Thoracic epidural anesthesia（TEA）is a widely used technique for analgesia after thoracic surgery. However, it has several adverse effects. The erector spinae plane block（ESPB）is a relatively simple and safe technique. This study aimed to compare the analgesic efficacy of ESPB and TEA.

Patients who underwent video-assisted thoracic surgery（VATS）were assigned to either the ESPB or TEA group. Numerical Rating Scale（NRS）pain scores were recorded at rest and during movement in both groups until 2 days after surgery. Adverse effects were also recorded.

Although the average NRS score in the ESPB group was less than 2 at rest and less than 4 during movement, these scores were significantly higher than those in the TEA group. There were significantly fewer patients with hypotension in the ESPB group. The ESPB is associated with low NRS scores and provides effective pain relief in patients undergoing VATS. The ESPB has the advantage of conferring a lower incidence of adverse effects.

A 20-year-old pregnant Japanese woman at 38 weeks of gestation was diagnosed with coronavirus disease 2019. She was transferred to our perinatal medical center for a cesarean delivery. Combined spinal and epidural anesthesia was used to reduce the risk of nosocomial infection. The operation was uneventful. The newborn was not infected, and the mother recovered soon. Furthermore, none of the staff involved were infected. The newborn was confirmed to have negative polymerase chain reaction results for severe acute respiratory syndrome coronavirus 2 for three consecutive days, following which both the mother and newborn were discharged on postoperative day 9.

Anaphylaxis occurring during anesthesia is an infrequent but serious complication. Muscle relaxants are the most frequent agents which cause anaphylaxis. Muscle relaxant-induced anaphylaxis is thought to occur through an IgE-dependent mechanism. In most cases, this kind of anaphylaxis requires previous exposure and sensitization to antigen. A 72 year-old male presented anaphylaxis during anesthesia with the first dose of rocuronium. The patient had undergone anesthesia with vecuronium three times before. A later intradermal test was positive for vecuronium and rocuronium, suggesting a cross reaction between rocuronium and vecuronium. Identifying the cause of anaphylaxis is important to avoid recurrence. We report this case together with a review of the literature.

We encountered an 80-year-old female patient with a ruptured aneurysm who developed severe laryngeal edema 40 min after extubation, despite a cuff-leak test showing negativity. The specificity of the cuff-leak test is high, but its sensitivity is too low to rule out post-extubation airway obstruction. Therefore, it is important to accurately assess the risk of post-extubation airway obstruction in high-risk patients to predict airway edema.

One of the most common side effects of opioids is pruritus. Opioid-induced pruritus occurs with the highest incidence in patients with cesarean delivery under spinal anesthesia and is refractory to conventional antihistamine treatment. Opioid-induced pruritus has been shown to occur via activation of gastrin-releasing peptide receptor（GRPR）signaling in the dorsal horn of the spinal cord in both basic research and in humans. Recent basic research suggests that activation of kappa opioid receptors（KOR）attenuates GRPR-mediated pruritus in the spinal cord. KOR agonists have also been shown to be effective for the prevention and treatment of opioid-induced pruritus in patients with cesarean delivery under spinal anesthesia in a clinical review. Further studies will be needed on the prevention and treatment of opioid-induced pruritus based on the mechanism of pruritus.

The response of medical staff to early warning in the status of patients varies from hospital to hospital. More and more hospitals have recently introduced the Rapid Response System（RRS）. The RRS is a tool used by hospitals to immediately assess and treat unstable hospitalized patients. RRS often recognizes signs in a patient before in-hospital cardiopulmonary arrest occurs, with its aim being to prevent in-hospital cardiopulmonary arrest by noticing the signs in advance and responding early. Our hospital introduced RRS in 2014 and physicians perform procedures in such patients in an attempt to prevent in-hospital cardiopulmonary arrest. Unfortunately, this has not led to a reduction in the number of in-hospital cardiopulmonary arrest cases. In this paper, we examine why healthcare professionals have not been able to reduce the incidence of in-hospital cardiopulmonary arrest despite increased awareness of RRS.

