A 47-year-old man had undergone unilateral whole-lung lavage and bilateral whole-lung lavage 9 and 2 times, respectively, during the previous 4 years. Seven out of the 11 treatments were performed with extracorporeal membrane oxygenation（ECMO）support. However, obtaining bilateral femoral venous access gradually became difficult due to a marked increase in proliferation of connective tissue around the blood vessel.

When his medical condition worsened again, we decided to perform unilateral whole lung lavage before hypoxemia became serious, in order to avoid the use of ECMO. As a result, the operation could be completed without ECMO support.

Early whole-lung lavage may eliminate the need for ECMO support in patients with pulmonary alveolar proteinosis in whom it is difficult to secure vascular access.

Coffin-Lowry syndrome is a rare X-linked genetic disorder characterized by short stature, characteristic facial features, skeletal malformations, psychomotor development delay, cardiac anomalies, etc. The syndrome may result in difficulties in securing the airway due to the characteristic facial features. Here, we report our experience regarding the successful management of a patient with this syndrome using general anesthesia.

A 66-year-old male patient, with a history of allergy to pineapple and house-dust, underwent endovascular surgery under general anesthesia and was administered sugammadex（200 mg）at the end of surgery. A few minutes later, generalized rash and decrease in blood pressure were observed. Because a hypersensitivity reaction to sugammadex was suspected, 0.2-mg adrenaline and 500-mg methylpredonisolone were administered to improve the patient’s condition. An electrocardiogram revealed ST elevation in the inferior leads, which improved spontaneously after blood pressure improved. Coronary angiography revealed no occlusion of the coronary artery. A skin-prick test, performed two months later, revealed negative results for sugammadex.

An 87-year-old man with worsening functional mitral regurgitation underwent transcatheter mitral valve repair under general anesthesia. Intraoperatively, we administered fluid aggressively to induce mitral regurgitation that had been reduced after anesthesia induction.

Subsequently, cardiac dilatation due to the excessive fluid and device irrigation made it difficult to capture the mitral valve leaflets. Diuretics and catecholamines were required for several days after the procedure. Mitral regurgitation during transcatheter mitral valve repair should be induced with vasoconstrictors rather than through fluid administration.

Autonomic dysreflexia（AD）is a matter of concern in anesthetic management for patients with chronic spinal cord injury. The patient was a 56-year-old man with complete paralysis from the 11th thoracic vertebra and below. He was scheduled for an orchiectomy to treat a left scrotal abscess. He reported no history of AD in activities of daily living. Since intravesical operation was not planned for this procedure, the possibility of intraoperative AD was considered to be low. The procedure could have been performed without anesthesia, but it was performed with monitored anesthesia care（MAC）to respond rapidly in case of AD onset. The surgery proceeded with continuous administration of dexmedetomidine（DEX）and intermittent administration of fentanyl. The bispectral index value was 35-78 and Richmond Agitation-Sedation Scale score was -1 to -2. AD did not occur during the surgery, and the anesthesia was managed safely. DEX has been reported to exert an inhibitory effect on AD. Therefore, this drug may be useful as a sedative during MAC for patients with spinal cord injury.

Here we present a case of a hemopneumothorax during posterior lumbar spinal fusion. Hemopneumothorax during posterior lumbar spinal fusion is a rare complication. A 68-year-old woman was diagnosed with degenerative lumbar spondylolisthesis and lumbar spinal canal stenosis（L1-5）, and a posterior lumbar spinal fusion surgery was performed as usual. After extubation, oxygen saturation decreased to approximately 92% with 6 L/min oxygen via a facemask, while systolic blood pressure decreased to approximately 80 mmHg. Chest ultrasonography indicated left pneumothorax. Chest X-ray and CT showed left hemopneumothorax. A thoracic drainage tube was immediately inserted in the intensive care unit. Oxygenation and blood pressure gradually recovered. The patient was discharged 28 days after surgery. Chest ultrasonography was very useful for diagnosing perioperative hemopneumothorax during posterior lumbar spinal fusion.

The current author perioperatively managed a 54-year-old female Muslim patient who was undergoing microvascular surgery. The patient had to be consulted since tenets of the Islamic faith prohibited the use of certain items or agents, e.g. biological products（porcine products）and alcohol could not be used during anesthesia.

