We examined the knowledge of both Japanese Society of Anesthesiologists（JSA）board certified anesthesiologists（n=10）and fellows of JSA（n=10）about the anatomical position of cricoid cartilage and the adequate pressure forces recommended for awake and anesthetized patients. Before and after having the opportunity to acquire experience of applying pressure we actually measured the cricoid pressure forces using a simple laryngotracheal simulator. Both JSA board certified anesthesiologists and fellows of JSA have enough knowledge of anatomical position of the cricoid cartilage but not of correct pressure forces. Before training in applying pressure, mean pressure force actually measured did not differ between specialists and supervisors but was significantly different from the recommended forces. After training, the difference significantly decreased（JSA board certified anesthesiologists：for awake patients 372 g → 450 g, for anesthetized patients 1132 g → 348 g；fellows of JSA：for awake patients 803 g → 419 g, for anesthetized patients 1147 g → 287 g）. The results show that both JSA board certified anesthesiologists and fellows of JSA should train to provide adequate procedures for cricoid pressure.

Anesthetic management of patients with Total Cavopulmonary Connection（TCPC, Fontan circulation）requires strict fluid administration. Here, we report the case of a 13-year-old boy with Fontan circulation who was scheduled to undergo scoliosis surgery. Anesthetic management was conducted using FloTrac and central venous catheter to monitor stroke volume variation（SVV）and central venous pressure（CVP）, respectively. Although temporal hypotension occurred following prone positioning, maintaining high CVP regained preferable hemodynamic states, whereas SVV failed to predict fluid responsiveness. In fluid management for Fontan patients, CVP may be more reliable than SVV.

We herein report the case of a 33-year-old woman who underwent implantation of a left ventricular assist device as an emergency treatment for acute exacerbation of heart failure. The patient underwent a Senning procedure for the transposition of the great arteries at the age of 15 months. Her cardiac function gradually declined following 3 pregnancies and an influenza virus infection, which triggered the acute exacerbation of heart failure. Implantation of a left ventricular assist device was planned. Despite the possibility of right ventricular heart failure and bleeding, we anesthetized the patient using transesophageal echocardiography in order to adequately monitor the patient’s hemodynamics during surgery. The number of adult patients with congenital heart disease needing surgery has increased in recent years. Therefore, it is necessary for the anesthesiologist to understand the pathological characteristics of each disease.

A 75-year-old man who was 162 cm tall and weighed 63 kg developed sudden back pain and dyspnea. He was diagnosed with a ruptured abdominal aortic aneurysm that was identified under the branch of the renal artery and underwent emergency Y-type artificial blood vessel replacement. He received 110 mg/day of dabigatran, and because his activated partial thromboplastin time was prolonged to 74.5 s, we administered idarucizumab to reverse the anticoagulant effects of dabigatran. Anesthesia was induced using ketamine, fentanyl, and rocuronium and was maintained with sevoflurane and remifentanil. After induction of anesthesia, we administered 5 g of idarucizumab to neutralize the anticoagulant action of dabigatran, and his activated clotting time significantly improved from 326 s to 109 s. Intraoperatively, we administered 100 units/kg of heparin for anticoagulation. After artificial blood vessel replacement, we administered 50 mg of protamine. After confirmation of hemostasis, surgery was successfully and safely completed without significant bleeding observed in the operative field. He reported no postoperative complications. Previous reports have described uncontrolled bleeding in patients receiving dabigatran, so we concluded that administration of idarucizumab was warranted in this case. This case report indicates that idarucizumab effectively reverses the anticoagulant action of dabigatran.

Previous studies have demonstrated that sugammadex can provide a reliable neuromuscular recovery from rocuronium-induced neuromuscular blockade（NMB）in patients with myasthenia gravis（MG）. We divided MG patients undergoing extended thymectomy into two groups based on reversal of NMB with sugammadex（S group, n=31）or no reversal of NMB（C group, n=15）and retrospectively compared their need for postoperative mechanical ventilation in the intensive care unit. More patients in the S group received rocuronium than patients in the C group（p=0.011）. The number of patients requiring postoperative mechanical ventilation in the intensive care unit was not significantly different between the two groups（6 cases in the S group vs. 4 cases in the C group）.

