Several guidelines for preventing surgical site infections have been announced recently, and anesthesiologists have started paying attention to antimicrobial dosage. Although some clinical guidelines recommend that 2.0 g of cefazolin be administered to patients weighing >60-80 kg and 3.0 g be administered to those weighing >120 kg, we administered 1.0 g to all patients. We investigated whether patient weight and other factors were related to onset of SSI. We found that the frequency of SSI is higher in patients with heavy body weight. Multivariate analysis revealed that bleeding and duration of surgery were also meaningful factors.

We performed awake tracheal intubation in a morbidly obese patient three times over a six-week period. A 57-year-old man, with a height of 173 cm, body weight of 150 kg, and body mass index of 50 kg/m² first underwent osteosynthesis of a left upper limb fracture. Based on his preoperative work-up, we expected difficulties with both mask ventilation and tracheal intubation. We therefore elected to induce general anesthesia following awake intubation. We used the McGRATH Video Laryngoscope and intubation took approximately 30 min because of difficulty encountered while identifying the vocal cords. Thirty-three days later, the same patient underwent osteosynthesis of a right hip fracture. On this occasion, the Airway Scope was used and intubation took only 10 min. Forty-two days after the initial surgery, the patient underwent osteosynthesis for bilateral upper limb fractures. The Airway Scope was used again and intubation took 15 min. This case suggests that the Airway Scope is potentially useful for awake tracheal intubation in morbidly obese patients.

A 31-year-old primigravida woman underwent a caesarean section. Hypertension and dyspnea were detected 2 hours after the caesarean section, and the patient was diagnosed as having type A aortic dissection 6 hours after the procedure. Cardiovascular surgery was performed 3 days later. Aortic dissection is very rare in pregnant women without underlying diseases, but should be suspected if severe hypertension or dyspnea is detected after a caesarean section. During anesthetic management of patients having undergone cardiovascular surgery after caesarean section, it is important to closely monitor obstetric bleeding.

Dexmedetomidine is an alpha-2 adrenoreceptor agonist that possesses sedative and analgesic properties and causes sympathetic inhibition. Dexmedetomidine has been investigated for a possible anticonvulsant effect and for use in epilepsy, but it is not clear whether dexmedetomidine has this anticonvulsant effect.

We used dexmedetomidine as a sedative drug during artificial ventilation for Gaucher disease myoclonic status epilepticus and experienced the termination of status myoclonus. The findings in this case suggest that dexmedetomidine may be effective for the treatment of status myoclonus.

Background：Desflurane reportedly irritates the airways more than other volatile anesthetic agents. We used the forced oscillation technique to examine whether desflurane influences respiratory resistance more than sevoflurane.

Methods：This prospective observational study was conducted in 32 patients undergoing transurethral resection of bladder tumors under general anesthesia. Maintenance anesthesia was provided with sevoflurane or desflurane. Respiratory resistance at 5 Hz（R5）and 20 Hz（R20）was measured the day before surgery and immediately after emergence from anesthesia using a MostGraph-01 device（Chest M.I., Tokyo, Japan）.

Results：Eighteen patients underwent sevoflurane anesthesia and 14 underwent desflurane anesthesia. There were no significant differences in participants’ demographic or clinical characteristics or pre-operative respiratory resistance parameters. There were significant increases in post-operative R5 and R20 values in both groups, but no significant difference between groups in R5 or R20 values.

Conclusions：Our findings suggest that desflurane does not increase postoperative respiratory resistance more than sevoflurane.

Bronchoscopes are used to check the position of a double-lumen tube and a monitor is used to share the image. However, such monitors are expensive and have a long set-up time. We speculated that a bronchoscope with a small monitor like those included with video laryngoscopes could be very useful. We thus created the i-NTER LENS^TM device for this purpose. We also created an application, called the ENDO SCOPE^TM which improves the performance of the i-NTER LENS^TM. By using the i-NTER LENS^TM, we can prepare a bronchoscope faster, and we can save clearer images by using the ENDO SCOPE^TM. This device and application will be helpful in the fields of distance medicine and disaster medical care.

We have worked to develop new diagnostic and therapeutic tools based on experimental proof-of-concept obtained through the analysis of pathological mechanisms underlying kidney diseases. For this purpose, for the first time in Japan, we introduced multiphoton laser microscopy with an in vivo bio-imaging system that revealed physiological functions of the kidney and various pathological mechanisms. We used these findings to develop new therapeutic means and biomarkers. In addition, we successfully established erythropoietin-producing cells from human iPS cells as a new therapeutic tool for renal anemia. Further development of erythropoietin-related drugs is expected in the future. We believe that these cells represent the only tool to help obtain proof-of-concept for mechanisms of action of such drugs. Here we discuss these kidney-related, multifaceted basic studies.

