The dose of intravenous patient-controlled analgesia（IVPCA）using fentanyl was retrospectively evaluated in 50 patients who underwent total laparoscopic hysterectomy（TLH）. Patients were divided into two groups（high- and low-dose group）according to the median dose of fentanyl administered. The background infusion rate of fentanyl was lower in the low-dose compared to the high-dose group（0.27±0.05 µg/kg/h vs. 0.37±0.04 µg/kg/h, p<0.01）, and fentanyl consumption was significantly less in the low-dose group during the first 24 hours postoperatively. The incidence of postoperative nausea and vomiting（PONV）was less in the low-dose compared to high-dose group（12% vs. 40%, p=0.02）. However, there was no significant difference in the requirement for bolus PCA or rescue analgesics；pain scores, assessed using the numerical pain rating scale, were also similar. In patients undergoing TLH with IVPCA, a background infusion rate of fentanyl 0.27 µg/kg/h was sufficient to provide effective analgesia, with decreased incidence of PONV.

We experienced a case of ventilation difficulty after intubation due to tracheal diverticulum caused by radical surgery for esophageal atresia/tracheoesophageal fistula repair. The patient was a seven-month-old male infant. Esophageal stricture was found after radical surgery for type C esophageal atresia, so an esophageal balloon dilatation under general anesthesia was scheduled. Tracheal intubation was easily accomplished after general anesthesia was induced, but audible breathing and chest movements were not detected after manual ventilation, so extubation was performed and mask ventilation initiated. Similar ventilation difficulties occurred after re-intubation, but ventilation became possible with a shallow intubation. Upon further investigation using bronchoscopy, it was determined that the ventilation difficulty had been caused by the tip of the tracheal tube straying into a posterior tracheal wall diverticulum. Tracheal diverticulum, which is a complication of radical surgery for esophageal atresia/tracheoesophageal fistula repair, should be considered as a potential cause of ventilation difficulties following intubation.

We encountered a patient whose Neurological Pupil index（NPi）decreased to zero without change in rSO₂ when perfusion in the left subclavian artery was stopped for anastomosis during selective cerebral perfusion. INVOS^TM（Covidien, Boulder, CO, US）is mainly attached on the forehead and rSO₂ represents the local oxygen saturation. Because of these characteristics, it is reportedly unsuitable for detecting decreased perfusion in the basilar artery region. In contrast, NPi, an independent indicator of a pupil recorder（NPi^®-200, NeuroOptics）, objectively evaluates the pupillary light reflex and represents the function of the brain stem through the cranial nerves II and III. In the present case, stenosis of the right vertebral artery was originally present. Perfusion of the basilar artery was believed to have decreased when perfusion of the left subclavian artery was stopped for anastomosis. At that time, only NPi decreased. We report that NPi could be used to monitor perfusion of the basilar artery region.

A 34-year-old woman 36 weeks into her twin pregnancy underwent an emergency cesarean section due to premature rupture of the membrane after spinal anesthesia. She had no remarkable abnormalities or cardiorespiratory symptoms during her perinatal period. Immediately after the delivery of the second twin, she nearly developed cardiac arrest. Quick action and cardiopulmonary resuscitation allowed her to recover within minutes, and she was transferred to the intensive care unit after the cesarean section. Echocardiography showed a markedly enlarged right ventricle, and catheterization of the pulmonary artery revealed pulmonary hypertension. The patient was diagnosed with idiopathic pulmonary artery hypertension. However, 10 months later, she was diagnosed with systemic lupus erythematosus. Authors believe that the pulmonary artery hypertension was accompanied with connective tissue disorder.

Congenital insensitivity to pain（CIP）is an extremely rare disease characterized by the loss of nociception mainly in the extremities. There is no consensus regarding the safety of anesthesia or the intraoperative analgesic needs of patients with CIP. We administered general anesthesia to a 49-year-old man with CIP undergoing total knee arthroplasty. We anesthetized the patient with total venous anesthesia using propofol and remifentanil. We measured the patient’s plasma concentration of adrenaline, noradrenaline, dopamine, and cortisol as stress hormones during and after anesthesia. In this case, a low dose of remifentanil could stabilize the hemodynamics and concentration of stress hormones. The response other than nociception induced by noxious stimuli, such as the autonomic reflex and stress hormone release, could also be attenuated. Therefore, patients with CIP need more optimized management of anesthesia.

