A thoracic epidural block is excellent in postoperative analgesia in thoracotomy, but cases in which thoracic epidural block is contraindicated are increasing due to the use of oral anticoagulants. Multimodal analgesia is therefore required, but the optimal combination of analgesia is not clear. Patients underwent thoracic surgery in our hospital were grouped in a local nerve block group and an intravenous fentanyl combination group. We separately examined the NRS（Numerical Rating Scale）every 3 hours after surgery, complications（nausea, vomiting, neuropathy）, and the use of other analgesic drugs. There was a significant difference between the two groups only in NRS 3 hours after entering the ICU. There were no significant differences between the two groups regarding nausea, vomiting, or neuropathy. Intravenous fentanyl combination was useful for postoperative analgesia after thoracic surgery.

Poor medication management in preoperative patients can lead to the cancellation of surgical procedures and perioperative complications, so we established a cooperative system between our hospital and community pharmacies to review preoperative medications. We asked community pharmacies to review home medications for preoperative patients and to discontinue some medications such as anticoagulants and antiplatelet agents before surgery. A high percentage of outpatient pharmacies responded, with 2 days being the median response time. In 55 patients who required medication reconciliation, all 24 patients who received preoperative pharmaceutical consultation underwent scheduled surgery. Of the 31 patients who did not receive pharmaceutical consultation, one patient's surgery had to be postponed due to noncompliance with medication. The establishment of a cooperative system between hospital and community pharmacies helped improve safety in perioperative patients.

We compared the performance of two types of endoscopy masks for fiberoptic intubation, the VBM endoscopy mask（VBM mask）and the Explorer endoscopy face mask（Explorer mask）. The masks were placed on manikins, and fiberoptic intubation was performed with positive pressure ventilation via the mask. Intubation time, maneuverability of the tracheal tube and scope, and tidal volume before and during fiberoptic intubation with the two masks were compared. There were no significant differences in intubation time, tube and scope maneuverability, or tidal volume before intubation attempt. Tidal volume was significantly reduced with both masks after intubation attempt. The degree of reduction in tidal volume was clinically safe with the VBM mask, but ventilation became difficult due to leakage with the Explorer mask. With respect to ease of fiberoptic intubation, both masks had almost the same performance, but in terms of mask ventilation, the Explorer mask required measures to prevent leakage.

A new intravenous anesthetic, remimazolam, is an adjustable general anesthetic that can be antagonized by flumazenil in the event of excessive sedation. We recently induced general anesthesia with remimazolam and remifentanil and maintained it with desflurane and remifentanil in a hydrocephalus patient with ventricular peritoneal shunt dysfunction. At the end of anesthesia, the effect of remimazolam was suspected to remain, and a systemic seizure occurred immediately after administration of flumazenil.

General anesthesia in patients with pneumothorax without thoracic drainage requires attention to airway pressure. We present the case of a patient with Graves’ disease who was on ventilator management for right pneumothorax and left tension pneumothorax. He had bilateral pneumothorax but was managed with spontaneous breathing with only a left thoracic drain. With forced ventilation for general anesthesia, placement of a right thoracic drain was considered, but we wanted to avoid additional preoperative invasion due to his hyperthyroidism symptoms. To force-ventilate this patient without a right thoracic drain, it was important to avoid positive pressure ventilation of the right lung as much as possible. The patient underwent a total thyroidectomy with one-lung ventilation followed by a tracheostomy. After replacing the tracheostomy tube, the patient was placed on double-lung ventilation and spontaneous breathing was quickly established. This is a noteworthy case in which a small amount of remimazolam was used and a smooth transition to spontaneous breathing was achieved. This case was managed without pneumothorax exacerbation.

When the cause of circulatory failure cannot be identified by transthoracic echocardiography （TTE）in ICU patients, transesophageal echocardiography（TEE）has been reported to be useful and is recommended in guidelines. TEE may be particularly useful in patients with circulatory failure immediately after cardiovascular surgery, because TTE may not provide good images due to the effects of mechanical ventilation and protective materials on the surgical wound. In this report, we describe the case of a cardiac tamponade confined to the right atrium and right ventricle after Stanford type A aortic dissection for which TEE was useful in diagnosis.

