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Coronavirus disease 2019 (COVID-19) has rapidly spread globally ever since the virus was first identified in December 2019 in Wuhan, China. Despite efforts to accelerate the supply of COVID-19 vaccines worldwide, the global pandemic has continued. Polymerase chain reaction (PCR) test is currently considered the gold standard for the diagnosis of COVID-19. However, the rate of false-negative PCR for COVID-19 has been reported to be over 10%. Furthermore, an asymptomatic period can last up to 14 days following the infection. Under these circumstances, standard anesthetic practice, surgery scheduling, and approaches to appropriate management of the operating room to protect both patients and medical personnel against COVID-19 transmission need to be reviewed and appropriately modified. In this review, based on our institutional experiences along with the guidelines reported elsewhere, we propose safer and more effective perioperative management amidst the COVID-19 pandemic.

Background and objectives Although previous reports have shown intraocular pressure changes during robotic-assisted laparoscopic prostatectomy, they did not discuss the time course of changes or the timing of the largest change. We conducted this study to quantify pressure changes over time in patients assuming the steep Trendelenburg position during robotic-assisted laparoscopic prostatectomy. Methods Twenty-one men were enrolled. Intraocular pressure was measured before anesthesia induction in the supine position (T0); 30 (T1), 90 (T2), and 150 minutes after assuming the Trendelenburg position (T3); and 30 minutes after reassuming the supine position (T4). End-tidal carbon dioxide and blood pressure were also recorded. To compare intraocular pressure between the time points, we performed repeated-measures analysis of variance. A mixed-effects multivariate regression analysis was conducted to adjust for confounding factors. Results The mean (standard deviation) intraocular pressure was 18.3 (2.4), 23.6 (3.0), 25.1 (3.1), 25.3 (2.2), and 18.1 (5.0) mmHg at T0, T1, T2, T3, and T4, respectively. The mean intraocular pressure was higher at T1, T2, and T3 than at T0 (p< 0.0001 for all). There was no significant difference between T0 and T4, and between T3 and T2 (p> 0.99 for both). Conclusions The Trendelenburg position during robotic-assisted laparoscopic prostatectomy increased intraocular pressure. The increase was moderate at 90 minutes after the position was assumed, with the value being approximately 7 mmHg higher than the baseline value. The baseline intraocular pressure was restored at 30 minutes after the supine position was reassumed. Trial registration UMIN ID 000014973 Date of registration August 27, 2014

Respiratory failure is a common complication in patients with myotonic dystrophy (MD) and might be a presenting symptom in the perioperative setting. We report the case of a 59-year-old woman with MD who underwent open cholecystectomy and developed postoperative respiratory failure. Without reintubation, the patient was successfully managed with bilevel positive airway pressure (BiPAP) and was discharged uneventfully. BiPAP may be considered as an alternative for postoperative respiratory failure in patients with MD. Careful observation of patients' postoperative condition and an earlier application of BiPAP are instrumental in avoiding retracheal intubation, which may cause further serious problems in patients with MD.

In general, preoxygenation is performed using a face mask with oxygen in a supine position, and oxygenation is maintained with manual mask ventilation during electroconvulsive therapy (ECT). However, hypoxic episodes during ECT are not uncommon with this conventional method, especially in morbidly obese patients. The most important property of ventilatory mechanics in patients with obesity is reduced functional residual capacity (FRC). Thus, increasing FRC and oxygen reserves is an important step to improve oxygenation and prevent oxygen desaturation in these individuals. Head-up position, use of apneic oxygenation, noninvasive positive pressure ventilation, and high-flow nasal cannula help increase FRC and oxygen reserves, resulting in improved oxygenation and prolonged safe apnea period. Furthermore, significantly higher incidence of difficult mask ventilation is common in morbidly obese individuals. Supraglottic airway devices establish effective ventilation in patients with difficult airways. Thus, the use of supraglottic airway devices is strongly recommended in these patients. Conversely, because muscle fasciculation induced by depolarizing neuromuscular blocking agents markedly increases oxygen consumption, especially in individuals with obesity, the use of nondepolarizing neuromuscular blocking agents may contribute to better oxygenation in morbidly obese patients during ECT.

