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We report two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. Case 1: A 74-year-old male was scheduled for debridement and skin grafting for a severe burn injury. We induced anesthesia with 4 mg of remimazolam and 20 mg of ketamine. The patient subsequently developed treatment-resistant severe hypotension. Case 2: A 59-year-old male was scheduled for laparoscopic-assisted sigmoid colectomy. We induced anesthesia with 9 mg of remimazolam. Within a few minutes, the patient developed treatment-resistant severe hypotension. As serum tryptase was elevated in both cases and only intravenous administration of adrenaline was effective, we considered the circulatory collapse might be due to anaphylaxis. We experienced two cases of circulatory collapse due to suspected remimazolam anaphylaxis during anesthetic induction. The prevalence of remimazolam anaphylaxis is not yet known, and further research is needed.",{"EN":132},"Two cases of circulatory collapse due to suspected remimazolam anaphylaxis",{"VOID":134},"[\"8328037100159506248\"]",{"VOID":136},"Masui K. Remimazolam besilate, a benzodiazepine, has been approved for general anesthesia!! J Anesth. 2020;34:479–82.\nDoi M, Morita K, Takeda J, Sakamoto A, Yamakage M, Suzuki T. Efficacy and safety of remimazolam versus propofol for general anesthesia: a multicenter, single-blind, randomized, parallel-group, phase IIb\u002FIII trial. J Anesth. 2020;34:543-53.\nDoi M, Hirata N, Suzuki T, Morisaki H, Morimatsu H, Sakamoto A. Safety and efficacy of remimazolam in induction and maintenance of general anesthesia in high-risk surgical patients (ASA Class III): results of a multicenter, randomized, double-blind, parallel-group comparative trial. J Anesth. 2020;34:491-501.\nTsurumi K, Takahashi S, Hiramoto Y, Nagumo K, Takazawa T, Kamiyama Y. Remimazolam anaphylaxis during anesthesia induction. J Anesth. 2021;35:571–5.\nMertes P, Demoly P, Malinovsky J. Hypersensitivity reactions in the anesthesia setting\u002Fallergic reactions to anesthetics. Curr Opin Allergy Clin Immunol. 2012;12:361–8.\nNevis IF, Binkley K, Kabali C. Diagnostic accuracy of skin-prick testing for allergic rhinitis: a systematic review and meta-analysis. Allergy Asthma Clin Immunol. 2016;12:20.\nGarvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R, et al. Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations. Br J Anaesth. 2019;123:e50–64.\nTakazawa T, Yamaura K, Hara T, Yorozu T, Mitsuhata H, Morimatsu H. Working Group for the Preparation of Practical Guidelines for the Response to Anaphylaxis, Safety Committee of the Japanese Society of Anesthesiologists. Practical guidelines for the response to perioperative anaphylaxis. J Anesth. 2021;35:778–93.\nVitte J, Amadei L, Gouitaa M, Mezouar S, Zieleskiewicz L, Albanese J, et al. Paired acute-baseline serum tryptase levels in perioperative anaphylaxis: An observational study. Allergy. 2019;74:1157–65.\nLjungström KG, Renck H, Strandberg K, Hedin H, Richter W, Widerlöv E. Adverse reactions to dextran in Sweden 1970-1979. Acta Chir Scand. 1983;149:253–62.\nHedin H, Richter W. Pathomechanisms of dextran-induced anaphylactoid\u002Fanaphylactic reactions in man. Int Arch Allergy Appl Immunol. 1982;68:122–6.\nShiratori T, Sato A, Fukuzawa M, Kondo N, Tanno S. Severe Dextran-Induced Anaphylactic Shock during Induction of Hypertension-Hypervolemia-Hemodilution Therapy following Subarachnoid Hemorrhage. Case Rep Crit Care. 2015;2015:967560.\nHarper NJ, Dixon T, Dugué P, Edgar DM, Fay A, Gooi HC, et al. Working Party of the Association of Anaesthetists of Great Britain and Ireland. Suspected anaphylactic reactions associated with anaesthesia. 