This report presents a male patient in his 60s who was diagnosed with muscle-specific receptor tyrosine-kinase（MuSK） antibody-positive myasthenia gravis（MG） because of a surgery-induced crisis. This patient presented with difficulty stabilizing his neck and trunk. He was initially diagnosed with cervical spondylotic myelopathy, but that diagnosis did not account for his current symptoms. Due to disturbances in his gait, a laminoplasty was performed early on in his treatment. On the eleventh day following surgery, the patient suffered cardiopulmonary arrest due to respiratory arrest and was admitted to the intensive care unit after being resuscitated. The patient tested positive for MuSK antibodies and was subsequently diagnosed with MG. He was administered immunoglobulin therapy, blood purification therapy and steroids before being transferred to a different hospital 79 days after surgery under non-invasive positive pressure ventilation. MuSK antibody-positive MG develops rapidly and the risk of crisis is high. In addition, this disease can be difficult to diagnose.

Pericapsular nerve group（PENG）block is an ultrasound-guided approach for blockade of articular branches to the hip. This technique is effective for analgesia after femur fracture operations. Here we report a case in which PENG block was also helpful in diagnosing hip pain due to hip osteoarthrosis. A patient in her 70s with right low back and leg pain caused by degenerative lumbar scoliosis and kyphosis underwent a lumbar nerve root block with pulsed radiofrequency, which reduced her pain. However, right lateral hip pain occurred afterward. We suspected that the pain was due to hip osteoarthrosis, so we performed a PENG block which alleviated her hip pain. PENG block may have diagnostic utility for hip pain derived from hip osteoarthrosis.

We report the case of a patient with decompensated cirrhosis who underwent total hip arthroplasty under general anesthesia combined with pericapsular nerve group（PENG） block and lateral femoral cutaneous nerve block. A 49-year-old man with alcoholic cirrhosis（Child-Pugh classification C） presented with bilateral hip pain that had been present for a few months. He was diagnosed with bilateral femoral head necrosis, and right total hip arthroplasty was scheduled. PENG block and lateral femoral cutaneous nerve block were used in combination with general anesthesia, and good analgesia was obtained. Three months later, left total hip arthroplasty was also performed under the same anesthetic approach. The postoperative course was uneventful, and the patient was discharged three months after the operation without major complications. A combination of PENG block and lateral femoral cutaneous nerve block may be useful for total hip arthroplasty in patients with severe complications.

At the Perioperative Management Center of our hospital, we have been showing patients a video about anesthesia before anesthesiology consultations in order to deepen their understanding of anesthesia. We conducted a survey regarding preoperative anesthesia explanations provided by a robot, Pepper, in order to collect opinions about this approach and the level of understanding developed after watching this explanatory video.

The survey was administered to patients themselves, their families, or a relative or guardian who watched Pepper’s explanation at the Perioperative Management Center from January 4, 2021 through March 31, 2021. The survey included questions about the anesthesia explanation provided by Pepper, the visibility of the screen during the explanation, and the voice and introduction of Pepper.

Valid responses were obtained from 325 out of 391 participants. The average respondent’s age was 57.5 years, and 53.8% of the participants were female. The level of understanding of the content of the preoperative explanation video was good, and more than 89% of the respondents answered positively about the ease of viewing Pepper’s screen, ease of hearing Pepper’s voice, and efforts to introduce Pepper. Overall, preoperative anesthesia explanation given by Pepper at the Perioperative Management Center received positive responses and showed good results.

Smokers have more intraoperative sputum, more postoperative complications such as wound infection and pulmonary complications, and higher mortality. Preoperative smoking cessation is known to prevent perioperative complications. Surgery is an ideal opportunity to quit smoking, but it is difficult for anesthesiologists alone to provide smoking cessation guidance. Perioperative Management Center, PERiO, in Okayama University Hospital offers outpatient smoking cessation services before surgery using counseling by nurses and smoking cessation aids. An anesthesiologist prescribes smoking cessation medication, and a pharmacist provides medication guidance. For patients who wish to quit smoking, the outpatient smoking cessation program is continued after discharge from the hospital. Multidisciplinary perioperative smoking cessation guidance in collaboration with the perioperative management team is useful, and nurses and pharmacists can play an important role.

In Japan, which has a large geriatric population, surgical indications for elderly patients have expanded through improvements in medical treatment. In an elderly patient, many complications can occur in the perioperative period including respiratory or cardiovascular organ compromise, falls, sarcopenia, and worsening of cognitive function. The ERAS protocol recommends prehabilitation as an environmental rationalization measure to improve surgical outcomes. Prehabilitation involves three interventions：an exercise regimen, psychological support, and nutritional support. This prehabilitation regimen has been shown to reduce postoperative pain and length of stay and improve physical fitness as compared to standard care. Unfortunately, Japan has yet to implement similar preoperative care due to a lack of preoperative preparation and support from insurance systems.

With the advent of the aging society, perioperative treatments have changed greatly due to the use of increasingly sophisticated treatments, etc. Instead of the preoperative, intraoperative, and postoperative management that had been performed separately by surgeons and anesthesiologists, perioperative support centers capable of providing seamless team treatment actively involve various staff across the entire perioperative period. The skilled operation of perioperative support centers improves safety and security, promotes early recovery, and enhances efficiency by shifting many of the conventional duties of physicians to the medical staff. The successful operation of such an organization depends on being able to form a high-quality team. Future anesthesiologists should therefore aim to become facilitator-type leaders for such organizations as perioperative management physicians.

