A 33-year-old man presented to our emergency department with vaso-occlusive crisis after few days of worsening shoulder, back, and hip pain refractory to oral opioids. He was admitted to the intensive care unit with severe painful sickle cell crisis with no response to high doses of IV morphine and adjuvant analgesics. A ketamine（10 mg bolus and 0.2 mg/kg/h infusion）-midazolam（2 mg bolus and 1mg/h infusion）regimen was administered along with the opioids, after which the patient felt comfortable for the first time since admission. Ketamine was discontinued on day 9 of hospitalization and the patient was discharged on day 12. He could transit to oral opioids compatible with discharge. Low dose ketamine midazolam IV infusion might be effective in reducing pain and opioid requirements in patients with sickle cell disease with severe painful crisis.

A 60-year-old man was scheduled for total left pneumonectomy, wedge resection of the tracheal branch, and tracheoplasty for left hilar squamous cell carcinoma. Tracheoplasty was started after intubation in the surgical field and ventilation. The intubation tube was withdrawn immediately after ventilation was stopped, and the surgery was continued.

Adjustment of no-ventilation time was performed using oxygen reserve index（ORi^TM）, and ventilation was resumed at an ORi^TM of 0.2 or less.

The total no-ventilation surgery time was 17 minutes 50 seconds and the lowest SpO₂ during the no-ventilation surgery period was 94%. ORi^TM is the relative index of PaO_2, which is in the 100-200 mmHg range. This method allows clinicians to perform continuous and noninvasive monitoring of the oxygen status for patients with SpO₂ over 98%. Therefore, the method of hypoxemia prevention can be determined faster through this method than through pulse oximetry.

In conclusion, we were able to avoid hypoxemia by adjusting no-ventilation time using ORi^TM.

Endoscopic trans-sphenoidal surgery（eTSS）mandates mouth breathing postoperatively because gauze packing of bilateral nasal cavity is necessary for hemostasis. We report a female patient in her fifties with obstructive sleep apnea（OSA）treated with nasal continuous positive airway pressure（nCPAP）who underwent eTSS. Her height was 160 cm, body weight was 97 kg, and body mass index was 38 kg/m². After extubation in the operating room, she was re-intubated in a CT suit because of glossoptosis due to cerebral hemorrhage. Thereafter, the length of her hospital stay was prolonged due to hypoxic-ischemic encephalopathy. The risk of airway obstruction is high after eTSS. Nasal airway insertion may be effective for postoperative management of OSA patients treated with nCPAP who underwent eTSS.

We performed a retrospective study of patients who refused blood transfusions for religious reasons during 3 years. Except for one emergency case, all eight patients who underwent planned surgery signed a transfusion refusal and exemption from responsibility certificate. Estimated blood loss ranged from a small amount to 500 mL. Patients accepted transfusion of derivatives of primary blood components, such as a plasma substitute（eight patients）, albumin solution（seven patients）, and intraoperative blood salvage（two patients）. Blood loss during surgery ranged from a small amount to 350 mL. No patients received blood products. Because of the small amount of estimated blood loss, we did not perform any specific perioperative strategies to avoid blood loss. Patients who completely refuse any blood transfusion in life-threatening situations might be transferred to another facility. In such situations, physicians follow the guidelines that medical providers should respect the patient’s autonomy for transfusion-free treatment. In case of rapid, massive blood loss, proper counseling and dialogue are required to convince patients to accept a blood transfusion.

Optimal cuff pressure is essential to avoid aspiration after tracheal intubation. In rapid sequence induction, one cuff filling method is to inject a fixed volume of 10 mL air and adjust immediately afterwards. However, this does not always ensure adequate initial cuff pressure. The aim of this study was to evaluate the initial cuff pressure of tapered-cuff tracheal tubes after injection of 10 mL air in vitro. For tracheal models with internal diameters(i.d.)of 18 mm, 19 mm, and 20 mm, the initial cuff pressure of the tapered-cuff tracheal tubes(i.d. 7.0 mm and 8.0 mm)exceeded 99 cmH₂O after injection of 10 mL air. For the tracheal model with i.d. of 22 mm, cuff pressures were 57±7.8 cmH₂O(i.d. 7.0 mm)and, 69.7±5.1 cmH₂O(i.d. 8.0 mm). All studied combinations showed considerably higher pressure than the ideal value of 25 cmH₂O. For tapered cuff, 10 mL air might be excessive.

The incidence of local anesthetic systemic toxicity varies widely from report to report, but serious cases are rare. We should recognize that patients who undergo regional anesthesia may have clinical conditions that are vulnerable to local anesthetic systemic toxicity. Reduction of the local anesthetic agent to a minimum required dose, careful monitoring, and preparation for prompt treatment are essential. Lipid resuscitation is recommended for severe local anesthetic systemic toxicity. However, its evidence has not been established yet and there is controversy regarding the dose of epinephrine.

On rare occasions, benzocaine, propitocaine, and other local anesthetics bring about methemoglobinemia that presents desaturation or cyanosis refractory to oxygen administration. Diagnosis can be confirmed by CO-oximetry, and treatment with methylene blue should be commenced when symptoms appear or methemoglobin concentration exceeds 30%.

I worked at the German Pediatric Heart Center and Pediatric General Hospital in Germany for six years, between March 2012 and March 2018, as a board-certified anesthesiologist. I describe some of my experiences in clinical practice as well as in daily life in Germany.

First, I will introduce the documentation and certifications that were required to apply for the license to practice medicine in Germany. Then, I will describe a number of my actual experiences in clinical practice in Germany, some of which are unimaginable in Japan and may therefore be interesting for my anesthesiologist colleagues in Japan.