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anterior mediastinal tumor (GAMT) resection is a challenging procedure, for which anesthesiologist might take to need special precautions. A 48-year-old male patient had been scheduled to undergo GAMT resection and superior vena cava (SVC) replacement. The tumor spread surrounding SVC and left main bronchus (LMB), resulting in small volume of his left lung. A soft left-sided double lumen tube (DLT) was selected to keep the patency of LMB during left one lung ventilation (OLV) against the tumor weight. Semi-awake intubation with spontaneous breathing was selected for DLT insertion to avoid lower airway occlusion. During left OLV after right open thoracotomy, his SPO2 decreased below to 90%. We performed selective right upper lobe bronchial blockade using the combination of DLT and bronchial blocker. The surgery was successfully completed with this strategy. Although such cases are rare, they are informative for anesthesiologists, providing optional strategies.",{"EN":270},"Specific airway management for SVC replacement during giant anterior mediastinal tumor resection",{"VOID":272},"[]",{"VOID":274},"Hartigan PM, Ng JM, Gill RR. Anesthesia in a patient with a large mediastinal mass. N Engl J Med. 2018;379:587–8.\nInoue M, Minami M, Shiono H, Miyoshi S, Takeda S, Ohta M, et al. Efficient clinical application of percutaneous cardiopulmonary support for perioperative management of a huge anterior mediastinal tumor. J Thorac Cardiovasc Surg. 2006;131:755–6.\nKarzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology. 2009;110:1402–11.\nEl-Tahan M, John Doyle D, Hassieb A. High-frequency jet ventilation using the Arndt bronchial blocker for refractory hypoxemia during one-lung ventilation in a myasthenic patient with asthma. J Clin Anesth. 2014;26:570–3.\nNakatsuka M, Wetstein L, Keenan RL. Unilateral high-frequency jet ventilation during one-lung ventilation for thoracotomy. 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Klippel-Trenaunay-Weber syndrome. Cutis. 1997;60:127–32.","https:\u002F\u002Flink.springer.com\u002F10.1007\u002Fs10440-022-00541-7",{"doi":731},"10.1007\u002Fs10440-022-00541-7",{"id":727,"text":733,"url":729,"identifiers":734},"Alwalid O, Makamure J, Cheng QG, Wu WJ, Yang C, Samran E, et al. Radiological aspect of Klippel-Trénaunay syndrome: a case series with review of literature. Curr Med Sci. 2018;38:925–31.",{"doi":731},{"id":18,"text":736,"url":18,"identifiers":737},"Barbara DW, Wilson JL. Anesthesia for surgery related to the Klippel-Trenaunay syndrome: a review of 136 anesthetics. Anesth Analg. 2011;113:98–102.",{},{"id":739,"text":740,"url":741,"identifiers":742},"418aa8bb-2fcb-4ecd-b176-1775ae409c9c","Tanaka Y, Sakamoto SI, Bito H, Sakamoto A. Anaesthetic management of an abdominal aortic aneurysmorrhaphy in Klippel-Trenaunay-Weber syndrome: a case report. 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Br J Anaesth. 2010;104:175–82.",{"doi":731},{"id":18,"text":766,"url":18,"identifiers":767},"Isono S. Obstructive sleep apnea of obese adults: pathophysiology and perioperative airway management. Anesthesiology. 2009;110:908–21.",{},{"id":769,"text":770,"url":771,"identifiers":772},"31195520-dfa9-4710-a9b4-bae8263c4fa9","Dobbs P, Caunt A, Alderson TJ. Epidural analgesia in an obstetric patient with Klippel-Trenaunay syndrome. Br J Anaesth. 1999;82:144–6.","https:\u002F\u002Fwww.sciencedirect.com\u002Fscience\u002Farticle\u002Fpii\u002FS0007091217394461",{"doi":773},"10.1093\u002Fbja\u002F82.1.144",{"id":18,"text":775,"url":18,"identifiers":776},"Pereda Marín RM, GarcíaCollada JC, Garrote Martínez AI, Miralles Serrano EM, Morales Aguilar JL. Anesthetic management of Klippel-Trénaunay syndrome and attendant gastrointestinal hemorrhage. A case report. 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There is no established method for monitoring brain function during cerebral congestion. We encountered a case of cerebral congestion caused by unexpected SVC clamping. A 64-year-old man underwent SVC clamping during lung tumor resection. The entropy and electroencephalogram monitoring values decreased with SVC clamping and increased in response to the release of congestion by phlebotomy and SVC declamping. Because entropy sharply reflects brain viability during cerebral congestion, it was considered helpful in evaluation of the monitoring of cerebral congestion.",{"EN":787},"Electroencephalogram evaluation of accidental cerebral congestion during unexpected superior vena cava clamping: a case report",{"VOID":789},"[\"11150861720106521124\"]",{"VOID":791},"Wuethrich PY, Ris HB, Magnusson L. Accidental cross-clamping of the superior vena cava: management and BIS evolution. J Clin Anesth. 