After the SARS-CoV-2 pandemic spread in Japan, a state of emergency was declared in April 2020. At our hospital, the number of available ORs was restricted in April and May 2020. To evaluate the effect of restrictions of OR capacity on the number/characteristics of surgeries and patients, we retrospectively examined data on patients who underwent surgery in April and May from 2017 to 2020. Values obtained in 2020 were compared with those obtained from the same period in the previous three years.

While the total number of surgeries decreased, the number of emergency surgeries remained steady, so the proportion of emergency surgeries increased. The proportion of patients with poor performance status（ASA-PS≥3）increased in both elective and emergency groups. The number of cesarean sections increased, suggesting a tendency for cases to concentrate in perinatal centers with sufficient capacity. In contrast, otorhinolaryngology surgeries decreased, reflecting the trend to avoid risk of infection from upper airway manipulation. Extremity surgeries also decreased due to their deferrable characteristics.

These findings suggest the need not only to prevent infection but to prepare for severe cases, emergency cases, and caesarean sections as well. It is important to consider the balance between the clinical needs of the region and the capacity of individual hospital facilities.

This single-center prospective study with 50 participants was conducted using train-of-four values obtained intraoperatively by neuromuscular monitoring and pharmacokinetics-pharmacodynamics（PK-PD）modeling for the rocuronium-sugammadex complex. Individual changes in the effect-site concentration of free rocuronium after administration and the effect-site concentrations of rocuronium at the time of complete recovery（Ce_r）were calculated using the model developed by Kleijn et al. When sugammadex was administered at the recommended dose stated in the package insert, median Ce_r was 0.43μg/mL（interquartile range, 0.29-0.62μg/mL）. The effect-site concentration of rocuronium remained below the Ce_r value determined in each case, and none of the participants had symptoms suggestive of residual neuromuscular block or recurarization. The PK-PD model appears to be useful for predicting free rocuronium concentrations.

Background：In airway management during prone thoracoscopic esophagectomy, we routinely employ a single lumen spiral tube and a bronchial blocker for one lung ventilation. The placement of the bronchial blocker improves tracheal and bronchial mobility during peribronchial lymph node dissection. We experienced two cases requiring careful preoperative consideration for one lung ventilation strategies.

Case presentation：In case 1, contralateral paraaortic lymph node dissection was required for curative resection. A Y-shaped double-balloon bronchial blocker（EZ-blocker^TM）was intubated into the trachea to occlude either right or left main bronchus ad libitum, resulting in preferable management of bilateral thoracoscopic surgery in prone position.

In case 2, preoperative CT revealed a right tracheal bronchus above the carina. We decided to employ two bronchial blockers following preoperative anesthetic conference. One was placed in the right tracheal bronchus as usual, and the other was placed outside the tracheal tube to occlude right bronchus intermedius. A guidewire was employed to selectively introduce the blockers to the right tracheal bronchus.

Conclusions：We experienced cases requiring careful preoperative preparation for one lung ventilation in prone thoracoscopic esophagectomy. Novel double bronchial balloon techniques were successfully employed for occlusion of main bronchus and/or tracheal bronchus.

A 29-year-old man who suffered from traumatic aortic dissection underwent partial arch replacement. He had difficult weaning from cardiopulmonary bypass because of low output syndrome, which was probably due to left ventricular myocardial damage caused by acute aortic valve regurgitation at the onset. To reduce left ventricular load for a middle- to long-term period, we decided to use a left ventricular assist device（LVAD）with ascending aortic perfusion, apex of left ventricle drainage. Three days after surgery, cardiac function gradually improved, and the patient was finally weaned from the LVAD.

The number of surgeries conducted at our hospital has increased in recent years, and the accompanying severe workload for anesthesiologists has made it difficult to provide appropriate postoperative anesthesia rounds. From April 2018, a perianesthesia nurse joined the operating room staff and began postoperative rounds together with the anesthesiologists. The day after surgery was performed, the nurse checked patients’ postoperative condition on electronic medical records before conducting the above-mentioned rounds. This let anesthesiologists perform their rounds more efficiently during regular working hours. In addition to reducing anesthesiologists’ burden, this approach increased hospital profits. The future aim for perianesthesia nurses at our hospital is for them to serve as coordinators among anesthesiologists, surgeons, and ward nurses. The hospital also aims to provide patients with an environment for receiving sufficient postoperative analgesia and prompt recovery.

