We report a 79-year-old male with severe laryngeal edema who underwent anesthesia for conversion to tracheostomy from cricothyrotomy on the day of the cricothyrotomy. We speculated that his laryngeal edema was caused by anaphylaxis because he complained of dyspnea approximately 30 minutes after meal. He had no history of surgery under general anesthesia. The tracheostomy was uneventfully performed under local anesthesia and conscious sedation with anesthetics administered prior to the surgery.

General anesthesia is superior to local anesthesia for tracheostomy because it provides better sedation, analgesia, and muscular relaxation during the surgery. However, awake tracheostomy is an option when spontaneous breathing should be maintained to secure the upper respiratory tract or when general anesthesia is contraindicated for a surgical patient.

We experienced three cases of acute subdural hematoma that occurred intraoperatively and postoperatively during cardiac surgery. In addition to heparinization, abnormal coagulation, and mannitol-induced decrease in brain volume, we considered the effect of intraoperative techniques（light shaking of the trunk during the removal of air bubbules）as a possible factor in the development of the hematoma. It is often difficult to make an early diagnosis of a neurological event after cardiac surgery due to the effects of anesthesia, postoperative sedatives, and analgesia. It is important to remember that acute subdural hematoma may occur in elderly cardiac surgery patients using extracorporeal circulation and to perform regular neurological evaluations after surgery to detect it early.

Pseudo-Meigs syndrome is a condition characterized by pleural effusion or ascites associated with intra-abdominal tumors other than benign ovarian tumors that can be successfully treated by resection. Here we report two cases of Pseudo-Meigs syndrome with pleural effusion that was not detected on preoperative chest radiographs, but was suspected upon an intraoperative postural change and confirmed postoperatively. In both cases, slightly decreased oxygenation was observed at induction of anesthesia, but respiratory status was stable intraoperatively and extubation was performed in the operating room. In patients with massive ovarian tumors compressing the pelvic and abdominal organs or ovarian tumors with fluid accumulation, Pseudo-Meigs syndrome with pleural effusion may develop rapidly even if preoperative examinations do not detect ascites. Perioperative care should take pleural effusion and ascites into consideration by observing respiratory status preoperatively and performing additional chest X-rays if necessary.

Airway management of patients with supraglottic lesion including laryngeal tumors is sometimes difficult due to tumor incarceration, disruption, or bleeding. We herein report the successful intubation of a patient with laryngeal granuloma on the right vocal fold without disruption of the tumor or airway obstruction using Airway scope instead of fiberoptic bronchoscope. In such cases, it is important to prepare an airway management strategy based on a precise preoperative assessment in order to prevent CICV（cannot intubate cannot ventilate）and tumor disruption.

An 11-year-old boy with a history of cerebral palsy due to severe neonatal asphyxia was admitted to the hospital for left pyelonephritis and septic shock caused by a left renal ureteral stone. During hospitalization, he was intubated twice due to worsening respiratory status with stridor, but both intubation maneuvers were difficult due to laryngeal edema and increased secretions. After extubation, laryngomalacia was diagnosed via bronchoscopy. Transnephrostomy nephrolithotripsy was scheduled to correct the pyelonephritis. The nephrostomy was already created under general anesthesia while the patient was intubated. Surgery through a nephrostomy was considered to be less invasive. Anesthesia management without tracheal intubation was considered desirable to avoid airway invasion, and the patient was managed with a high-flow nasal cannula and dexmedetomidine sedation. During the surgery, respiratory status and body movements did not deteriorate, and the surgery could be completed without tracheal intubation.

Glucose-6-phosphate dehydrogenase（G6PD）deficiency causes acute hemolytic attacks in response to oxidative stresses including invasive surgeries and antipyretic analgesics. A 38-year-old Chinese man was scheduled for laparoscopic adhesiolysis. In the preoperative interview, we learned of his hemolytic episodes due to G6PD deficiency. Upon operating room admission, an epidural catheter was inserted under sedation with midazolam and fentanyl. General anesthesia was induced and maintained with propofol and remifentanil. Hemodynamics and anesthetic depth of the patient were stable throughout the operation, and methemoglobin levels did not become elevated. We administered postoperative analgesia using patient controlled epidural analgesic. His pain was well controlled, and no additional analgesics were required. He was discharged without findings of hemolysis. We conclude that surgical stress was repressed by remifentanil, and postoperative analgesia was well managed by continuous epidural administration.