2010;22:139–42.\nUrayama H, Kawase Y, Ohtake H, et al. Physiological changes during acute obstruction of the superior vena cava, azygos, and internal thoracic veins in dogs. J Cardiovasc Surg. 1997;38:87–92.\nMasuda H, Ogata T, Kikuchi K. Physiological changes during temporary occlusion of the superior vena cava in cynomolgus monkeys. Ann Thorac Surg. 1989;47:890–6.\nDartevelle P, Macchiarini P, Chapelier A. Technique of superior vena cava resection and reconstruction. Chest Surg Clin N Am. 1995;5:345–58.\nSpaggiari L, Thomas P, Magdeleinat P, et al. Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: long-term results of a multicentric study. Eur J Cardiothorac Surg. 2002;21:1080–6.\nGoh MS, Chellappa V. Acute, unanticipated, and prolonged superior vena cava occlusion during pneumonectomy. J Clin Anesth. 2016;35:78–84.\nBennett C, Voss LJ, Barnard JPM, Sleigh JW. Practical use of the raw electroencephalogram waveform during general anesthesia: the art and science. Anesth Analg. 2009;109:539–50.\nHughes J, John E. Conventional and quantitative electroencephalography in psychiatry. 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We report a case of an infant who experienced fentanyl-induced anaphylaxis. A 2-month-old male was scheduled to undergo a Blalock-Taussig shunt. Following uneventful anesthetic induction, he experienced profound hypotension and generalized erythema. Anaphylaxis was clinically diagnosed, and he was treated with epinephrine, vasopressin, and fluids. The surgery was canceled, and he was transferred to the intensive care unit after restoration of his hemodynamic status. Intradermal testing was performed for all of the drugs given during the anaphylactic event on postoperative day (POD) 3. The results showed a positive reaction to fentanyl. For the second anesthesia scheduled on POD 5, morphine sulfate was selected as an alternative opioid. Anesthesia was maintained uneventfully with sevoflurane, morphine, and rocuronium. Intradermal testing revealed fentanyl anaphylaxis. We were able to manage the patient by using of morphine as an alternative opioid for the subsequent anesthesia.",{"EN":939},"Fentanyl-associated anaphylaxis in an infant with tetralogy of Fallot: a case report",{"VOID":941},"[\"11123794628951277640\"]",{"VOID":943},"Study of anesthesia-related critical incidents by the Japanese Society of Anesthesiologists 2004–2008 (in Japanese). 2010. https:\u002F\u002Fnsas.anesth.or.jp\u002FApp\u002FDatura\u002Fpdf\u002Finvestigation-3_1.pdf. Accessed 10 Feb 2019.\nMertes PM, Alla F, Tréchot P, Auroy Y, Jougla E. Anaphylaxis during anesthesia in France: an 8-year national survey. J Allergy Clin Immunol. 2011;128:366–73.\nMertes PM, Laxenaire MC, Leinhart A, Aberer W, Ring J, Pichler WJ, et al. Reducing the risk of anaphylaxis during anaesthesia: guidelines for clinical practice. J Invest Allergol Clin Immunol. 2005;15:91–101.\nMeters PM, Laxenaire MC, Alla F. Anaphylaxic and anaphylactoid reactions occurring during anesthesia in France in 1999-2000. Anesthesiology. 2003;99:536–45.\nBrockow K, Garvey LH, Aberer W, Atanaskovic-Markovic M, Barbaud A, Bilo MB, et al. Skin test concentrations for systemically administered drugs – an ENDA\u002FEAACI drug allergy interest group. Allergy. 2013;68:702–12.\nDewachter P, Mouton-Faivre C, Emala CW. Anaphylaxis and anesthesia: controversies and new insights. Anesthesiology. 2009;111:1141–50.\nCampbell RL, Hagan JB, Manivannan V, Decker WW, Kanthala AR, Bellolio MF, et al. Evaluation of National Institute of Allergy and Infectious Diseases\u002FFood Allergy and Anaphylaxis Network criteria for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol. 2012;129:748–52.