The purpose of this study was to compare the temperature estimated by TTP（T_TTP）and nasopharyngeal temperature（T_NASO）under hypothermic cardiopulmonary bypass. We examined the correlation and agreement between T_NASO and T_TTP. We identified 9 adult patients in whom T_TTP and T_NASO had been measured simultaneously during anesthesia for elective cardiovascular surgery. We compared T_NASO with T_TTP before CPB, during CPB with cooling T_NASO, during CPB with stable low T_NASO, during CPB with re-warming T_NASO, and after CPB. Correlations between absolute values of T_NASO and T_TTP were determined by linear regression. Bland-Altman analysis was used to examine the agreement between T_NASO and T_TTP. T_TTP was highly correlated with T_NASO in all 5 periods（p＜0.01）. Bland-Altman plots showed the 95％ LOA was not within ±0.5℃ in all 5 periods. Good agreement between the two methods of measurement was not seen. T_TTP and T_NASO have a good correlation but have poor agreement under hypothermic cardiopulmonary bypass.

A patient who complained of severe nausea after general anesthesia was treated with droperidol, resulting in respiratory depression.

When general anesthesia was introduced, there was no problem with mask ventilation and tracheal intubation, but after respiratory arrest, mask ventilation and tracheal intubation were difficult, and SpO₂ decreased to 17％. Tracheal intubation was possible using McGRATH. There were no neurological sequelae.

Postoperative nausea and vomiting（PONV）is a very unpleasant complication for patients and its prevention is important. Droperidol is a drug that can be used in Japan and is useful for both prevention and treatment of PONV. From this experience, however, we realized that significant respiratory depression may occur after administration of droperidol.

Left ventricular filling pressure（LVFP）has been reported to correlate with the severity of aortic stenosis（AS）. The perioperative management of aortic stenosis and a cerebral aneurysm in a patient with chronic thromboembolic pulmonary hypertension（CTEPH）based on LVFP is reported.

Transcatheter aortic valve replacement（TAVR）was planned for an 82-year-old woman with CTEPH. However, preoperative examination revealed a cerebral aneurysm. Because of exertional dyspnea due to CTEPH, it was difficult to determine the timing of surgical intervention for the AS and cerebral aneurysm. LVFP was therefore used as a marker for surgical decision-making. In this case, the preoperative LVFP was not increased, and surgery for the cerebral aneurysm was performed. After surgery, she developed dyspnea. At that time, LVFP was increased, and dyspnea was diagnosed as the cause of heart failure due to severe AS. After treatment for heart failure, TAVR for AS was performed. The patient discharged without any complications.

We report a patient who developed hypoxia due to pulmonary thromboembolism in addition to ipsilateral diaphragmatic paresis induced by interscalene block. A 70-year-old woman underwent arthroscopic rotator cuff repair under general anesthesia and interscalene block. At 24 hours postoperatively, immediately after ambulation, she developed dyspnea and a low SpO₂ of 88％. Chest computed tomography showed elevation of the right hemidiaphragm and embolisms in the left peripheral pulmonary artery. The interscalene block catheter was removed and anticoagulant therapy was started. The phrenic paresis and dyspnea were diminished on postoperative day 4. We should note the pulmonary embolism in the perioperative period of shoulder surgery. We experienced a patient who developed a pulmonary embolus while undergoing continuous interscalene block. It should be noted that pulmonary embolism may occur in patients undergoing upper limb surgery.

Splints are sometimes used to prevent anterior tooth fracture or subluxation during endotracheal intubation or endoscopic inspection. This study aimed to determine the proper design and material of a splint to protect against tooth fracture and subluxation. Two splint designs were examined： a full dental arch and a partial dental arch design between the left and right first premolars. Likewise, three splint materials were examined： soft, hard, and a combination of the soft material inside and the hard outside（soft-and-hard）. Strain gauges for measuring the load were individually attached to each tooth of a dentition model. An endotracheal intubation or endoscope mouthpiece was set on the models protected by one of the various types of splints. A load of 50 N was then applied on the laryngoscope blade or the dentition model, and the loads on each tooth were recorded.

The same tooth protection effect was observed with both partial and full dental arch designs. The combined soft and hard splint material provided the maximum tooth protection when compared with the other materials. The partial dental arch design using soft-and-hard splint material is recommended for tooth protection in cases of endotracheal intubation and endoscopic inspection.

In the perioperative period, prompt recognition of anaphylaxis and correct treatment are necessary to ensure a good outcome. However, deciding whether to continue or discontinue surgery is difficult. Perioperative anaphylaxis guidelines do not provide clear information about when to proceed with or to abandon surgery. Patient safety will improve when anesthesiologists, nurses, and surgeons have a common view of coping with perioperative anaphylaxis. This report introduces the perioperative anaphylaxis guidelines used at our hospital.

Perioperative dental assessment and oral hygiene management is important not only to avoid tooth injury but also to promote postoperative recovery. In hospitals that have a department of dentistry and oral surgery, patients can be advised to consult a specialist before surgery, but not all hospitals have one. Our hospital does not have such a department, and there were seven reports of tooth injury during the past five years（from April 2015 to March 2020）, most of which occurred at tracheal intubation. If oral hygiene is neglected, the number of microorganisms increases and could cause many diseases.

By consulting a specialist for dental assessment and oral hygiene before surgery, patients can receive proper dental protection and treatment which could allow them to avoid tooth injury and improve postoperative outcomes. It would be beneficial for patients to consult general dental practitioners before surgery. Incidentally, a perioperative oral hygiene management fee can be calculated.

