidural analgesia has been the mainstay of postoperative pain management. However, due to the increase in patients receiving anticoagulant therapy, epidural analgesia is contraindicated in many cases.
On the other hand, peripheral nerve block (PNB) techniques have progressed dramatically in the past 10 years. PNB has played a significant role in endoscopic surgery, but has also recently been applied in non-endoscopic procedures as well, which can be attributed to advances in ultrasound technology, allowing for safe and effective analgesia.
PNB may be selected first in thoracotomy, lower abdominal surgery, shoulder surgery, and elbow surgery, but multimodal analgesia is required in upper abdominal surgery.

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Novice anesthesiologists are required to learn various technical and non-technical skills during clinical anesthesia training. Osaka Medical College has established various systems to support young anesthesiologists in their studies based on educational guidelines for anesthesiologists. We provide several simulation-based training courses for difficult airway management, ultrasound-guided central venous catheter placement, peripheral nerve block, and advanced life support to cultivate both technical and non-technical skills such as the ability to think critically and cautiously, decision-making, leadership, and communication in emergency situations. Training hospitals should work to establish a supportive learning environment for novice anesthesiologists.

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I previously reported on the present crisis in publication activity regarding anesthesia research in Japan through editorials in the Journal of Anesthesia and Masui. In the present analysis I focus on anesthesia clinical research papers to estimate publication activity in Japan. As in previous analyses, I found that the publication of clinical research from Japan in 3 major anesthesia journals (Anesthesiology, Br J Anaesth and Anesth Analg) has declined greatly year after year. The number of papers from Japan that have been published has been lower than the number from China and South Korea since 2012. Between 2003 and 2014, publication declined by 83% in the 3 major journals and by 31% in all other anesthesia journals. Although the number of members of the Japanese Society of Anesthesiologists (JSA) increased by around 40% from 2003 to 2014, the number of publications is still declining and it is surprising that one article is published per 150 JSA members now. All Japanese anesthesiologists need to be aware of this serious problem.

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Various airway management algorithms have shown that management of impossible ventilation is an essential component of airway management. In emergency situations that require securing the airway, supraglottic devices such as a laryngeal mask are recommended, and may necessitate invasive airway management. For example, anesthesiologists must secure the patient’s airway as soon as possible during chest compression in case of cardiac arrest. Furthermore, there are several possible mechanisms for impossible ventilation such as anaphylactic reaction, severe asthma attack, or airway fire. We have developed several problem-based learning discussion type scenarios regarding serious airway problems related to impossible ventilation. Perioperative advanced life support simulation may be beneficial for training not only anesthesia residents but also medical staff in the operating room.

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We developed an advanced life support training course for physicians performing central venous puncture. The training course comprises 7 scenarios which involve severe complications that can develop during central venous insertion. We will discuss these scenarios using the problem-based learning discussion technique.
We believe that while physicians who are involved in central venous insertion should undergo the training course, it is absolutely essential for them to undergo the central venous catheterization practice seminar.
The advanced life support training course for physicians performing central venous puncture may be essential to supplement the central venous catheterization practice seminar.

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Massive hemorrhaging and acute myocardial infarction can cause crises in the operating room, so a simulation-based educational course for dealing with perioperative crise (ALS-OP) based on occasional case research in anesthesia and/or anesthesia educational guidelines may help improve medical safety in the operating room. To maximize the performance of advanced life support training in the operating room, the course content should be constructed using operating room situations, scenarios based on special operating room situations, environmental factors, and smooth communication with medical staff. Training that employs problem-based learning and discussion can be adjusted to the level of each participant, and non-technical skills such as team communication can also be cultivated. Problem-based learning and discussion may help improve medical safety in the operating room.

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Specific preventative methods and a rapid response system are requirements for pain clinics. Studies have revealed that severe complications are associated not only with drugs such as pregabalin, antidepressants, and strong opioids, but also with peripheral nerve blocks. Early detection and an appropriate response are essential for addressing these complications. Issues to consider include stellate ganglion block, accidental intrathecal injection of analgesics, local anesthetic toxicity, serotonin syndrome, and opioid withdrawal syndrome. Advanced life support training in pain clinics is important for improving medical safety.

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A sedation training course (SEDTC) based on ‘Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists’ was developed to improve safety in sedation, in particular through the education of non-anesthesiologists. This course focuses primarily on sedation depth control, monitored anesthesia care, and post-sedation management. For challenges such as awake intubation or postoperative management, SEDTC may also help to educate anesthesiologists. Furthermore, as anesthesiologists should be taking the lead in promoting the medical safety of sedation in various situations, SEDTC can effectively teach anesthesiologists how to inform non-anesthesiologists about the essential components of sedation.

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Ultrasound-guided central venous catheterization has been considered the gold standard practice in recent years because of its high success rate compared to the traditional anatomical landmark technique. However, lethal mechanical complications have been reported using the ultrasound-guided technique. Appropriate education is key to the clinical performance of ultrasound-guided central venous catheterization. Up to now, nobody has revealed an appropriate way to educate in this field.
Simulation education is clearly a solution to this question. This article reviews previous studies of simulation education in ultrasound-guided central venous catheterization around the world, and presents my trials for appropriate education in Japan.
The first step is to come up with an efficient way to educate young doctors. We need to change the goal of today’s standard not only focusing to higher success rate, but also preventing mechanical complications.

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