\nMertes PM, Tajima K, Regnier-Kimmoun MA, Lambert M, Iohom G, Gueant-Rodriguez RM, Malinovsky JM. Perioperative anaphylaxis. Med Clin N Am. 2010;94:761–89.\nMontañez MI, Mayorga C, Bogas G, Barrioneuvo E, Fernandez-Santamaria R, Martin-Serrano A, et al. Epidemiology, mechanisms, and diagnosis of drug-induced anaphylaxis. Front Immunol. 2017;8:614.\nDewachter P, Mouton-Faivre C. Patients who experience a perioperative anaphylactic reaction should not be skin-tested too early. Can J Anesth. 2007;54(9).\nHepner DL, Castells C. Anaphylaxis during the perioperative period. Anesth Analg. 2003;97:1381–95.\nLiccardi G, D’Amato G, Canonica GW, Salzillo A, Piccolo A, Passalacqua G. Systemic reactions fro skin testing: literature review. 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Inherited disorders of the neuromuscular junction. Int Anesthesiol Clin. 2006;44:91–106. https:\u002F\u002Fdoi.org\u002F10.1097\u002F00004311-200604420-00006.\nEmura M, Ishii H, Baba H. Anesthetic management of scoliosis surgery for a patient with congenital myasthenic syndrome (in Japanese with English abstract). Masui Jpn J Anesthesiol. 2014;63:911–4.\nCalişkan E, Koçum A, Sener M, Bozdoğan N, Ariboğan A. Caudal epidural anesthesia for a 2-year old child with congenital myasthenia gravis. Agri. 2008;20:49–52.\nMcBeth C, Watkins TG. Isoflurane for sedation in a case of congenital myasthenia gravis. Br J Anaesth. 1996;77:672–4. https:\u002F\u002Fdoi.org\u002F10.1093\u002Fbja\u002F77.5.672.\nChoi EK, Kwon N, Park SJ. Comparison of the effects of oxycodone versus fentanyl on airway reflex to tracheal extubation and postoperative pain during anesthesia recovery after laparoscopic cholecystectomy: a double-blind, randomized clinical consort study. 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encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a mitochondrial disease. We report here the safe use of remimazolam in a pediatric MELAS patient. A 10-year-old girl (118 cm, 16 kg) was scheduled for an open gastrostomy to improve nutrition and epileptic seizure control. We induced and maintained general anesthesia with remimazolam, remifentanil, fentanyl, and rocuronium. We also performed a bilateral subcostal transversus abdominis plane block before the surgery. The surgery finished uneventfully. After we discontinued remimazolam administration, the patient woke up immediately but calmly without flumazenil. Epileptic seizures did not occur during intra- and early post-operative periods. Remimazolam enabled us to provide a pediatric MELAS patient with general anesthesia without causing delayed emergence or epileptic seizures.",{"EN":1452},"General anesthesia with remimazolam for a pediatric patient with MELAS and recurrent epilepsy: a case report",{"VOID":1454},"Majamaa K, Moilanen JS, Uimonen S, Remes AM, Salmela PI, Kärppä M, et al. Epidemiology of A3243G, the mutation for mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes: prevalence of the mutation in an adult population. Am J Hum Genet. 1998;63:447–54. https:\u002F\u002Fdoi.org\u002F10.1086\u002F301959.\nUusimaa J, Moilanen JS, Vainionpää L, Tapanainen P, Lindholm P, Nuutinen M, et al. Prevalence, segregation, and phenotype of the mitochondrial DNA 3243A>G mutation in children. Ann Neurol. 2007;62:278–87. https:\u002F\u002Fdoi.org\u002F10.1002\u002Fana.21196.\nFricker RM, Raffelsberger T, Rauch-Shorny S, Finsterer J, Müller-Reible C, Gilly H, et al. Positive malignant hyperthermia susceptibility in vitro test in a patient with mitochondrial myopathy and myoadenylate deaminase deficiency. Anesthesiology. 2002;97:1635–7. https:\u002F\u002Fdoi.org\u002F10.1097\u002F00000542-200212000-00044.\nNelson JH, Kaplan RF. Anesthetic management of two pediatric patients with concurrent diagnoses of mitochondrial disease and malignant hyperthermia susceptibility: A case report. A A Case Rep. 2017;9:204–6. https:\u002F\u002Fdoi.org\u002F10.1213\u002FXAA.0000000000000565.