A 76-year-old woman underwent an emergent Bentall procedure. Once deep hypothermia was achieved, retrograde cerebral perfusion was initiated through the superior vena cava cannula. However, the central venous pressure remained unchanged, and a gradual drop in cerebral oxygen saturation was observed on the left side shortly after initiation of retrograde perfusion. The retrograde flow was increased without any change in the central venous pressure. Mechanical causes such as cannula malposition and impaired oxygenation due to defective cardiopulmonary bypass were excluded. Transesophageal echocardiography revealed an enlarged right atrium and right ventricle. The left regional cerebral oxygen saturation eventually decreased from 73% to 27%. The total retrograde perfusion time was 26 minutes and the procedure was otherwise uneventful. The patient was discharged on postoperative day 16 without any neurological complication. Postoperative computed tomography revealed a partial anomalous pulmonary venous connection from the left upper pulmonary vein to the innominate vein.

Tracheal deviation is often recognized in preoperative radiography. Although most of these cases are asymptomatic, mediastinal shift and rotation occasionally cause airway compression. We report our experience in the management of right bronchial stenosis aggravated by left upper lobectomy.

Preoperative chest radiography in a 71-year-old woman with lung abscess of the left upper lobe revealed destruction of the left upper lobe and tracheal displacement to the left. Chest computed tomography and fiber bronchoscopy showed right bronchial compression from the vertebral body, and sleeping difficulty in the supine position was observed. The induction and maintenance of anesthesia were uneventful, but postoperatively there was a sudden rise in airway resistance and a marked decrease in tidal volume while in the supine position. Fiber bronchoscopy showed exacerbation of right bronchial compression. We hypothesized that the left upper lobectomy aggravated the tracheal deviation and right bronchial stenosis. Because the right bronchus was compressed from posterior to anterior, we moved the patient to a sitting position and reversed neuromuscular blockade, which resulted in decreased airway resistance and adequate ventilation. Anesthesiologists should be aware that tracheal deviation can cause airway stenosis, and that preoperative evaluation and airway management therefore require careful consideration.

Droperidol was administered in a 29-year-old ovarian carcinoma patient undergoing laparotomy under general anesthesia twice to prevent postoperative nausea and vomiting. For the first operation, in addition to intravenous single-dose administration during the operation（1.25 mg）, intravenous intermittent administration was performed using intravenous patient-controlled analgesia until postoperative day 3（total 10 mg）. For the second operation, intravenous single-dose administration during the operation（1.25 mg）and postoperative continuous epidural administration until postoperative day 2（total 3.53 mg）were performed. Extrapyramidal symptoms did not develop after the first operation but developed after the second operation. There is a possibility that epidural droperidol administration causes extrapyramidal symptoms at a dose lower than that for its intravenous administration.

We retrospectively studied the reasons for cancellation of elective operation within two days preoperatively, except the cases younger than 20 years, for obstetrics and emergency surgery from January 2011 to December 2016. During the observation period, 1,036 cases were cancelled. Reasons for cancellation were “deterioration of patient condition” or “change in the indications of the operation” in 578 cases. “Personal schedule change in either surgeon or patient” was the reason in 284 cases. “Reasons related to preoperative assessment” was cited in 92 cases and reasons were “unknown” in 82 cases. Among the preoperative-related reasons, the number of insufficient risk assessments decreased. On the other hand, the number of failures in cessation of medication were static. Perioperative pharmacists are not stationed in our center. To reduce the cancellation of operations, a station of a pharmacist in our perioperative management center is necessary.

V-A ECMO（extracorporeal membrane oxygenation）has been utilized in the treatment of refractory cardiogenic shock and cardiac arrest. For those who remain dependent on ECMO, VAD（ventricular assist device）or central ECMO should be applied at the appropriate time to prevent and treat multiple organ failure.

We investigated clinical outcomes of cardiogenic shock patients treated with V-A ECMO with in the previous five years（n=69）. ECMO could be weaned off in 22（31.9%）patients, while VAD or Central ECMO was applied to 16（23.2%）patients. Thirty-one（44.9%）died on ECMO. Depending on the presence or absence of pulmonary congestion, right ventricular failure or organ dysfunction, different types of VAD/central ECMO were applied. As a result, acute phase organ dysfunction could be resolved before switching to long term mechanical circulatory support in survivors.