There is a growing concern regarding continued use of modern volatile anesthetics with potent greenhouse effects. Total intravenous anesthesia（TIVA）can be an alternative way to reduce impact on the Earth and future generations. Remimazolam is a new intravenous anesthetic approved for induction and maintenance. Being a short-acting benzodiazepine, the effect of remimazolam can be antagonized by flumazenil if necessary. Clinical benefits of using remimazolam instead of propofol have yet to be clarified. Anesthetists have so far paid attention primarily to short-term effects such as rapid recovery and low incidence of postoperative nausea/vomiting. However, much longer lasting beneficial effects of propofol, particularly for patients undergoing cancer surgery, have recently been recognized. Automatic control of intravenous anesthesia, the so-called "Robot Anesthesia", is now in the final stage of development. Novel drugs and means of administration may dramatically change the practice of TIVA in the foreseeable future, but the safety of TIVA still depends on adherence to simple and basic things, such as a secure venous route, correct preparation of drugs, and proper use of infusion pumps. In the field of intravenous anesthesia, what will change and what must not change in the next few years to come are discussed.

In Japan, remimazolam besilate was approved in January 2020 and launched in August 2020. The experience of remimazolam anesthesia for 3 months taught us advantages and disadvantages of propofol from the following four points of view； anesthesia induction, anesthesia maintenance, after the end of surgery, and the environment for propofol infusion.

For anesthesia induction, an advantage is the knowledge of induction dose, while disadvantages are infusion pain and possibility of severe hypotension. For anesthesia maintenance, advantages are the knowledge of electroencephalogram for propofol anesthesia and applicability for motor evoked potential monitoring under clinical range of propofol concentration, while a disadvantage is propofol infusion syndrome. After the end of surgery, advantages are the knowledge of the effect-site concentration for recovery from propofol anesthesia, suppression of laryngospasm, and prevention of postoperative nausea and vomiting.

For the environment for propofol infusion, there are merits such as availability of target-controlled infusion, numerous studies of the pharmacokinetics and pharmacodynamics of propofol, visibility of propofol solution, expectation of a commercial closed-loop system for propofol anesthesia and monitoring of exhaled propofol in daily clinical practice.

Remimazolam is a benzodiazepine with pharmacokinetics similar to that of remifentanil. Japan was the first country to approve its use as a general anesthetic.

Since the approved method of anesthesia induction may result in an overdose, a single, slow intravenous infusion of up to 0.2 mg/kg remimazolam is considered practical. Sufficient hypnotic effects can be expected with continuous intravenous infusion of remimazolam at 1 mg/kg/h while maintaining anesthesia. The use of flumazenil is recommended for the purpose of fully restoring cognitive function upon awakening from anesthesia. Remimazolam is superior to propofol in its hemodynamic stability, excellent pharmacokinetics, and the presence of its specific antagonist. Remimazolam can be a first-line drug for general anesthesia given its excellent properties.

Video-assisted thoracoscopic surgery（VATS）is less invasive than traditional open thoracotomy and improves patient outcomes. However, postoperative pain in such cases is unexpectedly severe. Effective postoperative analgesia is believed to reduce morbidity, accelerate recovery, and improve patient outcomes. Thoracic epidural anesthesia（TEA）has been commonly used for pain control after VATS. TEA is effective in achieving pain relief but has side effects, including urinary retention, postoperative nausea and vomiting, and hypotension. Because of these side effects, TEA has been questioned as the gold standard for pain management after VATS. In our institute, we performed thoracic paravertebral block（TPVB）as pain management for about 1,000 cases after VATS as an alternative technique to TEA and obtained good results. This article shows that TPVB is a safe and simple technique that can provide TEA-equivalent pain relief with fewer side effects than TEA. We therefore feel that TPVB is the ideal method for pain management after VATS.

Paravertebral spread of an erector spinae plane block（ESPB）is a controversial issue. Some cadaveric studies, consistent with clinical evidence, showed that the injectate spreads into the paravertebral space, while other studies reported the absence of paravertebral spread after ESPB injection. There are no guidelines to resolve this contradiction. Recently, some new peripheral nerve block procedures performed at regions close to the site of ESPB have been reported：mid-point transverse process to pleura, costotransverse notch, costotransverse foramen, and retrolaminar blocks. A common point among these procedures is the injection point of the local anesthetic that is slightly deeper than the ES plane. In this report, I tentatively name the procedures“modified ESPBs”and describe the clinical efficacy of these blocks by comparing them to local anesthetic spread to the paravertebral space. I believe this report will help readers address the contradiction.

Quality of perioperative care has been improving through the accumulation of knowledge regarding perioperative management. However, as each specialty is subdivided, there may be differences in management policies between anesthesiologists and intensivists. Though evidence on perioperative management has increased, most of it has been obtained under limited conditions. Anesthesiologists and intensivists are required to consult with each other and decide on how to manage each case, considering the condition of individual patients, the facility environment, and the manpower available, to provide better team medicine and improve patient outcomes.

Anesthesiologists need to be familiar not only with anesthesia but also with perioperative and postoperative management.

In terms of postoperative management provided in the intensive care unit（ICU）, we should consider the optimal management approaches in the operating room. Conversely, we should propose appropriate approaches for postoperative management in the ICU from the perspective of anesthesiologists in the operating room.

Providing perioperative management from the perspective of a patient’s clinical course rather than being limited by the narrow evidence observable in the operating room will improve the patient’s prognosis. Furthermore, experience in postoperative management will further improve our competence as anesthesiologists.

In this article, I would like to explore the seamless and interactive relationship between anesthesiologists and intensivists through the pros & cons in terms of understanding both, anesthesia and the ICU.