[Objective] The current state of postoperative debriefing education in cardiovascular anesthesia and the effect of manual introduction on anesthesia process time were investigated retrospectively.

[Methods] Cases of cardiovascular anesthesia were classified into two groups before and after the introduction of the manual, and the time from entering the operating room to the start of surgery was compared. The content of postoperative debriefing was analyzed using debriefing record forms.

[Results] The mean time from entering the operating room to the start of surgery significantly declined after introduction of the manual compared to the time taken before the manual was introduced （71 mins vs. 90 mins）. Only 31.9％ of postoperative debriefing was dedicated to non-technical skills.

[Conclusion] Although the introduction of the manual and postoperative debriefing significantly reduced cardiovascular anesthesia process time, the educational effect in terms of the degree of awareness of non-technical skills was lower than that of technical skills.

Hypotension frequently occurs during the induction of spinal anesthesia for cesarean section and can cause adverse maternal and fetal effects. Phenylephrine has been used as a vasopressor to prevent and treat hypotension following spinal anesthesia. We retrospectively investigated the effects of continuous prophylactic infusion of phenylephrine, compared with only bolus group. In the former group, the phenylephrine infusion was commenced at a rate of 1 mg/h immediately after spinal anesthesia, and a bolus of the vasopressor was administered when required. Continuous prophylactic administration of phenylephrine significantly reduced the incidence of hypotension and requirement of bolus vasopressor. The combination of a low-dose phenylephrine infusion and a small dose of vasopressor bolus is preferable, as it reduces the incidence of hypotension while avoiding reactive hypertension and bradycardia.

A four-year-old boy with recessive dystrophic Epidermolysis Bullosa（EB）underwent ophthalmic surgery. EB is a group of rare genetic conditions that result in easy blistering of skin and membranes. We held an interdisciplinary conference before the operation to avoid damage to the patient’s skin. Patient received operation under general anesthesia with the minimal monitor to reduce adhesive strength. We did fiberoptic intubation to avoid mechanical trauma. To reduce emergence agitation, opioid and dexmedetomidine were administered. Management of anesthesia for EB patients requires a precise plan to maintain safety.

Introduction：This report discusses two cases of intractable cancer pain patients who received high dose intrathecal or epidural morphine.

Case 1：A 70 year old man was diagnosed with rectal cancer. After opioid switching, his pain could be relieved by the use of 5 mg/day of transdermal fentanyl and 18 mg/day of intrathecal morphine.

Case 2：A 50 year old man was diagnosed with pleomorphic carcinoma. He was finally able to achieve sufficient enough pain control by the use of 18 mg/day of transdermal fentanyl and 90 mg/day of epidural morphine.

Discussion：It takes time to adjust high dose opioids and switching is not always performed according to the opioid conversion table. In these cases, the combination of systemic opioid administration and intrathecal or epidural analgesia could help lead to early discharge.

Acquired hemophilia A is a rare disease that presents with sudden bleeding symptoms due to an acquired inhibitor of factor VIII, and there is very little evidence for safe hemostasis in emergency surgery. We report a case in which cerebral hemorrhage suddenly developed during the course of treatment for acquired hemophilia A and emergency craniotomy was performed. Blood transfusion and hemostatic agents were administered with various coagulation monitoring parameters such as PT, APTT, fibrinogen, and activated clotting time（ACT）before and during surgery, and good hemostasis was obtained and intraoperative blood loss was kept low. Intraoperatively, it is important to administer hemostatic agents such as activated prothrombin complex concentrate and blood transfusion products at the appropriate time, referring to ACT and fibrinogen, which provide prompt results.

