We aimed to clarify the risk factors for early postoperative tetany after thyroid surgery in order to facilitate perioperative management by anesthesiologists. We retrospectively investigated the frequency of tetany occurring within 24 h postoperatively in 564 patients who underwent thyroidectomy. We also performed a multivariate logistic regression analysis of its risk factors. The frequency of postoperative early tetany onset was 26%(149 cases), with its risk factors being as follows: young age [odds ratio(OR): 0.98 per year of age(95% confidence interval(CI): 0.96-0.99)], female sex [OR: 2.59(95% CI: 1.41-4.78)], operation time [OR: 1.31 per 60 mins(95% CI: 1.02-1.67)], total thyroidectomy [OR: 2.31(95% CI: 1.49-3.58)], and postoperative calcium(Ca)value [OR: 0.33 per 1 mg/dL(95% CI: 0.21-0.50)]. Female patients, younger age, longer operation time, and total thyroidectomy factors can be used to prioritize postoperative management of patients with a high risk of postoperative tetany onset before postoperative Ca testing.

Hypotension is a common complication of anesthesia due to its inhibitory effects on cardiac function and vasodilatory action. Meanwhile, surgical patients occasionally develop tachyarrhythmias during anesthesia even if they have no history of arrythmia.

If tachyarrhythmia occurs during anesthesia, it is important to carefully select antiarrhythmic drugs as the use of those drugs can result in further decreases in the blood pressure.

Among various types of antiarrhythmic drugs, pilsicainide, a selective Na channel inhibitor, is considered to be a relatively safe and effective drug for intraoperative tachyarrhythmias due to its high selectivity to Na channels and minimal inhibitory effects on cardiac function.

Here we report two cases in which pilsicainide effectively treated tachyarrhythmia that suddenly occurred during anesthesia.

Pulmonary artery pressure and pulmonary vascular resistance have been reported to be elevated during anaphylaxis in animal model studies, but little is known about changes in pulmonary artery pressure during anaphylaxis in human. We report a case of lymphangioleiomyomatosis with bronchospasm and pulmonary hypertension correlated with drug-induced anaphylaxis during general anesthesia.

A 49-year-old woman who was diagnosed with pulmonary lymphangioleiomyomatosis was scheduled for bilateral lung transplantation. After anesthetic induction and pulmonary catheter insertion, cefotiam was infused slowly. Following infusion, peak inspiratory pressure rose, and tidal volume immediately dropped sharply. At the same time, pulmonary artery pressure rose. We assumed that bronchospasm had occurred due to drug-induced anaphylaxis. Epinephrine administration immediately improved bronchospasm and pulmonary hypertension.

Carinal reconstruction, which is rarely performed in cases of tracheal cancer, requires respiratory management of the patient. However, for the present patient, the surgery could be completed without using any extracorporeal cardiopulmonary life-support device after consulting a surgeon regarding the use/non-use of extracorporeal cardiopulmonary life-support devices, surgical postures, timing of tube replacement, and choice of tubes, and after formulating a plan for surgical anesthesia in advance. Due to unexpected issues including failure to perform the planned isolated lung ventilation because of insufficient length of the tracheal tube, the plan for surgical anesthesia had to be changed. While using this surgical method, it is necessary to prepare for various possible events.

In the normal or relatively early stage of neuropathic pain condition, the locus coeruleus（LC）-spinal descending noradrenergic inhibitory pathway is essential to pain-evoked endogenous analgesia, and gabapentinoids are often used as a first line treatment in neuropathic pain to produce analgesia. The present article focuses on 1）the role of the descending noradrenergic pathway for analgesia using gabapentinoids；2）the strategy of treating neuropathic pain based on neuroplasticity in this pathway after nerve injury；and 3）the mechanisms of LC dysfunction during chronification of neuropathic pain and translational approach to restore LC dysfunction using clinically available drugs.

In recent years, a growing number of studies on albumin and its use in critically ill patients have been published, providing important insights into the clinical use of albumin for the treatment of different pathological conditions. In patients with decreased intravascular volume secondary to trauma, surgery, or sepsis, the use of albumin is not associated with improvement in mortality compared with the use of crystalloids. As worsened prognosis has been noted in patients with traumatic brain injury, albumin is not effective for fluid resuscitation. The benefit of using albumin as a priming solution during open-heart surgery with cardiopulmonary bypass has not been proven. The use of albumin is not recommended in hemodynamically stable patients with hypoalbuminemia during the perioperative period. In clinical practice, albumin should be used based on an overall judgment by healthcare professionals.

Fluid optimization is one of the most important keywords in perioperative settings, and goal-directed fluid therapy（GDFT）is implemented as a promising strategy for perioperative fluid therapy. GDFT consist of baseline crystalloid infusion and fluid challenge with colloid. Voluven is the most frequently used synthetic colloid in Japan. A relatively high administrable upper limit of 50 mL/kg/day allows clinicians to avoid the use of albumin products which had been in large amounts until recent years. In terms of influence on kidney function and blood coagulation, which is known to be a disadvantage of HES（hydroxyethyl starch）products, recent reports show that voluven is comparable to crystalloids in perioperative settings, though more studies are needed. Finally, a questionnaire survey on intraoperative fluid usage was conducted and some results are introduced.

