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Introduction Continuous extracorporeal perfusion (ECP), or machine perfusion, holds promise for prolonged skeletal muscle preservation in limb ischemia-reperfusion injury. This study aimed to extend the amputation-to-replantation time window from currently 6 hours to 33 hours using a 24-hour ECP approach. Materials and Methods Six large white pigs underwent surgical forelimb amputation under general anesthesia. After amputation, limbs were kept for 9 hours at room temperature and then perfused by 24-hour ECP with a modified histidine-tryptophan-ketoglutarate (HTK) solution. After ECP, limbs were orthotopically replanted and perfused in vivo for 12 hours. Clinical data, blood, and tissue samples were collected and analyzed. Results All 6 forelimbs could be successfully replanted and in vivo reperfused for 12 hours after 9 hours of room temperature ischemia followed by 24 hours ECP. Adequate limb perfusion was observed after replantation as shown by thermography and laser Doppler imaging. All pigs survived without severe organ failure, and no significant increase in inflammatory cytokines was found. Macroscopy and histology showed marked interstitial muscular edema of the limbs, whereas myofiber necrosis was not evident, implying the preservation of muscular integrity. Conclusions The use of a 24-hour ECP has successfully extended limb preservation to 33 hours. The modified histidine-tryptophan-ketoglutarate perfusate demonstrated its ability for muscle protection. This innovative approach not only facilitates limb replantation after combat injuries, surmounting geographical barriers, but also broadens the prospects for well-matched limb allotransplants across countries and continents. [ABSTRACT FROM AUTHOR]

Background: There is no consensus regarding the choice of anesthetic method for patients with pulmonary hypertension (PH). We report two cases in which neuraxial anesthesia was safely performed without general anesthesia during open abdominal surgery in patients with severe PH. Case presentation: Case 1: A 59-year-old woman had an atrial septal defect and a huge abdominal tumor with a mean pulmonary arterial pressure (PAP) of 39 mmHg and pulmonary vascular resistance (PVR) of 3.5 Wood units. Case 2: A 23-year-old woman who had hereditary pulmonary artery hypertension (mean PAP, 65 mmHg; PVR, 16.45 Wood units). Both patients underwent open abdominal surgery under neuraxial anesthesia without circulatory collapse with intraoperative administration of vasoconstrictors. Conclusion: Although anesthetic care must be personalized depending on the pathology and severity of PH, neuraxial anesthesia may be an option for patients with severe PH undergoing abdominal surgery. [ABSTRACT FROM AUTHOR]

Background Quality of life (QoL) may be affected due to various reasons such as low back or leg pains with accompanying neurologic problems. Lumbar disk surgery is one of the most common performed surgeries to relieve those symptoms. Various anesthetic techniques can be used safely to perform lumbar disk surgeries. Properties that make an anesthetic technique good are mainly the quick onset and returning of the effects. This large retrospective study with patients who have undergone lumbar disk surgery under spinal anesthesia aims to evaluate the perioperative and postoperative parameters of the spinal anesthesia and review the literature. Methods Cases operated under spinal anesthesia between January 2017 and December 2020 were investigated, and 617 patients who underwent simple lumbar disk surgery were included in the study. Demographic characteristics and American Society of Anesthesiologists (ASA) physical status of the patients were recorded. Visual analog scale (VAS) and QoLscores were obtained before and after the operation. Results There were 282 (45.7%) male and 335 (54.3%) female patients with a mean age of 39.48 ± 16.71 years (range: 18–58 years) at symptom onset. The mean operating time was 46.3 minutes (range: 22–68 minutes). Average blood loss was 85 mL (range: 55–125 mL). All the patients were mobilized 6 to 12 hours after surgery. In our patient group, there were both high- and normal-risk groups in terms of the ASA physical status. During the clinical follow-up, a statistically significant improvement was found for the VAS and QoL scores (p < 0.05). Conclusions In this large retrospective study, our results have confirmed that spinal anesthesia is at least comparable to general anesthesia and even superior to it in some aspects. [ABSTRACT FROM AUTHOR]