The patient was a 32-year-old pregnant woman at 23 weeks of gestation. Her height and weight were 153 cm and 97 kg, respectively. She received McDonald’s surgery to treat threatened preterm labor. Spinal anesthesia using 25-G Quincke needle at the L3/4 intervertebral space succeeded in the third challenge. She complained of headache when taking the upright position at 6 h after the surgery, and she vomited at 17 h after the surgery. Post-dural puncture headache（PDPH）was suspected and intravenous and oral acetaminophen were administered, but they were ineffective. Goreisan was administered starting 26 h after the surgery. Clinical symptoms improved 18 h after starting this medication, and she could walk on foot at 24 h after starting it. Goreisan plays an important role in maintaining water homeostasis, which might be effective for PDPH. Pregnant woman can take Goreisan safely, making it a potentially effective therapeutic agent for suspected PDPH in pregnant women.

Lung transplantation in Japan involves a long waiting period due to the shortage of organ donations. This leads to progression of the recipient’s disease and the need for strict perioperative management. In preoperative assessment, we need to consider whether extracorporeal circulation support is necessary based on information from the recipient and donor and the timing of the procedure. Anesthesia induction needs to avoid elevated pulmonary vascular resistance and maintain systemic vascular resistance and perfusion pressure. In the reperfusion phase, gradual reintroduction of blood flow as well as restrictive fluid management and lung protective ventilation should be implemented to reduce primary graft dysfunction.

To solve the shortage of lung donor graft, Ex vivo lung perfusion, in which marginal lung grafts are evaluated under extracorporeal circulation, and lung transplantations from donors after circulatory death are being undertaken worldwide. Transplantation medicine requires the development of an organ donation system.

Due to progress in ultrasound imaging technology and the increasing use of antithrombotic therapy, ultrasound-guided abdominal wall blocks have been widely accepted in clinical settings. Based on anatomical findings, several approaches have been developed. However, performing efficient nerve blocks covering surgical incisions in each case is challenging. To achieve a successful block, it is essential to use the hydrodissection technique with an understanding of the important anatomical structures such as TAP plexus and linear semilunaris.

The purpose of this literature is to share information essential for performing transversus abdominis plane block and rectus sheath block correctly and efficiently.

The whole blood viscoelastic device has brought dramatic progression in coagulation management in cardiothoracic vascular anesthesia. At the same time, the device has provided new answers to old and unsolved problems including 1）the etiology of heparin resistance; 2）proper dosage of protamine for heparin reversal; and 3）advantages of point-of-care monitoring with a viscoelastic device in patient blood management. On those three tough questions in cardiothoracic vascular anesthesia, this review provides new practical information for physicians by analyzing and discussing the clinical data. First, thromboelastometry elucidates that the main etiology of heparin resistance is increased coagulation system including fibrinogen level and platelet counts rather than a decrease in antithrombin activity. Second, thromboelastometry elucidates that a proper protamine dosage for heparin neutralization is 0.73-fold of total heparin amounts. Third, previous reports and our clinical study with viscoelastic devices indicate that the main benefit of point-of-care monitoring with a viscoelastic device is a reduction in unnecessary blood transfusion in cardiothoracic vascular anesthesia. Fibrinogen replacement therapy with cryoprecipitate or fibrinogen concentrate may overcome the limitations of the viscoelastic device, and further clinical studies of fibrinogen replacement therapy are warranted in cardiothoracic vascular anesthesia in the future.