I hope the information can be helpful for my colleagues not only in the field of anesthesiology but in other fields as well, to get a feel for the atmosphere of clinical practice in Germany and to become motivated and challenged to experience it for themselves, in Germany as well as in other countries.

Although anaphylactic shock that occurs in the operating room is infrequent, it has to be dealt with promptly and appropriately because it is life-threatening if mishandled. Major causative agents are neuromuscular blocking agents and their antagonists and antibiotics. In addition to clinical symptoms, measurement of histamine and tryptase concentration in blood is useful for diagnosis. The first choice of drug treatment is adrenaline. Although the skin test is the gold standard for identifying causative agents, basophil activation tests that can be performed in vitro are promising tests. It is the anesthesiologist’s responsibility to identify the cause of the anaphylaxis since the patient may be at risk for anaphylaxis recurrence in the next surgery if the causative agent is left unidentified.

The Clinical Trials Act was implemented on April 1, 2018 in response to cases of data manipulation and conflicts of interest in clinical research. While maintaining a balance between promoting and regulating clinical research, the Clinical Trials Act sets minimum rules on the relationships among actors（authorities, clinical researchers, certified review boards, pharmaceutical dealers etc.）and clarifies procedures for clinical research to improve its quality. We would like to continue to improve the environment for clinical research to ensure its reliability.

Understanding the rights of patients is fundamental in modern medicine. Patients and their family members should be asked to participate in making decisions on medical procedures with the assistance of physicians and medical staff. In clinical studies, where drugs, medical devices and interventional techniques are tested prior to solid evidence and risk evaluation, accurate and carefully obtained informed consent is indispensable. Members of institutional clinical research review boards and ethics committees bear great responsibility when they evaluate clinical research protocols. In particular, the chairs of such committees should have ample knowledge regarding legal issues, economical support systems, social insurance refunding, etc, in addition to medical knowledge itself.

The Clinical Trials Act requires a lot of paper-work including on conflicts of interests and sets deadlines for submitting reports regarding unexpected adverse events etc. Due to the heavy responsibilities of investigators, the number of clinical trials has been dramatically decreasing. The clinical research center could play an important role in improving this situation. In the academic clinical research center at Osaka University Hospital, a brush-up meeting is carried out and application documents are examined before submission to the certified review board. If necessary, the meeting assists investigators in writing protocol in compliance with regulations. In addition, the meeting serves as a help desk for consultations, making protocols, and establishing research infrastructure. To promote clinical trials, the involvement of the clinical research center is essential.

We have performed more than 200 transfemoral（TF）transcatheter aortic valve implantations（TAVIs）under monitored anesthesia care（MAC）. At our institution, TF-TAVIs are generally performed under MAC. In some cases, however, we intentionally choose general anesthesia（GA）or switch from MAC to GA intraoperatively. Moreover, in some cases our decision to select MAC is questionable. Dexmedetomidine is primarily used for sedation and is occasionally used with ketamine. MAC is associated with more hemodynamic stability in patients than GA, but relatively deep sedation without a secured airway can sometimes lead to severe carbon dioxide retention. Therefore, strict monitoring of respiration is mandatory. Transthoracic echocardiography, instead of transesophageal echocardiography, is used in patients undergoing MAC. However, this choice can lead to delayed detection of complications and has a limitation in evaluating the aorta.

To deal with an increasing number of TAVI procedures, we changed anesthetic management from general anesthesia to monitored anesthesia care：MAC. This change enabled the number of same time interval to increase, and more stable vitals are achieved during procedure. In recent years, there have been some reports indicating the superiority of MAC over general anesthesia. This could be explained by generalization of growing use of the procedure or by getting used to the technique. More importantly, MAC could become the standard anesthetic care of TAVI in the near future.

The Building Standard Act, Fire Service Act, regulations for hospital safety, and guidelines for perioperative safety in Japan are insufficient for handling operating room fires, especially building and/or equipment fires. In this symposium, we discussed problems in revising these acts and regulations. Appropriate guidelines and education/training to deal with operating room fires were concluded to be necessary.

Operating room fires, which operating room staff including anesthesiologists are highly likely to encounter, are a very important risk management challenge. In the United States, the American Society of Anesthesiologists（ASA）and the Anesthesia Patient Safety Foundation（APSF）have issued guidelines, according to which educational opportunities to gain appropriate knowledge and skills are provided to health care providers in the field. In Japan, however, very few anesthesiologists participate in disaster drills conducted in hospitals and operating rooms. Few educational programs on operating room fire prevention and countermeasures are offered at present. As a result, extensive damage has been reported in rare cases of fire. Health care providers should remember that fire prevention and management are critical skills in operating rooms where patient safety is prioritized. It is essential to provide educational opportunities for health care providers to acquire skills in crisis management.

If a dry chemical powder extinguisher is used for operating room fires, the fine powder released from the portable extinguisher is scattered everywhere in the operating room. This can damage many electrical and mechanical devices. On the other hand, gaseous extinguishing agents like carbon dioxide cause no damage to electrical devices. However, carbon dioxide gas becomes toxic to the human body as its concentration increases. Therefore, the installation of carbon dioxide extinguishers in small spaces is regulated by the Japanese Fire Service Act. This paper provides basic information on the use of dry chemical powder fire extinguishers and carbon dioxide fire extinguishers in operating rooms and explains how to install carbon dioxide fire extinguishers in operating rooms.

At our institution, we reviewed our fire response in the operating room after experiencing a small fire that resulted from a short circuit of an operating light switchboard. To ensure the safety of patients, securing the safety of medical staff is a priority. To do that, it is essential to prepare an action card as an emergency response manual. As to the fire extinguisher to use in initially extinguishing fires, we should be aware of the effect on the human body and medical equipment of the existing ABC type powder fire extinguisher and consider deploying safer water-based fire extinguishers as well.