At our institution, we employ a FileMaker Pro database for postoperative pain management. The database has been enhanced by adding a function to perform real-time descriptive statistics independently within the system, aiming to understand the results of our rounds.

After obtaining approval from the medical ethics committee, we collected data from 7,925 patients between January 2018 and December 2022. Descriptive statistics were performed on the median Numeric Rating Scale values for pain at rest and during movement, separated by intravenous and epidural principal component analyses, and on the incidence of postoperative symptoms such as nausea, vomiting, headache, drowsiness, itching, and poor pain control. We conducted a verification for descriptive statistics to ensure consistency between values automatically calculated by the system and those calculated manually using the same dataset.

We confirmed consistency between the descriptive statistics automatically calculated by the system and manual calculations.

Purpose : To investigate postoperative frequency of antiemetic use and pain after emergence from general anesthesia using remimazolam.

Methods : The data of secondary endpoints in a randomized controlled trial that examined memory retention as the primary endpoint after emergence from general anesthesia using remimazolam were used. Patients undergoing breast surgery were enrolled and randomly assigned to receive propofol(control group)or remimazolam as general anesthetics. Antiemetic use immediately after surgery and from the time of returning to the ward until 24 h after surgery was investigated. The dose of analgesic medication administered from when the patient returned to the ward until 24 h after surgery, the patient’s immediate postoperative pain NRS values, and their pain NRS score 24 h after leaving the operating room(OR)were also recorded.

Results : Sixty-six patients(propofol, 32 ; remimazolam, 34)were assessed. Antiemetic use immediately after surgery was comparable(p=0.43)in both groups, but antiemetic use from the time the patient returned to the ward until 24 h after surgery was higher in the remimazolam group(p=0.03). The incidence of administration of analgesic medications from when the patient returned to the ward until 24 h after surgery(p=0.67), immediate postoperative pain NRS values(p=0.74), and pain NRS scores 24 h after leaving the OR(p=0.88)were comparable in both groups. Flumazenil was administered to 10 patients in the remimazolam group. Antiemetic use and pain was similar with and without flumazenil in the remimazolam group.

Conclusions : Remimazolam is less effective than propofol at inhibiting the frequency of antiemetic use. The effect on pain was similar with both anesthetic agents.

A 26-year-old female underwent a laparoscopic right hysterectomy and right adnexectomy under combined epidural and general anesthesia for a double uterus and chocolate cysts. Postoperatively, she experienced persistent numbness in the right lower limb, raising suspicion of complications related to the epidural anesthesia. She was therefore referred to the anesthesia outpatient clinic. Symptoms were localized to the sciatic nerve region, away from the puncture site of the epidural anesthesia, and MRI examination revealed hypertrophy of the right superior gemellus muscle. Additionally, detailed questioning revealed that the symptoms in the right lower limb were present preoperatively. The diagnosis was exacerbation of symptoms of pelvic outlet syndrome due to direct pressure on the buttocks during lithotomy positioning. Although there are established measures to manage nerve complications in the lithotomy position, complications arising from patient-specific causes are still possible, as in this case. It is therefore important to plan appropriate management for each patient through preoperative assessment.

Epidural catheter migration into the subdural space is a potential complication with epidural analgesia. Subdural analgesia can result in high spinal anesthesia leading to cardiac arrest, and requires prompt diagnosis and adequate measures. Therefore, it is necessary to identify and respond to subdural migration without delay. We experienced two cases of suspected subdural migration during labor analgesia with Horner’s syndrome. The catheter was withdrawn by 1 cm in the first case, and was replaced in the second case, resulting in the relief of Horner’s syndrome while maintaining effective analgesia in both cases.

Pregnancy related pelvic girdle pain is a clinical syndrome in which unidentified pain is observed in the pelvic girdle during the perinatal period. We administered epidural analgesia to a pregnant woman suspected to have this disease, and she was able to safely deliver her baby. The patient was in her twenties. Her pregnancy was progressing well, but at 36 weeks and 3 days, she recognized severe left groin pain. Contrast enhanced CT showed no cause, and this disease was suspected from the course of her pregnancy. The pain was refractory to analgesics, and vaginal delivery was difficult because she could not take birthing position. After epidural analgesia was administered, the left groin pain improved, and a baby was delivered by vaginal delivery. No pain was observed after delivery. As anesthesiologists, it is important to select appropriate analgesia for this disease.