Background Von Willebrand disease (VWD) is the most common inherited bleeding disorder in humans. Coagulopathies such as VWD are evidently risk factors for post-surgical bleeding. Perioperative management of patients with VWD remains controversial and is a major clinical concern. Case presentation A 5-year-old girl was scheduled for tonsillectomy under general anesthesia. Preoperative laboratory tests revealed prolongation of activated partial thromboplastin time and a mild decrease in von Willebrand factor (VWF) activity. Prophylactic administration of desmopressin or VWF was not performed. During tonsillectomy, oozing from the surgical wound was uncontrollable by conventional hemostasis techniques, but complete hemostasis was ensured by plasma-derived coagulation factor VIII concentrate containing VWF. Conclusion Pediatric patients with mild abnormalities in preoperative laboratory tests may have coagulopathies. Prophylactic intervention and/or the preparation of a sufficient amount of coagulation factor VIII concentrate containing VWF may be required in patients suspected of having VWD or with mild VWF deficiency.

Background: It is very rare but challenging to perform emergency airway management for accidental extubation in a patient whose head and neck are fixed in the prone position when urgently turning the patient to the supine position would be unsafe. The authors hypothesized that tracheal intubation with a videolaryngoscope would allow effective airway rescue in this situation compared with a supraglottic airway device and designed a randomized crossover manikin study to test this hypothesis. Methods: The authors compared airway rescue performances of the 3 devices—the ProSeal laryngeal mask airway (PLMA; Teleflex Medical, Westmeath, Ireland) as a reference; the Pentax AWS (AWS; Nihon Kohden, Tokyo, Japan) as a channeled blade-type videolaryngoscope; and the McGRATH videolaryngoscope (McGRATH; Medtronic, Minneapolis, MN) as a nonchanneled blade type in a manikin fixed to the operating table in the prone position. Twenty-one anesthesiologists performed airway management on the prone manikin with the 3 devices, and the time required for intubation/ventilation and the success rates were recorded. Results: The median (range) intubation/ventilation times with the PLMA, AWS, and McGRATH were 24.5 (13.5–89.5) s, 29.9 (17.1–79.8) s, and 46.7 (21.9–211.7) s, respectively. There was no significant difference in intubation/ventilation times between the PLMA and AWS. The AWS permitted significantly faster tracheal intubation than did the McGRATH (P = 0.006). The success rates with the PLMA (100%) and AWS (100%) were significantly greater than that with the McGRATH (71.4%). Airway management performance of the PLMA and AWS was comparable between devices and better than that of the McGRATH in the prone position. Conclusions: Considering that tracheal intubation can provide a more secure airway and more stable ventilation than the PLMA, re-intubation with a channeled blade-type videolaryngoscope such as the AWS may be a useful method of airway rescue for accidental extubation in patients in the prone position.

Background The purpose of this meta-analysis was to validate the efficacy of the sniffing position in the performance of intubation with direct laryngoscopy. Methods We searched MEDLINE, the Cochrane Central Register of Controlled Trials, Embase, and Web of Science. Six randomized controlled trials comprising 2759 adult participants were analyzed. The DerSimonian-Laird method was used to calculate pooled relative risk (RR) and the 95% confidence interval (CI) of Cormack-Lehane classification, Intubation Difficulty Scale, success rate of the first intubation, and weighted mean difference of intubation time. Results Compared with the other head positions, the sniffing position did not improve glottic visualization, success rate of the first intubation, or intubation time. However, the sniffing position was significantly associated with better Intubation Difficulty Scale compared with the simple head extension position. (RR,1.28; 95% CI, 1.15-1.42; p Conclusions Although patients do not benefit from the sniffing position in terms of glottic visualization, success rate of the first intubation, or intubation time, the sniffing position can still be recommended as the initial head position for tracheal intubation because the sniffing position provides easier intubation conditions.