Opioids are very useful for tracheal intubation, but they carry risks of glottic closure and muscle rigidity. In awake intubation, these complications can lead to serious or even fatal outcomes. We encountered a case of mild masseter muscle rigidity during awake intubation under remifentanil（0.1 μg/kg/min）. Muscle rigidity occurs in 2-8% of cases of remifentanil administration；high dosage and rapid injection of opioids are risk factors. In this case the dose was comparatively low, but muscle rigidity occurred. When using opioids for awake intubation, clinicians must bear in mind that muscle rigidity can occur before loss of consciousness.

In this study, we retrospectively investigated whether or not intraoperative sedation by dexmedetomidine（DEX）improved sleep disorders after urological surgery. Patients were classified into two groups based on the sedatives used in combination with spinal anesthesia：DEX group（n=73）and midazolam（MDZ）group（n=54）. The number of patients who used sleep-inducing drugs on the day of surgery in the DEX group（n=5）was significantly less than that in the MDZ group（n=13）. The result suggests that DEX could reduce the postoperative sleep disorders even though it is used only during surgery.

About forty years have passed since the arrival of the supraglottic airway device（SGD） “laryngeal mask airway”. The strongest advantage of the SGD is to be able to perform airway management rapidly compared with other new airway devices. In addition, the SGD can be inserted easily and ventilated in all situations. In the future, an evolution of the SGD must be performed and provided safe airway management.

Scavenging and non-scavenging（direct）effects are suggested as mechanisms for treatment of local anesthetic systemic toxicity by lipid emulsion. Scavenging effect was formerly called lipid sink, where lipid emulsion uptakes local anesthetics, reduces their concentration in the brain and in the heart, and transports them to the liver for facilitating elimination from the circulating blood. Direct effects include volume effect, an increase in energy supply to the heart, protective effect of mitochondria, and improvement of insulin signaling. The American Society of Regional Anesthesia revised the“Checklist for treatment of local anesthetics systemic toxicity”in 2017. Although the administration regimen of lipid emulsion has not changed for patients ≤ 70 kg, bolus 100 mL over 2−3 min, followed by 200−250 mL of 20％ lipid emulsion over 15−20 min is recommended for patients ≥ 70 kg. The maximum dose is 12 mL/kg. Lung injury and pancreatitis are typical complications by lipid emulsion, although their incidence is low. Blood tests to examine serum amylase and lipase are recommended after administration of lipid emulsion for resuscitation.

It is generally assumed that perioperative short-term mortality and morbidity of patients is greatly affected by preoperative physical status and intraoperative management of patients, but does anesthetic management really have an impact on the long-term prognosis or life prognosis of surgical patients? In cancer treatment, surgical resection is a mainstay of therapy, but it is undeniable that dissemination of cancer cells to adjacent organs and tissues and suppression of cellular immunity associated with surgical stress may result in cancerous metastasis and recurrence. If differences in anesthetic technique and management accelerate immune suppression and incidence of the recurrence of cancer, anesthesiologists should become sensitive to this fact and try to manage anesthesia giving full consideration to patients’ prognosis. Ensuring perioperative patient safety is a primary mission of anesthesiologists, but we have to broaden our vision to patient’s long-term life prognosis as well.

Acute postoperative pain mainly consists of tissue injury-induced inflammatory pain, and inadequate analgesia is linked to the incidence of chronic post-surgical pain. In addition to the immunosuppression caused by surgical stress in the postoperative period, inhaled anesthetics and opioids have immune-suppressive effects, implying that the use of these agents may inhibit acute inflammation and the wound-healing process, resulting in infection and delayed wound repair. The correlation between the development of postoperative pain and immunosuppression and the impact of postoperative analgesia in the outcome have been indicated in recent years.

Recent research findings have suggested the significance of perioperative management including anesthesia on cancer prognosis. Considering that the time to cancer relapse is usually more than a year, or at least months, those results are improbable at a glance because the perioperative period is quite short. However, various laboratory studies have recently revealed that the perioperative period is a “special time” that has a major impact on the growth of cancer. In this review, we explain the theoretical background as to why the perioperative period is considered to be special and introduce the results of representative experimental and clinical studies, as well as suggest ideas regarding what anesthesiologists can actually do to improve cancer prognosis.