In recent years the still relatively new short-acting benzodiazepine remimazolam has been approved and clinically implemented in several countries and regions. Remimazolam is also now approved in the EU and the market launch in Germany is expected in the not too distant future. This is therefore a good point in time to summarize the current evidence for various areas of application, including general anesthesia, sedation and intensive care medicine as well as different dosing schemes. [ABSTRACT FROM AUTHOR]

It remains unclear whether dosage adjustment of intravenous lidocaine is necessary during general anesthesia for elderly patients over 75 years old. This study aimed to investigate the effects of age on the pharmacokinetics (PK) and safety of intravenous lidocaine in patients undergoing general anesthesia. A total of 599 plasma samples were collected from 76 general anesthesia patients across three age groups: 18–64, 65–74, and ≥ 75 years. Lidocaine was administered intravenously at a dose of 1.5 mg/kg for the 18–64 and 65–74 years groups, while the dose was adjusted to 1.0 mg/kg for the ≥ 75 years group. The plasma concentrations of lidocaine and its active metabolites were measured using a validated ultra-performance liquid chromatography-tandem mass spectrometry assay, and the data were analyzed using a noncompartmental analysis. The results revealed no significant age-related differences in the PK of lidocaine and its metabolites. Among the three age groups, over 90 % of patient achieved a lidocaine concentration within a safe and effective range when the dosage was normalized to 1.5 mg/kg. In conclusion, age-based dosage adjustment was unnecessary for intravenous lidocaine in patients below 86 years undergoing general anesthesia. [ABSTRACT FROM AUTHOR]

Introduction: From a surgeon's perspective, appendicitis is treated with appendectomy and sometimes a normal appendix is removed. This study aimed to investigate the patients' perspectives on having surgery but not appendicitis and their involvement in treatment decisions. Methods: This study is reported according to the COnsolidated criteria for REporting Qualitative research (COREQ) guideline. Eligible participants either had a normal diagnostic laparoscopy with no resection of the appendix or a negative appendectomy confirmed by histopathology. Interviews were conducted using a semi-structured interview guide and transcribed verbatim. Data were analyzed using content analysis. Results: This study consisted of 15 interviews. Analysis of the interviews resulted in the formulation of four categories: (1) discovering the results of the histopathology report, (2) thoughts on having a normal appendix removed or left in situ, (3) the scarce use of shared decision-making, and (4) general anesthesia and the risk of a burst appendix made the participants nervous. Conclusion: The amount of information communicated to the patients before and after surgery was sparse. The participants were not aware of the histopathology results and the participants were not involved in decision-making and were generally anxious about anesthesia and a burst appendix. [ABSTRACT FROM AUTHOR]

The aim of this study was to assess factors associated with higher odds of undergoing repeat general anesthesia (GA2) for dental treatments. The authors studied children up to age 48 months of age enrolled in Medicaid who underwent dental treatment under first general anesthesia (GA1). The authors used a case-control design to compare children who had a GA2 within 48 months of GA1 (case patients) with those who did not (control patients). In total, 60 case patients were age and sex matched to 120 control patients. Mean (SD) age at GA1 was 38 (5.2) months for case participants and 40 (4.7) months for control participants (P =.08). Higher caries involvement of maxillary incisors (P =.04), and lower caries involvment of canines (P =.003), first molars (P =.012), and second molars (P <.001) at GA1 was associated with higher odds of occurrence of GA2. There was a significant inverse association between full-coverage restoration on canines (P =.003), first molars (P =.001), and second molars (P =.002) at GA1 and occurrence of GA2. There was a significant direct association between the use of composites or sealants on second molars in GA1 and occurrence of GA2 (P =.02). The number of extractions at GA1 was not associated significantly with the occurrence of GA2. The use of full-coverage restorations on primary molars and canines under general anesthesia (GA) was associated with lower odds of occurrence of GA2. Resin restorations and sealants on primary second molars were associated with higher odds of occurrence repeat GA. The findings support preferential use of full-coverage restorations for young children undergoing dental GA. Full-coverage restorations should be considered strongly for young children undergoing GA for dental treatments to reduce the risk of requiring GA2. [ABSTRACT FROM AUTHOR]