Pruritus is an unpleasant sensation that provokes scratching behavior. Neural pathways in peripheral itch have histaminergic and non-histaminergic pathways including protease-activated receptor 2 and Mas-related G-protein-coupled receptors. The incidence of pruritus is very high in patients who receive neuraxial opioids. However, we do not have a standardized treatment for opioid-induced pruritus. Recent basic research suggests that opioid-induced pruritus occurs via the activation of gastrin-releasing peptide receptor signaling. Several drugs with different mechanisms of action have been tried for treating opioid-induced pruritus. Further studies on opioid-induced pruritus are greatly needed.

The use of opioids, which has been increasing worldwide particularly in North America and Europe, carries the risk of opioid dependence and addiction. In Japan, the number of cancer survivors is increasing with the aging of the population. We have encountered many cases of cancer patients with chronic non-cancer pain, in which we have been worried about whether to use opioids. How should new opioids approved for them be used, and what precautions should be taken to avoid opioid dependence, addiction, and other risks?

Although opioid analgesics are partially effective for chronic pain, dependence/addiction is a major problem. Strictly selecting and monitoring patients and signing treatment contracts are important, especially if strong opioid analgesics are prescribed. In this study, the author examined the analgesic effect and dependence/addiction to fentanyl patch（FP）for chronic pain. The intensities of pain were lower compared to before prescription in 12 patients to whom FP were continuously prescribed for over a year. One patient was suspected to have developed opioid dependence/addiction. However, the opioid-related aberrant behavior developed by FP was inhibited by re-exhibiting the strict treatment contract signed before prescribing FP.

Recommendations for basic life support in the JRC 2015 Guidelines announced in October 2015 are discussed below. The JRC recommends that chest compressions should be performed at a rate of 100-120/min. It recommends a chest compression depth of approximately 5 cm while avoiding depths greater than 6 cm. Pauses in chest compressions should be minimized, and the chest compression fraction should be as high as possible and at least 60%. The JRC suggests that individuals in close proximity to an individual suspected of having cardiac arrest and who are willing and able to perform CPR should be notified of the event via technology or social media. The importance of chest compressions highlighted in the JRC 2015 Guidelines has been inherited from JRC Guidelines 2005 and 2010.

JRC CPR guidelines 2015 was developed according to the CoSTR, a scientific review constructed by ILCOR using the GRADE process. Digested recommendations in the guidelines are listed as below：1. Automatic mechanical CPR devices and ECPR have limitations on usage. 2. Adrenalin should be given to victims with non-shockable rhythm as quickly as possible. 3. After ROSC, hypoxia should be avoided and hyperoxia is suggested to prevent, but 100% oxygen should be administered until determining oxygenation level by SpO₂, etc. 4. TTM should be done for unresponsive OHCAs and IHCAs with any initial ECG rhythms. Keeping BT at the pre-determined level in the range of 32-36℃ for at least 24 hours. Hyperthermia after the rewarming is suggested to avert. 5. Especially in OHCAs treated with therapeutic hypothermia, the prognostication should be done more than 72 hours after ROSC. 6. All OHCAs with ROSC, but facing death, should be considered as potential organ donors.

The important changes regarding ACS in the 2015 JRC guidelines for resuscitation are introduced in this paper. The guidelines recommend prehospital 12-lead ECG acquisition with hospital notification for adult patients with suspected STEMI, and recommend against using hs-cTnT and cTnI alone measured at 0 and 2 hours to exclude the diagnosis of ACS. They suggest that when UFH or ADP-receptor antagonists are given to suspected STEMI patients with a planned primary PCI approach, administration can occur in either the prehospital or in-hospital setting. They recommended PCI as the preferred reperfusion strategy for STEMI, because of lower reinfarction rates. However, fibrinolysis and early transfer for angiography may be a reasonable alternative in settings where access to PCI may be limited or delayed. They recommend emergency cardiac catheterization laboratory evaluation in comparison with cardiac catheterization later in the hospital stay or no catheterization in select adult patients with ROSC after OHCA of suspected cardiac origin with ST elevation on ECG. Many gaps in knowledge are also discussed with a view to future recommendations.

