We analyzed a series of 657 parturients that had cesarean sections between January 2016 and April 2019 using data from electronic patient records. Of the 118 women who experienced headaches, 42％ had a primary headache, 42％ a post-dural puncture headache, and 15％ a headache due to gestational hypertension/preeclampsia. Contrary to popular belief, headaches other than post-dural puncture headaches may be experienced after cesarian section. Anesthetists should be aware of the importance of carefully observing these headache’s characteristics, associated symptoms, and elevated blood pressure in order to give differential diagnoses and provide appropriate treatment.

Perianesthesia Nurses（PANs）are popular nationwide. However, there is no unified definition of a PAN. A questionnaire was conducted for anesthesiologists, operating room nurses, and surgeons to perform subsequent tasks as PANs. Three-hundred fifty seven people were enrolled in the study. The overall response rate was 69%. Eighty-seven percent agreed with current PAN activities. However, the questionnaire revealed that 78% of surgeons were not familiar with current PAN activities. Fifty seven percent of surgeons, 72% of anesthesiologists, and 76% of nurses reported that they are bothered by PAN’s medical practices. In order to perform tasks as PANs, it will be necessary to further evaluate the questionnaire and use the results to improve daily activities.

A 75-year-old woman was diagnosed with chronic thromboembolic pulmonary hypertension（CTEPH）14 years ago and had severe pulmonary hypertension resistant to drug treatments.

Laparoscopic sigmoid colectomy was scheduled for sigmoid colon carcinoma. Preoperative right heart catheterization revealed severe pulmonary hypertension, and balloon pulmonary angioplasty（BPA）was performed. The surgery was performed after improvement of pulmonary hypertension. During the operation, right heart function was monitored using ΔPaCO₂-EtCO₂ in addition to a non-invasive cardiac output monitor, and the procedure was completed without any complications. Non-cardiac surgery in patients with CTEPH can be safely performed with appropriate preoperative evaluation and intervention such as BPA.

A 69-year-old woman presented with two tumors in the left main bronchus and left upper lobe. The surgical team proposed left bronchoplasty from the right thorax in the left lateral decubitus position. During the period when left（lower side）lung ventilation was not available, we performed right（upper side）one-lung ventilation（OLV）using high-frequency jet ventilation（HFJV）for two hours. Although right OLV in the left lateral decubitus position is disadvantageous in terms of oxygenation and surgical view, exposure was sufficient and a PaO₂ of up to 421 mmHg was achieved. This case demonstrated that upper side OLV is not impossible with the use of HFJV even in patients with both lungs.

We experienced a case of tracheostomy under sedation with dexmedetomidine and a small amount of fentanyl in a patient with severe trismus due to buccal tumor. We preoperatively determined that subconscious intubation would be difficult due to mental retardation and risk of complete oral cavity obstruction with tumor. The patient, a 36-year-old man with mental retardation, was scheduled for tracheostomy, buccal malignancy resection, left-sided total cervical dissection, and lateral femoral valve grafting for squamous cell carcinoma of the left buccal skin. In this case, we were able to manage the patient without causing fluctuations in respiratory and circulatory dynamics. However, depending on the extent of the patient’s mental retardation, preoperative evaluation may not be sufficient, and an appropriate management method should be selected for each case after careful consideration of multiple options including oxygenation with NHF or jet ventilation.

We conducted 220 postmortem computed tomography（CT）examinations in 2018 at Tokyo Women’s Medical University Medical Center East. The most common indication for postmortem CT was sudden death of unknown cause. Radiologists interpreted 64 out of the 220 imaging series. The cause of death was identifiable by postmortem CT in 11 cases with radiology reports and 40 without them. Although autopsy imaging was better than judicial dissection for detecting some fractures, intracranial pathologies, and aortic dissection, postmortem CT had low accuracy in diagnosing ischemic heart disease, which is the most common cause of death. Inquests were performed on 169 cases for which the cause of death could not be determined by postmortem CT.

Stellate ganglion block is an accepted treatment modality for head and neck pain and pain from the shoulders to the arms, but since it can cause complications such as hematoma, it is contraindicated for patients taking antithrombotics in particular and must be used with caution. Deep sternocleidomastoid fascia release is considered to be almost as effective as stellate ganglion block and has fewer potential complications.

We performed deep sternocleidomastoid fascia release in a patient with pain due to arteriosclerosis obliterans in the arm. The pain alleviated consequently. Fascia release may be used as an additional treatment option for patients complaining of arm pain.

