The effects of remifentanil（RF）and fentanyl（F）on heart rate（HR）and blood pressure（BP）under about the same effect site concentration were compared. Eighty patients with scheduled general anesthesia were randomly assigned to two groups, RF group and F group. The patients underwent general anesthesia. RF or F was administered so that the effect site concentrations were both approximately 3 ng/mL. Maximum percentage decrease from the baseline values of HR, systolic BP（SBP）, diastolic BP（DBP）, and mean BP（MBP）were compared between the two groups. The numbers of phenylephrine and atropine administrations were also compared. Regarding RF, the maximum reduction rate（％）of HR, SBP, DBP, and MBP was 20.3±15.9, 39.5±12.8, 35.0±12.2, and 35.7±12.1％（M±SD）, respectively. Regarding F, the maximum reduction rate（％）of HR, SBP, DBP, and MBP was 19.2±15.8, 34.9±11.8, 28.4±11.7, and 29.7±11.1％, respectively. As a result of detailed examination of the effects of lean body mass, age, phenylephrine, and atropine, it was considered that F and RF had almost the same effects on the maximum reduction rate（％）of HR, SBP, DBP, and MBP at approximately 3 ng/mL of the effect site concentration.

Spina bifida is a malformation of the spinal cord and its surrounding structures that leads to difficulties with spinal anesthesia. A case of a patient with spina bifida occulta who was given spinal anesthesia is presented. A woman in her 20s was to undergo a planned cesarean section due to a previous cesarean section. Preoperative magnetic resonance imaging（MRI）showed a dichotomy in the spinal cord, low-placed conus medullaris, and normal structure at the L4/5 level. Considering the patient’s wishes and the impact on the fetus, spinal anesthesia was selected as the first choice. In the operating room, the L4/5 space was confirmed by sonography, and spinal anesthesia was performed by the paramedian approach with a sufficient anesthesia area. The surgery was completed without any trouble. Spinal anesthesia for patients with spina bifida is controversial. In the present case, spinal anesthesia was performed safely with careful confirmation of the puncture position by preoperative imaging.

Protein-losing enteropathy（PLE）and plastic bronchitis（PB）are critical complications after the Fontan procedure and are known risk factors for mortality. Percutaneous lymphatic embolization in 2 patients with PLE and 1 PB patient was performed under general endotracheal anesthesia with positive pressure ventilation. Hemodynamics were carefully monitored by an adequate administration of fluid and Liberal use of catecholamines. The 2 cases with PLE had an uneventful perioperative course, but the PB case experienced an airway emergency due to bronchial obstruction with mucus plugs after induction of anesthesia. In patients with Fontan circulation undergoing noncardiac surgeries, it is crucial to assess preoperative status including Fontan-related complications and design strict anesthetic plans on a case-to-case basis.

Congenital aberrant fibrinogenemia is an extremely rare hemorrhagic disease. In this case, we treated our patient with concentrated fibrinogen preoperatively because of a low plasma fibrinogen level of 52 mg/dL and a high risk of bleeding. In addition to the standard coagulation tests, we used rotational thromboelastometry（ROTEM）, which allows us to confirm coagulation ability before and after administration of concentrated fibrinogen. We performed perioperative management without any problems. ROTEM can identify the necessary minimum coagulation factors and reduce the risk of thrombotic and embolic complications due to overdose of clotting factors and is useful for perioperative management.

The left internal jugular vein is reported to have more mechanical complications in central venous catheter placement, than the right, so the left internal jugular vein is not selected for VV ECMO unless the right internal jugular vein is unavailable. A 64-year-old male with severe pneumonia had an obstructed right internal jugular vein due to thromboembolism, which was caused by a previous central venous catheter insertion in this vein. Therefore, the left internal jugular vein was utilized for VV ECMO. In order to successfully perform VV ECMO using the left jugular vein, the course and diameter of the vein must be carefully evaluated by sonography and CT scan prior to placement. Insertion requires cautious, fluoroscopy-guided manipulation, and the cannula tip must be precisely positioned to avoid mechanical complications during VV ECMO.