Patients with amyotrophic lateral sclerosis (ALS) present an increased risk of postoperative respiratory failure after general anesthesia. We report the case of a 71-year-old man with ALS who underwent emergency laparotomy for small bowel strangulation. After surgery, he remained intubated and was transferred to the high care unit under mechanical ventilation, due to unstable hemodynamics requiring inotropic support. On postoperative day (POD) 3, he was extubated under stable hemodynamics and respiratory status. Immediately after extubation, bilevel positive airway pressure (bilevel PAP) was prophylactically applied to prevent postoperative respiratory failure, which may have been caused by respiratory muscle fatigue, attributed to general anesthesia and surgical stress. On POD 7, bilevel PAP was smoothly weaned off because no signs and symptoms of respiratory failure were observed. On POD 10, he achieved 30 m-walk without rest. No postoperative complications were observed up to one month after surgery. Postoperative respiratory failure may lead to death in patients with neuromuscular disorder. Non-invasive ventilation (NIV) reduces respiratory muscle fatigue, resulting in easy sputum expectoration, promoting CO2 washout, and better oxygenation. Consequently, the prophylactic use of NIV to avoid postoperative respiratory insufficiency should be considered in patients with ALS after emergency operation under general anesthesia.

Tracheal intubation is challenging in patients with severe cervical spine pathology. In such cases, awake fiberoptic intubation is the gold standard and safest option for tracheal intubation. However, this technique requires the patient's understanding and cooperation, and therefore, may be contraindicated in patients with refusal or poor tolerance. Herein, we report successful orotracheal intubation in a patient with limited mouth opening and severe cervical spine rigidity under general anesthesia using an extraglottic airway device and a gum-elastic bougie under C-arm fluoroscopic guidance.

We compared the effects of the Airway Scope(®) on haemodynamic responses during tracheal intubation with those of direct laryngoscopy in normotensive and hypertensive patients. The systolic blood pressure, diastolic blood pressures and heart rate were recorded: (a) before anaesthesia; (b) immediately before intubation; (c) at intubation; and (d) 1, 2, 3, 4 and 5 min after intubation. In normotensive patients, the increase in blood pressure and heart rate over time were significantly lower with the Airway Scope than with the Macintosh laryngoscope (p 0.05). We conclude that the Airway Scope attenuates haemodynamic responses to tracheal intubation in comparison with the laryngoscope in normotensive but not in hypertensive patients. You can respond to this article at http://www.anaesthesiacorrespondence.com.

Gamma-aminobutyric acid (GABA) has been shown to induce excitation on immature neurons due to increased expression of Na+-K+-2Cl- co-transporter isoform 1 (NKCC1), and the transition of GABAergic signaling from excitatory to inhibitory occurs before birth in the rat spinal cord and spreads rostrally according to the developmental changes in cation-chloride co-transporter expression. We previously showed that midazolam activates the hippocampal CA3 area and induces less sedation in neonatal rats compared with adolescent rats in an NKCC1-dependent manner. In the present study, we tested the hypothesis that propofol-induced loss of righting reflex (LORR) but not immobilizing actions are modulated by NKCC1-dependent mechanisms and reduced in neonatal rats compared with adolescent rats. We estimated neuronal activity in the cortex, hippocampus and thalamus after propofol administration with or without bumetanide, an NKCC1 inhibitor, by immunostaining of phosphorylated cyclic adenosine monophosphate-response element binding protein (pCREB). We studied effects of bumetanide on propofol-induced LORR and immobilizing actions in postnatal day 7 and 28 (P7 and P28) rats. The pCREB expression in the cortex (P = 0.001) and hippocampus (P = 0.01) was significantly greater in the rats receiving propofol only than in the rats receiving propofol plus bumetanide at P 7. Propofol-induced LORR or immobilizing effects did not differ significantly between P7 and P28. Bumetanide significantly enhanced propofol-induced LORR (P = 0.031) but not immobilization in P7 rats. These results are partially consistent with our hypothesis. They suggest that propofol may activate the rostral but not caudal central nervous system dependently on NKCC1, and these differential actions may underlie the different properties of sedative and immobilizing actions observed in neonatal rats.