\nKam PC, Cardone D. Propofol infusion syndrome. Anaesthesia. 2007;62:690–701. https:\u002F\u002Fdoi.org\u002F10.1111\u002Fj.1365-2044.2007.05055.x.\nPerks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. Br J Anaesth. 2012;108:562–71. https:\u002F\u002Fdoi.org\u002F10.1093\u002Fbja\u002Faes027.\nWesolowski AM, Zaccagnino MP, Malapero RJ, Kaye AD, Urman RD. Remimazolam: pharmacologic considerations and clinical role in anesthesiology. Pharmacotherapy. 2016;36:1021–7. https:\u002F\u002Fdoi.org\u002F10.1002\u002Fphar.1806.\nSneyd JR, Rigby-Jones AE. Remimazolam for anaesthesia or sedation. Curr Opin Anaesthesiol. 2020;33:506–11. https:\u002F\u002Fdoi.org\u002F10.1097\u002Faco.0000000000000877.\nShioji N, Everett T, Suzuki Y, Aoyama K. Pediatric sedation using dexmedetomidine and remimazolam for magnetic resonance imaging. J Anesth. 2022;36:1–4. https:\u002F\u002Fdoi.org\u002F10.1007\u002Fs00540-021-02957-1.\nRiley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: explanation and elaboration document. J Clin Epidemiol. 2017;89:218–35. https:\u002F\u002Fdoi.org\u002F10.1016\u002Fj.jclinepi.2017.04.026.\nRafique MB, Cameron SD, Khan Q, Biliciler S, Zubair S. Anesthesia for children with mitochondrial disorders: a national survey and review. J Anesth. 2013;27:186–91. https:\u002F\u002Fdoi.org\u002F10.1007\u002Fs00540-012-1488-1.\nBrogden RN, Goa KL. Flumazenil. A reappraisal of its pharmacological properties and therapeutic efficacy as a benzodiazepine antagonist. Drugs. 1991;42:1061–89. https:\u002F\u002Fdoi.org\u002F10.2165\u002F00003495-199142060-00010.\nFootitt EJ, Sinha MD, Raiman JA, Dhawan A, Moganasundram S, Champion MP. Mitochondrial disorders and general anaesthesia: a case series and review. Br J Anaesth. 2008;100:436–41. https:\u002F\u002Fdoi.org\u002F10.1093\u002Fbja\u002Faen014.\nMiyamoto Y, Miyashita T, Takaki S, Goto T. Perioperative considerations in adult mitochondrial disease: a case series and a review of 111 cases. Mitochondrion. 2016;26:26–32. https:\u002F\u002Fdoi.org\u002F10.1016\u002Fj.mito.2015.11.004.\nSasaki H, Hoshijima H, Mizuta K. Ringer’s acetate solution-induced precipitation of remimazolam. Br J Anaesth. 2021;126:e87–9. https:\u002F\u002Fdoi.org\u002F10.1016\u002Fj.bja.2020.11.021.\nHashimoto K, Sasaki T, Hachiya T, Onoguchi K, Takakura H, Oshiumi M, et al. Superior hepatic mitochondrial oxidation-reduction state in normothermic cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2001;121:1179–86. https:\u002F\u002Fdoi.org\u002F10.1067\u002Fmtc.2001.113599.\nFinsterer J, Stratil U, Bittner R, Sporn P. Increased sensitivity to rocuronium and atracurium in mitochondrial myopathy. Can J Anaesth. 1998;45:781–4. https:\u002F\u002Fdoi.org\u002F10.1007\u002FBF03012149.\nYamamoto T, Kurabe M, Kamiya Y. Re-sleeping after reversal of remimazolam by flumazenil. J Anesth. 2021;35:322. https:\u002F\u002Fdoi.org\u002F10.1007\u002Fs00540-021-02915-x.\nGodai K. What are mechanisms of re-sedation caused by remimazolam? J Anesth. 2021;35:466. https:\u002F\u002Fdoi.org\u002F10.1007\u002Fs00540-021-02926-8.\nYamamoto T, Kurabe M, Kamiya Y. A mechanism of re-sedation caused by remimazolam. J Anesth. 2021;35:467–8. https:\u002F\u002Fdoi.org\u002F10.1007\u002Fs00540-021-02930-y.\nCantineau JP, Porte F, d’Honneur G, Duvaldestin P. Neuromuscular effects of rocuronium on the diaphragm and adductor pollicis muscles in anesthetized patients. Anesthesiology. 1994;81:585–90. https:\u002F\u002Fdoi.org\u002F10.1097\u002F00000542-199409000-00010.\nSuzuki Y, Doi M, Nakajima Y. General anesthesia with remimazolam in a patient with mitochondrial encephalomyopathy: a case report. JA Clin Rep. 2021;7:51. https:\u002F\u002Fdoi.org\u002F10.1186\u002Fs40981-021-00454-8.\nKitaura A, Kosumi R, Iwamoto T, Nakao S. Remimazolam anesthesia for transcatheter mitral valve repair in a patient with mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) syndrome: a case report. 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