Aerosol spread of COVID-19 virus during extubation remains a problem in patients with COVID-19. To solve this problem, we devised a method to prevent aerosol spread of the virus during extubation using the Explorer endoscopy face mask. With this method, the tracheal tube is removed from the right-sided hole with the one-way valve of the bronchoscopy mask which is attached to the face without any gaps, and the patient is then observed while wearing the mask until measures to prevent aerosol spread of the virus are no longer necessary. This method has the advantages of simplicity, low residual aerosol due to the small aerosol spread space, and the ability to treat upper airway emergencies after extubation without delay. However, some problems remain such as the lack of proven effectiveness in preventing aerosol spread and the inability to perform tracheal intubation under aerosol spread prevention measures.

A guideline is defined as 1） a text containing recommendations based on scientific evidence developed using systematic reviews, which is 2） designed to support patients and healthcare providers and 3） used as a decision-making tool in clinical practice. Guideline users should acquire knowledge of medical practice guidelines by reading the literature or attending training courses on how to use the guideline. The quality and appropriateness of the guideline itself must then be evaluated based not only on its recommendations but on the background on which they are based, particularly the quality of the evidence and the method used to make the recommendation. Unfortunately, high-quality practice guidelines are very scarce in the field of anesthesiology. Clinicians should participate in the development of high-quality guidelines and try to adequately understand and use them to improve the quality of their practice.

In order to decrease complications from epidural anesthesia, we will need good disposable needles that can be used with the hanging drop technique to ensure safety going forward. I therefore examined several disposable needle tips and observed the condition of absorbed solution through the needle hub. When I inserted aluminum foil into the disposable needle hub, I was able to see the absorption of a drop of water more clearly. When I asked the manufacturer to make a disposable needle with metal hub, he said that we have to need a long time to product an ideal metal hub needle, so he made A and B type devices（metal-pin）for me instead of new epidural needle. A can be used with the hanging drop technique and the loss of resistance technique. B is used with the hanging drop technique only. When I tried them in my clinic, I was able to see the absorption of a drop of water clearly. I found out that these metal devices were useful for hanging drop technique. In order to decrease serious complications, I would recommend these metal devices until good disposable needles become available.

A multidisciplinary heart team is considered safe and effective in determining treatment strategies. Indications for transcatheter aortic valve replacement have expanded from high-risk to low-risk patients, reducing the role of surgeons as gatekeepers. In recent years, opportunities for heart team meetings have been drastically reduced due to work style reform and avoidance of the three Cs （closed spaces, crowded places, and close-contact settings）. We conducted a questionnaire survey in each department because we were concerned about restrictions affecting heart team communication. According to our findings, most participants felt that the heart team was both necessary and functioning effectively. Although restrictions have increased, it is important to continue maintaining good communication between departments.

At New Tokyo Hospital, multi-disciplinary conferences on heart diseases are held every morning, and anesthesiologists attend most of these conferences. Since anesthesiologists, cardiac surgeons, and interventional cardiologists meet often, clear communication exists among cardiac team members. By involving anesthesiologists in discussions with the cardiac team, the latter can develop treatment plans from an anesthetic point of view. Through these discussions, we anesthesiologists can also comprehend the perspectives of surgeons and cardiologists in daily practice. This can help us expand our range of abilities.

The patient’s characteristics, cardiac echo findings, the various image examination and standard laboratory tests effect perioperative risk and the planning of surgical procedures. All members of the heart team share in risk evaluation and in planning scheduled surgical procedures. In the preoperative conference, members of the heart team discuss the various aspects of the operation, and make decision on device types, sizes, and methods of approaching the operation. The role of the scrub nurse is to discuss and suggest the nursing care which is necessary for a safe operation during the heart team conference. If scrub nurses would like to become the moderator of the heart team, they have to consider the mental state of patients and improve the operation nursing.