A 71-year-old man with acute coronary syndrome underwent emergency coronary artery bypass surgery. The patient took aspirin and prasugrel hydrochloride prior to surgery. There were no problems with tracheal intubation or anesthesia progress. After being intubated for 29 hours he developed hoarseness immediately after extubation. We initially suspected recurrent laryngeal nerve paralysis caused by the surgery, which we elected to treat conservatively. However, because his hoarseness had not improved at 13 days after surgery, we evaluated his vocal cords using laryngoscopy. This revealed a tracheal mucosal ulcer and edema due to the aspiration of a tablet. It was removed by laryngoscope. By 4 months, the patient’s vocal cord mobility had improved. This prolonged hoarseness was vocal cord paralysis associated with tracheal mucosal damage caused by aspiration of preoperative medication.

Chronic expanding hematoma（CEH）in thorax can cause mediastinal shift followed by respiratory and cardiac failure along with its progression. Induction of general anesthesia and positive pressure ventilation will likely worsen the symptoms. The present case showed right heart compression and cardiac failure by huge CEH in right thorax. Two-stage surgery consisting of volume reduction surgery under epidural anesthesia and radical surgery under general anesthesia was conducted safely without hemodynamic compromise.

A 75-year-old male was scheduled to undergo thoracoscopic lung resection. An epidural catheter was inserted at Th 7-8. A test dose of 2％ lidocaine with adrenaline（3 mL）effectively impaired cold sensation at Th 7-8 without motor paralysis or extensive sensory block. After induction of general anesthesia, 8 mL of 0.25％ levobupivacaine was administered and epidural infusion was initiated. After extubation, extensive bilateral sensory block and motor paralysis were found below Th 5-6. The continuous epidural infusion of levobupivacaine was stopped. The placement of the epidural catheter was examined radiologically by X-ray. Injection of a contrast medium into the catheter showed a linear dense collection confined to the posterior aspect of the spinal cord, indicating subdural tubing. The catheter was removed. About six and a half hours after stopping epidural infusion, impaired sensory and motor functions had fully recovered. The patient was discharged from the hospital without any neurological complications on the 8th postoperative day.

Ultrasound-guided thoracic paravertebral block（TPVB）was used to provide postoperative analgesia for a 25-day-old boy who underwent surgery for biliary atresia. We performed TPVB from the T9/10 intercostal space with a linear probe in plain approach using a 22 G needle. 5 mL of saline and 2 mL of 0.2％ ropivacaine was injected, and the spread of the drug was confirmed over five intervertebral spaces. The patient was extubated in the operating room and followed at the intensive care unit. Dexmedetomidine was administered at 0.7μg/kg/hours, followed by 50 mg of acetaminophen provided every 8 hours. The patient’s postoperative respiratory status and circulation were stable, and no additional analgesics were needed. Effective postoperative analgesia is critical to avoid stress reactions and to stabilize respiratory function and circulation even in newborn infants, and TPVB may be useful for postoperative analgesia in these circumstances.

The vessels noted during rectus sheath block are superior and inferior epigastric arteries and veins running in the same rectus sheath. We experienced a patient with cerebral palsy in whom the abdominal aorta was found immediately below the right rectus abdominis muscle during anesthetic management of laparoscopic gastrostomy, resulting in the avoidance of rectus sheath block on the same side. The vertebral body was palpable from the body surface due to severe scoliosis to the right and emaciation. As a result, the abdominal aorta in the retroperitoneum, along with the vertebral body, was located immediately below the right rectus abdominis muscle. Patients with severe scoliosis might have organ and vessel dislocations that differ from the surface anatomy and thus merit a careful pre-scan before peripheral nerve block.

Anesthetic agents and anesthesia-related medicines directly suppress the natural immune system and acquired immunity. Operation stress brings about a systemic inflammation reaction. Therefore, pathogenic bacteria can easily invade a patient’s body when a clean environment is not maintained. Perioperative management must be performed appropriately to minimize the risk of infection. Hand hygiene is the most effective, simple, easy, low-cost protective measure and is essential for infection control.