We present the case of an 88-year-old man who underwent an emergency laparotomy due to suture failure on the 6th postoperative day after a sigmoid colon resection. Following the surgery, the surgeon opted to manage the patient in the ICU without extubation. However, the patient continued experiencing difficulty breathing when attempts were made to adjust the cuff pressure of the tracheal tube. Despite conducting X-rays, echocardiography, and bronchoscopy to investigate the issue, the underlying cause remained unidentified. Our suspicion turned towards cuff failure, leading to the replacement of the intubation tube. Upon inspection, we discovered that the cuff inflation line was severely bent at a right angle and obstructed by the bite block. Notably, the bite block was smaller than anticipated, contributing to the obstruction of the cuff inflation line. The accident occurred in this case because the inflation line of the endotracheal tube was not checked for obstructions.

We encountered a case of anaphylaxis with sudden hemodynamic changes during orthopedic surgery that required differentiation from pulmonary embolism. Anaphylaxis was difficult to diagnose intraoperatively because of the absence of skin symptoms. However, the clinical diagnosis of anaphylaxis was confirmed postoperatively due to the presence of wheals. Fresh frozen plasma or two human serum albumins were assumed to be the causative agents rather than other blood products, anesthetics, or disinfectants. Subsequently, a significant increase in serum tryptase level was detected and the diagnosis of anaphylaxis was confirmed. Postoperatively, red blood cells were again transfused and there was no recurrence of anaphylaxis. Two years later, general anesthesia administered with the same anesthetics and using the same disinfectants was uneventful. Anesthesiologists should not rule out anaphylaxis because of the absence of skin symptoms.

Prolonged activated partial thromboplastin time（APTT）can be caused by hypofunction of coagulation factors or antiphospholipid syndrome（APS）. Since the former and the latter show bleeding tendency and thrombotic tendency, respectively, different management depending on the cause of prolonged APTT is needed.

A woman in her 80s was scheduled for revision hip arthroplasty. Preoperative examination revealed prolonged APTT and low FXI activity, leading to a diagnosis of FXI deficiency. Although fresh frozen plasma（FFP）was administered before surgery, APTT was not shortened to normal. To evaluate coagulation function, we performed thromboelastography, which did not show a decline in coagulation function. Based on the results of TEG, we decided to perform THA rather than minimal surgery and not to administer fresh frozen plasma during surgery. The patient was diagnosed as having APS after surgery. Thromboelastography may be useful in determining surgical technique and transfusion strategy in a patient with prolonged APTT.

To improve the quality of sedation-related safety, it is important to understand its problems, analyze their causes, and consider countermeasures. We report on an in-situ sedation course based on that of the Japanese Association for Medical Simulation in the Endoscopy Department, wherein multidisciplinary staff performed sedation. After the course, discussions were held based on a questionnaire. These were useful in understanding problems, analyzing their causes, and considering countermeasures.

Local anesthetics have been used in clinical practice for more than 100 years, and as science has progressed, a wide variety of pharmacological actions have been revealed. In the pharmacological actions of local anesthetics, it is important to understand the mechanism of blockade of voltage-gated Na⁺ channels（Na_v）based on their basic properties. Actions on a variety of other targets also modify local anesthetic actions. Furthermore, the analgesic effects of systemic lidocaine administration have long been known, and recent systematic reviews have confirmed its efficacy. It is speculated that a wide variety of mechanisms may be involved. Other relevant findings include the potential of Na_v expressed in non-excitable cells as a therapeutic target and the study of Na_v subtype-selective blocking agents, which have received considerable attention.

Gastrointestinal endoscopic procedures are highly invasive, and immobilization with deep sedation equivalent to general anesthesia are required to reduce the risk of serious complications related to these procedures. Since deep sedation suppresses airway, respiratory, circulatory, and other defense mechanisms, anesthesiologists should manage it, but it is impractical for anesthesiologists to be involved in all procedures. We therefore created a deep sedation protocol that can be performed by gastroenterologists based on dexmedetomidine, which does not cause respiratory depression and has analgesic properties. In esophageal ESD, immobilization is especially important because of the high risk of perforation and serious complications, and we permit the residual effects of deep sedation.