The issue of extracorporeal membrane oxygenation in patients with complex congenital heart disease is indispensable for discussing ECMO in the pediatric population. Although a clear consensus is lacking on the proper indication of ECMO in this population, induction of ECMO should be considered earlier when hemodynamics are unstable to avoid circulatory collapse. Hemorrhagic complication is not rare and should be treated with supplemental treatment according to its etiology. Aggressive systemic ventricle decompression should be considered for better and earlier systemic ventricle functional recovery. Better ECMO management in patients with characteristic single ventricle of complex congenital heart disease requires a better understanding of the unique physiology of patients with single ventricle, and ECMO management specific to the physiology of each patient is required.

Awake craniotomy is primarily performed for the resection of a brain tumor encompassing the eloquent cortex, including the language and motor areas. Awake craniotomy facilitates live intraoperative speech and motor monitoring with the primary objective of maximum tumor resection and the preservation or enhancement of complex brain function. Currently, the asleep-awake-asleep method using general anesthesia before and after live brain function monitoring and the awake-awake-awake method using conscious sedation without invasive airway devices through the operation comprise the main anesthetic techniques for awake craniotomy. Both anesthetic techniques require an understanding of monitored anesthesia care（MAC）, a concept defined as “a specific anesthesia service for a diagnostic or therapeutic procedure that may include varying levels of sedation, analgesia and anxiolysis as necessary”. The provider of MAC must be prepared and qualified to convert to general anesthesia when necessary.

In this article, we provide an outline of MAC in awake craniotomy and discuss its advantages and precautions in its implementation.

Monitored Anesthesia Care（MAC）refers to systemic patient management performed under surveillance by an anesthesiologist intraoperatively as well as during examination and treatment. The three-fold objective of MAC is safe sedation, alleviation of anxiety, and pain control. The proper application of MAC leads to an increase in patients’ satisfaction as well as faster recovery and return to activity.

At our institution, many cases of orthopedic surgery are performed under MAC, primarily involving regional anesthesia and sedation. The most common example of such management is that used for patients undergoing shoulder joint surgery. Herein, we introduce a method of MAC for application during surgery to repair a torn rotator cuff.

Intravenous sedation, monitored anesthesia care（MAC）, is often applied to dental patients with dental fear and/or anxiety about dental treatment. Dental treatment is characterized by the following features：the treatment field and airway are secured at the same site, water is used in the oral cavity, most subjects are outpatients, and patients repeatedly receive a series of dental treatments in a short period. Therefore, special care is necessary when conducting sedation in dentistry to ensure safety. For these reasons, the Japanese Dental Society of Anesthesiology recently published Practice Guidelines for Intravenous Conscious Sedation in Dentistry（Second Edition, 2017）. These guidelines were edited in accordance with the procedural manual for evidence-based medical care of the Working Group of the Society, consisting of board-certified dental anesthesiology specialists. The purpose of these guidelines is to help patients who cannot receive standard dental treatments receive appropriate dental treatments by undergoing safe and effective intravenous conscious sedation. In the present article, I provide a brief outline of the guidelines and discuss essential concepts of sedation, the various purposes of sedation, and the method and level of sedation depending on individual purposes.

Although there are many indications of pediatric monitored anesthesia care（MAC）such as cardiac catheterization, MRI, gastrointestinal endoscopy, and renal biopsy, anesthesiologists are able to provide MAC only to a few children due to the lack of manpower. In fact, the pediatrician or physician in charge is often called upon to provide sedation during an examination or procedure. As a result, the patient’s safety and comfort are compromised, and problems with the accuracy of the examination may occur. General anesthesia with tracheal intubation is preferable to deep sedation in cases of pediatric cardiac catheterization because the patient’s arterial CO₂ may be controlled more easily. In some cases, sedation or general anesthesia may be more risky than the examination or procedure itself, so it is important to discuss the need for the examination with the physician in charge before performing it. For high-risk anesthesia cases, the availability of an anesthesiologist is also very important.

Various types of ultrasound-guided thoracic wall nerve blocks have been described. In performing thoracic wall nerve blocks, a particular muscle plane or fascia where local anesthetic should be injected needs to be identified instead of the nerve or plexus, and care should be paid to avoid pneumothorax and vascular injury. In this article, tricks and tips for thoracic paravertebral block using intercostal in plane approach and Pecs block are described.

