Perioperative pain management of Cesarean section（C-section）is important. In the present study, we retrospectively compared 3 types of anesthesia management, i.e., spinal intrathecal anesthesia（Spi group）, Spi combined with epidural anesthesia（CSEA group）, and Spi with nerve block（Block group）, for earlier post-operative ambulation to prevent pulmonary embolism, analgesia, and anesthesia-related complications. Statistically significant differences in early ambulation were found in the three groups and in a pair comparison between the Spi and Block groups. The least post-operative analgesics were less in CSEA groups, and no statistically significant difference was observed among groups in post-operative complications. These results suggest that earlier post-operative ambulation effect did not differ between CSEA and Block groups, and that Spi with nerve block can be considered for simplified anesthesia management of C-section with less anesthesia related complications.

The fascia iliaca compartment block（FICB）, a lumbar plexus block that can block the femoral nerve, lateral femoral cutaneous nerve, and obturator nerve, is used as analgesia for femoral neck fractures and hip osteoarthritis. However, local anesthetic is administered in the compartment, and in some cases analgesia is insufficient. The spread of the local anesthetic after suprainguinal FICB as observed on inguinal echocardiography confirmed that it was administered to the intended position and provided adequate analgesia. Inguinal echocardiography was useful for evaluation after suprainguinal FICB.

We experienced a case of psychogenic non-epileptic seizure（PNES）after awakening from general anesthesia. The patient was a 34-year-old woman. Two hours after returning to the room from an orthopedic surgery under general anesthesia, she developed generalized seizures. Diazepam was administered, and 20 minutes later the convulsions subsided, but she continued to have upper body dominant convulsions for 1 to 3 minutes. There were no neurological abnormalities other than convulsions, and no abnormalities on head imaging examination.

An electroencephalogram（EEG）examination revealed no epileptic waves during the seizures, and the EEG was always awake, leading to the diagnosis of PNES. When seizures are observed, it is necessary to carefully diagnose and treat them by searching for the cause in parallel with the treatment, and if treatment-resistant seizures persist, PNES should be considered.

A 74-year-old male（height：159 cm, weight：65 kg）was diagnosed with prostate cancer and scheduled for robot-assisted radical prostatectomy. CT revealed a paratracheal air cyst during the preoperative evaluation.

We considered the risk of tracheal air cyst perforation and mediastinal emphysema induced by positive pressure ventilation. We inserted the laryngeal mask airway and found the tracheal fistula at 7 cm above the tracheal carina under bronchoscopy, and we fixed a tube in depth where the cuff of the tracheal tube did not cover the fistula. Surgery was safely concluded under general anesthesia with no intraoperative respiratory problems.

At our hospital, we perform cesarean sections in pregnant women with COVID-19. We have performed eight cesarean sections in pregnant woman with COVID-19 in the operating theater. The patients’ages ranged from 27 to 37 and their weeks of gestation from 36 to 40 weeks. Four cases with birth of labor were emergency surgeries. Seven patients had multiple clinical symptoms including cough and fever, and four received preoperative antibody therapy. All patients were managed with combined spinal and epidural anesthesia, and three had intraoperative shivering. Two patients suffered from postoperative pneumonia, but conservative therapies were effective. None of the newborn infants or the staff involved with these cesarean sections was infected because of strict measures taken to prevent the spread of COVID-19 infection.

We describe two cases of chest wall reconstruction using pedicled latissimus dorsi musculocutaneous flap. It is often difficult to place the thoracic epidural catheter because the latissimus dorsi muscle attaches directly to the spinous processes of vertebrae Th5-L5. We therefore administered single-shot epidural analgesics at the level of the Th8/9 epidural space before induction of general anesthesia containing 2 mg of morphine and 4 mL of 0.375% levobupivacaine. In case 1, the patient had minimal post-operative pain throughout hospitalization. Although right atelectasis was noted immediately after surgery, it resolved spontaneously the next day. In case 2, the patient complained of moderate postoperative pain at postoperative day 0 to 1, which gradually resolved. Neither of the patients manifested with critical adverse events secondary to the administration of opioids or epidural procedure. Both the quality of analgesia and patient satisfaction were better than with conventional postoperative analgesic management mainly using continuous intravenous opioids and non-regional anesthesia.

Sleep-related breathing disorders（SRBD）are observed in approximately 50% of patients with heart failure（HF）and in 5–10% of patients without HF, half of which are cases of central sleep apnea（CSA）. It is known that there may be a shift between CSA and obstructive sleep apnea（OSA）overnight and/or during follow-up. Although the multiple sleep latency test shows objective sleepiness in patients with SRBD and HF, patients do not complain of subjective sleepiness. Treatment is based on the type of SRBD. Continuous positive airway pressure（CPAP）is the first choice of treatment for OSA, whereas CPAP, adaptive servo-ventilation（ASV）, and/or oxygen therapy are used for CSA after providing proper medication for HF. Several multicenter randomized controlled trials with ASV have not shown improvement in the prognosis of CSA in patients with HF. During the post-operative period, surgical interventions may bring about exacerbation or shifts in SRBD.

