We evaluated the accuracy of patient’s body weight estimated by their relatives, focusing on differences in patients’ and relatives’ gender.

Two hundred and thirty patients scheduled for elective surgery were included in this study. The correlation coefficients（r²）and mean difference ±1.96 standard deviation between estimated and measured body weight were 0.81, -2.3±10.2 kg, 0.94, -0.3±5.5 kg, 0.81, -0.5±6.1 kg, and 0.87, -0.8±6.5 kg in male relatives - male patient, female relatives - male patient, male relatives - female patient, female relatives - female patient respectively.

These data indicate that patient’s weight estimated by their relatives was generally reliable. Body weights estimated by female relatives seem to be more accurate than those by male relatives.

We examined the incidence and risk factors of postoperative cognitive dysfunction（POCD）in 41 patients who underwent carotid endarterectomy（CEA）. All had a preoperative brain MRI and carotid ultrasound, and 25 patients had cerebral perfusion scintigraphy. POCD was found in 16 patients（39％）. Multiple analysis identified echolucent carotid plaque（Odds ratio［OR］, 10.0）, preoperative cerebral infarcts on MRI（OR, 4.0）, and education≦9 years（OR, 8.6）as independent preoperative predictors of POCD. Additionally, patients with POCD had significantly higher incidence of the area with reduced cerebrovascular reactivity to acetazolamide. Cerebral microembolism as well as decreased blood perfusion reserve might have played a role in the pathogenesis of early POCD.

Brain tumors accompanying pregnancies are extremely rare. We report the case of a 33-year-old woman who experienced spasms 2 hours after cesarean section that resulted in an initial diagnosis of a brain tumor.

The patient complained of headaches and nausea during the course of her pregnancy, and was suspected to have hyperemesis gravidarum. As the patient had a previous cesarean section, the present delivery was also performed through cesarean section under combined spinal-epidural anesthesia. Two hours after surgery, the patient experienced loss of consciousness with clonic spasms；a computed tomography scan revealed a pineal tumor. Tissue diagnosis indicated a germ cell tumor.

Although headaches and nausea during the later stages of pregnancy are frequently indicative of hyperemesis gravidarum, it is necessary to also consider the possibility that these are signs of rare organic intracranial diseases such as cerebral hemorrhage and brain tumors.

A 60-year-old man underwent total laparoscopic prostatectomy at our facility. Ventilatory impairment was not observed during surgery, but subcutaneous emphysema developed from the neck to the femur after surgery. No airway obstruction or severe respiratory acidosis occurred, and he was extubated 1 hour postoperatively. His respiratory state was stable, and his postoperative recovery was uneventful. However, 28 hours after returning to the ward, he complained of dyspnea and anterior chest pain and exhibited a transiently decreased percutaneous oxygen saturation. Computed tomography showed development of subcutaneous emphysema with no airway obstruction. We administered oxygen and performed a supraclavicular skin incision for degassing. Although subcutaneous emphysema is a known complication of laparoscopic surgery, this is the first reported case in which the symptoms appeared more than several hours after surgery.

Oral and nasal intubation sometimes interferes with surgical procedures in maxillofacial trauma patients. In these cases, tracheostomy is usually selected for airway management. Submental tracheal intubation is an effective alternative to oral and nasal tracheal intubation or tracheostomy. Submental tracheal intubation provides a good view and correct articulation. Ten patients underwent submental tracheal intubation without complications since December 2015 at our hospital. Submental tracheal intubation avoids the severe complications of tracheostomy. Submental tracheal intubation is useful as an airway management surgical procedure in maxillofacial trauma patients.

Robotic-assisted laparoscopic radical prostatectomy（RALRP）requires a pneumoperitoneum and a steep Trendelenburg position, which causes a significant increase in intraocular pressure. As a result, there is controversy about the surgical indication of RALRP for patients with glaucoma. We adopt RALRP for glaucoma patients who were diagnosed as early stage by an ophthalmologist. We measured intraocular pressure during RALRP in five patients with glaucoma. In these patients, intraocular pressure was comparable to non-glaucoma patients and there were no ocular complications. In this report, we describe perioperative management for RALRP with early stage glaucoma.

