The present study evaluated the details of postoperative ipsilateral shoulder pain and occurrence site, presence or absence of adverse events, range of motion, and postoperative getting out of bed in patients after esophagectomy in the prone position to check right arm positioning. On postoperative day 1, the incidence of shoulder pain was 47.6%. Sixty percent of patients suffered pain in the superior part of the trapezius. Whether pain was present or absent, there was no significant difference in operation time, prone time, or bleeding volume. No adverse events were observed. Pain was reported by around half of patients, and ipsilateral shoulder pain and range of motion of the right shoulder joint started showing improvement by postoperative day 3.

A 53-yr-old man underwent thoracoscopic right lower lobe pneumonectomy for lung cancer. There were no significant events in his medical history or routine preoperative laboratory examinations. During the surgery, pericardial fenestration was performed. Sudden ST elevation in ECG lead Ⅱ with a drop in blood pressure was noted following intrathoracic irrigation with warm distilled water. These events gradually normalized after suction of the water from the pericardial space. His postoperative examination showed normal cardiac function. These events suggest that temporary coronary spasm or pericarditis may occur following invasion of distilled water through the fenestration. This case report suggests that more careful management is required when irrigation with water is performed in the presence of pericardial fenestration.

When the patient with suspected neuromuscular disease is put under anesthesia, the risk of malignant hyperthermia should be considered.

In our case, extremely emergent cesarean operation was performed due to highly prolonged transient bradycardia of the fetus after induced labor. The fetus was suspected to have neuromuscular disease because of dysphagia with polyhydramnios. Since hereditary neuromuscular disease had not yet occurred in the mother, we performed general anesthesia with rapid sequence induction and were able to manage the perioperative period well. We were able to provide safe anesthesia by preparing for the possibility of malignant hyperthermia. To take prompt and appropriate action for such rare case, we suggest to take sufficient communication consistently.

In Nepal, there are a lot of traffic injuries that require anesthesia to treat. In these cases, patients must pay the entire cost of general anesthesia. In addition, anesthesiologist have access to limited medicine and equipment. As a result, the demand for regional anesthesia is very high compared to Japan. However, ultrasonic devices that anesthesiologists use have low resolution for providing peripheral nerve block. Anesthesiologists can use neural stimulators only for patients who can purchase nerve-blocking needles made for electrostimulation. In most cases, patients must be kept in a sitting position to puncture for spinal and epidural anesthesia. Virtually the only anesthetic used for spinal anesthesia is hyperbaric 0.5% bupivacaine. Anesthesiologists generally use bupivacaine for epidural anesthesia and a mixture of 0.5% bupivacaine and 2% lidocaine with 1：100000 adrenaline for brachial nerve block.

A brief history of airway management is provided at the beginning of this presentation. Starting in the 1990’s, three major developments in airway management occurred. The first involved advances in monitoring devices. Pulse oximeters rapidly detect and objectively measure hypoxemia, and capnography evaluates ventilation condition. Secondly, supraglottic airways have become popular and play a role equal to endotracheal intubation in anesthesia practice. Finally, video laryngoscopes make it possible to intubate endotracheal tube without direct visualization of the vocal cord. Based on these three developments, the American Society of Anesthesiologists revises its practice guidelines for management of the difficult airway two times every 10 years, and the Japanese Society of Anesthesiologists introduced airway management algorithm in 2014.

It is crucial to detect cerebral ischemia for neuro-monitoring. Regional cerebral oxygen saturation led to a great advance in neuro-monitoring. Furthermore, preoperative diagnostic imaging allows us to evaluate cerebrovascular reactivity to detect cerebral ischemia. On the other hand, we need to take into account both the limitations and benefits of neuro-monitoring.