Robot-assisted radical total cystectomy is considered less invasive than open cystectomy with fewer postoperative complications. However, the steep Trendelenburg position and pneumoperitoneum required in these cases may precipitate significant intraoperative circulatory changes, and patients with low cardiac function show a high risk of heart failure. We report the case of a 74-year-old man diagnosed with the dilated phase of hypertrophic cardiomyopathy who was scheduled to undergo robotic-assisted total cystectomy for bladder cancer. Using a pulmonary artery catheter and transesophageal echocardiography, we preoperatively evaluated the effects of the steep Trendelenburg position required for this operation on circulatory dynamics and decided that the operation could be performed in a 25° head-down position. Intraoperatively, we administered sufficient muscle relaxant to ensure that the operation could be safely performed with a minimum head-down angle, and he underwent the procedure successfully without circulatory collapse. The patient showed an unremarkable postoperative course with strict monitoring of circulatory dynamics and was transferred to the hospital on the ninth postoperative day.

We present the perioperative care of a giant ovarian tumor accompanied by a large amount of pleural effusion and ascites in a 53-year-old woman. Her right lung severely collapsed, and her mediastinum deviated to the left on admission. At first, 6,140 mL of pleural effusion was drained for seven days, and then 3,200 mL of ascites was drained on the day before the operation. We focused on hypoxemia at the induction of general anesthesia, reexpansion pulmonary edema, and hemodynamic changes during drainage and removal of the tumor. Providing further gradual drainage is essential, especially when the lung collapse is severe.

Peripheral nerve block was performed for postoperative pain management of transapical approach（TA）transcatheter aortic valve implantation（TAVI）and minimally invasive cardiac surgery（MICS）. Case 1 was an 87-year-old man who received pectoral nerve block for TA-TAVI. Case 2 was a 28-year-old woman who received serratus plane block for MICS. Peripheral nerve block for 2 days helped with pain management, but extending its duration may provide better pain relief.

We report a case of postoperative respiratory arrest with the suspicion of recurarization in a 69-year-old man with left pyelolithiasis who was scheduled for left percutaneous nephrolithotrispy under general anesthesia. He had a history of diabetes and renal dysfunction and had undergone a total pelvic surgery for sigmoid colon cancer and partial hepatectomy for metastatic liver cancer. During anesthesia, rocuronium was used as a muscle relaxant with a pharmacokinetic model as a reference, without any neuromuscular monitoring. Post-surgery, sugammadex was administered to the patient. Further, he was extubated after the recovery of spontaneous respiration and showed no abnormal vital signs, so he was allowed to leave the operating room. Seventy-five minutes after returning to the ward, he suffered from respiratory arrest. Re-administration of sugammadex helped in recovering spontaneous respiration.

We conclude that neuromuscular monitoring in patients is necessary and sugammadex should be administered adequately for the prevention of recurarization.

Primary right atrial tumors are relatively rare. We report anesthetic management of a 45-year-old woman who underwent surgical resection of a giant right atrial tumor. Preoperative computed tomography and transthoracic echocardiography revealed a giant right atrial mass that measured approximately 70 mm in diameter. Intraoperative manipulation of the right atrial tumor led to diminished blood flow to the cardiac chambers, with a consequent severe reduction in blood pressure. Hemodynamic stability was maintained using intensive fluid and pressor agent administration under transesophageal echocardiographic guidance. It is important to monitor patients closely for lung infarction and/or valvular dysfunctions secondary to tumor embolism.

Neuroleptic malignant syndrome（NMS）is a serious condition associated with the initiation or discontinuation of drugs such as antipsychotics. Here, we report a case of NMS in which initiation of adequate treatment was delayed because we could not make a diagnosis until the patient’s condition became severe. A 60-year-old man with a heavy drinking habit underwent surgery under general anesthesia. Although surgery and recovery from anesthesia were uneventful, he began to show signs of restlessness approximately 7 hours after surgery. Haloperidol was administered on the assumption that his restlessness was due to postoperative delirium and/or alcohol withdrawal. However, his disturbance of consciousness worsened along with the appearance of fever, sweating, and muscle rigidity. Laboratory testing revealed elevated serum creatine kinase levels（sCK-levels）. On the second postoperative day（2-POD）, he developed cardiopulmonary arrest that required resuscitation. Based on extremely elevated sCK-levels together with hepatic and renal dysfunction, he was diagnosed as NMS and underwent treatment with dantrolene and hemodialysis in the intensive care unit. The treatment was effective and he was transferred to the general ward on 9-POD, hemodialysis was discontinued on 22-POD, and he was discharged on 108-POD. Initiation of appropriate treatment without delay based on an accurate diagnosis is important for the management of NMS.