In this study, we retrospectively analyzed analgesic effects of peripheral nerve block in ICU patients. Eleven patients in the ICU at Tohoku University Hospital from January 1 to July 31, 2017 were included in this study. Most patients（8 cases, 73%）complained of severe pain with lesions in the costal nerves area which was treated by various approaches to costal nerve blocks such as intercostal nerve block, transversus abdominis plane block, parasternal intercostal nerve block. The median numeric rating scale（NRS）for pain score decreased from 6 to 2 after the PNB procedure（p = 0.002）. The interval from the nerve block to the first administration of an analgesic was 8 hours（median value）. This suggests that PNB reduces pain intensity and potentially leads to better systemic conditions without side effects in ICU patients with intractable pain.

Anesthesiologists are sometimes consulted by doctors from other departments for pain treatment.This paper addresses the appropriate response in such scenarios.

Basic knowledge of pain is essential to provide consultations for pain treatment. Effective medication differs depending on the nature of the pain；therefore, it is essential to plan the treatment in accordance with the patient’s pathology.

Complex Regional Pain Syndrome（CRPS）may develop into serious symptoms after a minor injury. If CRPS is suspected, the patient should be referred to a specialized treatment facility at an early stage.

Mild headache can be due to a subarachnoid hemorrhage or vertebral artery dissection. Pain can also be the first symptom of a malignant tumor.

It is essential that patients form a habit of self-examination and document their findings in medical records.

Postoperative decline of immune function increases the risk of cancer recurrence after curative surgery. Regional anesthesia may reduce this risk by providing better pain condition, opioid reducing effect and direct antitumor efficacy of local anesthetics. Some epidemiologic studies suggest a favorable effect. However, more convincing evidence is needed to show the antitumor effect of regional anesthesia in clinical settings.

Neuraxial anesthesia had been reported to reduce postoperative mortality and serious complications. However, recent studies showed no relevant effect. The current trend is to analyze the influence of anesthesia technique on the prognosis of high-risk surgical patients using secondary data sets derived from large-scale studies. The purpose of this literature review is to introduce recent studies on whether anesthesia technique affects the prognosis of high-risk surgical patients undergoing particular surgical procedures.

Postoperative delirium is a common surgery-related neurocognitive complication, particularly in elderly patients. It is reported to be associated with long-term cognitive decline. Although growing evidence demonstrates that neuroinflammation contributes to the development of postoperative delirium, there is currently no preventive strategy. On the other hand, previous studies have shown that a multidisciplinary approach could prevent the development of hospitalized delirium in 30-40% of cases. In particular, regional anesthesia is potentially beneficial for the prevention of postoperative delirium through its superior postoperative analgesia and general anesthetic-sparing effect. This article discusses the role of regional anesthesia in the prevention of postoperative delirium.

I studied at SimTiki simulation center at Hawaii in 2015. I learned various simulation-based educational methods of interprofessional education（IPE）and was certified as a healthcare simulation educator（CHSE）by the Society of Simulation and Healthcare.

In Japan, various attempts at IPE have been made. Ethical, spatial, and economic problems are barriers to the introduction of IPE. Simulation-based education may be one solution to this problem.

We have performed perioperative team training utilizing simulation to acquire various technical and non-technical skills in perioperative safety and team development. We utilized problem-based learning, task trainer, simulator, and simulated patients.

Simulation education in Japan such as the AHA-ACLS training course has been introduced mainly from the US. However, simulation courses should be developed on the basis of medical culture and educational science in each country. Thus, international discussion about the difference of educational science and medical culture may be significant.