Summary Background: Cardiac tamponade is rare but one of the most serious complications in relation to central venous catheters (CVC). The tip of the CVC should be placed outside the pericardium to avoid tamponade. In adults, the carina is always located above the pericardium; therefore, the carina is a reliable landmark for CVC placement. We examined whether the carina could also be an adequate landmark for CVC placement in neonates. Methods: The study was conducted using nine fresh neonatal cadavers. The longitudinal distance between the carina and the pericardium as it transverses the superior vena cava (the pericardial reflection: PR) was measured. Results: The median postconceptional age (gestational age in weeks + weeks after delivery) at autopsy was 35 (range: 23–42) weeks. The PR was located at a distance of 4 mm above to 5 mm below the carina. Unlike in adults, the position of the PR varies in relation to the carina in neonates. In seven of the nine subjects, the location of the PR was above the carina. Conclusions: In neonates, the carina is not always located above the pericardium, as it is in adults; therefore, the carina is not an appropriate landmark for CVC placement.

We compared the Airway Scope with a gum elastic bougie and fibreoptic bronchoscope in a manikin with a simulated Cormack and Lehane Grade 3 laryngoscopic view. Twenty-seven anaesthetists intubated the trachea of the manikin with these devices and the time required for intubation was measured. They were then asked to rate the subjective difficulty of intubation (1 = very easy; 5 = very difficult). Mean (SD) intubation times were 16.6 (11.2) s with the Airway Scope, 29.4 (10.9) s with the gum elastic bougie (p < 0.0001), and 30.6 (20.0) s with the fibreoptic bronchoscope (p < 0.0001). The median (range) difficulty was 2 (1-4) with the Airway Scope, 3 (2-4) with the gum elastic bougie (p < 0.001), and 2 (1-5) with the fibreoptic bronchoscope (p = 0.014). In Cormack and Lehane grade 3 laryngoscopic views, the Airway Scope may enable faster and easier tracheal intubation than does a Macintosh laryngoscope with a gum elastic bougie or a fibreoptic bronchoscope.

To evaluate the effect of head position on the performance of intubating supraglottic airway devices, we compared the success rate of blind intubation in the head-elevated and the pillowless head positions with the LMA Fastrach and the air-Q, and the change of glottic visualization through the air-Q.We assigned 193 patients to two groups according to the device used and subgrouped by head position used for intubation: Fastrach/pillowless, Fastrach/head-elevated, air-Q/pillowless, and air-Q/head-elevated. Blind intubation through the Fastrach or the air-Q was attempted up to twice after induction of general anesthesia. Before the attempt at blind intubation with the air-Q, the percentage of glottic opening (POGO) score was also fiberscopically evaluated at the outlet of the device in both head positions in a cross-over fashion.The Fastrach significantly facilitated blind intubation compared with the air-Q in both the pillowless and head-elevated positions: 87.2% in Fastrach/pillowless vs 65.9% in air-Q/pillowless (P=.048), 90% in Fastrach/head-elevated vs 53.7% in air-Q/head-elevated (P.001). The head-elevated position did not significantly affect the success rate of blind intubation for either device (P=.97 in Fastrach, P=.37 in air-Q). Although the head-elevated position significantly improved the POGO score from the median (10-90 percentile) 60% (0-100%) in the pillowless position to 80% (0-100%) (P=.008), it did not contribute to successful blind intubation with the air-Q.Although the head-elevated position improved glottic visualization in the air-Q, the head position had minimal influence on the success rate of blind intubation with either the Fastrach or the air-Q.