Seizure control and continuous EEG monitoring are essential for status epilepticus, especially the nonconvulsive type. The therapeutic time window for thrombolytic therapy in acute ischemic stroke is 4.5 hours. For acute ischemic stroke, combined reperfusion therapy with thrombus remover and thrombolytic therapy（rt-PA）is recommended in certain cases. The risk of vertebrobasilar infarction is increased in cases with transient neurologic attack. Sepsis associated encephalopathy is a diffuse brain dysfunction which manifests coma and delirium. Critical care with respiratory and circulatory management with intravascular cooling should be performed in severe heat stroke.

Postoperative cognitive dysfunction（POCD）is one of most challenging problems in the perioperative management of geriatric patients. Although its pathogenesis involves various factors, accumulating evidence suggests that inflammatory responses in the hippocampus, a brain area closely related to cognitive function, play a key role in the development of POCD. Preclinical evidence has shown that microglia in a normal aged brain are shifted towards the inflammatory phenotype, known as “microglial priming”. Primed microglia can trigger an exaggerated release of pro-inflammatory cytokines, which contribute to prolonged neuroinflammation following a peripheral immune challenge. More importantly, it may be modifiable. Therefore, surgery-induced neuroinflammation processes including the microglial activation pathways will be promising therapeutic targets in the management of POCD. In this review, we discuss the current overview and preclinical highlights regarding postoperative cognitive dysfunction. We further discuss some perspectives on preventive strategies against POCD based on the findings of our preclinical research.

Recent studies evaluating postoperative changes in cognitive function have focused on three areas. The first area is investigating the existence of long-term postoperative cognitive dysfunction（POCD）. Although the existence of this condition has been questioned in recent reports, it cannot readily be denied considering the high dropout rate due to the poor prognosis of patients with POCD during long-term observation. The second area is demonstrating the association between management of anesthesia and the development of POCD. Accumulating evidence suggests that maintaining adequate levels of regional cerebral oxygen saturation can reduce the occurrence of POCD. The third area is investigating the existence of postoperative cognitive improvement（POCI）, as demonstrated after procedures such as carotid endarterectomy, cardiac surgery, and orthopedic surgery. These surgeries can reduce the risk of embolic events in the brain and/or improve activities of daily living（ADL）, so patients’cognition may improve after surgery. POCI may offer a ray of hope because improvement of postoperative ADL could ultimately reduce the occurrence of POCD.

Paraplegia is a devastating complication of thoracic endovascular aortic repair（TEVAR）. In order to reduce the incidence of spinal cord injury, blood pressure management, cerebrospinal fluid drainage, intraoperative neuromonitoring will be examined as a spinal cord protection strategy in TEVAR. In addition, TEVAR is characterized by late onset of spinal cord injury. Anatomical factors and hemodynamic factors may be considered as factors related to the time of occurrence of the disorder. Blood pressure management, cerebrospinal fluid drainage, and intraoperative neuromonitoring are also included in the guidelines as essential items for improving patient prognosis.

Nociceptive stimuli reach the brain from peripheral sites of surgical injury through the spinal cord. Optimization of postoperative pain treatment may not only lead to increased patient comfort but may also reduce complications, improve perioperative outcome, and prevent prolonged pain. The role of calcitonin gene-related peptide has recently been reported to be more important than the role of substance P in transmission and modification of pain, but the mechanisms by which these peptides transmit and modify nociceptive pain are not clear. In this paper, we discuss the mechanisms of postoperative pain compared with inflammatory pain in animal models.

Obstetric critical hemorrhage remains the leading cause of maternal death. Three major causes of obstetric critical hemorrhage are amniotic fluid embolism, uterine atony, and uterine rupture. It is important to secure surgical hemostasis and start blood transfusion early with a 1：1 ratio of red cell concentrate to fresh frozen plasma. Because fibrinogen is the key factor for hemostasis, fibrinogen levels should be maintained by fresh frozen plasma, cryoprecipitate, or fibrinogen concentrate if necessary. The new guidelines for treating obstetric critical hemorrhage published in 2017 are expected to improve maternal outcome.

In 2016, there were many news reports concerning artificial intelligence learning by itself. For example, AlphaGo（Google DeepMind）won a Go match against a professional high-level player, and an automatic driving bus ran for a test on public road. In the area of anesthesiology, automated anesthesia is associated with artificial intelligence. There are currently a number of automated systems which maintain drug concentrations of anesthetics. Another automated anesthesia system, which administers an anesthetic drug to maintain these pharmacodynamic effects, requires appropriate electroencephalographic monitoring and continuous measurement of the actual drug concentration. Computer-assisted anesthetic management can compensate for shortcomings of anesthesiologists and improve medical quality in daily practice.