When evaluating the safe conduct of examinations and procedures through successful sedation as a measure of "quality", the foundational elements for quality improvement include （1）clarifying the goals of sedation and analgesia, （2）understanding the level of sedation, （3）identifying risk factors for adverse events, and （4）comprehending pharmacokinetics. Given the current situation where anesthesiologists in Japan are heavily engaged in operating room duties and the reimbursement for intravenous sedation is lower compared to general anesthesia, an immediate increase in the direct involvement of anesthesiologists in sedation outside the operating room is not feasible, and much of the sedation responsibility must be delegated to non-anesthesiologists. However, for cases with a high risk of adverse events, direct involvement by anesthesiologists is desirable. To address the problem, an increase in reimbursement for intravenous sedation is needed to improve the conditions surrounding sedation outside the operating room.

NORA（Non Operating Room Anesthesia）is riskier than anesthesia inside the operating room, and many sedation accidents have been reported. The Joint Commission International（JCI）states that "sedation is roughly equivalent to general anesthesia". The Japanese Society of Anesthesiologists has created a "Practical Guide for Safe Sedation" for non-anesthesiologists and other professionals. Various third-party evaluations of hospital function place emphasis on how facilities deal with invasive examinations, especially when using sedatives, and it is time for facilities to establish management systems. Based on the "Practical Guide for Safe Sedation", we will report on progress in our hospital’s sedation system and surveillance.

The policy for providing perioperative care to patients who refuse blood transfusions, as typified by Jehovah’s Witnesses, is either “relative non-blood”, in which blood is transfused in situations where life cannot be saved except by transfusion, or “absolute non-blood”, in which blood is not transfused under any circumstances. Since different blood fractions are not allowed in each patient, some blood fractions may be used in absolute non-blood patients. In absolute non-blood surgery, strict perioperative management is essential, with adequate patient and family dialogue and careful consideration by the multidisciplinary conference and the ethics committee. Although the psychological burden on the healthcare providers is sometimes excessive, their efforts to push the limits of perioperative management can contribute to their growth.

In recent decades, clinicians have given greater attention to the importance of minimizing and avoiding exposure of patients to allogeneic（donor）blood transfusion. However, caring for patients without blood transfusion can sometimes pose a challenge to clinicians. Healthcare providers may encounter this clinical scenario when patients object to blood transfusion therapy for religious, cultural, or health reasons, when blood bank inventories are low, or when allogeneic blood is not available （such as during a disaster or an epidemic）. Respect for patient autonomy upholds fundamental human rights. Thus, clinical strategies for blood conservation and optimal management of patients’ own blood are relevant to all anesthesiologists.

Mounting evidence published in the medical literature demonstrates that even major medical and surgical interventions can be successfully performed without blood transfusion. This is achieved through the rigorous and systematic use of combinations of clinical strategies that treat anemia, manage coagulopathy, and minimize blood loss. The objective of such strategies, tailored to each clinical situation, is to minimize blood loss, optimize autologous blood management, support hematopoiesis, and enhance tolerance of anemia. Moreover, studies indicate that the clinical and economic outcomes of such care are comparable to or superior to those of patients receiving allogeneic blood transfusions.

As a result of significant reforms, physicians are subject to new restrictions on overtime hours to improve work-life balance and prevent burnout. One proposed solution is task shifting or sharing, where certain responsibilities are delegated to other medical professionals.

As team-based care becomes more prevalent, the issue of criminal liability in cases of professional negligence resulting in patient harm or death has come to the question of individual responsibility. The legal principle known as the "principle of trust" plays a crucial role in determining the scope of duty of care in negligent crimes. If this principle applies, negligence liability may not be questioned for certain supervising physicians who acted reasonably based on their level of experience and expertise. However, the principle of trust may not extend to inexperienced medical professionals, potentially placing the supervising physician at risk of being held accountable for their negligence.

Civil lawsuits for damages arising from breaches of professional obligations or torts have come to the question of liability for damages. Many of these suits target hospitals as employers, regarding the liability of hospitals for damages in team-based care.

In our hospital, there are nurse practitioners who have acquired additional skills in medical thinking and judgment and perform a certain level of medical treatment. Their implementation of relatively low-risk medical practices on the basis of specific instructions from physicians is increasing. In future, because of the progress of physician work-style reform, task shifting or task sharing to nurse practitioners is expected to further increase the demand for them to implement new low-risk medical practices. We have therefore clarified the low-risk medical practices that the nurse practitioners in our hospital perform under the specific instructions of physicians, and have established an approval system for nurse practitioners to perform new low-risk practices in the future. As a result of these efforts, we expect that the activities of nurse practitioners will become well known within the hospital and that their activities will be audited from the perspective of medical safety. We also expect that more appropriate task shifting or task sharing will be promoted to meet patient needs.