My future goal is to establish simulation-based IPE training from the Japanese Association for Medical Simulation. I believe that the Japanese Association for Medical Simulation can produce evidence-based simulation education for IPE in the future.

What is needed to "connect" medical education and clinical practice? Educational design, quality of instructors, and instructor training in responding to participant needs are all important. How should you acquire skills, such as basic life support, observation using ABCD evaluation, diagnosis of trauma patients, multiple injury cases and disaster responses, that can be used on-site? Instructors who can facilitate scenario development and fulfill participant needs are needed. Training new instructors is necessary to provide better education. We will achieve the "connection" between medical education and clinical practice by in- and out-of-hospital multidisciplinary staff simulations such as rescue courses and medical rallies.

I participated in basic life support and advanced cardiac life support courses of the American Heart Association in 2006 and have participated in various courses on difficult airway management and sedation of the Japanese Association for Medical Simulation since 2008. We have held two-day North Osaka Simulation Seminars which include central venous catheter, sedation, and difficult airway management since 2013. During instruction, I recognized the importance of evaluating participants’ understanding, effective course management, and instruction which meets the background and objectives of participants. While the simulation-based training course is constructed by educational technology, instructors play an essential role. Simulation instructors should cultivate the most important skill -instruction- after the training course by debriefing on their performance during the course.

This article outlines essential points in developing simulation-based educational seminars from the viewpoint of outcome-based education and instructional design. During the development of simulation-based education seminars, setting of both learners（entrance）and outcome（exit）, Kirkpatrick model, ARCS motivation model are essential considerations.

We examined the current status of simulation training in Japan. Participants and methods：We specifically evaluated 38 courses of simulation training. We compared developers, subjects, course objectives, and number of days of course attendance. Results：In Group A, 86.7% of the training involved knowledge, technical skills, and nontechnical skills. However, in Groups B and C, this proportion was lower. Mean number of days of attendance was 1.87 days for Group A, 1.36 days for Group B, and 1.13 days for Group C. Discussion：The course developed in Japan covered a substantial amount of material in a short time. In terms of learning efficiency, this training is inadequate. Knowledge by self-learning is best obtained through e-learning, and technical and nontechnical skills are best learned through group training.

The number of criminal trials for medical malpractice has been increasing since 1999. In cases of criminal medical malpractice tried from 1950 to the end of 2017, the majority of defendants received a suspended sentence in summary or normal trials, but six defendants in five cases were sentenced to imprisonment without the possibility of probation. These cases of imprisonment without probation were examined, revealing five factors that were concurrent with the malpractice and might have influenced judicial decisions：（1）concealment of information, （2）plural victims, （3）questionable immediate response to the malpractice, （4）questionable dealing with victims and their families, and（5）criminal intent. These factors show a lack of ethics among the medical professionals involved and seem to have given judges an unfavorable impression and contributed to the sentences of imprisonment.

Patient safety is a field where in-house lawyers are expected to play an active role in medical institutions. Since the lawyers who work for the patient safety section can detect the risks of disputes with patients among the incident reports, they can provide legal advice at the early stage and prevent disputes. In addition, there are a wide variety of situations in which lawyers can show their abilities in patient safety, such as fact-certification and report preparation in individual medical accident investigations, the revising of informed consent documents and various manuals, and the establishment of systems in the hospital to respond to revisions of the law, etc. On the other hand, the work of lawyers in medical institutions should not be limited to patient safety. They should also be committed to other legal affairs such as governance, contracts, and labor. It is a challenge for the future to consider how to utilize lawyers in the organization in order to make the most of their abilities.

Nara Medical University currently has contracts with three lawyers at university corporations and university hospital. University corporations mainly consult on various issues such as disciplinary actions related to staff and students. At hospital they are helpful for taking on various tasks such as litigation and participation in trials in addition to consultations regarding issues with patients. The role of lawyers in university corporations and hospitals is expected to increase in the future.