The monitoring guidelines of the Japanese Society of Anesthesiologists revised in 2019 recommend mandatory use of neuromuscular monitoring devices when muscle relaxants are used. We conducted a retrospective observational study to determine whether campaigns for routine use of neuromuscular monitoring device led to appropriate management of muscle paralysis during emergence from anesthesia in 267 adult patients who received rocuronium for scheduled anesthesia and surgery over a 28 month period at our university hospital. Although the campaigns significantly and progressively improved both usage rate of neuromuscular monitoring devices during induction of anesthesia（56% to 94%）and the appropriate muscle paralysis management rate（38% to 64%）, anesthesiologists failed to properly restore muscle strength in one-third of patients even at the end of the campaigns due to insufficient doses of sugammadex and determination of sugammadex dose without information from neuromuscular monitoring. These findings suggest that the use of neuromuscular monitoring devices alone may not ensure complete recovery of muscle strength in patients receiving muscle relaxant during anesthesia and surgery.

Patients who underwent knee arthroplasty under general anesthesia were evaluated for the incidence of postoperative nausea and vomiting（PONV）and food intake in a retrospective observational study. They were divided into two groups：30 patients who received ondansetron at the end of surgery（ONDA group）and 29 patients who did not receive ondansetron（CONT group）. The incidence of PONV, antiemetic drug use, and iv-PCA discontinuation rate were all significantly lower in the ONDA group. Mean food intake up to the first postoperative day was significantly higher in the ONDA group and significantly lower in the group with PONV than in the group without PONV. These results suggest that Ondansetron can be effective in the treatment of PONV and food intake after knee arthroplasty.

Diagnosis and securing an intact airway are rendered difficult following airway obstruction secondary to endotracheal tube kinking in the mouth. A 72-year-old female was scheduled for posterolateral fusion for thoracic pyogenic spondylitis treatment. After induction of anesthesia, she was intubated with a Parker Flex-Tip^TM tube fixed at 19-cm level. The patient was placed in a prone position with Mayfield head pins. The patient had no teeth and the tracheal tube moved due to the weight of the tracheal tube with the artificial nose attached. The tracheal tube was then pushed in. After the surgery began, the patient developed an acute sustained elevation in peak airway pressure. A bronchoscope cannot be advanced through the endotracheal tube due to a near complete luminal occlusion at the proximal 21-cm level. Thus, the tracheal tube kink in the mouth was unbent with fingers to maintain tube patency and provide adequate ventilation. The remainder of the operation was uneventful.

A 65-year-old woman with severe COVID-19 was treated with tracheal intubation and prone positioning therapy. Oxygenation improved and extubation was attempted, but the patient was reintubated due to stridor and inadequate sputum expectoration. Another attempt was made to extubate the patient 5 days later, but the patient was reintubated due to dysphonia and insufficient sputum expectoration. A tracheostomy was performed as extubation was deemed difficult in the short term. The tracheal cannula was removed on day 17 post-tracheostomy, but dyspnea developed, and the tracheal cannula was reinserted. Laryngoscopy and CT scan of the neck by an otolaryngologist revealed that the patient had arytenoid cartilage dislocation and bilateral laryngeal paralysis. Laryngeal function should be evaluated with attention to arytenoid cartilage dislocation and bilateral laryngeal paralysis during prolonged intubation or prone positioning, which places stress on the larynx.

The case was a 39-year-old male who was aware of a headache centered in the left eye socket and extending to the forehead. Autonomic symptoms of tears and congestion of the conjunctiva were also observed. This case was diagnosed as short-lasting unilateral neuroralgiform headache attack with conjunctival injection and tearing（SUNCT）due to the presence of pain and autonomic symptoms. At the beginning of treatment, drug therapy with lamotrigine provided good analgesic control. In this case, because the artery adjacent to the trigeminal nerve could be confirmed, it was determined that there was an indication for surgery, and surgery was eventually performed. As a result, the symptoms were completely cured and the treatment results were good. SUNCT is a refractory disease and is primarily treated with medication. However, if the cause of the onset of the disease is confirmed and an accurate diagnosis is made, there may be a possibility of surgical indication.

With the coronavirus 2019 pandemic, there have been increased opportunities for anesthesiologists to perform emergency endotracheal intubation outside the operating room in patients with respiratory failure. Difficult endotracheal intubation and severe airway-related adverse events occur much more commonly in such settings due to limited time and resources, noisy and chaotic environments, and the minimal physiological reserve of patients. To manage inherent risks in emergency airway management outside the operating room, the following four steps are of crucial importance：（1）prior risk evaluation and planning；（2）maximization of initial endotracheal intubation attempt success；（3）safety redundancy with backup plans and devices that are fast, simple, and easy to deploy；and（4）emergency surgical airway. With the most recent evidence, this article reviews how each of these steps applies to emergency airway management outside the operating room in the era of COVID-19.