Patients with cancer may experience effects of the disease itself as well as complications induced by cancer therapy. These patients often have unexpected clinical conditions due to chemotherapy or radiation therapy. Perioperative management of patients with cancer should be considered carefully. Opioids are widely used for perioperative pain management, but they may influence cancer progression or recurrence due to their immunosuppressive effects. Regional anesthetic techniques may offer benefit by reducing the need for opioids. Intravenous anesthesia is associated with slightly lower mortality after cancer surgery than inhalation anesthesia. There is insufficient evidence to determine which techniques should be recommended to reduce the risk of metastasis or recurrence after cancer surgery. There is no adequate evidence to change the current anesthetic technique for cancer patients.

Chronic postsurgical pain（CPSP）is strongly correlated with a psychological component, with preoperative depression and anxiety being well known risk factors of CPSP. Some animal studies have reported that psychological stress not only leads to depression and anxiety but also activates spinal microglial cells to cause spinal neuroinflammation and central sensitization. These changes may lead to the exacerbation of postoperative acute pain and delayed recovery. Perioperative cognitive behavioral therapy and patient education may help prevent the development of CPSP. Perioperative antidepressants may also help provide pain relief for patients with CPSP, but their prophylactic effects remain unclear, so multi-directional studies will be needed to better understand the mechanisms underlying CPSP.

Chronic postsurgical pain（CPSP）is a serious surgical complication that impairs patients’ quality of life. A multidisciplinary approach and participation of a pain physician is important to treat CPSP and provide physical and psychological pain management. Nociceptive pain relief in CPSP can be obtained with acetaminophen, nonsteroidal anti-inflammatory drugs, and opioid analgesics. Gabapentinoids（Ca-channel α2δ ligands）such as pregabalin or mirogabalin, antidepressants such as tricyclic antidepressants or serotonin-noradrenalin reuptake inhibitors, and several opioid analgesics are prescribed for neuropathic pain. CPSP at the surgical site and failure of pharmacotherapy necessitate invasive treatments such as repeated neural blockade using local anesthetic alone or in combination with steroids, botulinum toxin therapy, radiofrequency thermocoagulation, and pulsed radiofrequency.

More than 50 years have passed since Fleckenstein named verapamil calcium-channel blocker based on efficacy as a coronary vasodilator for the first time in 1967. In the field of anesthesiology, calcium-channel blockers are used to suppress supraventricular arrhythmia, reduce coronary and cerebral vasospasm, and control hypertension. They may also be used for myocardial protection, relaxation of the uterus, and hypotensive anesthesia. Both volatile and intravenous anesthetics need attention to act mutually with calcium-channel blockers, due to inhibit heart and neuronal L type electric current. Recent challenges with respect to calcium-channel blockers include increasing use of various combination drugs and effects on cerebral circulation and cognitive function.

Among the major antihypertensive drug classes, beta adrenergic receptor antagonists（beta blockers）have beneficial effects in protecting cardiac function especially in patients with heart failure. The previous guidelines for the management of patients undergoing noncardiac surgery recommended beta blocker therapy to decrease major adverse cardiac events（MACE）in patients with coronary heart disease or more than one cardiac risk. However, risks for bradycardia, stroke or death by preoperative onset of beta-blockers have emerged from systematic reviews, leading to an updating of the guidelines, which now recommend that management of beta blockers after surgery be guided by clinical circumstances and that beta-blocker therapy not be started on the day of surgery. In this narrative review, the change in concepts to support perioperative beta blocker therapy as well as the mechanisms of action of agents in this class are described.

The image of perioperative nitrates is that they may be useful in reducing the incidence of cardiovascular events. However, clinical studies and meta-analyses to date have not shown that nitroglycerin is effective in reducing the incidence of cardiovascular events and protecting against myocardial ischemia. Therefore, there are no explicit recommendations in the guidelines but rather concerns about tolerance and hypotension/excessive preload reduction. Mechanistically, nicorandil may be beneficial in the perioperative period, but the evidence is insufficient. Therefore, the use of both nitrates and nicorandil by convention in the perioperative period should be avoided.

Inhibition of the renin-angiotensin system with angiotensin II receptor blockers（ARB）and angiotensin-converting enzyme inhibitors（ACE-I）is widely used in the treatment of hypertension, heart failure, chronic kidney disease, and coronary artery disease with left ventricular dysfunction. In perioperative settings, administration of ARB/ACE-I on the morning of surgery can cause anesthesia-induced refractory hypotension, but current policies on whether to continue or withhold ARB/ACE-I are conflicting. Recently, studies assessing the association between perioperative ARB/ACE-I use and major morbidity in noncardiac surgery have been published. These studies confirm that the continuation of ARB/ACE-I on the morning of noncardiac surgery is associated with increased intraoperative hypotension, but its association with mortality and major morbidity remains unclear and will need to be resolved through large randomized trials. The recommendations of perioperative ARB/ACE-I use in the newest guidelines are also introduced.