【Introduction】Outlines regarding guidelines of in-hospital medical response to mass casualty incident（MCI）in United Kingdom（UK）and recent experience of MCI in France are introduced. 【UK guidelines】MIMMS（Major Incident Medical Management and Support）guideline provides key conceptions concerning the priority at the time of surge capacity of operation room（OR）. 【In-hospital responses to the terrorist attacks in Paris in November 2015】 Pitié Salpêtrière University Hospital performed simultaneous surgical operation in up to 10 in 13 ORs in 23 traumatized patients. 【Conclusion】 Not only the reception sections but also the OR response plan to MCI can mitigate confusion in an actual case.

We classify disasters into 2 types：compensated and uncompensated disasters. We are able to continue our regular medical practices during a compensated disaster. Beyond our medical capacity, that is, under uncompensated disasters, we can not perform the medical services demanded. It is very important that we previously understand the vulnerability of our own facilities and equipment for a disaster, and that we ask ourselves questions about our business continuity strategy and overall needs. We should not just create our organization’s business continuity plan（BCP）but also individual BCP. Your own BCP helps you with your best practice for any disasters.

We have a social security system for health care in Japan. That system has to be changed. It was created in the 1960’s without taking into account an aging society with a low fertility rate. The system is not appropriate for a modern and future society. The medical service insurance system which is part of the social security system is changing from a hospital-contained to an area-contained type based on the importance of the value of the medical service, meaning the quality of medical service divided by cost.

It is important for anesthesiologists to work as members of acute medical service today and in the future. Therefore, we have some strategies for providing patients the safe and effective one at ward, emergency outpatient, intensive care unit and operating room. For example, medical staffs consisted of multiple specialists in the operating room and intensive care unit, preoperative outpatient consultant, ERAS（enhanced recovery after surgery）.

Given the tight insurance finances associated with Japanese medical care, ongoing improvements in medical productivity are needed. Physicians and patients will be encouraged to make medical decisions with cost-effectiveness in mind. When discussing productivity within the disciplines of anesthesia and surgery, it is essential to separate technological productivity from organizational productivity. The medical economics of anesthesia and surgery are discussed as “Clinical practice productivity（Performance：cost-efficacy of such as surgery or drug therapy）× Organizational management productivity（Volume：Market factors like number of cases and operating rate）= Economic impact（Socioeconomic significance）.” The former contributes to the medical fee system, and the latter relates to hospital management strategies. Future medical system reforms should consider the balance between both elements.

Our institution is the School of Medicine at a private university, and the university hospital generates far more revenue than the total amount of student fees and subsidies. High proportions of the hospital revenue are from surgical procedures and intensive care. Through efficient management of operating rooms, the number of operations has increased, which has greatly contributed to the university management. Today, the operating rooms play an important part in the business of running the university.

On the other hand, payments for surgical procedures and intensive care are calculated based on the diagnosis procedure combination（DPC）system. Many institutions have increased the number of operations through effective use of operating rooms and implemented an ingenious measure to shorten the lengths of inpatient hospital stays without compromising patient safety. However, the recent increase in the demand for minimally-invasive surgery - such as robot-assisted surgery and the use of hybrid operating rooms - has presented new challenges to efforts to increase operating room efficiency and manage patient safety. In connection with minimally-invasive procedures, the efficiency and safety of the operating room as a whole are required more than ever, and economical efficiency should also be considered.

Preoperative management in the anesthesia outpatient clinic has become popular in Japan. At the anesthesia outpatient clinic, it is required to obtain appropriate informed consent from the viewpoint of medical safety for various anesthetic subjects. The procedure to obtain informed consent from the patient and family requires a number of steps such as preparation/consent formulation, printing, signature, digital scanning and so on. We recently introduced a digital paper^TM（Sony, Japan）for acquiring informed consent in the anesthesia outpatient clinic. In this review, we present a new way to perform paperless preoperative anesthesia management.

In recent years, the introduction of perioperative management team project has started. This time, on attitude survey was conducted to consider job type configuration and how to proceed with the perioperative management team. As a result, 32% people did not know about the perioperative management team. Next, respondents answered several types of work such as anesthesiologists, nurses, surgeons, clinical engineers, pharmacists, dentists and clerks. Among them, the indicators of work could be realized immediately were highly selected. In addition, regarding the image of the nurse anesthetists, assistance work under the direction of the anesthesiologist were expected. In the future, it will be desirable to clarify the definition of the perioperative management team and standardize the role and cooperation of each work type.