Anesthesiologists in Kanagawa Prefecture are unevenly distributed between the western and eastern parts of the prefecture. Since preoperative anesthesia explanation and obtaining informed consent(IC)for anesthesia are tasks outside the operating room, it is expected that in medical regions with a low number of full-time anesthesiologists per capita, the burden of obtaining IC may be significant. We administered a survey in hospitals in our prefecture to determine whether the burden of IC varies by region. Our findings demonstrated that the burden of IC increased under various circumstances, including when 1)the number of full-time anesthesiologists per population is low, 2)there are 5 or more days of elective surgeries scheduled per week, and 3)the annual case volume per full-time anesthesiologist is high. These circumstances likely reflect increased workload, highlighting the need to establish a system involving the government to address the uneven distribution of anesthesiologists in the prefecture.

Background : In recent years, catheter ablation(ABL)under general anesthesia has been increasingly used to improve the success rate of ABL by minimizing pain and the risk of patient movement during the procedure. To date, the incidence of perioperative anesthesia-related complications related to ABL is not known in Japan. We retrospectively examined the incidence and risk factors of postoperative nausea and vomiting(PONV)in following ABL under general anesthesia.
Methods : Of 161 patients who underwent ABL under general anesthesia between October 1, 2018, and September 14, 2020 at our hospital, 159 patients who did not undergo emergency surgery were included. We divided the patients into PONV and non-PONV groups according to the presence or absence of PONV within 24 h after surgery. The main outcome was the incidence of PONV within 24 h after surgery. We also retrospectively compared patient background and perioperative factors before surgery.
Results : PONV was observed in 30 of the 159 patients(18.9%). Significant demographic differences between the PONV and non-PONV groups were identified. These included non-smoking(66.7% vs 37.2%, p = 0.005), non-habitual drinking(86.7% vs 49.6%, p <0.0001), female sex(60% vs 19.4%, p <0.0001), total infusion volume(7.0 mL/kg/h vs 6.1 mL/kg/h, p = 0.0397), and crystalline liquid use(6.8 mL/kg/h vs 5.8 mL/kg/h, p = 0.0350). No significant differences were found in the other explanatory variables. Multivariate analysis revealed that female sex(odds ratio : 3.03 ; 95% CI : 1.11-8.29, p = 0.0305)and non-habitual drinking(odds ratio : 4.31 ; 95% CI : 1.33-13.94, p = 0.0149)were independently associated with PONV. In addition to PONV, gastrointestinal symptoms such as gastric discomfort and heartburn were observed in 21 patients(13.2%).
Conclusion : Female sex and non-habitual drinking were risk factors for PONV in ABLs under general anesthesia. It is necessary to pay attention to the same PONV risk factors in ABL as those in conventional general anesthesia surgery.

We report a case of balloon aortic valvuloplasty（BAV）prior to cecal cancer surgery in a patient with symptomatic severe aortic stenosis who was undergoing dialysis. The patient, a 74-year-old man, was estimated to be 1-2 months away from colorectal obstruction due to cancer and required prompt surgical intervention. Since the patient was a high-risk case, we conducted a multidisciplinary discussion and decided to perform BAV before cancer surgery. The patient’s symptoms and echocardiographic findings improved after BAV, and laparoscopic ileocecal resection was performed 8 days later without any difficulties in anesthesia management. This case showed that although BAV is a palliative technique, it may be useful as an intervention before non-cardiac surgery.

An 82-year-old woman was diagnosed with myasthenia gravis. Due to the progression of her primary disease, a tracheostomy was performed to secure her airway. In a conventional tracheostomy for an intubated patient, there are concerns about the effects of this procedure on the respiratory status caused by ventilatory leakage and the release of positive end-expiratory pressure due to breakage of the tracheal tube cuff as well as blood and other secretions which may drip into the trachea. Furthermore, in patients requiring management with a high oxygen concentration, ventilation leakage caused by tracheal tube cuff breakage also poses a risk of ignition when using an electrical scalpel. Cricoid fenestration for intubated patients involves creating a tracheal opening at a high position on the cricoid cartilage, which is less likely to cause breakage of the tracheal tube cuff and may therefore help avoid the above-mentioned effects on respiratory status. In this case, we selected cricoid fenestration as the tracheostomy technique because the patient was managed with invasive mechanical ventilation and had experienced respiratory failure. Good intraoperative respiratory management was successfully achieved.

