Deep neck abscess causes cervical swelling, swallowing difficulty and opening disorder and becomes a severe emergency life-threatening disease when the inflammation reaches the mediastinum. In addition to antimicrobial drug administration, abscess incision and drainage under general anesthesia is often required early, but airway condition should be evaluated in advance and considered before induction. Between August 2017 and April 2018, six adult patients（2 men and 4 women）underwent general anesthesia for deep neck abscess incision and drainage. Three patients underwent nasal intubation while conscious due to opening disorder and upper airway narrowing, with one being orally intubated while conscious and two being orally intubated under general anesthesia. A flow chart in our hospital was created focusing on the results of these six patients with or without an opening disorder and upper airway narrowing.

A 20-year-old woman with fever and general fatigue was transferred to our intensive care unit because of pancytopenia, liver and kidney dysfunction, and disseminated intravascular coagulation. She was diagnosed with hemophagocytic lymphohistiocytosis（HLH） according to the HLH 2004 guidelines. Virological tests on admission indicated a high serum Epstein-Barr virus（EBV）load, and she was diagnosed with EBV-associated HLH on the 4th day. Administration of high dose methylprednisolone, continuous hemodiafiltration（CHDF）and plasma exchange（PE）was initiated. Despite the treatment, her condition deteriorated and she was intubated and ventilated mechanically on the 7th day because of alveolar hemorrhage. After implementing etoposide in accordance with the HLH 2004 guidelines on the 8th day, her condition started to improve. She became free from mechanical ventilation and PE on the 13th day and from CHDF on the 14th day and recovered without subsequent sequelae. Prompt initiation of etoposide and cyclosporine was important for refractory adult EBV-associated HLH.

An 80-year-old woman was scheduled for total aortic arch replacement and thoracic endovascular aortic repair（TEVAR）to repair chronic type B aortic dissection with thrombosed false lumen. Cerebrospinal fluid drainage（CSFD）was inserted without difficulty before general anesthesia for TEVAR because of high risk of spinal cord ischemia. The cerebrospinal fluid was transparent at the start of drainage and became bloody after systemic heparinization temporarily during surgery. On postoperative day 2, CSFD was removed. At that time, coagulation studies were within the normal range but platelet count was 48,000 per microliter. That night, leg and low back pain occurred and became progressively worse. Paraplegia occurred on postoperative day 4, and magnetic resonance imaging examination of lumbar spine demonstrated hematoma compressing the cauda equine, so she was taken for emergency laminectomy. Almost all of the hematoma was in the subdural space. After the surgery, paraplegia gradually improved.

Among patients with aortic valve stenosis（AS）, left ventricular outflow tract obstruction（LVOTO）due to myocardial hypertrophy and left ventricular outflow tract obstruction（LVOTO）after aortic valve replacement（AVR）, there are cases in which systolic anterior movement（SAM）remains in the systolic mitral valve. In addition to AVR in consultation with the surgeon in cases with cardiac muscle hypertrophy due to AS, Morrow surgery was added in case 1, and papillary muscle bundle resection was added in case 2. As there are no clear standard indications for Morrow surgery and papillary muscle bundle resection, accurately determining flow velocity of the left ventricular outflow tract on preoperative transthoracic echocardiography（TTE）and intraoperative transesophageal echocardiography（TEE）is important for predicting the risk of LVOTO and SAM. Decisions regarding the type of operation should be made in consultation with the surgeon based on the findings in the hypertrophic myocardium.

【Back ground】There is no established means to identify pre-operative smoking patients and confirm smoking status.

【Materials and Methods】We investigated whether exhaled carbon monoxide（ExCO）can be measured from smoking intubated patients using a breath carbon monoxide（CO）concentration measuring device.

【Result】CO was detected in 85（88.5%）of 96 patients. Preoperative admission days were significantly correlated with ExCO value, but Brinkman Index and days from anesthetic consultation to surgery did not significantly correlate with ExCO values.

【Conclusion】Measurement of ExCO concentration could be useful for determining the smoking status of surgical patients.

The Clinical Practice Guidelines for Chronic Pain（published in 2018）describe pharmacotherapy, interventional treatment（IVT）, psychosocial approach, and rehabilitation in the management of chronic pain and recommend a multidisciplinary approach that integrates perspectives from different disciplines.

When performing IVT, including nerve block, it is important to determine the cause of pain and provide treatment with consideration to each patient’s condition.

IVT, including nerve block, is useful in pain management. We believe that it contributes to early improvement of chronic pain, and that its inclusion can provide an opportunity to establish multidisciplinary therapy, which is usually performed in a pain clinic setting.

