In recent years, the American Society of Anesthesiologists（ASA）has issued a statement on the prevention of respiratory complications in the perioperative period. Respiratory rate measurement is often neglected in the post anesthesia care unit（PACU）. The purpose of this observational study was to compare the accuracy of three different methods for measuring the respiratory rate of patients in the PACU：capnometer, visual measurement, and chest wall impedance method. We enrolled 38 patients who were admitted to the PACU after emergence from general anesthesia. Comparison of the capnometer and visual methods（paired t-test）showed no significant difference in the numerical values（p=0.475）with a 95%CI ［-0.7, 0.3］. A significant difference was observed, however, between the chest wall impedance method and the visual method（p<0.001；95%CI ［2.3, 5.2］）. Capnometer was highly reliable, while the impedance method was less reliable.

A 68-year-old woman was scheduled for total knee arthroplasty. During the operation, anesthesia was maintained with sevoflurane, remifentanil, and fentanyl（total 400 µg）. For post-operative analgesia, a periarticular multimodal drug cocktail（morphine 5 mg, ropivacaine, dexamethasone and adrenaline）and continuous fentanyl infusion（12.5 µg/h）via intra-venous patient controlled analgesia（IV-PCA）was administered. Ninety minutes after the patient left the operating room, an anesthesiologist was called because the patient’s respiratory rate decreased to less than 8 breaths/min. Although we immediately discontinued IV-PCA and administrated naloxone, respiratory instability persisted. Consequently, continuous administration of naloxone and non-invasive positive pressure ventilation therapy was necessary for recovery. A simulation using the AnestAssist^TM PK/PD system（Fentanyl PK parameter in Shafer model）indicated that the density of fentanyl was too low to induce respiratory depression. We strongly suspected that the morphine included in the cocktail was the cause of the severe respiratory depression. Opioids included in a cocktail could induce an unexpected increase in opioid blood concentration. Adequate observation and monitoring is important for the management of patients who are administered a periarticular multimodal drug cocktail with opioid.

Healthcare staff in the operating room（OR）need managerial skills as well as specific knowledge of surgical treatment. The best practice of OR management, however, remains to be established. OR management includes OR scheduling, OR utilization, OR cost-counting, management of surgical devices and safety in the OR. It is also influenced by various resources, such as the number of nursing staff, medical equipment, and size of the OR. Above all, professionalism is essential in OR management, since the mission of OR staff is to provide both patients and surgeons with the best environment for operations. This paper discusses OR management in our own country in comparison with that in the US.

The physiologic and biochemical basis of neuromuscular transmission was discussed in the session. Neuromuscular blocking agents are used to improve conditions for tracheal intubation, to provide immobility during surgery, and to facilitate mechanical ventilation. The only depolarizing agent in use is succinylcholine. All other drugs available are non-depolarizing. The presynaptic release of acetylcholine is triggered by the influx of calcium through voltage-dependent calcium ion channels. Muscle relaxants compete with acetylcholine for the same binding sites. They interfere with normal function of the acetylcholine receptor binding site or with opening and closing of the receptor channel. This review highlights several specific aspects of neuromuscular transmission that are germane to pharmacology for neuromuscular paralysis.

The Department of Patient Safety Promotion of the Japan Council for Quality Health Care（JCQHC）has offered a workshop on patient safety in central venous catheterization（CVC）since 2009. The purpose of the workshop is to increase patient safety at hospitals accredited by JCQHC, offer cutting-edge techniques of CVC, and discuss the management of hospital CVC. Follow-up questionnaires six month after the workshop reveal that many physicians play an important role in increasing patient safety in CVC.

Randomized controlled studies（RCTs）offer the most reliable information to evidence-based medicine. Nevertheless, some studies use inappropriate methods or reach misleading conclusions. There are several items to check by which we can relatively easily judge whether a randomized controlled study provides evidence of high or low reliability. Studies whose hypotheses are unclear, which lack clearly defined aims, whose primary outcome measures do not match the study aim, whose conclusions are drawn from secondary outcome measures, or which show significant differences that are not clinically meaningful, should not be regarded as providing highly reliable evidence. In this review, I describe eight simple items by which one can judge whether or not the results of a randomized controlled study can be used for evidence-based medicine.