This question was reviewed from two different standpoints：albumin production and nutrition therapy. Contrary to common belief, albumin synthetic capability, which once is decreased after acute insult, is not likely to be enhanced within the first two days after ICU admission（early phase）, then followed by an increase beyond normal levels while having its own limits（biphasic response）. Considered in terms of another standpoint, namely aggressive nutrition therapy, after many years of heated debates, early full feeding has been contraindicated in the latest guideline on clinical nutrition in ICU because it exerts various metabolic adverse effects associated with overfeeding. In conclusion, the answer to the question in our title is “no”.

Surgical invasion induces nociceptive stimuli, in which signals ascend from the spinal cord to the cerebral cortex, evoking nociception. It simultaneously causes autonomic responses and body movement. Surgical invasion also causes inflammatory responses and tissue damage during and after surgery, increasing C-reactive protein（CRP）levels in blood. Early increases in postoperative CRP levels are associated with severe postoperative complications. On the other hand, general anesthesia suppresses nociception. Nociception monitoring under general anesthesia estimates a quantified balance between nociception and anti-nociception by using variables evoked by autonomic responses or in the electroencephalogram. A nociception monitoring value during surgery has the potential to be an objective indicator of surgical invasion.

Transcatheter aortic valve replacement（TAVR）was first described in 2002, when minimally-invasive treatment for cardiac diseases began. Then, the concept of structural heart diseases was proposed, under which catheter intervention and minimally-invasive cardiac surgery（MICS）have developed. TAVR and transcatheter mitral valve repair, which are generally used in the cases of high risk patients, allow early recovery after these interventions. Meanwhile, MICS, which is defined as a small thoracotomy incision and video-assisted surgery in the Japanese health insurance system, has some pitfalls associated with the cardiopulmonary bypass system and narrow surgical sites. However, MICS will contribute to creating a therapeutic opportunity for younger patients who are reluctant to receive conventional surgeries, because of its cosmetic advantage and early social rehabilitation.

Cardiac arrest is the most serious complication during spinal anesthesia. Between 1945 and 2000, several hundred patients including many children and adolescents died due to high spinal anesthesia in Japan. These deaths were attributed either to the patient’s general physical condition or to the poor quality of the local anesthetics used. In my 1999 book Deaths During Spinal Anesthesia in Japan, I explain that the true cause of such deaths is the lack of careful observation of patients during and after spinal anesthesia. It was a strong warning to non-anesthesiologist physicians who administer spinal anesthesia. Since that time, the number of deaths has declined dramatically. Complications can be avoided by discarding the assumption that your patient is not at risk for cardiac arrest, and by observing your patient for at least two hours after spinal anesthesia.

Spinal anesthesia is a simple technique that provides perfect anesthesia and analgesia during the surgical period, so it is widely used for various surgeries. Some complications associated with spinal anesthesia, though rare, are serious, requiring appropriate management to prevent or minimize their incidence.

This article reviews the major complications of spinal anesthesia and an overview of complications of spinal anesthesia in Japan such as severe bradycardia and hypotension, total spinal block, spinal cord injury, and cerebrospinal fluid leakage after meningeal puncture. Physicians need to understand the pathophysiology, significance, associated risk factors, and management of these complications.

Regular reminders and warnings on methods of preventing complications are essential to reinforce our knowledge of the procedure and enhance its safety.

Epidural anesthesia has made steady progress in Japan, but in recent years complications from it have increased and as a result it now accounts for half of medical errors related to departments of anesthesiology. I conducted a questionnaire survey of departments of anesthesiology at university hospitals around the country which suggested that many doctors have switched from the hanging drop technique using metal needles which can reliably identify the epidural space to the loss of resistance technique using disposable needles which poses the risk of dural puncture. Because of accidents with disposable needles, one-third of university hospitals reject epidural anesthesia by young doctors. Since epidural anesthesia has become an integral part of today’s practice of anesthesia, we should ensure that its progress is not set back by the use of inappropriate needles. Since complications result more often from the use of inappropriate needles than from a lack of competence on the part of doctors, we will need good disposable needles that can be used with the hanging drop technique to ensure safety going forward.

Epidural anesthesia is widely used for intraoperative and postoperative analgesia, but it can lead to various complications. Although most of these are minor, such as nausea, vomiting, hypotension and urinary retention, serious complications can occur as well, resulting in permanent nerve injury. Spinal epidural hematoma and epidural abscess are among the most serious and well-known complications. This paper describes cases of complications after epidural anesthesia which have occurred in our hospital and been reported in the literature from Japan. We should provide proper education for young clinical fellows to reduce the incidence of complications resulting from improper procedures. An acute pain service can play an important role in early detection and early treatment of these complications.

Among all the types of continuous peripheral nerve blocks that are performed in the trunk region of the body, the efficacy of a continuous thoracic paravertebral block has been most frequently evaluated via randomized controlled trials. When compared with a continuous thoracic epidural block, a continuous thoracic paravertebral block induces similar post-thoracotomy analgesia with less-serious adverse events. In addition, recent studies have indicated that the postoperative analgesic effects of a thoracic paravertebral block can be improved by choosing an appropriate approach for catheter insertion and a suitable mode for local anesthetic administration. For example, programmed, intermittent bolus injections are better than continuous infusion with respect to producing a sensory block that spreads over a wider region. Regarding abdominal wall blocks, some studies conducted on continuous transversus abdominis plane blocks have been reported. Further, bilateral continuous transversus abdominis plane blocks using an oblique subcostal approach significantly reduce cumulative opioid consumption after lower abdominal surgery. Although some countermeasures have been suggested, the most crucial drawback of a continuous transversus abdominis plane block might be its inability to induce anesthesia over a wide region.