Special accommodations beyond anesthesia have to be made during the perioperative management of Muslim patients. These include dealing with interpreting difficulties, providing halal meals, a proscription on a male physician examining an unmarried female patient, and understanding different customs.

This report provides an overview of Islam, describes which biological products are proscribed by the Islamic faith, and discusses points to be aware of when perioperatively managing Muslim patients based on cases encountered at this Hospital.

The anesthesiologist specialist system was founded by the Japanese Society of Anesthesiologists（JSA）in October 1954, making it the oldest traditional specialist system in Japan. Meanwhile, the Japanese Medical Specialty Board（JMSB）was established in May 2014, and since FY2018 the specialist training program in the field of anesthesiology has been transferred to the specialist training course for anesthesiology of the JMSB. In FY2019, for the board-certified anesthesiologists of the JSA, the renewal process will be transferred to the JMSB sequentially. The new accreditation system and the updated standards of the JMSB will be discussed here.

The medical specialist program for basic diagnosis and treatment departments started under the Japanese Medical Specialty Board in April 2018. The Japanese Society of Intensive Care Medicine is a subspecialty of two basic areas of the Japanese Society of Anesthesiologists and the Japanese Association for Acute Medicine, and preparations are underway for it to start in 2021. In the new specialist system, intensive care specialists are a subspecialty of anesthesiology and emergency departments but should not be limited to these departments. Therefore, it is necessary to seek the understanding of related academic societies and the Japanese Medical Specialty Board so that intensive care specialists can be recognized as a subspecialty of other specialists.

The subspecialty that the Japanese Society of Cardiovascular Anesthesiologists is aiming at, as stated in its philosophy, is as follows：“The goals of the cardiovascular anesthesiologist board system as a subspecialty of anesthesiologists are to provide anesthesiologists with sufficient expertise and skills regarding cardiovascular anesthesia so that they can perform high-quality and safe cardiovascular anesthesia, to train specialists who can play educational and leadership roles, and to contribute to the promotion of the health and welfare of the citizens of Japan”. The society operates its own education and specialist board system. In the future, with the goal of obtaining accreditation by the Japanese Medical Specialty Board after obtaining approval from the Japanese Society of Anesthesiologists, we will continue to consider requirements and make necessary improvements to the current system. We will continue to work for the benefit of patients, medical staff, and society.

The Japan Society of Pain Clinicians was established with the objective of advancing and promoting the field of medicine focused on the diagnosis and treatment of acute and chronic pain. In response to societal needs, and with the objective of member education, a physician certification system and an educational system were established in 1989. There are 310 designated training facilities and 1,600 certificated specialists. A new certification system will be established following renewal of the Japanese Medical Specialty Board. Details of new certification system and differences between the present and the new system are described.

Intraoperative motor evoked potential（MEP）has been used to monitor the integrity of the descending motor pathway in surgeries with a risk of postoperative motor dysfunction. Methodology for stimulation and recording corresponding to usage of anesthetics and the various types of surgery is essential in order to perform reliable MEP monitoring. Recently, the tailoring of MEP warning criteria to different types of surgery based on anatomy are recommended because there is no valid one criterion that fits all different types of surgery. Confounding nonsurgical factors including anesthesia and hypotension associated with MEP suppression（hemodynamic fade）should be ruled out before warning surgeons.

Motor evoked potential（MEP）monitoring is more affected by anesthetics than any other form of neurophysiologic intraoperative monitoring. Anesthetics attenuate MEP responses in a dose-dependent manner. Anesthesiologists need to be familiar with anesthetic management in MEP monitoring. Total intravenous anesthesia using propofol and opioids（e.g., remifentanil and fentanyl）may be the optimal anesthetic regimen for MEP monitoring. Inhaled anesthetics（e.g., sevoflurane and desflurane）may also be used if initial baseline MEP can be measured with high reproducibility. The depth of anesthesia should be kept at a constant level based on EEG monitoring and a neuromuscular monitor.