Transcranial Doppler（TCD）and transcranial color flow imaging（TCCFI）can measure intracranial arterial blood flow velocity using low-frequency ultrasound（2 MHz）. TCCFI but not TCD can roughly image the brain structure using B mode. In addition, TCCFI can visualize blood flow in the anterior cerebral artery, middle cerebral artery, internal carotid artery, and posterior cerebral artery using color mode and can measure blood flow velocity using Doppler mode with angle correction. Both TCD and TCCFI can evaluate cerebral autoregulation and carbon dioxide reactivity as well as changes in cerebral blood flow velocity in response to changes in pathological conditions such as cerebral vasospasm and increased intracranial pressure. Although TCD and TCCFI are not widely used in Japan, noninvasive bedside monitoring using these modalities can provide abundant information for treatment of patients.

It is widely recognized that target temperature management（TTM）plays an important role minimizing secondary brain injury, but standard care by TTM, especially by therapeutic hypothermia（e.g., timing of induction, cooling methods, target temperature of cooling, duration of maintenance, management after rewarming, etc.）remains controversial. Many physiological changes occur during TTM including change of hemodynamics, deficiency of coagulation, electrolyte imbalance, immune suppression, and shivering. The main problem of shivering is that it increases oxygen consumption and generates significant amounts of heat. To prevent and treat shivering, sedatives, opiates and/or neuromuscular agents are administered during TTM. Hypothermia reduces metabolic rate and leads to drug overdoses. Overdoses of anesthetic agents not only inhibit respiratory and circulatory function but also make it difficult to assess neurological functions and prognosis after TTM. To perform TTM safely, it is important to recognize the effects of TTM on drug disposition, metabolism, and response, and to monitor their effects and concentrations in each period.

I have been a father for the last 16 years. As you can perhaps appreciate, raising 5 children is challenging for both me and my wife. Of course, I appreciate the great support I get from so many people and the incredible smiles of our children. Earlier, I was not interested in housekeeping and child-rearing. However, I changed my opinion about these activities when faced with my third child’s hospitalization at the age of five weeks. When my fifth child was born, I took paternity leave for around six weeks to help with housekeeping and childcare. This allowed my wife to start working after our youngest child entered kindergarten. I would first like to introduce some important events in my family, and then I would like to discuss gender equality in my family.

One-third of graduates of medical school are now female, and more than half of new anesthesiologists are female. Therefore, employment support systems for female anesthesiologists are essential to ensure the manpower for perioperative medicine in Japan. To support female anesthesiologists, the role of their bosses is important. Ikuboss, which means bosses who comprehend childcare, are needed in departments of anesthesiology. To support the employment of female anesthesiologists, a department that supports female employees in the hospital is also important.

Among several non-surgical cardiovascular interventions, catheter ablation of atrial fibrillation（CA-AF）is a major procedure that requires sedation or anesthesia. CA-AF is performed under general anesthesia by anesthesia professionals in most of patients in the United States. On the other hand, it is performed by cardiologists in most cases in Japan due to a shortage of anesthesiologists. Some of these patients suffer severe complications such as air embolism and cardiac tamponade due to inappropriate airway management. In 2014, the Japanese Heart Rhythm Society（JHRS）started educating to electrophysiologists and other medical staff in safe and effective sedation and airway management through lectures and hands-on seminars. The lectures cover the basics of sedation/anesthesia, monitoring of respiration using capnography, appropriate usage of sedatives, anesthetics and analgesics such as propofol and fentanyl, and airway management using supraglottic airways. JHRS made these lectures mandatory for receiving and renewing certification as a JHRS Certified Arrhythmia Specialist. As a result, usage of capnography increased from 1.6% in 2012 to 21.5% in 2017. However, the goal is still far away, and further education will be required. In addition, systems of management and education for safe sedation/anesthesia that are optimized to each institution should be established where anesthesiologists have the most important role.

Peripheral nerve blocks in children are characterized by lack of evidence and difficulty in judging the effect of blocks, in addition to differences in technical aspects such as local anesthetic dose, needling technique and ultrasound images compared to adults. Although peripheral nerve blocks in children are considered to be highly safe based on large-scale surveys from North America, they are not necessarily safe in Japan as we have different numbers of cases and educational systems. Using blocks that have a definite effect, responding to pain after the effect of single shot nerve block has worn off, asking the surgeon to use local anesthesia on the surgical field, and providing multimodal analgesia are all important to provide postoperative analgesia in children.