Global standards for medical education require all medical schools in Japan to implement outcome-based curriculums. We have developed and carried out undergraduate lecture modules in anesthesiology which are designed to be relevant to clinical practice in the future and to focus on acquisition of core competencies rather than specialty-specific details. We expected our students who completed these modules to hold accurate perceptions of anesthesiologists. Qualitative analysis of open-ended questionnaires answered by those students revealed that they shared various stereotyped perceptions of anesthesiologists including that they “just make patients sleep without doing anything during operations”, and “have no contacts with patients”, which were properly corrected only after completing anesthesiology clerkship. These results suggest that our limited educational resources available to undergraduate education in anesthesiology should be distributed not to passive and ineffective lectures but to effective on-site teaching during clinical clerkships. The COVID-19 pandemic, along with the need for accreditation of undergraduate medical education, has made anesthesiology clinical clerkships much more difficult to implement than before. We, as members of the healthcare profession, should make every effort to address these difficulties and develop new educational strategies based on the FAIR principle for effective learning.

In accordance with the international certificates guidelines for Japan Accreditation Council for Medical Education（JACME）, participation in clinical clerkships is required in medical school in Japan. It is time for university hospitals to reconsider the education system in medical school. Due to the COVID-19 pandemic, however, we have not been able to provide hands-on clinical clerkships for the past three years. In addition, the increased number of procedures/operations in university hospitals has made it difficult for us to spare enough time for medical students. Although we still face some challenges in the education system, I believe the Anesthesiology department offers students great opportunities to acquire the essential clinical competency which will prepare them to become doctors. This article describes how we have improved the clinical clerkship to attract more medical students and provided them with more effective clinical clerkship and better clinical experience in anesthesiology.

Since 2023, medical actions by ‘Student Doctors’ during their clinical clerkship became public, leading to dramatic change on undergraduate medical education. While no specific specialty has responsibility for rapid response systems, cardiopulmonary resuscitation, central venous catheter, or palliative care education, anesthesiologists have considerable knowledge in these fields. In this review, I discuss undergraduate medical education from the viewpoint of outcome-based education and suggest our inherent role in providing a general approach to critical care and pain medicine.

Sepsis-associated encephalopathy（SAE）is defined as diffuse brain dysfunction accompanied by sepsis in the absence of direct central nervous system infection. SAE is related not only to increased mortality but to prolonged cognitive dysfunction, so neuroprotective intervention is believed to be important. As the pathophysiological mechanisms of SAE through which systemic inflammation causes neuroinflammation and finally leads to brain dysfunction are complicated, effective therapies have not yet been established. Although there are several problems in the field of basic research on SAE, we outline the recent evidence for SAE pathophysiology and the management of SAE in this review.

Sepsis is a major risk factor for mental health disorders. Brain dysfunction associated with sepsis is referred to as sepsis-associated encephalopathy（SAE）, which may present with abnormal behavior, delirium, and even coma. The mechanisms underlying SAE are diverse and remain the subject of wide-ranging research. Electroencephalography（EEG）may serve as a powerful tool for evaluating brain function in clinical research. To date, several researchers performed EEG analyses to predict and detect at an early stage delirium in patients admitted to intensive care units. They focused on abnormal basic waves and abnormal rhythms using long-term EEG. A high prevalence of electrical seizures in patients with sepsis was observed, and the severity of seizures was associated with mortality. Diagnostic criteria for SAE remain undefined, but EEG evaluation may be a useful diagnostic aid. Early EEG abnormalities were also associated with prognosis in patients with COVID-19. Machine learning-based EEG interpretation will serve as a sensitive tool to measure the severity of delirium. In this article, we summarize EEG studies associated with sepsis.

The availability and use of labor analgesia in Japan has been increasing in recent years, but remains much lower than in Europe and the United States. The presence of an anesthesiologist is extremely important for safety when considering anesthesia management and response to emergency cesarean section, obstetric hemorrhage, and other unexpected complications. However, there are facilities where obstetricians administer labor analgesia themselves due to a lack of available anesthesia personnel. In response to several cases of maternal mortality during labor analgesia, government agencies and academic societies are working towards safe obstetric anesthesia management. This article summarizes principles of safe labor analgesia from the standpoint of anesthesia management, based on recommendations from academic societies and obstetric anesthesia literature.