We report two cases of intraoperative abnormal hypertension which occurred during hemostasis around the adrenal glands using a soft coagulation system. The first case was a 60 year old man who underwent pancreatic tail excision for pancreatic neuroendocrine tumor. The second patient was a 70 year old man who underwent laparoscopic hepatectomy for hepatic cancer. In both cases, vital signs during the operation were stable. However, transient rapid rise in blood pressure occurred when bleeding from the adrenal gland was stopped using a soft coagulation system. Unlike conventional electric coagulation systems, soft coagulation does not discharge and stops bleeding by Joule’s heat. We conjecture that when a soft coagulation system was used for hemostasis of the adrenal glands, hypertension occurred as a result of the heat affecting the adrenal medulla and release of catecholamine.

The practice of ultrasound-guided regional anesthesia with a home-made phantom is useful. In the commonly used agar phantom, background echogenicity is low and the needle tip is emphasized. A phantom made with sodium alginate（ArP）increases background echogenicity. The visibility of the needle tip is dependent on the relative echogenicity of the needle with respect to the tissue with which it comes in contact. We pierced a 20G epidural needle into the agar phantom and ArP. Differences in echogenicity of the needle tip and shaft with respect to the various parts of each phantom were analyzed with the Welch t-test. The difference in echogenicity between the needle tip and its surroundings was significantly small with ArP（p<0.01）. Since ArP does not emphasize the needle tip, it may be more appropriate for ultrasound-guided regional anesthesia.

Postoperative respiratory depression is a critical complication. It has been shown that most severe respiratory depression events can be prevented using a better monitoring and hospital system. Although respiratory rate is an important predictor of critical events, it is often neglected. We use the respiratory monitoring system SafetyNet^TM（Masimo, US）to prevent life-threatening respiratory events after general anesthesia. We are also developing a system, SafetyNet^TM・NMU, to notify us of a respiratory monitor alarm anytime and anywhere using a mobile device. It notifies floor nurses of SpO₂, respiratory rate, and pulse rate alarms via a mobile device.

Dysphagia is caused by various diseases, and its pathology is also diverse. Swallowing disorder patients not only restrict oral intake but also face the risk of pneumonia due to aspiration, so appropriate diagnosis and treatment of swallowing disorder are necessary. Videoendoscopic examination（VE）for swallowing is essential to diagnose pathology, and the scoring assessment of VE proposed by us is useful for evaluating the manner and severity of swallowing disorder and the possibility of oral intake. On the other hand, videofluorographic examination should be considered for evaluating laryngeal elevation and opening of the upper esophageal entrance. Conservative treatment including swallowing rehabilitation and oral management is generally recommended, but in the cases with severe dysphagia or decreased cognitive function, surgical treatment may be required to restore oral intake and prevent aspiration pneumonia.

In the end-stage of cardiovascular disease, many patients can be rescued by invasive devices. However, since the limit of treatment is unclear for patients with refractory heart failure, it is not uncommon for them to encounter death without sharing the way they want to live with their healthcare providers and family and maintaining their dignity. Therefore, the statement on end-stage cardiovascular care in the Japanese Circulation Society clearly divides the end-of-life and end-stage condition and stresses the importance of withholding or terminating treatment and end-of-life of comprehensive care, including palliative care, from an early stage. We have created guidelines for end-of-life care in emergency and intensive care medicine jointly with the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine. The guidelines show that if medical teams have reached the limit of implementing the best treatment, they may terminate or withhold treatment based on discussions between multidisciplinary medical team members and family with respect to the patient’s intention. Ethical issues and circumstances are outlined in these guidelines.

The nutrition strategies adopted by anesthesiologists as part of enhanced recovery after surgery（ERAS^®）protocols are intended to maintain nutritional status by reducing the invasiveness of the surgery and to promote early recovery. Reducing invasiveness controls harmful reflexes due to stimulation of the sympathetic nervous system and prevents protein catabolism and abnormal glucose tolerance. The early drinking, eating, and mobilizing after surgery that are recommended in ERAS^® protocols are possible when early recovery from invasion is attained. The authors have named this “DREAM,” using the first letters of the 3 activities, and used it as a concrete target for postoperative recovery.

Evaluation of nutritional status before surgery is one of the specific nutrition strategies used by anesthesiologists. Furthermore, they make plans before surgery to shorten the duration of fasting and prevent carbohydrate intake and dehydration. During surgery, they reduce invasive reactions through analgesia, properly managed infusions, and steps to prevent intraoperative carbohydrate loading and postoperative nausea and vomiting（PONV）. Proper analgesia and PONV prevention is also performed after surgery. Postoperative DREAM can be accomplished when anesthesiologists include nutrition strategies as part of anesthesia management.