In an ultra-aging society, it is important to maintain postoperative daily living functions after all surgeries, including brain surgery, considering the development of postoperative delirium and cognitive decline. To this end, intraoperative neuromonitoring and early recovery after surgery（ERAS）can be advocated. Various methods are used for intraoperative neuromonitoring, such as motor evoked potentials, visual evoked potentials, and bulbocavernosus reflex. ERAS requires a multifaceted approach, including prehabilitation before surgery, prevention of postoperative nausea and vomiting, and pain management using scalp blocks. It has been reported that the implementation of ERAS can shorten hospital stays, and that scalp blocks can reduce postoperative pain and narcotic use.

A modified thoracoabdominal nerves block through the perichondrial approach（M-TAPA）has been reported to provide extensive abdominal analgesia after a single dose of local anesthetic. However, from an anatomical perspective, the analgesia provided by M-TAPA is unlikely to extend to the region innervated by the lateral cutaneous branches. This suggests that when performing M-TAPA, anatomical factors that facilitate local anesthetic infiltration or entry into regions other than the intended site. We identified a novel administration site, located in the space between the endothoracic fascia, diaphragm, and costodiaphragmatic recess（SEDIC）, which is immediately adjacent to the conventional M-TAPA administration site. Administration of local anesthetics into the SEDIC, a procedure we termed the re-modified TAPA, resulted in extensive abdominal analgesia, including the region innervated by the lateral cutaneous branches.

Pediatric airways that are difficult to manage have historically been viewed as unusual occurrences in children who are developing normally. Studies indicate that its incidence in neonates and infants is comparable to that in adults and even higher when defined as requiring more than three laryngoscopy attempts. Once a difficult airway is encountered in pediatric patients, the risk of complications such as airway trauma and hypoxemia increases significantly, especially in neonates and infants. Therefore, careful preparation and cautious anesthetic induction are crucial for safe airway management in children. Genetic syndromes like Down syndrome may allow for the preoperative identification of a difficult airway, facilitating appropriate planning and risk reduction. However, unanticipated cases still occur, necessitating prompt and effective decision-making. When a difficult airway is expected, thorough preparation, proper device selection, and a clear strategy to secure the airway within three attempts are essential. This study highlights the importance of preparation and induction strategies for managing difficult pediatric airways, with the aim of enhancing safety and minimizing complications.

Tracheal intubation while preserving spontaneous breathing is an option for managing airway difficulties. In pediatric patients, anesthesiologists must preserve spontaneous breathing while achieving sufficient loss of consciousness. The depth of anesthesia must be adjusted to a level that permits airway maneuvers. Careful anesthetic planning and technique optimization are required.
Anticipating difficult airways with appropriate pre-anesthetic assessment is important to facilitate backup plan preparation and minimize complications associated with the procedure. The following considerations are essential to allow procedures to be performed under stable conditions. First, spontaneous breathing must be maintained by carefully achieving the desired level of sedation via continuous infusion of a familiar intravenous anesthetic. Second, local anesthetics should be used to reduce stimulation and immobilization during airway maneuvers. Third, oxygen must be administered throughout the procedure.

Apneic oxygenation refers to the delivery of oxygen to the lung in the absence of spontaneous respiration or mechanical ventilation. Apneic oxygenation during tracheal intubation in pediatric patients has been shown to delay desaturation, to significantly increase the success rate of initial tracheal intubation, and to contribute to hemodynamic stability during tracheal intubation, which suggests its usefulness in physiologically difficult airways. Apneic oxygenation during difficult airway management in pediatric patients is recommended in the guideline of the American Society of Anesthesiologists and the joint guideline of the European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia. In this article, we will present some evidence on the role of apneic oxygenation in pediatric airway management.

The accurate documentation of airway management in difficult airway cases is critical for ensuring patient safety in subsequent anesthetic procedures. However, a traditional anesthesia record with written information is inherently limited by its lack of objectivity and precision. Our institution has adopted a novel approach to recording comprehensive information during airway management by combining and integrating a wide-angle camera with a video laryngoscope with a recording function to address these shortcomings. This method enhances the accuracy and reproducibility of documentation and proves invaluable in educational settings and video-based feedback. Technical limitations and medicolegal concerns must be addressed to fully realize its potential. In this article, we outline the benefits and limitations of video documentation and discuss its implications as a pivotal step toward the inevitable transition to the "era of comprehensive airway management recording".