Secure hemostasis is essential to achieve good outcomes after cardiovascular surgery because it is associated with less transfusion and shorter hospital stays. However, intraoperative use of anticoagulants and cardiopulmonary bypass can result in a tendency to bleeding and make it difficult to achieve secure hemostasis. The causes of intraoperative bleeding can be classified into surgical bleeding originating from a relatively large bleeding site, which develops during dissection and anastomosis, and consumption coagulopathy associated with a smaller bleeding site which is exaggerated by loss of coagulation factors and platelets due to surgical bleeding and hemodilution by use of cardiopulmonary bypass. Because transfusion alone is less effective in controlling surgical bleeding, the surgeon should control such bleeding in the operative field using surgical procedures to maximize the effect of supplemental treatment by anesthesiologists. To achieve effective and secure intraoperative hemostasis, surgeons and anesthesiologists should cooperate, sharing information about the cause of bleeding and the strategy of hemostasis.

While total gas flow is a matter of concern in low flow anesthesia, inhaled oxygen concentration during the perioperative period should be closely monitored as well. Administration of high concentrations of oxygen during induction of anesthesia is an established measure to store oxygen in the lungs. However, just a short period of preoxygenation easily causes absorption atelectasis. The World Health Organization published a guideline to prevent surgical site infection in 2016 which recommends giving 80 percent oxygen intraoperatively as well as for 2 to 6 hours in the immediate postoperative period. This recommendation has become an issue of heated debate among anesthetists worldwide, and subsequent studies comparing high versus low oxygen concentration in surgical patients did not show a clear advantage of high fraction of inspired oxygen（FIO₂）. High FIO₂ increases partial pressure of arterial oxygen but may also increase the risk of perioperative oxidative stress. What percentage of oxygen should be given to which patients and when remains unclear.

Herein, I discuss two different patterns of optimal oxygenation during general anesthesia to reduce perioperative invasion.

In non-thoracic surgeries where dual-lung ventilation can be performed, performing ventilation with an inhaled oxygen concentration ＜60％ to avoid absorptive atelectasis and acute lung injury due to high oxygen concentration is important, while leaving a safety margin for respiratory problems. In this situation, it is important to select the lowest concentration of inhaled oxygen that the anesthesiologist in charge considers safe and to remove the invasion from ventilation by preserving the degree of alveolar patency.

In thoracic surgery requiring one-lung ventilation, promoting lung collapse to ensure a good surgical view is also important. Therefore, inducing absorptive atelectasis efficiently by complete denitrification prior to one-lung ventilation is important. Lung collapse may reduce the mechanical invasiveness of surgery, which occupies a large part of the perioperative invasion, by providing a good surgical view.

Idiopathic Pulmonary Fibrosis（IPF）is a common type of Interstitial Lung Disease（ILD）which during its development can lead to acute respiratory failure, often referred to as acute exacerbation （AE）. As surgical stress and general anesthesia are believed to induce AE, special care is required in perioperative management. AE is believed to be more prevalent among the Japanese population. In multicenter studies conducted in Japan, 9.3% of surgeries on Interstitial Pneumonia Associated with Lung Cancer patients developed AE and 43.9% who developed AE died as a result. Risk factors to look out for include decreased lung capacity and UIP pattern on chest CT scans. The best perioperative oxygen concentration for Interstitial Pneumonia Associated with Lung Cancer patients is the lowest concentration that the anesthetist can administer safely.

Automated systems are being used in various fields of modern society. Rapid aging of populations is one factor promoting automation. In perioperative care, recent progress of automated systems has enabled precise titration of total intravenous anesthesia and fine control of blood pressure. Quality of anesthetic depth and haemodynamics may be superior to that achieved by manual control by humans. However, even the most sophisticated automated systems do not always bring the best results. So-called Automation Surprise and Skill Atrophy can cause accidents when automated systems perform in unexpected ways. By using smart automation system of drug delivery, anesthetists may be freed from mundane, repeated tasks and theoretically be able to spend much more time on clinical decision making and/or communication with colleagues. If the spare time is used just for digital distractions, patients’safety cannot be guaranteed.