Intraoperative motor evoked potential（MEP）monitoring is generally a safe technique but can inadvertently cause harm. Transcranial electrical stimulation（TES）can cause excitotoxic or thermal injury of the brain or scalp. Direct cortical stimulation may cause electrochemical injury at the electrode-tissue interface. Careful observation and avoidance of excessive electrical stimulation are important to prevent adverse events. Other safety concerns include invasive electrode complications, seizures, arrhythmia, bite injuries, and movement-induced injury. Tongue and lip bite injuries by jaw muscle contractions are the most commonly reported complications during MEP monitoring. Frequent intraoperative checking of the position of the soft bite block and around the mouth is recommended. Movement in the surgical field caused by TES may disturb surgical manipulation. Therefore, the timing of stimulation for MEP monitoring should be selected carefully. Skull defects, cortical lesion, epilepsy, and implanted bioelectric devices are considered to be relative contraindications. Benefits and risks should be considered carefully before MEP monitoring in patients with a relative contraindication. Sharing knowledge about adverse events associated with MEP monitoring and communication among monitorists, surgeons, and anesthesiologists are critical for successful monitoring of MEP and for safety.

Cerebrospinal disorder occurs with a certain frequency in thoracic descending aortic aneurysm surgery and thoracoabdominal aortic aneurysm surgery, with paraplegia being the most serious complication. In surgery where there is a risk that motor dysfunction will occur, it is important to preserve motor function after surgery by monitoring it during surgery. To that end, anesthesia management needs to be able to safely and appropriately record motor evoked potential（MEP）and evaluate its changes. We describe how to evaluate and respond to changes in MEP. In aortic surgery, use of extracorporeal circulation, cross-clamp, and hypothermia, etc. require attention in evaluating MEP. We also outline cerebrospinal fluid drainage, which is one strategy against paralysis. By sharing information on MEP monitoring and cerebrospinal fluid drainage, we aim to contribute to the anesthesia management of spinal cord protection in aortic surgery and to contribute to the improvement of patient prognosis.

The sugar-protein glycocalyx is known to coat the healthy endothelium, but its ultrastructure has not been well described. Scanning electron microscopy revealed that the endothelial glycocalyx layer in continuous and fenestrated capillaries was substantially thicker than that in the sinusoids. The endothelial glycocalyx in the heart and lungs presented itself as a broccoli- or moss-like structure and covered the entire luminal endothelial cell surface. In the kidney, it nearly occluded the endothelial pores of the fenestrated capillaries and was also present on the surface of the renal podocytes. In the liver sinusoids, it appeared very thin and did not occlude the pores. In a mouse lipopolysaccharide-induced experimental endotoxemia model, the endothelial glycocalyx of the capillaries was found to be severely disrupted；that is, it appeared to be peeling off the cells and forming clumps. The latter may provide a morphological basis for the microvascular endothelial dysfunction associated with septic injury of the organs.

Upper airway obstruction often occurs in patients receiving sedatives, opioids and muscle relaxant and can cause fatal respiratory complications. Since currently available respiratory monitors are unable to accurately diagnose upper airway obstruction, there is an urgent need to develop accurate techniques for monitoring upper airway obstruction. Nasal pressure measurement, which is routinely performed to detect upper airway obstruction in sleep medicine, can effectively monitor respiration and upper airway obstruction in perioperative and critical care medicine as well.

Autopsy imaging（Ai）is an examination procedure to identify causes of death using CT scan or magnetic resonance imaging. Ai is performed to prevent missing a crime or in cases where a medical-related death is suspected. However, Ai system is going to be socially accepted and more popular in the future. Because CT scan is already used throughout Japan, it is possible for anybody to have Ai anywhere. No other method for identifying causes of death is as effective as Ai. Ai will play a more important role in the medical accident investigation system in the years ahead.

Unlike civil judgments, not all of criminal medical judgments are publicized.

According to documents released by public organizations, a total of 444 defendants were indicted for professional negligence in criminal judgment from 1950 to the end of 2017. Of these 444 defendants, 127 were taken to court and 23 won acquittals. In contrast, for general crimes, the Public Prosecutors Office demand a judgement for 8.3% of the cases that they received, and 99.8% of the cases on trial were found guilty. In criminal malpractice cases, several judgments of acquittal were made recently over medical skills. However, the rate of acquittals has been relatively invariable during this period. Although the number of reports of malpractice by medical institutions made to police has been decreasing since 2015, 58 cases have been referred to medico-legal autopsy, and the possibility that malpractice could be brought to criminal judgment still remains. This article examines responses to malpractice claims by medical institutions.