Remimazolam, an ultra-short benzodiazepine, acts on γ-aminobutyric acid（GABA）receptors in the brain to induce sedation. While GABA receptors, which are involved in pain modulation, are present in the spinal dorsal horn, the analgesic effects and cellular mechanisms of remimazolam in this region remain unexplored. We analyzed synaptic transmission through behavioral experiments and in vitro whole-cell patch-clamp recordings from neurons in the dorsal horn.
Intrathecal injection of remimazolam resulted in behavioral analgesia, reducing mechanical allodynia in the context of inflammatory pain.
In vitro whole-cell patch-clamp recordings revealed that remimazolam significantly increased the frequency and decay time of GABAergic miniature inhibitory post-synaptic currents and enhanced GABA currents elicited by exogenous GABA application.
However, remimazolam had no significant effect on the frequency of miniature excitatory post-synaptic currents or the amplitude of monosynaptic excitatory post-synaptic currents evoked by Aδ- and C-fiber stimulation.
The findings of this study suggest that remimazolam exerts its analgesic effects through the enhancement of GABAergic inhibitory transmission in the spinal dorsal horn, suggesting its potential utility as a spinal analgesic for inflammatory pain.

Macroscopic neuroscience, often referred to as "brain science", has revolutionized our understanding of pain, revealing it to be a complex emotional experience generated in the brain rather than mere sensory input. This paper explores the emotional aspects of pain uncovered through non-invasive brain imaging techniques and proposes novel treatment approaches leveraging brain plasticity. Notably, conditions previously diagnosed as "psychogenic" have been redefined as "nociplastic pain", understood as disorders based on altered brain function. Applying neuroscientific insights to clinical practice, we introduce the concept of a "healing virtuous cycle" for patients living with pain. We discuss the balance between pain-related and reward system brain regions, adaptive changes in chronic pain patients’ brains, and the importance of cognitive-behavioral interventions in pain management. This research aims to contribute to improving the quality of life of chronic pain patients by applying neuroscientific findings in clinical settings, emphasizing the emotional nature of pain and the brain’s plasticity in pain perception and management.

Chronic pain, which has a significant impact on healthy life expectancy and productivity, is not just an individual problem： social factors also contribute to its exacerbation and chronicity. Using data from a web-based large-scale epidemiological survey conducted on 52,353 people across Japan（aged 20 to 64 years, average age： 42.7, women’s ratio： 49.9％）, we examined the prevalence of pain and the distribution of psychosocial risk factors. The prevalence of moderate to severe chronic pain was 19.1％. However, there was a difference of up to 8.3％ in the prevalence of moderate to severe chronic pain among prefectures, and it was also found that the stress and mood states of each prefecture affected prevalence（p＜0.001）. These findings suggest that social supports at the regional level are required to combat chronic pain.

Palliative care physicians witness the death of many patients, leading to thoughts regarding their own life and death. As one myself, I perform Noh theatre training to aid my mental health. Noh is a 700-year-old traditional form of entertainment. These plays are based on myths as well as classics such as Heike Monogatari and The Tale of Genji. They depict death as a familiar presence and the souls of the dead as existing close to the living. The shite（protagonist）is often a god, demon, or ghost, that appears in front of a picture of an oimatsu（old pine tree）on the Noh stage. It voices its regrets and longing for life to the waki（supporting character）, who is often a Buddhist or Shinto priest. In the end, it disappears after saying “Please mourn for me”. While performing, I sometimes feel as if I am hearing the voices of patients who have died. Watching a Noh play calms one down mentally, similar to a church mass. Acting in Noh is like meditation. I strive to continue cultivating my mental health and care for patients facing death using Noh.

The knowledge and technical skills of anesthesiologists play a crucial role in various aspects of palliative care. However, beyond these clinical competencies, there is a profound need for an attitude that honors and accompanies the patient’s life journey and personal values. Drawing inspiration from the Shikoku Pilgrimage concept of “Dōgyō Ninin”（“traveling together”）, the author reflects on the deeper meaning of “walking alongside” the patient and reexamines the unique role anesthesiologists can play within palliative care.

As an anesthesiologist, I became involved in cancer pain relief and was faced with the reality that even after severe cancer pain had been alleviated, patients still suffered intensely and deeply, and I was at a loss about what I should do as a doctor. Through my experience in caring for many patients, however, I learned that even though patients suffer as human beings, they find meaning in life and live out their final moments in their own way, and that the connections they have with their families and those around them are what give them the will to survive. Palliative care is about relieving the patient’s physical pain while empathizing with their deep suffering and healing their loneliness. The realization that I play a part in supporting the connection of patients to life and hope gives meaning to my existence as a doctor.