Observational studies include cohort studies, cross-sectional studies, case-control studies, case series studies and descriptive studies. Each study design has good and bad points. If bias in an observational study is not recognized, misunderstanding about the contents of the study may occur. Factors that produce misunderstanding include random error, systemic error, confounding of cause-result relation and adjustments of them. To understand these factors and adjustments will prevent misunderstanding of observational studies.

Translational research aims to develop a new therapeutic strategy based on findings from basic science. Scientists, clinicians and patients keen for new treatment options are disappointed to see many projects end in failure. Even though clinicians are not usually required to know about the basic science during their daily practice, it is worth knowing why many projects seeking a new therapy are unsuccessful.

In the present paper, we discuss how we can evaluate data from basic science in terms of reproducibility and consistency with clinical medicine.

Patients with severe heart failure requiring left ventricular assist device（LVAD）implantation have difficulties following acute changes in preload and afterload because of a poor hemodynamic reserve. Furthermore, their low cardiac output state and hepatic and renal dysfunction have significant effects on pharmacokinetics and pharmacodynamics. Thus, anesthesiologists should titrate doses of anesthetic drugs to avoid cardiac depression and marked change of loading condition.

Some critical issues after LVAD implantation to preserve pump output from LVAD include maintaining normovolemia, right ventricular contractility, low pulmonary vascular resistance, and adequate pump setting. Anesthesiologists should thoroughly understand the characteristics of patients with severe heart failure and features of LVAD in the anesthetic management of patients with LVAD implantation.

Traditional cardiac surgery is performed via median sternotomy to access the mediastinum and coronary structures. Recently, the use of minimally invasive cardiac surgery（MICS）via right mini-thoracotomy has become widespread. Furthermore, robotic-assisted cardiac surgery, which uses the da Vinci surgical system, has been performed. We herein summarize anesthetic management for robotic-assisted mitral valve plasticity and atrial septal defect closure.

After the induction of anesthesia, the venous cannula was cannulated through the right internal jugular vein. Intraoperative transesophageal echocardiography（TEE）is important for guiding the cannula to the right positon. Moreover, anesthesiologists must evaluate myocardial function and mitral valve findings and atrial septal defect before and after the surgical procedure. One-lung ventilation is required to produce ports for the robotic arms. If hypoxemia occurs before beginning the robotic procedure, then bilateral lung ventilation is needed.

As robotic cardiac surgery is a completely endoscopic mitral valve surgery, anesthesiologists must understand the details of the surgical procedure and the findings of the TEE examination.

Minimally invasive cardiac surgery（MICS）is defined as cardiac surgery performed thorough a small incision instead of traditional total sternotomy. The advantage of MICS is less surgical invasion. To provide a good surgical environment, several considerations are required in anesthetic management. One-lung ventilation, effective use of transesophageal echocardiography, and regional oxygen saturation monitoring are important in addition to the standard practices necessary for cardiac anesthesia. Because direct observation of the heart is limited, transesophageal echocardiography is necessary to assess cardiac function or condition in MICS. Good communication between staff is very important to ensure a good outcome after MICS.

In many hospitals in Japan, team approaches are used in which various kinds of medical staff work together in systemic ways. In such situations, a great many collaborating teams are organized closely and in complex ways with each another. Since the October 1, 2015, a new law for reporting and investigating fatal accidents has been in force, so the directors of facilities for medical care are responsible for reporting fatal cases to the Japan Medical Safety Research Organization and are also responsible for investigating the circumstances leading to mortality. From an ethical standpoint, our activities to enhance medical quality including such investigations are intended to respect both the dignity and the wishes of every patient. At the same time, the directors are also responsible for respecting to autonomy of medical staff as well as their dignity. When considering the practical or legal aspects of inquiries into accidents at our hospital, we need to maintain our professional ethics in medicine.

To manage endoscopic surgery safely, systems of education and safety management were set up in Showa University Hospital.

The system of education consists of 4 stages and licenses.

Step 1 is a lecture on basics and theories in endoscopic surgery.

Step 2 is experience of basic techniques in endoscopic surgery with dry box.

Step 3 is practical training in an animal lab.

Step 4 is introduction to endoscopic surgery clinically.

The system of safety management consists of the following items.

1. Management committee of endoscopic surgery

2. Seminar for endoscopic surgery

3. Report of complications

4. Risk management at operation section

These systems are operated by mainly safety management section at Showa University Hospital.