In the era of direct oral anticoagulants, physicians are expected to manage patients with anticoagulation therapy appropriately based on the characteristics of each anticoagulant. Physicians must consider both bleeding and thrombosis risks in perioperative management because maintaining a balance between these risks is crucial. The management of patients with anticoagulation therapy in emergency surgery is challenging for anesthesiologists because bleeding risk is usually higher than in elective surgery. Recently, specific antidotes to direct oral anticoagulants have been shown to be effective in bleeding due to anticoagulants, but these agents are generally expensive. Physicians need to understand the characteristics of antidotes as well as anticoagulants.

In anesthetic management for awake craniotomy, it is important to provide prompt and stable anesthesia induction and awakening and to prevent pain and other complications that may occur during surgery, especially during the awake period. Like other institutions in Japan, we use the Asleep-Awake-Asleep（AAA）technique for anesthetic management during awake craniotomy, which combines intravenous anesthesia, mainly based on propofol, with a cranial nerve block. In the past, we have anesthetized patients ranging from 12 to 84 years of age, but we now recognize that preoperative anesthetic management should be modified according to patients’diverse backgrounds. In addition to stratification of management based on age, it is also necessary to identify risk factors in advance that may prevent successful completion of awake craniotomy. An understanding of these risk factors can facilitate sophisticated anesthesia management.

Over the past 20 years, the surgical indication of intracranial lesions adjacent to the eloquent cortex has expanded since awake craniotomy was introduced in Japan. In general, complete resection is the goal of operations. Besides maximizing resection, avoiding neurological deterioration should be the goal for neurosurgical cases. Intraoperative neurophysiological monitoring can detect transient changes in somatosensory, auditory, and visual functions caused by surgical interventions even when patients are anesthetized. However, complete assessments of the motor and language functions of unconscious patients are impossible, so awake craniotomy has a significant impact in this context. This article discusses optimal methods for evaluating motor and language functions based on a review of the recent literature. Anesthesiologists should play a role in continuous monitoring of the patient’s conscious level during awake craniotomy.

Intraoperative anesthesia management during awake craniotomy（AC）may be complicated by various side effects such as intraoperative pain, seizure, vomiting, and nausea which occur when the patient is awake. Preoperative evaluation to assess the risk of possible complications is key to successfully performing AC anesthesia, as it helps take preventive measures before the patient awakens. AC is a challenging procedure that requires the anesthesiologist to have comprehensive knowledge and skill. For best outcomes, anesthesiologists must preoperatively evaluate patients, initiate appropriate preventive measures, and be prepared to promptly respond to complications.

In awake craniotomy, somnolence is a serious problem that prevents the achievement of the goal of this procedure, which is to maximize the removal of parenchymal brain lesions such as brain tumors and epileptic foci while preserving brain functions. However, there have been few studies on the evaluation, prediction, and treatment of somnolence in awake craniotomy, and no effective methods of prediction or treatment have been established. In this paper, we present our efforts to address the issue of somnolence in awake craniotomy and describe the current state of research on predictors and evaluation methods of somnolence in awake craniotomy.

Anesthesiologists are able to acquire and maintain numerous skills necessary for critical care based on daily anesthesia practice. The Japanese Society of Anesthesiologists encourages us to explore a broad field of anesthesia-related practices such as emergency medicine, intensive care, pain management, and palliative care. Although recent hospital management based on the DPC system has forced us to provide OR anesthesia as a first priority, the author suggests that young physicians should be given the opportunity to experience out-of-OR fields to develop general expertise in the whole of critical care.

The advantages of training anesthesiologists in intensive care are clear. A thorough knowledge of postoperative care helps these physicians make informed decisions regarding anesthesia protocols, allowing their patients to recover safely, comfortably, and quickly. Furthermore, training in pediatric intensive care, in addition to that in adult intensive care and/or anesthesia, provides the following advantages：

（1）Improves personalized care skills

（2）Improves the ability to obtain and analyze information from patients and monitor systems

（3）Improves knowledge regarding the choice and use of sedatives

（4）Provides increased experience in heart-lung interactions

（5）Improves the ability to explain treatments to family members

（6）Provides increased opportunities to conduct medical research

For the maximum achievement of the above abilities, it is also imperative to create a system allowing anesthesiologists who primarily provide care to adult patients to receive safe and secure training in pediatric intensive care units, which is usually an unfamiliar environment.