［Background］We investigated the safety and efficacy of local anesthesia and sedation（LAS）for TAVI procedures.

［Methods］One hundred and sixteen TAVI procedures were performed at Teikyo University Hospital from November 2016 through November 2017. Fourteen of these were performed under LAS. For the 14 cases, we retrospectively analyzed preoperative status as well as intraoperative and postoperative complications. In addition, for each LAS case, we assigned 14 general anesthesia（GA）cases with matched EuroSCOREⅡ and compared procedural time and postoperative recovery.

［Results］Most LAS cases had severe respiratory complications. Two of the 14 cases had difficulty in airway and respiratory management. Right ventricular infarction occurred in one case. No case required urgent conversion to GA. There were no significant differences in anesthetic and procedural time or ICU and hospital length of stay.

［Conclusions］Efficacy of LAS was explored in the management of TAVI cases with severe respiratory complications. There was no significant difference in elapsed time and postoperative recovery compared with GA. Sufficient care should be taken for airway and respiratory management.

We report a 69-year-old woman with feet pain and feet numbness due to fatty filum terminale. Magnetic resonance imaging, especially T1-weighted transverse section image, was very useful for diagnosis. There is no definite opinion of long-term progress in patients with fatty filum terminale. Thickness over 2 mm must be judged abnormal. Watchful waiting is necessary to see whether patient’s symptom change, so we plan to begin annual magnetic resonance imaging.

Here we report a case of cardiogenic pulmonary edema just after emergency caesarean section. Under a diagnosis of threatened preterm labor, the patient had been administered ritodrine hydrochloride over a long period（approximately 11 weeks）. She underwent emergency caesarean section under spinal anesthesia due to premature rupture. Two hours after the end of surgery, the patient complained of dyspnea. Based on a typical chest X-ray pattern of pulmonary edema and impaired left ventricular contraction with focal asynergy of the anteroseptal wall on echocardiography, we diagnosed the cause of dyspnea as cardiogenic pulmonary edema. Although ritodrine hydrochloride is a useful drug for treating threatened preterm labor, adverse effects such as myocardial injury and pulmonary edema are well known. Ritodrine hydrochloride was presumed to be the cause of cardiogenic pulmonary edema in this case. However, peripartum cardiomyopathy might be considered another cause of cardiogenic pulmonary edema, because administration of tocolytics is considered a risk factor for peripartum cardiomyopathy. In patients with long-term administration of ritodrine hydrochloride, careful respiratory and circulatory management is required during the perioperative period of caesarean section.

A female in her 60s weighing 60 kg had become stuporous due to schizophrenia. At the first electroconvulsive therapy（ECT）session, 125 mg thiopental and 60 mg suxamethonium were administered. The fifth ECT could not induce seizure, and the dosage of thiopental was reduced to 75 mg. A BIS monitor was used to ensure that the patient was unconscious.

Remifentanil was continuously administered at 0.5 μg/kg/min for 4 minutes, then 50 mg thiopental was given. The patient fell asleep, and seizure was induced by electrical stimulus. At the third course, the dosage of thiopental was reduced to 12.5 mg, but electric stimulus did not induce seizure.

The anesthetic agent was then switched from thiopental to ketamine. Administration of 30 mg ketamine alone resulted in seizure induced by electric stimulus, but the patient’s mental condition deteriorated. When the dosage of ketamine was reduced to 10 mg with concomitant use of remifentanil, electrical stimulus induced seizure and the patient’s mental condition improved.

Malignant hyperthermia is a muscle disorder with autosomal dominant inheritance that presents mainly during general anesthesia with an abrupt temperature elevation.

Genetic predisposition, loss of suppression, and a trigger factor are all involved in the onset of malignant hyperthermia. Predisposition to malignant hyperthermia is difficult to diagnose during the preoperative workup. Clinical manifestations are non-specific but death may occur if it is not promptly recognized and treated.

The Japanese Society of Anesthesiologists established guidelines for the management of malignant hyperthermia in 2016 so that members could deepen their understanding of malignant hyperthermia and put the guidelines into practice.

These guidelines describe measures necessary to make the patient’s life the first priority. However, it is still necessary to understand the on-site situation and pathophysiology of the actual disease, since the guidelines provide only general rules that need to be adapted to each case.

Anesthesiologists are highly specialized in pain management and systemic management of patients and can also play an important role in palliative medicine. On the other hand, anesthesiologists tend to get limited information on palliative care and have fewer chances for training, which makes it difficult to have detailed image of palliative care. In this article, I suggest what is necessary for anesthesiologists to be palliative care doctors from the point of view of palliative care unit physicians.

Anesthesiologists and pain clinicians acquire skill in assessing and controlling pain, which is important for palliative care, and they also excel in general management.

In addition, their experience as producers of surgical teams helps them play an important role as coordinators of multi-occupational collaboration in home health care teams.

Pain clinic outpatient clinic is palliative care itself.

The difference between palliative care in general hospitals and palliative care in palliative care units and home health care facilities is that, in the former, palliative care is provided to patients who are undergoing cancer treatment. Thus, knowledge of cancer treatment is essential for the palliative care physician to provide proficient palliative care. Compared to other physicians, palliative care physicians who are originally anesthesiologists may be better at assessing and treating pain and may be more familiar with opioid analgesics and adjuvant analgesics. They are also used to being consulted by primary physicians. However, they may not be accustomed to being primary physicians themselves and may need training as a primary physician when becoming palliative care physicians at palliative care units and home health care facilities. In addition to clinical duties, palliative care physicians at a university hospital have academic duties and need to be involved in the education of medical students and residents as well as graduate students.