We studied the use of tele-anaesthesia between Sado General Hospital (SGH) located on Sado Island and Yokohama City University Hospital (YCUH) located in mainland Japan. The two sites were connected via a virtual private network (VPN). We investigated the relationship between the bandwidth of the VPN and both the frame rate and the delay time of the tele-anaesthesia monitoring system. The tool used for communication between the two hospitals was free videoconferencing software (FaceTime), which can be used over Wi-Fi connections. We also investigated the accuracy of the commands given during teleanaesthesia: any commands from the anaesthetist at the YCUH that were not carried out for any reason, were recorded in the anaesthetic records at the SGH. The original frame rate and data rate at the SGH were 5 fps and approximately 18 Mbit/s, respectively. The frame rate at the transmission speeds of 1, 5 and 20 Mbit/s was 0.6, 1.6 and 5.0 fps, respectively. The corresponding delay time was 12.2, 4.9 and 0.7 s. Twenty-five adult patients were enrolled in the study and tele-anaesthesia was performed. The total duration of anaesthesia was 37 hours. All 888 anaesthetic commands were completed. There were 7 FaceTime disconnections, which lasted for 10 min altogether. Because no commands needed to be given during the FaceTime disconnection, the telephone was not used. The anaesthesia assistance system might form part of the solution to medical resource shortages.

Background: General anesthesia induces long-lasting cognitive and learning deficits. However, the underlying mechanism remains unknown. The GluA1 subunit of AMPAR is a key molecule for learning and synaptic plasticity, which requires trafficking of GluA1-containing AMPARs into the synapse. Methods: Adult male rats were exposed to 1.8% isoflurane for 2 h and subjected to an inhibitory avoidance task, which is a hippocampus-dependent contextual fear learning paradigm (n = 16 to 39). The in vitro extracellular field potential of hippocampal synapses between the Schaffer collateral and the CA1 was evaluated using a multielectrode recorder (n = 6 per group). GluA1 expression in the synaptoneurosome was assessed using Western blotting (n = 5 to 8). The ubiquitination level of GluA1 was evaluated using immunoprecipitation and Western blotting (n = 7 per group). Results: Seven days after exposure to 1.8% isoflurane for 2 h (Iso1.8), the inhibitory avoidance learning (control vs. Iso1.8; 294 ± 34 vs. 138 ± 28, the mean ± SEM [%]; P = 0.002) and long-term potentiation (125.7 ± 6.1 vs. 105.7 ± 3.3; P < 0.001) were impaired. Iso1.8 also temporarily increased GluA1 in the synaptoneurosomes (100 ± 9.7 vs. 138.9 ± 8.9; P = 0.012) and reduced the GluA1 ubiquitination, a main degradation pathway of GluA1 (100 ± 8.7 vs. 71.1 ± 6.1; P = 0.014). Conclusions: Isoflurane impairs hippocampal learning and modulates synaptic plasticity in the postanesthetic period. Increased GluA1 may reduce synaptic capacity for additional GluA1-containing AMPARs trafficking.

Background: It has been shown that γ-aminobutyric acid exerts excitatory actions on the immature brain due to the increased expression of Na+–K+–2Cl− cotransporter isoform 1. The authors sought to clarify whether midazolam, a γ-aminobutyric acid–mimetic hypnotic agent, causes neuronal excitation that can be blocked by bumetanide, a selective inhibitor of Na+–K+–2Cl− cotransporter isoform 1. Furthermore, the authors examined whether bumetanide potentiates the sedative effects of midazolam in neonatal rats. Methods: The authors measured the effects of midazolam with or without bumetanide on the cytosolic Ca2+ concentration ([Ca]2+i) in hippocampal slices (n = 3 in each condition) from rats at postnatal days 4, 7, and 28 (P4, P7, and P28) using fura-2 microfluorometry. Neuronal activity in the hippocampus and thalamus after intraperitoneal administration of midazolam with or without bumetanide was estimated by immunostaining of phosphorylated cyclic adenosine monophosphate–response element–binding protein (n = 12 in each condition). Furthermore, the authors assessed effects of bumetanide on the sedative effect of midazolam by measuring righting reflex latency (n = 6 in each condition). Results: Midazolam significantly increased [Ca]2+i in the CA3 area at P4 and P7 but not at P28. Bumetanide inhibited midazolam-induced increase in [Ca]2+i. Midazolam significantly up-regulated phosphorylated cyclic adenosine monophosphate–response element–binding protein expression in a bumetanide-sensitive manner in the hippocampus at P7 but not P28. Bumetanide enhanced the sedative effects of midazolam in P4 and P7 but not P28 rats. Conclusion: These results suggest that γ-aminobutyric acid A receptor–mediated excitation plays an important role in attenuated sedative effects of midazolam in immature rats.