We report a case of cardiac arrest under spinal anesthesia for transurethral resection of bladder tumor. After the anesthetic effect disappeared, cardiac arrest reoccurred and the patient was diagnosed with sick sinus syndrome. On preoperative evaluation, the patient did not show any bradycardia risk factors for spinal anesthesia and had no history of arrhythmia or syncope, so the risk of bradycardia was thought to be low. However, cardiac sympathetic blockade due to high spinal anesthesia, bradycardia-inducing reflexes such as the Bezold-Jarisch reflex, and the manifestation of sick sinus syndrome combined to cause bradycardia and cardiac arrest. In spinal anesthesia, the possibility of bradycardia and cardiac arrest should always be considered, even in patients with low risk of bradycardia and no abnormalities in their preoperative evaluation.

Radical-7^® is a multifunctional pulse oximeter from Masimo Co Ltd. Its features include high-accuracy pulse oximetry at low perfusion, accurate monitoring of respiratory rate, monitoring of oxygenation in the range of PaO₂ 100–200 mmHg, non-invasive measurement of the hemoglobin concentration（SpHb）, peripheral perfusion status（perfusion index）, and a dynamic hemodynamic index（Pleth Variability Index：PVI）. The PVI is useful as a dynamic index of fluid responsiveness, similar to the previously used dynamic indices, such as stroke volume variation and pulse pressure variation. Pain, respiratory status, catecholamine infusion, and different measurement sites can significantly affect the PVI. However, the PVI is less invasive than other commercially available dynamic indices. The SpHb can be used to continuously monitor hemoglobin concentration, but it is less accurate than actual measurement. However, it is useful for monitoring during the perioperative period when the risk of bleeding is high.

Pulmonary artery catheterization is the gold standard for invasive cardiac output monitoring in critically ill patients, but its indications are limited due to the risk of infections and complications. Except in cardiac surgery patients, cardiac output is typically measured as arterial pressure-based cardiac output（APCO）. The LiDCO（lithium dilution cardiac output）Rapid V3 has a rapid mode that uses an APCO sensor and a continuous non-invasive arterial pressure（CNAP）mode. In the latter mode, arterial pressure is measured continuously using a finger cuff with correction based on upper-arm blood pressure, and cardiac output is calculated after every beat. This review describes the usability and features of the LiDCO Rapid V3, as well as the PulseCO algorithm that is common to both modes.

Improvement in the quality of circulatory management during anesthesia increases patient perioperative safety. In clinical settings, invasive monitoring is sometimes necessary to understand hemodynamic state that cannot be visualized. However, invasive monitoring such as pulmonary arterial catheter can cause serious complications. With the recent concept of Enhanced Recovery After Surgery（ERAS）, which aims to facilitate early recovery from surgery, non-invasive monitoring without complications is ideal. The Clearsight system^®（Edwards Lifesciences, Tokyo, Japan）is a relatively new device which allows continuous non-invasive arterial pressure and cardiac output measurement using an inflatable cuff placed around a finger. Here, we introduce the principle of the Clearsight system^®, compare it with other circulatory monitoring systems, describe suitable cases for its use, and present our case series.

Grade A caesarean section refers to the most urgent caesarean section.

After the decision is made, surgery should be started immediately to deliver the baby as soon as possible without considering any other requirements.

Indications include placental abruption, umbilical cord prolapse, uterine rupture, and maternal respiratory and circulatory insufficiency.

To perform grade A caesarean section quickly and safely, it is necessary to standardize the language, process, and roles of various healthcare workers, such as anesthesiologists, obstetricians and gynecologists, neonatologists, and nurses, and to improve the hardware aspects．

It is essential for a multidisciplinary team to study and simulate grade A caesarean section and make improvements according to the prevailing conditions at each hospital.

Our hospital has anesthesiologists and scrub nurses on call during night hours and on weekends and holidays. Herein, we reported on responses to Grade A caesarean sections at our hospital. Initially, we prepared a protocol to standardize communication methods as well as drugs and materials, and we conducted simulation training. As a result, we were able to shorten duration from Grade A declaration to delivery. However, the reduction in duration was smaller in out-of-hours Grade A cases. We therefore arranged for cooperation between obstetric nurses, obstetricians, and the head nurse in preparing for anesthesia and surgery. In order to provide prompt medical care even outside regular service hours, we conduct simulations involving multiple professionals including obstetricians, obstetric nurses, head nurse on duty, anesthesiologists, pediatricians, scrub nurses, and medical engineers once every three months.

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. When I inserted aluminum foil into the disposable needle hub, I found that the absorption of a drop of water became more clear. When I asked the manufacturer he said this would take a long time, so he made a device（metal-pin）for me instead. When I tried it in my clinic, I watched the absorption of a drop of water clearly. I found out that a metal device was useful for hanging drop technique. In order to decrease serious complications, I would like to recommend the device until good disposable needles become available.