Worsening respiratory symptoms are the leading cause of rapid response system（RRS）calls from wards. Many patients presenting these symptoms can only be treated with supplemental oxygen, but some require advanced airway management. Airway management in general wards is more difficult than in the operating room because these rooms are small and dark, lack airway management tools, lack support from well-trained persons, and so on. As specialists in airway management, anesthesiologists are responsible for making airway management in these wards safer.

At Johns Hopkins hospital, the Difficult Airway Response Team（DART）has been introduced to improve airway management safety in the ward. This is an ideal system for improving safety, but introducing it directly into our own medical system would be difficult. The DART system has three components： operations, safety, and education.

Compared to operation center staff, general ward staff lack knowledge of the DAM algorithm and new airway management devices. When anesthesiologists work to secure airways in general wards, this gap in knowledge can make it difficult to manage airways smoothly. Anesthesiologists must provide education to help diminish this gap.

Precise evaluation of cardiovascular risk（especially diastolic function）and the possibility of managing that risk are crucial. Right ventricular heart failure including pulmonary hypertension and adult congenital heart disease must be carefully evaluated. Assessment of atherosclerotic lesions is also important for determining vascular risk. Patients with cardiovascular risk are judged with respect to operative severity in order to titrate anesthetics. In perioperative management, selection of a monitoring system and preparation of a mechanical assist system are crucial.

With the increase in the number of diabetic patients, there has been a corresponding increase in opportunities for anesthetic management of diabetic patients. Microangiopathy and macroangiopathy related to diabetes mellitus are particular concerns.

The presence of diabetic retinopathy indicates the presence of impaired cerebral autoregulation.

Diabetic patients are more likely to present with difficult laryngoscope and intubation because of stiff joint syndrome.

Automatic neuropathy may induce a delay in gastric emptying and disturbance of usual respiratory response to hypoxemia when using sedative agents in the preoperative period.

Preoperative adequate glycemic control in diabetic patients may improve perioperative outcomes.

Pain relief is the essential problem in palliative care for cancer patients. In order to relieve cancer pain, it is necessary to precisely diagnose the cause of pain and deal with it by appropriately combining drug therapies and non-drug procedures accordingly. Nerve blocks are one of the most significant non-drug procedures and may relieve cancer pain that is difficult to control with drug therapies alone. We can administer various types of nerve blocks, and they can be widely applied depending on the cause and location of pain. Peripheral nerve blocks are mildly invasive and can be safely performed even in patients with poor general status or bleeding disorder. Appropriate use of peripheral nerve blocks can be expected to further improve the QOL of cancer patients.

Interventions performed by anesthesiologists to treat cancer pain mainly include neurolysis and spinal analgesia. However, the use of interventions has been less common in recent years with the rise of palliative care, which focuses on the use of opioids and analgesic aids. Interventions are still necessary, but only a few anesthesiologists are capable of performing these procedures. In this session, the authors will briefly explain when they believe spinal anesthesia is indicated in cancer pain patients. In addition, we will discuss the activities of the “Mobile Expert” education program in Okinawa and explain why this concept is a useful one for popularizing interventions and educating young physicians.

Home care medicine is available to patients who suffer from a decline in daily activities due to cancer pain or pain associated with other chronic diseases and aging. We usually provide drug therapy, but its side effects threaten a comfortable and secure life, and in some cases it can increase the risk of death from fractures and poor oral intake. We therefore avoid administration of multiple drugs, and at the request of the patient, we also combine the use of nerve block and interventional treatment such as trigger point block, sacral epidural block, and intraarticular injection with drug therapy. Continuous subcutaneous injection of opioid analgesics or nerve block therapy is useful for pain control. In addition, a pain clinic may contribute to the effective treatment of patients when subjected to the risk of interventional therapy at home. It is therefore necessary to enhance the cooperation of physicians from general hospitals and community home care clinics.

The medical accident investigation system implemented in 2015 is a non-punitive learning system that investigates the causes of patient deaths and helps prevent recurrence. In the cases reported so far in this system, invasive medical practices such as surgery account for more than 50％ of death-related medical care. In some cases, it is difficult to determine whether the medical care provided is related to death. On the other hand, the introduction of this system has promoted the proper implementation of informed consent and reduced unexpected deaths. However, the system used to support decision-making by patients based on a thorough understanding of the content of the explanation needs improvement, and its development will be a challenge going forward.