The King Vision laryngoscope is a newly developed video laryngoscope. We conducted a simulation study to evaluate the efficacy of the King Vision in novice personnel. Thirty-one registered nurses with no previous experience with tracheal intubation were enrolled. Participants made 6 consecutive attempts at intubation of the manikin’s trachea with a Macintosh laryngoscope (MAC) and the King Vision with channeled blade (KVC) and non-channeled blade (KVNC) in a randomized cross-over fashion. The Grading Scale of Intubation Difficulty (GSID) was rated on a 5-point scale. Overall median (range) intubation times (sec) were 16.9 (8.0–60.0) with the MAC, 20.5 (7.2–60.0) with the KVC, and 60.0 (11.0–60.0) with the KVNC. The KVNC required significantly longer intubation time compared with the MAC or the KVC (p

Background. It has been shown that the R(‐) isomer of 1-methyl-5-phenyl-5-propyl barbituric acid (MPPB) induces loss of the righting reflex (LRR), while S(+)-MPPB causes pure excitatory effects, including convulsions, in vivo. Methods. We studied the effects of the depressant and convulsant MPPB stereoisomers on rat hippocampal acetylcholine (ACh) release in vivo, using a brain microdialysis technique in freely moving animals. Results. R(‐)-MPPB 60 and 90 mg kg ‐1 i.p. decreased ACh release from the rat hippocampus by 44.1 (8.2)% and 60.8 (8.2)%, respectively. In the hippocampus, the local application of bicuculline, a g-aminobutyric acid (GABA)A receptor antagonist, 1 mmol litre ‐1 antagonized the inhibitory effects of R(‐)-MPPB 90 mg kg ‐1 i.p. In contrast, R(‐)-MPPB, S(+)-MPPB 60 and 90 mg kg ‐1 i.p. increased ACh release to 151.8 (6.8)% and 169.6 (11.1)% of the basal release, respectively. Conclusions. Our results demonstrated that R(‐)-MPPB decreased, while S(+)-MPPB increased, rat hippocampal ACh release and that the inhibitory effects of R(‐)-MPPB may involve the GABAA receptor in vivo. These data imply that changes in hippocampal ACh due to these agents may be related to their central inhibitory and stimulatory actions in vivo.

We report a case of SAPHO syndrome accompanying progressive osteoarthritis. In this 43-year-old woman, difficult intubation was expected due to unilateral hyperostosis of the mandible and spinal degeneration. As far as we know, anesthetic management of this disease has not been reported. Therefore we made an anesthetic plan based on spinal degenerative disease which was considered to have similar problems of intubation and the case was managed without problems. As this syndrome is a progressive disorder, careful perioperative management is required each time.

