Surgery scheduling is an important and challenging responsibility of hospital management. It has become more difficult to maintain the number of surgeries scheduled per day due to the spread of COVID-19. Under these circumstances, it is important to efficiently utilize limited resources such as operating rooms, anesthesiologists, and nurses and perform each surgery with maximum time efficiency. In our hospital, we changed the process such that the surgeon predicts pre-operatively the estimated operating theatre time in addition to the surgery time at the timeout. As a result, the discrepancy between the predicted time and the actual time has decreased and the percentage of major overbooking of surgeries has decreased by 40% over a 3-month period. Our study suggests that the operational efficiency of surgery departments can be improved with a minor modification.

Surgical restrictions have been initiated four times in Japan since the COVID-19 pandemic began in 2020. The number of operations was restricted during emergency declaration periods in our operation center. To evaluate the effect of these restrictions on surgical procedures, we retrospectively examined data on patients who underwent surgery from 2017 to 2021 at our hospital.

In 2020, the number of elective surgeries, emergency surgeries, surgeries of poor performance status（ASA-PS＞＝3）and cardiac/upper digestive organ operations decreased significantly, reflecting people’s hesitation to visit medical facilities due to fear of contracting SARS-CoV-2 infection. In 2021, the number of elective surgeries increased, while emergency operations decreased. The increase in elective surgeries is likely due to growth in the vaccination rate. The number of cesarean sections and otorhinolaryngology surgeries did not change significantly.

These findings suggest that we need to not only prevent SARS-CoV-2 infection but to facilitate medical examination and surgical procedures. In the COVID-19 era, it is important to consider preparing for new infectious disease pandemics in the future.

A 74-year-old woman with situs inversus totalis was scheduled for thoracoscopic right upper lobectomy due to lung cancer. Preoperatively, we examined the strategy of one lung ventilation during surgery. Considering the surgical procedure, the patient’s bronchial length, and past literature, we made an anesthesia plan to intubate a right-sided double lumen tube into the right（anatomical left）main bronchus with bronchoscopy. General anesthesia was induced with intravenous administration of propofol, remifentanil and rocuronium. Due to our careful preparation, intubation and intraoperative management were carried out uneventfully without any postoperative complications.

This issue introduces a novel anesthesia handover checklist and the results of a survey of anesthesiologists after the checklist’s introduction. A survey was first conducted to determine the baseline situation among anesthesiologists. After that, the novel checklist was installed in each operating room and department members were encouraged to utilize it during anesthesia handovers. Three months later, the survey was readministered to investigate anesthesiologists’ response to the novel checklist. The proportion of anesthesiologists who felt that the handover was “inappropriate” decreased from 86% to 41%. The percentage of anesthesiologists who“encountered an unexpected situation due to inadequate handover” decreased from 69% to 33%. Ninety percent of the anesthesiologists surveyed indicated that they would like to continue using the novel checklist. The introduction of the novel handover checklist increased the proportion of anesthesiologists who felt handovers to be appropriate. The utilization of this novel checklist may lead to an increased awareness of appropriate anesthesia handovers.

Transpulmonary thermodilution（TPTD）devices（PiCCO^TM, Getinge, Gothenburg, Sweden and VolumeView^TM, Edwards Lifesciences Corporation, Irvine, CA, USA）are used to measure cardiac output and extravascular lung water. Although extravascular lung water can be used as an indicator to reduce excess fluid infusion, we do not have robust evidence that management with TPTD decreases the mortality rate. Risks and medical costs should be considered before using a TPTD device.

Blood lactate concentration is now commonly used as an indicator of mortality and morbidity, especially in patients with sepsis and after cardiac surgery. When elevated blood lactate levels are observed, the impact of surgical procedures and drugs as well as tissue hypoxia and the enhancement of anaerobic metabolism need to be considered. Recently, the lactate shuttle theory that lactate is used as an energy source in skeletal muscle, heart, and brain has received a lot of attention. It is more important to identify and deal with the cause of elevated blood lactate concentrations than make an effort to decrease the blood lactate level itself.