The key anesthetic strategy that accelerates aggressive rehabilitation after major abdominal surgeries consists of the following four elements：1. Epidural anesthesia, 2. Administration of drugs against systemic inflammatory response syndrome, 3. Volume therapy based on hydroxyethyl starch solution, and 4. Deep neuromuscular block. Aggressive rehabilitation helps the patient regain health and sustain exercise immediately after major abdominal surgery, which may possibly lead to improvement of long-term prognosis.

Blood transfusion has gradually become safer, though it is still associated with complications such as immune reactions and transfusion-associated circulatory overload and prognosis. The patient blood management（PBM）program allows avoidance of allogeneic blood transfusion as much as possible. In PBM, preoperative assessment of anemia, iron deficiency, and antithrombotic therapy are performed, followed by correction of anemia and coagulopathy. To minimize intraoperative blood loss, surgical strategy and anesthetic management should be considered beforehand. To reduce postoperative bleeding, it is important to maintain and monitor body temperature as well as oxygen levels and proper drug interventions, if necessary. Even if blood transfusion is inevitable, appropriate and minimum transfusion should be considered in such cases.

Autologous blood is the best blood transfusion therapy for avoiding allogeneic blood transfusion-related adverse effects. The methods commonly used to obtain autologous blood during the perioperative period can be initiated prior to the operative procedure（autologous preoperative donation, hemodilutional autologous blood transfusion）or during surgery（cell scavenging）. Hemodilutional autologous blood transfusion（HAT）involves the controlled removal of whole blood immediately prior to the operation and has many advantages including a lack of burdensome preparation, maintained coagulability and platelet function in the withdrawn blood, and usability even in patients with malignancy or infection. In addition, combining two or more methods can increase the probability of avoiding allogeneic blood transfusion-related complications. Since the 1990s, we have actively promoted the selection of HAT as the first choice for blood transfusion therapy in patients expected to experience a large amount of blood loss during scheduled surgery at our hospital. As of 2008, approximately 90% of surgical patients with hemorrhaging of <2,000 g and 40% of patients with blood loss between 2,000 g and 3,000 g were able to avoid allogeneic blood use. The safety of allogeneic blood transfusion has improved dramatically in recent years, making it possible to avoid HCV, HBV and HIV infection, but transfusion-related acute lung injury still has a high mortality rate, and managing immunomodulation-related recurrence remains a challenge. Recent improvements in hemostasis as well as minimally invasive surgical techniques and high-functioning surgical energy devices may reduce or even eliminate the need for autologous blood transfusion including HAT in the future.

On entering the 21st century, coagulation management that includes fibrinogen has increasingly been regarded as important. Japanese antifibrinolytic therapy has contributed to reduction in blood transfusion around the world. Although there are many reports of blood transfusion reduction by the blood transfusion algorithm in cardiovascular surgery, there have been few in general surgery. In general surgery, the need for fresh frozen plasma is related more to a reduction of fibrinogen than the amount of bleeding. To reduce unnecessary blood transfusions, we have developed clinical simulation systems to predict reduction of fibrinogen according to bleeding volume, and we have stratified a starting amount of fresh frozen plasma near the trigger level（130 mg/dL）. In emergencies, the “dry hematology” method is useful for measuring fibrinogen（5 minutes）. It is very important to feedback the information obtained from clinical reports and studies toward patient blood management.

We considered the anesthesiologist’s social standing in view of past revisions of anesthesia fees under the National Medical Insurance System.

Anesthesiologists are evaluated based on the services they provide and the expectations the public has of them. The basic anesthesia fee, namely general anesthesia（L008）, which was valued at 1 in 1986, had greatly increased to 1.74 in 2002.

However, recent harm to the anesthesiology profession, probably attributable to the misbehavior of some anesthesiologists, resulted in a reduction in the basic anesthesia fee from 1.74 to 1.71, with the reduced portion assigned to other specific anesthesia services.

Anesthesiology covers an extremely wide field and involves an extremely heavy responsibility, and to continue meeting the public’s expectations, it is necessary to increase efficiency while ensuring safety. It means that the range of procedures that anesthesiologists should perform and those delegated to assisting staff members should be clearly defined.

Such a system would allow smooth teamwork among medical professionals in the peri-operative team and help the team adapt to future changes.

The social standing of anesthesiologists in Japan was historically reviewed. In 1960, Anesthesiology was accredited as a specially approved medical specialty for approving registered anesthesiologists. Exclusive training for more than two years under an adequate mentor is required for candidates to be qualified as registered anesthesiologists. In 1962, the Japan Society of Anesthesiology（JSA）established a system to qualify board-certified anesthesiologists as proper mentors responsible for the training of candidates. The society launched the first qualification system in the history of medical practice in Japan. Although the system contributed to greater recognition from the medical community, public recognition of the system and board-qualified anesthesiologists has not been adequately achieved. The JSA should provide to society authentic information about anesthesiology and anesthesiologists.