The purpose of this article is to explain the basics of public health and graduate schools of public health to clinical anesthesiologists. In response to the world-wide pandemic of novel coronavirus disease 2019, public health and graduate schools of public health have attracted a lot of attention among the general public as well as clinicians. However, few people really understand what these are. Unfortunately, a number of clinicians misunderstand what public health is because of their experience in national medical licensure examination. The author focuses on the five basic areas of public health that are generally taught at graduate schools of public health all over the world. The degrees of MPH and DrPH that are awarded in graduate schools of public health upon graduation are also mentioned.

This report proposes an additional career option for freshly board-certified anesthesiologists of proceeding to graduate schools of public health where they can learn the five main competencies of epidemiology, biostatistics, health policy and management, occupational and environmental health science, and social and behavioral science. These public health related skills and knowledge, especially epidemiology and biostatistics, enable them to conduct a clinical research project, educate an anesthetic resident, and upgrade their clinical skills. In addition, the number of graduate schools of public health is rapidly increasing, so several important points are discussed to help choose a suitable one.

The pandemic caused by the novel coronavirus 2019（COVID-19）and its impact on the medical field has reminded not only clinical anesthesiologists but all physicians of the importance of clinical research and public health as well as basic research. Since conventional medical research has been heavily weighted toward basic research, we believe that future clinical anesthesiologists will need to cultivate balanced medical knowledge that enables them to cope with unprecedented crises. This article presents an overview of the latest publications and their findings on perioperative topics related to COVID-19 that may be of particular importance to anesthesiologists in Japan.

We have developed a device that automatically administers propofol, remifentanil, and rocuronium using a feedback system consisting of an electroencephalogram, a muscle relaxant monitor, three syringe pumps, and a personal computer. This device is expected to help reduce human error and promote proper use of drugs, thereby increasing patient safety and reducing medical costs. This device is hardly affected by noise, unnecessary for an analgesic monitor, and is equipped with a new neuromuscular relaxation monitor. However, being concerned with blood pressure, heart rate, infusion volume and blood transfusion selection, anesthesiologists are still responsible for them. We believe this device will establish a system that enables anyone to receive anesthesia anytime, anywhere, with greater safety.

The robotic anesthesia system we developed titrates the optimal dose and optimal maintenance concentration of intravenous anesthetics（propofol, remifentanil, and rocuronium）based on patient background information and physiological information（bispectral index, train of four values）continuously obtained during surgery. Syringe pumps containing each drug are controlled externally. Our aim is not to enable surgery without the presence of an anesthesiologist but to assist the work of the anesthesiologist. Exploratory investigations of operating conditions with systems that automatically adjust the infusion of intravenous anesthetics have already been conducted. In order to show non-inferiority compared with adjustment by an anesthesiologist, a non-inferiority randomized controlled trial was performed to compare the system with conventional anesthetic management by an anesthesiologist in adult patients undergoing planned surgery. Data from a total of 56 patients, 28 in the manual adjustment group and 28 in the automated adjustment group, were analyzed. No serious adverse events, adverse events in which there was a causal relationship with test equipment, or problems with the test equipment were observed during the study period. The primary endpoint was the proportion of time in which proper anesthetic management with the three intravenous anesthetics was obtained during surgery. The mean value ± standard deviation for this was 73.2 ± 17.2％ in the automated adjustment group and 59.9 ± 29.1％ in the manual adjustment group. The lower limit of the 97.5％ one-sided confidence interval was 0.51, and the p-value（one-sided）was 0.002. The results confirmed the non-inferiority of automated adjustment of the infusion of intravenous anesthetics versus manual adjustment.

