We evaluated the effect of volume expansion and the fluctuation of oxygenation, electrolyte and acid-base balance after 30 min bolus intravenous infusion of 1 liter 6%HES70/0.5（Salinhes^®）and lactated Ringer（Solulact^®）. Seventy-two patients undergoing laparotomy with general anesthesia were randomly divided into a Salinhes^® infusion group（n=36）and a Solulact^® infusion group（n=36）. The volume expansion effects of Salinhes^® and Solulact^® were 78.4% and 36.8% of infused volume, respectively. Plasma potassium, chloride and bicarbonate ions and base excess fluctuated significantly after Salinhes^® infusion. PaO₂/FiO₂ ratio deteriorated significantly after Solulact^® infusion, though there was no significant difference between the groups in the relative variation of oxygenation. In rapid infusion, the volume expansion effects of both Salinhes^® and Solulact^® can be more than expected. However, attention should be paid to the electrolyte and acid-base balance disturbance after Salinhes^® infusion and the deterioration of oxygenation after Solulact^® infusion.

Background and aim：The efficacy and safety of preoperative oral rehydration therapy（ORT）were investigated in hemodialysis patients with a narrow safety margin of fluid and electrolyte intake and a risk of delayed gastric emptying.

Methods：Two hundred patients receiving hemodialysis and undergoing general surgical operations were divided into ORT and infusion groups. In the ORT group, clear fluid was orally administered until 180 min prior to anesthesia instead of routine drip infusion. Serum electrolyte and blood sugar levels, the pyloric cross-sectional area, and gastric juice volume were measured before anesthesia induction. Postoperative weight gain was also evaluated as a fluid balance index.

Results：The ORT group had higher levels of fluid intake, electrolytes, and glucose than the infusion group. There were significantly fewer patients presenting with hyponatremia or hyperglycemia in the ORT group. Serum electrolyte and blood sugar levels were more favorable in the ORT group. No significant difference was found in postoperative weight gain among the two groups, suggesting that preoperative ORT did not result in fluid overload. No significant differences were noted in the pyloric cross-sectional area or gastric juice volume.

Conclusion：ORT is useful and safe for preoperative fluid management of hemodialysis patients.

An 89-year-old female was scheduled to undergo surgery for oral cancer. After anesthetic induction, a reinforced endotracheal tube was inserted through the tracheotomy site along with a gum-elastic bougie following oral intubation without any difficulty. However, ETCO₂ was not clearly confirmed. Tracheal laceration was found at the posterior wall by using a bronchial fiberscope. One right lung ventilation, which was afterwards switched to left lung ventilation, was immediately established followed by emergent repair of the tracheal rupture. Throughout the event, oxygenation was maintained and the patient was also hemodynamically stable.

After the operation, she was transferred to the ICU with intubation and sedation. Mechanical ventilation was disconnected on POD 5 and she was discharged to the ward on POD 7 without any disability. We should reconsider the suitability of the routine use of GEB-guided tube insertion.

Patients who undergo surgery for complex congenital cardiac anomalies exhibit intracardiac structural changes, so advancing a transcutaneous catheter into an intracardiac target site is sometimes risky and difficult in such patients. This report describes the case of a 4-year-old male with total cavopulmonary connection（TCPC）involving a common atrium and a single ventricle who underwent successful cardiac catheter ablation for paroxysmal supraventricular tachycardia. During the ablation procedure, a transcutaneous catheter was inserted into the femoral vein and advanced into the atrium through the extracardiac conduit under transesophageal echocardiographic monitoring because the inferior vena cava is isolated from the right atrium in patients with TCPC. We consider transesophageal echocardiography to be a safe monitoring method that can aid the insertion of catheters into intracardiac target sites in such patients.

We report a case of anesthetic management of tympanoplasty in an infant with Waardenburg Syndrome（WS）. WS is an autosomal dominant inherited disease that is characterized by congenital sensorineural hearing loss, hair hypopigmentation, and pigmentary disturbances of iris. Less than 5 anesthetic experiences have been reported to date. Anesthetic considerations of WS are hearing loss, convulsion, muscle tone abnormality, and malnutrition. Our 20 month-old patient was scheduled for cochlear implantation with general anesthesia. Induction of general anesthesia was performed with nitrous oxide, oxygen, and sevoflurane. Air, oxygen, and sevoflurane were used for maintenance of anesthesia. Endotracheal intubation was uneventually performed using rocuronium 1 mg/kg. Pentazocine 3 mg was given as postoperative analgesia. Emergence from anesthesia was smooth. Postanesthetic course was also uneventful.