We report a case of a 35-year-old woman with myotonic dystrophy and severe obesity of BMI 43.3 who showed persistent apnea at emergence after ovarian resection. The patient received an iv induction with minimum dose of propofol and vecuronium 3 mg. Anesthesia was maintained with propofol, 50% nitrous oxide and 50% oxygen mixture and epidural anesthesia. Additional vecuronium 0.5 mg was administered twice. Surgery was performed uneventfully within 130 minutes and iv propofol was discontinued. The patient awoke promptly after termination of nitrous oxide but no spontaneous breathing appeared with end-tidal CO2 of 60 mmHg. Because she could obey the order to breathe, the endotracheal tube was removed 40 minutes after discontinuation of propofol. Spontaneous breathing at the rate of 17 x min(-1) started soon after extubation. We assume that this apnea was caused by breath holding. Whether this breath holding is specific to myotonic dystrophy or not, anesthesia for patients with this disease requires careful attention for perioperative respiratory management.

Background. The aim of this study was to examine ethanol-consumption-related changes in the effects of propofol on rat hippocampal acetylcholine (ACh) release. Methods. Male Sprague–Dawley rats received a solution of ethanol (20% v/v) for 24 weeks while controls received tap water. The effects of propofol were examined by in vivo microdialysis, with ACh release from the hippocampal regions determined by high-performance liquid chromatography with electrochemical detection (HPLC–ECD). Results. Propofol 50 mg kg−1 i.p. significantly decreased basal hippocampal ACh release in ethanol-treated and control rats by 50.4 ( sem 4.7)% and 38.3 (11.1)%, respectively. Propofol 100 mg kg−1 i.p. significantly decreased basal hippocampal ACh release in ethanol-treated and control rats by 67.5 (3.7)% and 55.9 (7.4)%, respectively. The reduction in hippocampal ACh release induced by 50 or 100 mg kg−1 i.p. propofol was not significantly different between ethanol-treated and control rats. There was no significant difference in the duration of sleep between the two groups. Conclusions. These results demonstrate that chronic ethanol consumption does not augment the inhibitory actions of propofol on rat hippocampal ACh release. These findings appear to be inconsistent with the notion that chronic ethanol intake enhances the propofol-induced inhibition of the hippocampal cholinergic system and related mental dysfunction.

For decades, a chronic shortage of anesthesiologists in Japan has been a serious problem. According to a personal survey conducted from 2002 to 2006 by Koichi Tsuzaki, MD (Associate Professor of Anesthesiology, Keio University School of Medicine, Tokyo Japan), more than one million surgical procedures required general anesthesia while only 6207 qualified anesthesiologists were available. The annual procedure volume per anesthesiologist ranges from 174 to 209 in Japan (Table 1; these data were obtained from our written communication with Dr Tzuzaki on December 20, 2008). However, anesthesiologist manpower is much less than this. The actual number of surgeries requiring general anesthesia was underestimated by this survey, which did not collect data from all Japanese medical institutions. Moreover, the Japanese Society of Anesthesiologists (JSA) reported that over 30% of general anesthetic practices are provided by surgeons, and not by anesthesiology specialists.1 While the shortage of surgeons has recently emerged as a critical issue, this crisis jeopardizes the already depleted manpower for anesthetic practice. In Japan, only medical doctors (MDs) are allowed to administer general, spinal, and epidural anesthesia and nerve blocks. Therefore, it has been suggested that non-MDs should be trained to administer anesthesia. These non-MDs include both nurses and dental anesthetists (dentists who administer general anesthesia in orofacial and dental surgeries). The Ministry of Health, Labor and Welfare in Japan has proposed the introduction of a nurse anesthetist. Critical debate has been ongoing but the proposal remains controversial.2 The JSA strongly opposes this idea, insisting that anesthesia is a medical practice and has to be performed by well-trained MDs. Moreover, the JSA argues that the lack of governmental resources hinders the establishment of the alternative pathway of educating a registered nurse into becoming a qualified nurse anesthetist because it will necessitate additional manpower and cost. We believe that we have to refuse a system such as that of the Certified Registered Nurse Anesthetists in the United States, where nurse anesthetists can administer anesthesia without supervision by MD anesthesiologists. The Japanese Association of Critical Debate on Establishing a Scheme for Nurse Anesthetists in Japan