The popularity of abdominal wall blocks has dramatically increased in recent years. Anesthesiologists are changing from thoracic epidural analgesia to peripheral nerve blocks as a postoperative pain management tool due to increasing use of minimally invasive laparoscopy and widespread use of postoperative anticoagulation therapy. Initially, transversus abdominis plane（TAP）block was introduced with the technique of ultrasound guidance. Many blocks, such as subcostal TAP block and quadratus lumborum block, are used to obtain extensive abdominal analgesia compared to TAP block. This review describes the applied anatomy of the abdominal wall and basic technical considerations of these blocks.

Continuous nerve block has advantages with providing good analgesia, patients’ satisfaction, and fast recovery from surgery. However, dislodgement of the catheter tip and leakage of local anesthetics（LA）from the insertion point may decrease its analgesic effect. Cyanoacrylate glue makes it possible to fix the catheter in place without leakage.

Recently, we have selected various type of catheters for continuous nerve blocks, but each catheter has characteristic ways of spreading injectate, fixation, and handleability of catheterization.

We should choose continuous or intermittent LA infusion based on the type of catheter selected.

Kurashiki Central Hospital is a large-scale general hospital with 1,166 beds and 29 operating theaters, with 59 junior residents employed in 2017. In 2012, we experienced a large drop in anesthesiologists due to retirement, which necessitated drastic reform of operating theater management methods and the working conditions of anesthesiologists in order to increase staff numbers.

We undertook a questionnaire targeted at senior residents about their reasons for selecting an education hospital, which showed that there was an emphasis on positive working relationships with colleagues in addition to the contents of the senior residency program. This suggests that we should teach junior residents not only the skills of anesthesia, but the general anesthesiologic perspective and viewpoints.

Here we report on the application of educational technology to improve the simulation-based sedation training course（SEDTC）hosted by the Japanese Association for Medical Simulation and discuss the significance of interprofessional training for practical medical safety improvement. SEDTC consists of lecture, basic airway management, sedative and analgesic discussion, patient sedation depth evaluation, and scenario-based training. However, merely participating in the SEDTC can achieve level 1（reaction）or level 2（learning）in the Kirkpatrick model. Medical safety improvement of level 3（transfer）or level 4（result）in the Kirkpatrick model can be achieved when all members involved in sedation undergo experiential learning and achieve consensus. To achieve level 3 or 4 in the Kirkpatrick model, we added a questionnaire and discussion to determine which points require improvement, both for particular individuals and for the medical safety system.

Yoshiharu Habu, a famous shogi player, wrote in his book that imagination accepts the phenomena that will occur in the future and realize them, and that the creative power is a kind of idea that makes imagination work and realize something concrete. The product of the creative power that made imagination act on navigation systems and robotics becomes a fully automatic endotracheal intubation system. However, evolution of medical technology does not always guavan tee the medical safety, so DAM training will be necessary in the future. When we imagine the future of DAM training and create it, it is necessary to design both a course for airway management in non-prospective medical care such as in emergency departments and for airway management in prospective medical care such as operating room anesthesia.

Since beginning the first High-Performance Patient Simulator（HPS）Workshop in multi-facility participation in Osaka in December 2002, 28 workshops have been held under the Japanese Association for Medical Simulation. The HPS technological backbone developed in 1995 is based on a physiological model constructed on a computer using a manikin as a man/machine interface, but in recent years transformational changes have been made with using techniques such as a remote simulation lecture（TelSim）by the development of high-speed Internet communication, an addition of augmented reality（AR）to HPS, a simulation under the virtual reality（VR）environment. As one of the topics behind these technologies, we will present an imaginative thinking towards the future of the HPS.

The central venous catheterization（CVC）seminar teaches ultrasound-guided techniques and includes simulator training. It was developed with the purpose of eliminating complications due to central venous puncture. However, those who have completed the CVC seminar have not been able to contribute sufficiently to patient safety in hospitals. In order to utilize the skills acquired by CVC seminar experts clinically, the seminar needs to be changed. The three points of focus in changing the seminar are outcomes-based education, self-learning system, and patient safety assurance. This report documents the changes to the CVC seminar that are underway.

Although most medical staff recognize the risk of sedation, an effective educational training course has not been developed. In March 2018, “Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018：A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia” were developed by the American Society of Anesthesiologists. The guidelines emphasize preparation of sedation, monitoring including capnography, sedation person in charge and rapid response system, principle of sedative and analgesic administration, and evaluation after sedation. The sedation committee of the Japanese Association for Medical Simulation plans to improve simulation-based training courses to enhance moderate sedation safety.