Furthermore, I introduce "surgical smoke" from the point of view of protecting medical staff working in an operating room from occupational illness.

Caesarean section is a common emergency surgery for anesthesiologists. In many cases, there is no time for lengthy pre-operative checks, such as when the placenta is prematurely displaced.

“A super-emergency caesarean section” is defined as a caesarean section which is such a particularly urgent event that surgery is initiated immediately after deciding on the need for the procedure without considering any other factors, and the baby is delivered as soon as possible. In general, the interval from initiation to delivery of the baby is approximately 30 minutes. Currently, many strategies are adopted to reduce the time to delivery at many perinatal medical hospitals. In order to manage anesthesia more safely, it is necessary to review the special characteristics of pregnant women and conduct comprehensive preoperative evaluations of pregnant women and their fetuses in a short time.

In category 1 cesarean section, we anesthesiologists make every effort to deliver the baby as soon as possible. We may sometimes be so stretched that we forget about pre-anesthetic evaluation of the mother. But we need to assess the patient and make the anesthetic plan quickly and appropriately even in such extreme circumstances, in order to provide safe anesthesia. For example, airway assessment is essential, because rapid sequence induction, which is usually the choice of anesthetic induction in category 1, is not indicated if difficult airway is anticipated. If the patient is preeclamptic, blood pressure should be carefully controlled at induction of anesthesia to avoid cerebral hemorrhage. Occasionally the cause of non-reassuring fetal status is maternal low cardiac output or hypoxia.

Simulation training for stat emergency cesarean section（Grade A）is recommended for any novice anesthesiologist who is about to experience a stat emergency cesarean section. The implementation of a scenario simulation for stat emergency cesarean section is presented in this paper.

Simulation training helps to achieve mastery in preparing to perform risky procedures in clinical settings. A simulator is required for simulation training. If there are commercial products, trainees can choose the best ones. However, if commercial products are not available, somebody must create the simulator. The author lists three factors that must be considered when creating new simulators：appropriate design, reasonable production costs, and attractive products for the user.

Progress in simulation education may create a new need to make simulators. Effective simulators can achieve a positive impact and good outcomes not only in simulation education but also in clinical settings.

Central venous catheterization（CVC）is a medical procedure that is routinely performed for the purpose of systemic administration such as nutritional administration, venous line keeping, and drug administration. However, CVC is associated with serious complications. Since a considerable number of medical incidents related to CVC have occurred, efforts have been made to prevent recurrence at each medical institution. However, when medical accident reporting was started by the medical accident investigation system at our hospital, it was found that some deaths as a result of CVC still occurred. Although the effectiveness of ultrasound-guided CVC has been evaluated, there can still be complications. This section introduces the surveys and results of CVC management conducted at our hospital, as well as development of a device that enables safe CVC.

In recent years, virtual reality（VR）and augmented reality（AR）have made remarkable progress, and high-performance, low-cost devices are appearing every day. There is a full range of application development environments, allowing for free software and general PC development. VR/AR immersive experience makes it possible to visualize and experience simulation results. Repeated experience can be sublimated into an adventure. VR/AR has a wide range of applications including training in the aerospace field, design support and safety education in the manufacturing industry, and surgical support in the medical area. This paper defines the terms VR/AR and describes practical examples of their use in disaster risk reduction education and future issues.

Since the discovery of rapid eye movement（REM）sleep in the 1950s, it is known that mammals and birds have two different sleep states：REM sleep and non-REM sleep. Recent advances in genetics have enabled researchers to identify many neuronal circuits responsible for the regulation of the two states of sleep. Moreover, the physiological functions of each sleep state are now becoming gradually unveiled, especially in the areas of learning and memory. In addition, the relationship between sleep and various diseases such as dementia have attracted increasing attention. Sleep abnormalities including REM sleep behavior disorder often precede dementia. Here, we focus on REM sleep and review recent findings on its mechanism, roles, and involvement in dementia.