The enhanced recovery after surgery（ERAS）program suggests that perioperative nutritional care can inhibit catabolism and improve insulin resistance. However, the administration of nutrient substrates during surgery is not mentioned in the ERAS program. Previous studies have demonstrated the inhibition of catabolism by the administration of glucose or amino acids under general anesthesia. On the other hand, hyperglycemia resulting from administration of nutrient substrates is known to contribute to postoperative complications. We here explain the problems with intraoperative nutrition as well as its potential.

The international definition of sepsis was revised as “life-threatening organ dysfunction caused by a dysregulated host response to infection” in February 2016. Therefore, the old definition of “sepsis” without organ dysfunction is no longer “sepsis” in the new definition. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016（J-SSCG 2016）were published at the end of 2016 by both the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine.

Although International Surviving Sepsis Campaign Guidelines have already spread worldwide, the reason why we made Japanese original guidelines was to construct a basis for creating and transmitting evidence around the world from Japan.

As a result of the formulation of the guidelines, an unexpectedly increasing number of organic networks, such as multicenter studies and systematic reviews, have been established between the two societies.

This is a review summarizing the methodological considerations behind the development of the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016（J-SSCG2016）, which was presented at the 36th Annual Meeting of the Japan Society for Clinical Anesthesia. The recommendations in these guidelines were developed through 4 sequential processes：generating the clinical questions, performing systematic reviews, evaluation of quality of evidence, and establishment of recommendations.

There are 4 categories of recommendations：“recommendation to do”, “weak recommendation to do”, “weak recommendation not to do”, and “recommendation not to do”. However, the clinical recommendation is fundamentally successive. In this regards, we should note that “weak recommendation to do” and “weak recommendation not to do” are not opposite recommendations.

This review summarizes five sections on the diagnosis and treatment of infection in the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016, which was presented at the 36th Annual Meeting of the Japan Society for Clinical Anesthesia. We focus on the sections on diagnosis of infection, diagnostic imaging, source control, antimicrobial therapy, and immunoglobulins. We show and expound the clinical questions and answers, respectively.

In December 2016, the joint committee of The Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine published The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016（J-SSCG 2016）. Before publication, the joint committee opened the draft of the J-SSCG 2016 to the annual congress of The Japan Society for Clinical Anesthesia in November 2016 and asked for public comments via the web site.

In this section, transfusion therapy, diagnosis and treatment of DIC, and venous thromboembolism prophylaxis, which were presented in lectures at the annual congress of The Japan Society for Clinical Anesthesia, are introduced in accordance with the J-SSCG 2016. For the detailed contents of each section, we refer you to the text in the J-SSCG 2016 on the website.

Although the Japanese Guidelines for the Management of Sepsis 2012 and Surviving Sepsis Campaign Guidelines addressed blood glucose management and steroid use, the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016（J-SSCG 2016）are the first guidelines to address intensive care unit（ICU）-acquired weakness（ICU-AW）and post-ICU syndrome（PICS）, as well as temperature management. Recently, mortality in patients with sepsis has declined, and this has led to an interest in the quality of life of survivors and their families amongst intensivists and medical staff. Therefore, ICU-AW and PICS are now considered relevant issues. It is well known that hyperthermia and hypothermia are common in patients with sepsis, but there are no guidelines to address temperature management in these patients. This section describes the following four issues：1）blood glucose management, 2）steroid use, 3）ICU-AW/PICS, and 4）temperature management. Clinical questions that are newly addressed or revised in the J-SSCG 2016 are discussed.

In lawsuits regarding pain-related problems, there are few cases that ask “Who is responsible for the patient’s pain?”. This may be associated with the ambiguous way we think of chronic pain. In this article, therefore we describe what the pain is based on the definition of the IASP（International Association for the Study of Pain）, and we then discuss the various pain-related factors such as pain-related behavior and its reinforces and perceived injustice associated with injury.

There has been a severe shortage of manpower in ORs and ICUs in Japan, which has hampered efforts to improve the quality of perioperative medicine and streamline it. To solve this problem, Aichi Medical University Hospital began to employ Japanese Nurse Practitioners three years ago. These are advanced nurses who are allowed to support physicians by performing more invasive procedures than ordinary nurses. We found that they could help not only compensate for a shortage of manpower（especially of anesthesiologists）but also optimize the quality and efficiency of perioperative medicine. I believe Japanese Nurse Practitioners could play a key role in providing high-quality, efficient perioperative medicine throughout Japan.

The Medical Specialist scheme is currently being reviewed, so the detailed scheme may change in the near future. In this paper, the author explains the history of the medical specialist and the criteria for recertification.