Anesthesia is commonly provided by anesthesia care teams in the US, Great Britain, and Ireland. In Japan, however, anesthesia care teams are uncommon. However, perioperative management teams like anesthesia care teams in the US have been adopted in anesthesia care in Japan. In this article I discuss the history of perioperative management teams in Japan, the role of perioperative management teams, and their relationship with specified medical acts of nurse and anesthesia.

In the perioperative period, clinical pharmacists are involved in the management of medicines, and this requires strict control. However, pharmacists are also expected to improve the patient’s safety and quality of healthcare. At Toho University Medical Center Omori Hospital, pharmacists have checked medicines during the preoperative period and informed anesthesiologists if medicines need to be discontinued since 2013. As members of the acute pain service team, pharmacists also assess postoperative pain and complications to minimize pain- and analgesic-related adverse effects by suggesting optimal analgesic usage. As a result, we have been able to reduce the frequency of surgery suspension and shorten the length of the hospital stays. Clinical pharmacists play an important role in perioperative medicine.

We have been operating a short stay surgery center（SSSC）at Tokai University since 2010. Coordinator nurses specialized in perioperative nursing are used at the center. They arrange schedules so that preoperative patients can undergo tests smoothly and give informed consent, and they sort out and hand over patients’ information to prevent it from being left unattended. As a result, coordinator nurses greatly contribute to reducing the time taken by anesthesiologists and surgical nurses for preoperative examinations. Since they need a certain level of experience and knowledge, however, we do not have sufficient human resources at present. We will establish a training and personal development system for nurses to expand the range of their activities in the future.

According to “A national assessment of perioperative management in outpatient clinics and their rates of surgery cancellations,” a study conducted by the Japan Operative Nursing Academy, there was a lower rate of cancelled surgeries in the 46.4% of medical facilities which reported undertaking perioperative management in their outpatient clinics, which suggests its importance in preparing patients for surgery.

In the current medical setting with high numbers of high-risk patients, in addition to physical assessment, assessment of the patient’s lifestyle needs and education incorporating the family in meeting these needs is needed. The operative nurse operates at the core of the perioperative management team, undertaking risk-assessment and supporting each team member. Assessment with predetermined quality indicators is able to assess the results of perioperative management in the outpatient clinic.

The concept of the perioperative management team was formulated 11 years ago.

Different facilities employ their own versions of team-based health-care, such as perioperative centers, perioperative management teams, and patient support management teams.

Despite the practice of team-based health-care, its definition and scope have not yet been standardized.

As a result, perioperative management teams have not been added to the medical fee schedule.

Most clinical research originates from an ambiguous question or idea in clinical practice. It is important to be able to translate such a question or idea into a clinically testable hypothesis before beginning research. However, generating a “good” hypothesis is sometimes harder than expected. Thus, in a series of our peripheral vascular access studies, we performed a hypothesis-generating-type study as the first phase, and then progressed to a hypothesis-driven-type study based on the results. Here, we reconsider the importance of generating a hypothesis through our two-phase studies.

The practice of clinical medicine is based on the results of clinical trials. The ability to alter clinical practice based on our own clinical research is quite exciting. Clinical research themes need not be “epic”, but instead can be simple. A clinical question raised by an industrious clinician should also be of importance to other clinicians, even if the question of significance seems trifling. In addition, approaching the day-to-day performance of anesthesia with the aim of finding a clinical question that is worthy of investigation for superior patient management can make usual anesthesia management more interesting and fascinating. I believe it is important to be of a mind-set to conduct clinical trials voluntarily and willingly, and not just on orders from others.

It is important to maintain oxygen content（CaO₂）when we manage maternal hemorrhage. CaO₂ is a function of cardiac output, oxygen saturation, hemoglobin concentration, and arterial oxygen partial pressure. However, these parameters cannot be monitored continuously with precision. In“Guidelines for Management of Critical Bleeding in Obstetrics,”the Shock Index（heart rate/systolic blood pressure）is recommended for evaluating maternal hemodynamics. Specifically, both“SI ≧ 1.0”and“SI ≧ 1.5”are decision points for starting transfusion in the guidelines. Normally, cardiac and respiratory functions are not severely impaired in pregnant women, so it is crucial to maintain the hemoglobin level. It is therefore necessary to develop a rapid blood delivery system and provide blood products safely and reliably.

Sedation during endoscopic procedures is indispensable for the safe and effective control of pain and anxiety of the patient to obtain expected effects from procedures.

In 2013, “Guidelines for Sedation in Gastrointestinal Endoscopy” were published by the Japan Gastroenterological Endoscopy Society to provide guidance on appropriate methods of sedation when sedation is necessary for endoscopic procedures. The will and consent of the patient must be obtained only after the physician provides the patient with an adequate explanation of the procedures and the sedation the patient will receive.

Since potential adverse effects include severe respiratory depression, which is life-threatening, measures must be taken to prevent adverse effects from occurring. Endoscopists should take into consideration the mechanisms of action of sedative and analgesic agents, patients’ characteristics, and risk management especially against changes in respiratory and circulatory conditions. Furthermore, team medical care must be readily available in case of adverse events during procedures.

In recent years, modern Japanese medical practice has risen close to the world standards. However, several fields in anesthesia still lag behind, at times putting patients in danger. Procedural sedation is one example. Minor surgeries are often seen as straightforward, but sedation for small surgeries actually requires higher-level anesthesia techniques. In fact, there are still many ambiguous aspects in sedation practice, such as a lack of guideline adherence and the question of who, based on what criteria, should be allowed to give non-anesthesiologists permission to use procedural sedation.

In this manuscript, comparisons of medical standards in Japan and other countries will be discussed. Furthermore, proposals of how anesthesiologists might help contribute to the safety and well-being of patients undergoing sedation will be presented.