Successful surgery is not only about performing the treatment without error, but also about providing a series of supports that take into consideration the patient’s life. In order to achieve these goals, multidisciplinary team medicine is essential. Having established a Perioperative Management Team in 2014, our Department of Rehabilitation Medicine provides preoperative respiratory rehabilitation from the outpatient clinic in order to raise the level of patients’ physical functions. In an effort to ensure the patient’s early ambulation, we try to initiate rehabilitation as soon as possible after the surgery. In 2018, we also started preoperative in-hospital rehabilitation centering on esophageal cancer. By providing an approximately one-week preoperative strengthening rehabilitation period, more patients are able to undergo surgery with improved physical strength. As a result, we are seeing reductions in the postoperative hospitalization period. What follows is an introduction to the benefits of coordinated cooperation used by the Perioperative Management Team at our hospital.

Pneumoperitoneum has important effects on cardiovascular during laparoscopic surgery. Pneumoperitoneum stimulates catecholamine secretion and activation of the renin-angiotensin system, which increases mean blood pressure and peripheral vascular resistance. Cardiac output rises in the early phase of insufflation but then declines slightly or remains the same as before insufflation, reflecting a gradual decrease in venous return and increase in afterload. This increase in cardiac output in the early phase of pneumoperitoneum is due to a temporary increase in venous return and preload as blood stored in the visceral veins is pushed out into the central venous system after pneumoperitoneum. In the elderly and patients with many comorbidities, cardiac output can be greatly reduced by insufflation and should be carefully managed.

Minimally invasive laparoscopic surgery has been increasing since it hastens recovery and shortens hospital stays. However, this technique requires pneumoperitoneum and Trendelenburg position, which can lead to lung atelectasis and hypoxemia during surgery and increase the risk of postoperative pulmonary complications（PPCs）. Recent studies suggest that perioperative lung protective ventilation strategies can reduce the occurrence of PPCs, resulting in reduced morbidity and mortality. Perioperative lung protective strategies should therefore be followed in respiratory management during surgery.

There are three major complications related to the position of laparoscopic colorectal surgery：neuropathy, well leg compartment syndrome, and pressure ulcers. I have outlined their causes, risk factors, and preventive measures. To prevent these complications, it is important to understand the risk factors before surgery and maintain the patient in a comfortable position so as not to apply excessive pressure during surgery. From our data obtained by monitoring body pressure during the operation, we inferred that long duration of pressure load is also a contributing factor. Early detection and early treatment of complications are essential, and if they occur, the underlying factors should be analyzed and future safety measures devised.

Airway emergencies outside the operating room（OR）remain a serious threat to patient safety. Serious complications can result not only from insufficient knowledge and skills but from inadequate communication, equipment, and a lack of skilled human resources as well. The Anesthesia Department at Tokyo Women’s Medical University Hospital operates a hospital-wide airway emergency management team. The team surveyed anesthesiologists in the department to identify unknown problems outside the OR. Forty-three of 54 anesthesiologists（79.6％）including 32 anesthesiologists who had experience in emergency airway management outside the OR responded. Twenty-eight（87.5％）had faced problems including a lack of requested items（most common；n＝13, 46％）and inappropriate assistance by ward staff（second most common；n＝9, 32％）. Anesthesiologists should educate ward staff about airway management and find ways to help them replenish airway carts.

In recent years, various airway securing devices have been developed and the safety of airway management has been greatly improved in terms of hardware. In addition, the DAM algorithm has been developed to improve the safety of airway management in the operating room, and safety has also been improved in terms of software. Airway management in the operating room is considered to be safer than that performed outside the operating room. In addition, anesthesiologists and nurses work as a team to secure the airway on a daily basis, thus creating a high level of teamwork to deal with difficulties in managing the airway. On the other hand, the response to difficulties in managing the airway outside the operating room, such as in emergency rooms and hospital wards, can still be improved. In fact, it has been reported that rates of difficult intubation and complications are higher when the airway is managed outside the operating room.

Anesthesiologists and otorhinolaryngologists are often asked to assist in airway management outside the operating room such as in emergency rooms and hospital wards. In order to improve the safety of airway management outside the operating room, it is desirable to create an environment in which anesthesiologists and otolaryngologists can appropriately use their skills. In the U.S., the Difficult Airway Response Team（DART）program has been established to deal with difficulties in airway management mainly by anesthesiologists and otorhinolaryngologists. In Japan, however, a DART program has not yet been established. In this paper, I will review my own experience and discuss issues that need to be considered in order to establish a DART program based on the DART request criteria in the U.S.

Surgical tracheostomy and percutaneous tracheostomy are two procedures that can be performed to secure an adequate airway in patients with difficulty breathing when noninvasive management is contraindicated. Technical skills and procedural dexterity should be considered when deciding which procedure to perform. Non-technical skills are also crucial in executing technical skills in a competent manner. Non-technical skills can be refined through lifelong learning, routine practice, and interprofessional communication among nurses and physicians in the emergency, anesthesiology, and otolaryngology departments. This paper discusses the influence of a team’s technical and non-technical skills on successfully securing an adequate airway in an emergency case of acute epiglottitis.

Development of a difficult airway outside the operating room is associated with a higher risk of serious outcomes than in an operating room optimized for airway management. Reliable ventilation and oxygenation are important to save these patients. Early application of a supraglottic airway device（SGD）in a difficult airway situation can provide airway rescue. Various guidelines for anesthesiologists and other general health care workers recommend the use of an SGD as an emergency airway management device. In reality, however, SGDs are rarely used outside the operating room. To promote the use of SGDs outside the operating room, we provide the following recommendations：（1）select the specific SGD to be used；（2）actually place the SGD in the emergency cart；and（3）provide airway management education including how to use the SGD.