The patient is a 63-year-old woman. She underwent coronary artery bypass grafting for unstable angina pectoris. Immediately after withdrawal of the cardiopulmonary bypass and the start of protamine administration, the patient’s blood pressure dropped rapidly. Fluids and vasopressors were given, but her blood pressure did not rise, so heart-lung machine resumed. Based on clinical findings, anaphylaxis was suspected, adrenaline was started, and intra-aortic balloon pumping was inserted. These treatments stabilized her breathing and circulation, and the patient was again weaned from the cardiopulmonary bypass. Her blood tryptase level was measured over time and was high 100 minutes after the onset of shock, and decreased to within the standard value 24 hours later. Although the causative agent could not be identified, it was diagnosed as shock caused by anaphylaxis.

We experienced a rare case of swelling of the left submandibular gland and tongue after right head lobe tumor resection in the park bench position. The patient was a 23-year-old woman who was extubated after confirming that she was sufficiently awake from general anesthesia after the operation. Left cervical swelling appeared 5 hours after the operation. Thirteen hours after the operation, airway obstruction due to swelling of the left submandibular gland and tongue occurred, and tracheostomy was performed. We speculated that the submandibular gland and surrounding tissues were swollen as a result of compression of the submandibular duct and arteries and veins due to cervical flexion and tracheal tube placement which impaired the return of blood in the lingual veins and resulted in a swollen tongue. Given that submandibular gland and tongue swelling can occur as postoperative complications, signs of cervical swelling should be carefully monitored and tracheal intubation should be performed before airway stenosis progresses.

Contralateral tension pneumothorax can be caused by mediastinal pleura injury in the course of intrathoracic manipulation during robot-assisted esophagectomy in the prone position due to its use in combination with artificial pneumothorax and one-lung ventilation. We have developed step-wise measures against contralateral tension pneumothorax including diagnosis of contralateral tension pneumothorax by lung ultrasound, surgical enlargement of the perforation, lung recruitment maneuver, and PEEP adjustment. Herein, we report a successful case of robot-assisted esophagectomy in the prone position in which these measures were applied. The patient was a 72-year-old man. After SpO₂ fell to 90% during intrathoracic manipulation, lung ultrasound confirmed the rapid diagnosis of pneumothorax. These measures promptly improved contralateral lung ventilation and oxygenation. Our measures may therefore be useful in cases of respiratory failure with suspected contralateral tension pneumothorax.

Mucopolysaccharidosis（MPS）is a rare genetic disease which is characterized by deformities and other abnormalities of various organs. The management of difficult airways is the most crucial element in anesthetic management. Among several types of MPS, type VII is extremely rare, and there have been only a few case reports regarding general anesthesia management. We describe the case of a 7-year-old boy with MPS type VII whose previous surgery was cancelled due to an airway problem after tracheal intubation at the age of two.

We report a case in which a triple-barreled intravenous infusion tube（Safetouch^®, NIPRO Co, Osaka, Japan）connected to the central venous route was twice accidentally opened to the atmosphere. The patient was a 59-year-old woman. After cardiovascular surgery, the central venous route was disconnected when she entered the intensive care unit, opening the route to the atmosphere. The next day, when the medication route was disconnected from the central venous route, the nurse in charge did not attach the plug, and the route was opened to the atmosphere a second time. The error in this case was examined from the perspective of human factors. The procedure for closing the route was changed to prevent recurrence of the accident and human error. Additionally, NIPRO was asked to manufacture a closed connector tube for the non-patient side. In conclusion, we developed preventive measures against opening of the central venous route from the viewpoint of human factors.

In this article, we extensively discuss the usage of central venous catheters（CVCs）, CVC-related complications and risks, criteria for CVC thickness, multiple approaches of real-time ultrasound-guided CVC puncture techniques, determination of ideal CVC insertion lengths, and the peripherally inserted central catheter insertion method. It is important to understand the characteristics of ultrasound to be able to perform real-time ultrasound-guided CVC insertion more accurately and safely and to learn approaches other than the ones with which the attending anesthesiologist is familiar. Understanding the condition of the target vessel during the pre-scan procedure and ability to switch to another approach if necessary are crucial for better management in each case.

Pediatric ultrasound-guided peripheral vascular access（PUGPVA）has become a relatively easy technique in environments where high-performance ultrasound machines are readily available. PUGPVA can be difficult to apply since children’s peripheral vessels are thin and the elasticity of limbs and vessel walls can lead to the failure of puncture. Providers should improve the way they grasp the needle and use an ultrasound probe for appropriate manipulations and confirm the exact portion of the ultrasound probe that transmits ultrasound waves to estimate the optimal angle for needle puncture via simulation-based trainings. Anesthesiologists can educate not only other anesthesiologists but also pediatricians and pediatric cardiologists who desire to acquire PUGPVA skills. The ability to educate novices and improve their PUGPVA skills may be useful for the survival of anesthesiologists, as the work of anesthesiologists is gradually shifting to nurse anesthetists.