In our robotic anesthesia system that automatically regulates three drugs（propofol, remifentanil, and rocuronium）, sequence control based on the procedure of drug administration by the anesthesiologist within the range described in the package insert and model-based closed-loop control to achieve the target value（35 ≤ BIS ≤ 55, TOFC＝1）was conducted by evaluating the state of the individual using biometric information such as BIS and TOFC in order to achieve the target values. For remifentanil, for which no index of analgesic effect was available, we used a concentration that did not require a large change in propofol concentration to achieve stable sedation. To improve safety, we added a response function for various emergency situations.

Automation is increasingly used in many areas of our life. Healthcare cannot be an exception. Although anesthetists may not recognize as such, blood pressure measurement and artificial ventilation are done automatically. So called“Robot anesthesia”is a system to control administration of a hypnotic, an opioid analgesic, and a neuromuscular blocking agent. This system functions primarily based on closed-loop feedback. Processed electroencephalogram such as bispectral index（BIS）and train of four（TOF）count are used as surrogate parameters of hypnosis and muscle relaxation. Even if the Robot anesthesia has become routine, keeping an eye on a secure intravenous route and confirming that BIS and TOF count have been measured correctly continue to be of paramount importance. Technology of automation may reduce workload of mundane clinical tasks, but it is premature to say that automation can definitely increase safety and quality of clinical anesthesia. Anesthetists will need to understand how“Robot”is working and coexist with various automated systems. It is also unknown whether automated total intravenous anesthesia using propofol and an opioid analgesic provides best outcome for any surgical procedures. Humans will decide for whom and for what kind of operation Robot anesthesia is indicated.

Computer-based management seemed to be comparable to manual management and probably superior to manual management especially in longer cases, considering the durability of human alertness. There were a few adverse events in the computer-based anesthetic management group, which might be considered in a future revision. These included abnormally high-dose remifentanil administration, a significant hemodynamic response due to a delay in increasing anesthetic doses during continuous use of electrocautery, and postoperative shivering or nausea. In addition to solving the manpower shortage, allocating trainees to more complex and difficult cases will help improve the quality of training at teaching hospitals.

As mentioned, the following features may be of value in a future revision：1）alternative methods when input from BIS monitoring is not available；2）configuration change of opioid weight or upper limit establishment of opioid concentration；3）variable combination of inhalational or other intravenous anesthetics with remifentanil；and 4）a hemodynamic management system.

Our hospital conducted a robotic anesthesia clinical trial with 28 participants. Fourteen received automatically adjusted anesthesia using a robot and 14 manual anesthesia management. The robotic anesthesia could be safely managed in surgeries that were less invasive and did not significantly affect circulation. In robotic anesthesia, the most important monitoring tools are the bispectral index（BIS）and quantitative neuromuscular blockade monitoring.

However, in minimally invasive surgeries such as laparoscopic surgery, the patient is placed in a position where both upper limbs are wrapped around the body, which makes evaluation difficult. Several companies have introduced electromyography（EMG）-based neuromuscular monitors, which promise to improve the accuracy of neuromuscular blockade evaluation and are expected to become the first choice in neuromuscular monitoring for the safe management of robotic anesthesia.

The robotic anesthetic system Dogen is an anesthetic maintenance system that automatically administers propofol, remifentanil, and rocuronium to patients based on electroencephalographic and muscle relaxation monitoring. In this clinical trial, we tested six cases of manual anesthesia versus robotic anesthesia using this system to verify its efficacy and safety. Although the system was able to provide generally stable anesthetic management in most cases, the analgesic doses may have been increased more than necessary in one case because of indirect effects of ephedrine on the central nervous system and the bispectral index value. This robotic anesthetic system has the potential to reduce the risk of human error and to improve the productivity of anesthesiologists, but an adequate knowledge of anesthesiology is essential for its use.