Remimazolam is an ultrashort-acting benzodiazepine intravenous anesthetic that has recently been released. When using the total intravenous anesthesia technique, electroencephalogram（ECG）monitoring is recommended to maintain adequate depth of sedation. However, ECG during the administration of remimazolam sometimes differs from that of the previously standardized propofol in that beta waves are more likely to be observed, Burst Suppression is less likely to be detected, while higher processed ECG values are likely to be calculated. These factors make ECG monitoring challenging to interpret, so the condition of the patient must be comprehensively monitored when remimazolam is used.

The prognosis of patients with congenital heart disease（CHD）has dramatically improved, leading to an increase in the proportion of patients undergoing heart surgery in adulthood. Adult CHD（ACHD）comprises various primary diseases. Patients with ACHD are exposed to complex and special hemodynamics from childhood and have complications that differ from those of normal adults. For anesthesia management in cardiac surgery, it is essential to understand the pathophysiology and severity of heart disease and thoroughly evaluate the patient’s condition before surgery. Herein, we present a case of ACHD encountered at our hospital and describe preoperative evaluation and perioperative management for ACHD.

Many patients with congenital heart disease are now entering adulthood, and an increasing number of patients with adult congenital heart disease（ACHD）are undergoing noncardiac surgery. ACHD is a systemic disease, and preoperative evaluation is crucial in anesthetic management for noncardiac surgery. However, there is no evidence that one method of anesthesia is superior to another for the anesthetic management of noncardiac surgery in patients with ACHD. Therefore, it is important to assess the hemodynamics in individual cases, evaluate the risks of the procedure, and anticipate possible complications.

Anesthesia for pediatric cardiac surgery combines the peculiarities of pediatric anesthesia with those of cardiac anesthesia, which some people may feel sets a high threshold. It is important to：first, be aware that it is pediatric anesthesia；second, understand how to control systemic and pulmonary blood flow；and finally, smoothly connect to postoperative intensive care management. Several considerations must be made in terms of the anesthesia method and choice of vasoactive agents；however, solid evidence regarding this is lacking. While understanding the characteristics of the anesthetic and vasoactive agents, it would be beneficial to get habituated to using them according to the circumstances of the institution.

About 150 pediatric cardiac surgeries are performed in our hospital each year, making it one of the leading surgical facilities for such surgeries among Japan’s national university hospitals. However, the number of cardiac surgery slots reserved for pediatric patients is limited. In addition, the number of ICU beds is small compared to the size of the hospital. We are trying to fix these problems.

In anesthesia management, we have several devices such as ultrasound-guided vascular puncture, including central venous catheter placement by supraclavicular approach, and transverse thoracic muscle plane block. We frequently use transesophageal echocardiography（TEE）for intraoperative management and carefully determine indications for TEE from baby weight around 2 kg. In addition to standard evaluations, we measure pulmonary venous blood flow to determine pulmonary artery banding size and to detect anastomotic abnormalities that can occur in systemic-to-pulmonary artery shunts and Fontan-type surgeries.

The intubating stylet is a powerful tool for facilitating tracheal intubation. Although stylets improve the maneuverability of the tube, the rigidity of styletted tubes can cause laryngeal complications. This study investigated the potential risk for laryngeal injury when using a stylet and assessed the optimal method of stylet extraction through in vitro experiments and mathematical analysis. When the stylet was extracted along a straight path towards the stylet end, the distance travelled by the tube tip significantly increased as the bending angle increased. Mathematical analysis revealed that the stylet should be diagonally extracted at an appropriate angle rather than along a straight path towards the direction of the stylet end. In simulated tracheal intubation, the extraction force and force applied to the vocal cords both significantly increased as the bending angle increased. Compared to the hockey-stick-shaped stylet, the arcuate-shaped stylet resulted in smaller force. The present results indicate the potential risk for vocal cord injury when using hockey-stick-shaped stylets with large bending angles. The intubater or assistant should therefore use great caution during stylet extraction and tube insertion.