A questionnaire survey of members of the Japanese Association of Children's Hospitals and Related Institutions was conducted in order to clarify the current status of pediatric regional anesthesia in Japan. Although the survey was not exhaustive, we found trends in the selection of regional anesthesia and local anesthetics for common pediatric surgeries, the practice of epidural anesthesia, and the occurrence of serious complications.

Postoperative delirium（POD）is an acute disturbance of consciousness, attention, and perception. Its course is transient and reversible, but since POD aggravates postoperative course, some intervention is required. POD is similar to but different from Postoperative cognitive dysfunction（POCD）. Recently, we recognized both of them as a Perioperative Neurocognitive Disorder（PND）. Early detection and treatment are essential to prevent serious sequelae. Although we have not identified a confirmed mechanism of POD’s development, we recognize that surgical stress, superabundant anesthetics, and postoperative pain are causative. POD is thought to develop when these factors affect the inflamed（vulnerable）brain, so we need to protect the vulnerable brain from these factors.

Postoperative cognitive dysfunction（POCD）and postoperative delirium（POD）are the most common types of postoperative cognitive impairment. Both POCD and POD are generally reversible, but some cases persist for a long time and are assumed to be associated with dementia. The incidence of POCD after cardiac surgery tends to be higher than after noncardiac surgery, possibly due to higher inflammation in cardiac surgery and preoperative cognitive impairment due to heart failure. The pharmacological approach currently lacks sufficient evidence. Multimodal and multidisciplinary team approaches including prehabilitation are required to prevent POCD and POD. In this review, we discuss the differences between cardiac and noncardiac surgery in the prevention of postoperative cognitive impairment.

Cardiac surgery is associated with a higher incidence of postoperative delirium（POD）than other surgeries and presents special features such as the use of the heart-lung machine and postoperative intensive care unit（ICU）management. Neuroinflammation has been suggested to be associated with the development of POD, but treatment methods have not yet been established. Pain control is the first POD prophylactic management that anesthesiologists should implement. However, it is important to take continuous measures throughout the perioperative period including preoperative identification/sharing of data of patients at high risk of delirium, intraoperative embolism control, anesthesia depth monitoring to prevent cerebral infarction, and postoperative sedation/analgesia management. As cardiac surgery becomes less invasive, cardiac anesthesia will be performed more frequently in elderly and high-risk patients, making POD more prevalent. POD is a severe postoperative complication that impacts the cognition and life prognosis of patients and requires multidisciplinary collaboration in which the anesthesiologist plays a key role.

Background：Deterioration of prognosis due to perioperative neurocognitive dysfunction has become a problem due to aging.

Purpose：To clarify the relationship between neurocognitive dysfunction after extracardiac surgery and related factors.

Subjects/Methods：The subjects were 504 patients who underwent elective extracardiac surgery from April 2019 to December 2020. We evaluated physical function, cognitive function, mental function, and ADL ability（BI）before surgery, divided the patients into two groups according to the presence or absence of postoperative delirium, and added perioperative data for comparative study and factor analysis.

Results：A significant difference was found in anesthesia time, bleeding amount, intubation time, age, preoperative walking speed, preoperative cognitive function, and BI in the comparison between the two groups. The related factor was BI（OR：0.86）and the cut-off value was 92.5 points.

Conclusion：The onset of postoperative delirium may be affected by preoperative physical and cognitive mental functions in addition to items related to surgery.

In severe COVID-19 cases, diffuse alveolar lesions, which are similar to the lesions observed in acute respiratory distress syndrome（ARDS）, occur in lung tissue. Therefore, a lung protection strategy similar to that used for ARDS is adopted in mechanical ventilation for the management of respiratory failure. Recently, the use of a high-flow nasal cannula combined with awake prone positioning therapy has been shown to avoid the need for intubation in many cases. Accordingly, the management of severe COVID-19 cases has changed significantly since the early days of the pandemic. We describe our management policy and the recent results of treatment of severe cases at our hospital.

COVID-19 is a highly contagious infection and a serious disease that can lead to rapid deterioration of disease status and the need for life support equipment such as extracorporeal membrane oxygenation（ECMO）. Effective treatment while preventing nosocomial infections requires the cooperation of all hospital personnel including medical and administrative staff and various contract personnel. Considering the patient's return to society, it is important to take an comprehensive approach that includes the patient's family as well as local hospitals and home health care that supports rehabilitation and the chronic phase of the disease.