The indication of chest surgery should be determined by a patient’s surgical resectability, postoperative respiratory function, preoperative physical function, and feasibility of one-lung ventilation. The postoperative respiratory function of a patient undergoing chest surgery is often evaluated by the predicted postoperative percent forced expiratory volume in 1 s and the percent diffusing capacity of carbon monoxide of the patient. When these values are less than 30%, they indicate high risk for the patient. The cardiopulmonary function of a patient can be evaluated by exercise tolerability. A maximum oxygen consumption of less than 10 mL/kg/min indicates that the patient is at high risk. One-lung ventilation greatly affects a patient’s gas exchange and circulation, so the feasibility of one-lung ventilation should be assessed in patients proposed for chest surgery. Preoperative alveolar-arterial difference of oxygen, presence and extent of pulmonary hypertension and right heart dysfunction, and predicted tidal volume in one-lung ventilation may be useful in this assessment. A patient’s coexisting diseases require preoperative interventions. In high-risk patients, the indication of surgery is re-evaluated after optimization of their physical function by reducing the risk of coexisting diseases and prehabilitation. Prehabilitation is a shift from risk management to risk attenuation.

Thoracic surgery is defined as any operation involving the lungs and trachea, which are important organs for life support. During thoracic surgery, anesthesiologists oversee anesthesia and respiratory management. Thus, anesthesiologists play an important role in thoracic surgery, for which they require advanced and specialized skills. In this paper, I discuss the knowledge and techniques necessary for general anesthesia management such as one-lung ventilation, respiratory management, and selection of analgesic methods, while providing a report of the literature on previous self-study cases. This paper will help younger anesthesiologists understand the anesthesiology required for thoracic surgery.

In the field of thoracic surgery, the surgical approach has evolved from a traditional open thoracotomy to a minimally invasive approach such as video-assisted thoracic surgery（VATS）and robotic surgery. However, the key points for anesthesia during thoracic surgery are the same regardless of the approach. First, the thoracic cavity is very narrow, being less than half the size of the abdominal cavity；second, thoracic surgery is a very high-risk procedure because of the proximity of pulmonary vessels with a high blood flow. Therefore, proper ipsilateral lung collapse and complete muscle relaxation are important for adequate surgical access and a safe procedure.　

In addition, considerations that fall outside the domain of either thoracic surgery or anesthesiology should not be left to the other department, but should be confronted in a mutually complementary manner. Such interdepartmental collaborations are important for the safe intraoperative management of patients.

The perioperative pulmonary rehabilitation for lung surgery was mainly reviewed based on the results of meta-analysis of preoperative, postoperative, preoperative/postoperative rehabilitation, enhanced recovery after surgery（ERAS）, and incentive spirometry（IS）.　

Preoperative pulmonary rehabilitation requires at least 2 weeks. Changeable risk factors for pulmonary complications should be improved as much as possible, focusing on exercise therapy. After surgery, ERAS should start early, and comprehensive interventions such as respiratory care, early mobilization, pain control, IS, and chest physiotherapy should be effective. Postoperative rehabilitation centered on aerobic exercise should be performed even during the postoperative stable period.　

Perioperative pulmonary rehabilitation improves postoperative pulmonary complications, pneumonia, length of hospitalization, reduction of thoracic drainage, exercise tolerance, physical activity, quadriceps muscle strength, pulmonary function, respiratory muscle strength, health-related quality of life（HRQOL）, dyspnea, and fatigue. Although it is currently difficult to improve the mortality rate, perioperative pulmonary rehabilitation could potentially improve it in the future.

In conventional medical safety, preventing the recurrence of accidents by identifying their causes of implementing countermeasures has been the mainstream approach. However, there is a limit to the effectiveness of preventive measures, and the increased use of procedures to prevent accidents can cause new accidents. In recent years, the focus has shifted to an approach that seeks to enhance the ability to maintain safety by investigating why accidents do not occur in daily operations. However, there are no clear guidelines on the significance of evaluating why daily operations are going well or on practical approaches. This paper summarizes recent trends and future approaches in medical safety research based on the evolution of past safety research approaches and accident models.

Japan’s medical accident investigation system was enforced in October 2015 under the Amended Medical Care Act established in 2014. The purpose of the system is to promote patient safety and prevent the recurrence of medical accidents. The system does not impose legal penalties. Information on medical accidents and analyses of related data are published in the form of monthly and annual reports. The number of reports and the method used for “in-hospital Investigations” have been criticized, and 16 reform proposals have been published. Under the system, hospitals are asked to conduct in-hospital Investigations that involve collecting and analyzing data to identify the causes of accidents. At the request of medical institutions and bereaved families, a Medical Accident Investigation and Support Center（ISC）investigation is performed. About 9％ of investigations are now ISC investigations. The lack of legal penalties under the system is likely to become a problem in the future.