Although the number of anesthesiologists has steadily increased in Japan, the shortage of anesthesiologists remains a problem. There are still many surgical cases whose general anesthesia is performed by a surgeon. Anesthesia by surgeon can hardly be standardized, and the levels of anesthetic technique and knowledge may vary among surgeons. Anesthesia by surgeon may, therefore, tend to become insufficient for promoting perioperative patient safety and team-oriented medical practice. To ensure the quality of anesthesia, anesthesiologists should train surgeons who continue to practice anesthesia in clinical anesthesia and help them study updated anesthesiology. Such support and cooperation from anesthesiologists may contribute to improving the social standing of our profession. On the other hand, if surgeons perform anesthesia in order to increase their own income, this needs to be dealt with in some way including institutional regulations at the academic society or government level.

Japan, faced with a low birth rate and a super-aging society, must improve its social security sustainability. The medical community needs to assist in this effort by promoting various reforms based on professional autonomy, such as role-sharing between public and private hospitals, promotion of the use of primary care physicians（“kakaritsuke physicians”）, optimization of the national medical expenditure, and efforts to extend healthy life expectancy.

These efforts call for enhanced professional autonomy among anesthesiologists. The tax withheld on the referral fee for the so-called “anesthesiologist dispatch service” is one source of social security revenue. Various efforts by academic societies are underway to earn and ensure trust from the public and the medical community and to realize sustainable social security, but the key issue here is for anesthesiologists to develop more professional autonomy. Having self-discipline will be an essential requisite for anesthesiologists to improve their own social standing.

Propofol is a remarkable anesthetic agent which is widely used in general anesthesia and intensive care. However, while propofol infusion syndrome（PRIS）is a rare complication related to high-dose propofol infusion, it is potentially fatal. Further, the mechanism of PRIS remains unclear, and there is no effective treatment. Although PRIS usually occurs with large doses of propofol administered for an extended period, a recent case report described its occurrence with low-dose propofol infusion. Hence, we need to increase our knowledge of PRIS.

Propofol Infusion Syndrome（PRIS）is a severe complication that occurs during propofol infusion that includes hepatomegaly, fatty liver, hyperlipemia, metabolic acidosis, rhabdomyolysis and myoglobinemia. Because PRIS cases were first reported in children, use of propofol for the purpose of sedation during artificial respiration in children has been contraindicated in Japan. PRIS possibly develops as a result of lowered ATP production due to the inhibition of mitochondrial function and fatty acid metabolism. PRIS appears more commonly in children because their metabolism and elimination of propofol are prolonged due to their higher dependency on fat metabolism. Safe application of propofol has been indicated as the precise mechanism of PRIS has become clearer.

The pros & cons and proper use of the intravenous anesthetic propofol in children was discussed at the 38th Annual Meeting of the Japan Society for Clinical Anesthesia. A 2-year-old boy who underwent surgery for cervical lymphangioma in February 2014 died due to acute circulatory failure resulting from propofol infusion syndrome（PRIS）three days later in the intensive care unit（ICU）. The use of propofol in children under mechanical ventilation in the ICU is contraindicated in JAPAN. PRIS has also been reported in adults. Rapid intravenous flash injection during continuous administration of 1% propofol during artificial ventilation management is also prohibited in ICUs in Japan. Propofol and its solvent lipids increase the risk of embolism and mitochondrial injury in ICU management. It is necessary to pay attention to blood concentration and administration period during continuous infusion of propofol. We look forward to a full review and proper revision of user’s manuals for many intravenous drugs in the field of anesthesiology by the Ministry of Health, Labor and Welfare and the Pharmaceuticals and Medical Devices Agency in Japan.

Recent anesthesia-related maternal deaths have been found to be caused by local anesthetic systemic toxicity（LAST）or respiratory arrest due to high spinal anesthesia, all during labor epidural analgesia. Safety of neuraxial anesthesia must be the prerequisite for providing analgesia during labor for healthy parturients. Adequate anesthesiology training is the key for safe labor epidural analgesia, not only for successful procedures but also for management of critical events such as LAST and respiratory arrest. Both LAST and high spinal anesthesia should be prevented by the administration of a test dose upon epidural catheter placement, followed by small incremental dosing of local anesthetic throughout the course of labor. Because labor epidural analgesia（LEA）is often provided when inducing labor with oxytocic in Japan and LEA is associated with increased incidence of instrumental vaginal delivery, obstetric care providers including midwives must be prepared to manage postpartum hemorrhage.