A 68-year-old woman underwent placement of a peripherally inserted central venous catheter （PICC） from her left basilic vein to administer antibiotics for treatment of postoperative wound infection on postoperative day 54. On postoperative day 101 when she underwent skin grafting, it was found that muscle relaxant administered through PICC during induction of general anesthesia showed no effect. After the skin grafting, plain CT was performed and extravascular perforation of PICC was confirmed. When no backward blood flow from PICC or no administered drug effect through PICC is found, image inspection for abnormal catheter tip positioning of PICC has to be performed. When PICC perforation is confirmed, careful therapeutic plan after PICC removal including need for surgical hemostasis should be considered prior to PICC removal.

In spinocerebellar degeneration（SCD）patients, vocal cord movement disorder can result in the development of sleep apnea. It is possible that administration of general anesthesia causes vocal cord movement disorder in SCD patients. Here, we report our experience with two SCD patients for whom airway management was achieved safely by observation of the vocal cords using fiberscope. Preoperative assessment of the vocal cords is necessary for SCD patients, and the use of a fiberscope allowed the observation of vocal cord movement after extubation to assess the upper airway. Because of the possibility of delayed sleep apnea onset following surgery, airway management needs to be maintained in the intensive care unit during the postoperative period.

A 63-year-old male underwent shoulder arthroscopy in the beach-chair position. The patient exhibited hypoactive emergence from general anesthesia and right hemiparesis was clearly present. His blood pressure（BP）was mostly maintained in the range of 80-96/50-65 mmHg during the operation, even though BP fell to 70/48 mmHg for several minutes. No remarkable findings were indicated in cranial CT/MRI and cerebrovascular angiography performed hours after surgery. However, extensive cortical infarction in the left hemisphere was confirmed through cranial MRI performed a week after surgery. Considering that the result of the cerebrovascular angiography showed no potential abnormalities, the cerebral infarction could have been initiated by low BP of short duration during the surgery. In conclusion, it is necessary to strictly avoid hypotension during procedures involving anesthesia for appropriate BP management.

An 80-year-old woman underwent emergency craniotomy and aneurysmal neck clipping for subarachnoid hemorrhage. Although serious hypotension occurred after induction of general anesthesia, surgery proceeded with a diagnosis of hypovolemic shock. Approximately two months later, ventriculoperitoneal shunt placement was scheduled for hydrocephalus following subarachnoid hemorrhage. After induction of general anesthesia, the patient developed serious hypotension accompanied with generalized redness. Anaphylactic shock was diagnosed and surgery was canceled. Serum tryptase and histamine was elevated, and skin prick test was positive for rocuronium. Even during emergency operation, when we encounter a patient with hypotension unresponsive to normal dose of vasopressors, we always consider the possibility of anaphylaxis without skin redness.

Fluorescein, a fluorescent dye, has recently begun to be used in craniotomy to improve the tumor resection rate and avoid neurological complications.

Errors of CO-oximetry occurred in 3 patients after fluorescein administration.

Three patients were administered fluorescein at 1,000 mg intravenously. After administration, measurement of CO-oximetry using RapidPoint 405^TM（SIEMENS）including the hemoglobin concentration became impossible.

The errors are believed to have occurred as the measurement wavelength of CO-oximetry was near the wavelength of the absorption peak of fluorescein.

Aging is the biggest risk factor for postoperative cognitive dysfunction（POCD）. With aging, the number of surgeries in elderly people increases, so POCD may become a major social issue. The subject method of evaluating clinical studies of POCD are not yet standardized, and the elucidation of POCD has not advanced. On the other hand, animal studies strongly suggest that neuroinflammation is associated with the onset of POCD. Perioperative care to inhibit neuroinflammation is expected to play a key role in future prophylactic strategies to prevent POCD.

Surgical positions can result in various complications in the perioperative period. When nonanesthetized patients are placed in a nonphysiological position and feel numbness and pain, they can move their bodies to prevent disorders. However, it is difficult to confirm whether anesthetized patients are in a forced position, occasionally causing serious disorders. As anesthesiologists, we need to acquire correct knowledge regarding surgical positions, understand factors that cause various complications associated with surgical positions, and take appropriate preventive measures. In this manuscript, we explain perioperative peripheral neuropathy and tissue/organ functional impairment as complications associated with surgical positions and describe points requiring attention in the management of the anesthetic stage to prevent various complications.