Epidural anesthesia and analgesia has been recognized as a key strategy for perioperative management of patients undergoing abdominal surgery, especially with upper abdominal incision. This article indicates a clinical practice of epidural anesthesia with or without general anesthesia for abdominal surgery and reviews the clinical utility and current status of epidural analgesia after abdominal surgery along with the history of postoperative analgesia. The superiority of epidural analgesia to intravenous opioid in terms of providing better pain relief at movement and early intestinal movement and decreasing the incidence of postoperative pulmonary complications has been established for decades. However, the results of recent clinical studies using multimodal analgesia consisting of regional anesthesia, non-opioid analgesics, and opioids have drawn this superiority into question. Furthermore, one clinical study revealed that the number of malfunctions of postoperative epidural analgesia may be higher than we have expected.

Under these circumstances, will epidural analgesia disappear from the options selected for postoperative pan relief? Epidural analgesia will be replaced by the multimodal analgesia using peripheral regional analgesia, non-opioids, and rescue opioids for laparoscopic surgery and lower laparotomy. However, its clinical utility will not fade away in pain relief after major upper abdominal laparotomy. Moreover, the accumulation of knowledge and skills of epidural analgesia as well as clinical intervention in postoperative patients by teams such as acute pain relief teams will be crucial for improving the quality of postoperative epidural analgesia.

Ipsilaterally guided epidural anesthesia was successfully provided using a catheter to 96% of 176 cases that underwent sports-associated orthopedic knee surgeries. Ipsilaterally placed epidural catheters provided ipsilaterally dominant blocks. On the third postoperative day, complete unilateral blocks were eventually demonstrated in 80% of the cases, where motor functions were preserved well enough to promote rehabilitation. This epidural procedure provided ideal analgesia without or with minimal motor impairment, which might make this regional anesthesia a promising option in place of peripheral nerve blocks.

In recent years, the use of epidural analgesia has decreased because of increases in laparoscopic assisted surgery and in the internal use of anticoagulants in patients leading to the formation of an anti-blood platelet agent, etc. In the first edition of the ERAS protocol on colorectal surgery, epidural analgesia is recommended for open abdominal surgery. The purpose of using epidural analgesia is to suppress protein catabolism, which is responsible for harmful effects（sympathetic nerve stimulation）, which are not only seen when using postoperative analgesia. On the other hand, in the fourth edition of ERAS protocol revision for colorectal surgery, epidural analgesia is not recommended for laparoscopic abdominal surgery. This creates awareness over adverse events related to epidural analgesia such as decrease in blood pressure and leg exhaustion.

This recommendation is based on data obtained overseas, and therefore needs an argument for its adaptation to postoperative superintendence in Japan.

An aging population and declining birth rate have resulted in a significant increase in demand for healthcare and put additional burdens on healthcare professionals. Therefore, providing efficient healthcare through digital technology has become a priority. With the aim of improving treatment efficacy, we have developed the medical device, mediVR KAGURA, for rehabilitation by means of virtual reality（VR）technology through industry-academia collaboration activities at Osaka University. This device is being utilized to manage ataxia, walking and upper limb disabilities, cognitive dysfunction, and chronic pain. The safety of the training, which is performed in the sitting position, and its high therapeutic efficacy are appealing features to physicians. These effects can be explained centrally by functional integration or what is also known as cortical reorganization in the brain. This section reviews how gamification concepts are reflected in therapeutic effects, focusing on the following three concepts：（1）non-verbal communication；（2）affordance to induce awareness and behavioral changes；and（3）reinforcing successful experiences by stimulating rewards and emotions during rehabilitation. Although the use of VR technology in rehabilitation medicine has produced disappointing results in recent decades, we believe that mediVR KAGURA will open up new avenues and help more patients worldwide.

Learning methods that incorporate gaming have been the new trend recently. New guidelines issued by the American Heart Association in 2020 indicates that "Gamified Learning" would be incorporated into cardiopulmonary resuscitation（CPR）training as a resuscitation education science.

In the new CPR training course based on this guideline, artificial intelligence（AI）was implemented in eLearning. This AI automatically optimizes learning. In addition, the COVID-19 pandemic has affected face-to-face training, and training in many courses and educational institutions has been discontinued. To remedy this situation, a mobile app for remote CPR training has been developed. The app also incorporates gaming elements that enhance learners’ competitiveness. This article reports on the information presented at the symposium of the 16th Annual Meeting of the Japanese Association for Medical Simulation.