Postoperative complications are the main cause of perioperative mortality and morbidity. In addition, high-risk surgical patients account for only 12.5％ of all surgical procedures but more than 80％ of postoperative mortality. Perioperative goal-directed therapy（GDT）is one approach for improving postoperative outcomes in high-risk surgical patients. In a recent meta-analysis, it was shown that perioperative hemodynamic optimization is associated with fewer postoperative complications. Thus, GDT has come to be considered to be the standard of perioperative care because it has demonstrated strong clinical evidence to decrease the complication rate. Despite these evidence based recommendations, the implementation of GDT is still poorly achieved in daily clinical practice. Significant variability in routine GDT application could be related to different approaches and standards of specific hemodynamic monitoring. Recently, surveys on hemodynamic monitoring and management in high-risk surgery have been performed among Japanese, North American, European, Korean and Chinese anesthesiologists, which showed a considerable gap in clinical practice for hemodynamic monitoring and management among different populations. In this section, we will discuss the current application and problems of GDT protocol in Japan using data from these surveys.

Appropriate perioperative fluid management, especially in Goal-Directed Therapy（GDT）, plays an important role in Enhanced Recovery after Surgery（ERAS）. Some systematic reviews have suggested that perioperative GDT decreases postoperative complications such as infection, respiratory and bowel function and hospital stay, but recent multi-center randomized controlled studies arrived at different conclusions. The overall goal of perioperative GDT is to maintain central euvolemia and avoid excess salt and water during not only the intraoperative phase but also the pre- and post-operative ones. For low risk patients, “zero-balance” should be recommended, while for high-risk patients undergoing high-risk surgery, individualized GDT should be considered based on surgical and patient risk factors. Without other problems, detrimental postoperative fluid overload would not be justified and “permissive oliguria” could be tolerated.

The perinatal medical system in our hospital was changed in unexpected ways after the obstetric anesthesia team was established. Not only doctors but also midwives were affected. Changes included an increase in patients along with changes in clinical techniques, medical systems, themes of meetings, and individual consciousness. These changes are thought to be the most important thing to provide safety medical care for the high-risk pregnant women.

Recently in Japan, the importance and role of anesthesiologists in peripartum medical care has been increasingly recognized. In the peripartum unit of the University of Tokyo Hospital, a specialized position for anesthesiologist was newly established in 2013. In this article, the author describes how systems for providing anesthetic service to parturients have improved in the last two years and discusses the significance of obtaining a specialized position for anesthesiologist in the peripartum unit of a university hospital.

The Medical Accident Investigation System（MAIS）was established according to the Amended Medical Service Law（2014）and enacted in October 2015 to help ensure the safety of medicine and prevent the recurrence of medical malpractice. The latest statistical document is released every month, it looks that understanding of medical care providers is not still enough. In addition, neither debate over a vision of what MAIS should be nor consideration of operational issues are yet to settle.

There are a wide array of issues ranging from the definition of medical accidents to procedures of investigation and the role of reporting.

This section describes basic elements of the system anesthesiologists need to know in their daily medical practice. Problems with MAIS are also discussed.

Flash visual evoked potential（VEP）has been used to monitor the integrity of the optic pathway during neurosurgical procedures, in which the optic pathway is at risk of injury, under general anesthesia. The introduction of a light-stimulating device consisting of a high-luminosity light-emitting diode（LED）and electroretinography（ERG）to ascertain the arrival of the stimulus at the retina have provided better conditions for stable VEP recording under general anesthesia. On the other hand, total intravenous anesthesia with propofol is important for successful VEP recordings because inhaled anesthetics have a suppressive effect on VEP waveform. Flash VEP monitoring allows us to detect intraoperative reversible damage to the visual pathway and enables us to prevent permanent problems.

Epiduroscopy is a new, minimally invasive diagnostic and therapeutic modality for intractable low back pain. Numerous studies have demonstrated its utility in reducing low back and leg pain in patients with lumbar disk herniation, degenerative lumbar spinal stenosis, and failed back surgery syndrome. Recently, several authors described potential uses and new techniques for epiduroscopy. In this article, we review the physiologic rationale and the available clinical evidence discussed at the Japan Society of Epiduroscopy.

In Japan, many lumbar surgeries are performed every year. After some initial surgeries, however, low back pain, leg pain and sensory disturbance remain, increase or recur. Surgery with such poor results is called failed back surgery syndrome（FBSS）. Treating FBSS is sometimes very difficult because it can have a variety of causes. In addition, FBSS causes multiple operated back. Before causing this negative chain, FBSS should be eradicated, but this will be difficult. FBSS is a one-sided value from the patient’s side so treating it faces an inherent limitation.