Background: Latin America comprises an extensive and diverse territory composed of 33 countries in the Caribbean, Central, and South America where Romance languages–languages derived from Latin are predominantly spoken. Economic disparities exist, with inequitable access to pediatric surgical care. The Latin American Surgical Outcomes Study in Pediatrics (LASOS‐Peds), a multi‐national collaboration, will determine safety of pediatric anesthesia and perioperative care. Objective: Below, we provide a descriptive initiative to share how pediatric anesthesia in Brazil, Chile, and Mexico operate. Theses descriptions do not represent all of Latin America. Descriptions and Conclusions: Brazil an upper middle‐income country, population 203 million, has a public system insufficiently resourced and a private system, resulting in inequitable safety and accessibility. Surgical complications constitute the third leading cause of mortality. Anesthesiology residency is 3 years, with required rotations in pediatric anesthesia; five hospitals offer pediatric anesthesia fellowships. Anesthesiology is a physician‐only practice. A Pediatric Anesthesia Committee within the Brazilian Society of Anesthesiology offers education through seasonal courses and workshops including pediatric advanced life support. Chile is a high‐income country, population 19.5 million, the majority cared for in the public system, the remainder in university, private, or military systems. Government efforts have gradually corrected the long‐standing anesthesiology shortage: twenty 3‐year residency programs prepare graduates for routine pediatric cases. The Chilean Society of Anesthesiology runs a 1‐month program for general anesthesiologists to enhance pediatric anesthesia skills. Pediatric anesthesia fellowship training occurs in Europe, USA, and Australia, or in two 2‐year Chilean university programs. Public health policies have increased the medical and surgical pediatric specialists and general anesthesiologists, but not pediatric anesthesiologists, which creates safety concerns for neonates, infants, and medically complex. Chile needs more pediatric anesthesia fellowship programs. Mexico, an upper middle‐income country, with a population of about 126 million, has a five‐sector healthcare system: public, social security for union workers, state for public employees, armed forces for the military, and a private "self‐pay." There are inequities in safety and accessibility for children. Pediatric Anesthesiology fellowship is 2 years, after 3 years residency. A shortage of pediatric anesthesiologists limits accessibility and safety for surgical care, driven by added training at low salary and hospital under appreciation. The Mexican Society of Pediatric Anesthesiology conducts refresher courses, workshops, and case conferences. Insufficient resources and culture limits research. [ABSTRACT FROM AUTHOR]

To evaluate the effect of body position on transesophageal atrial pacing (TEAP) in dogs. Prospective, experimental trial. A total of eight mixed-breed dogs, median body mass 25 kg (range 11–31 kg). TEAP was performed using a 6 Fr (2 mm) pacing catheter introduced transorally and positioned in the lower esophagus in left lateral recumbency. The catheter was withdrawn in 5 mm increments until successful TEAP. The minimum pacing threshold (MPT) was determined at each 5 mm increment until atrial capture could not be achieved at a maximal pulse amplitude of 40 mA. The zone of capture (ZOC) was the total distance over which TEAP was achieved. The same process was repeated in right lateral, ventral and dorsal recumbency. A linear mixed model was used to assess the impact of body position on TEAP and ZOC. TEAP was achieved in all body positions. There was significant random effect of individual dogs on ZOC (p = 0.048) but not on MPT (p = 0.109). MPT was 11.56 ± 8.65 mA (mean ± SD), 8.43 ± 2.29 mA, 10.63 ± 6.91 mA and 10 ± 7.44 mA for dorsal, left and right lateral, and ventral recumbency, respectively. ZOC was 5.12 ± 2.08 cm, 6.35 ± 2.41 cm, 5.94 ± 3.23 cm and 5.31 ± 2.2 cm for dorsal, left lateral and right lateral, and ventral recumbency, respectively. Neither ZOC (p = 0.363) nor MPT (p = 0.716) varied significantly between body positions. TEAP can be performed successfully in all body positions in dogs. Body position did not significantly influence MPT or ZOC values for TEAP. Further studies are needed to compare the efficacy of TEAP with the efficacy of standard pharmacological therapy for management of bradycardia during general anesthesia in dogs. [ABSTRACT FROM AUTHOR]

Background: The distribution and elimination of infused crystalloid fluid is known to be affected by general anesthesia, but it is unclear whether changes differ depending on whether the patient is operated in the flat recumbent position, the Trendelenburg ("legs up") position, or the reverse Trendelenburg ("head up") position. Methods: Retrospective data on hemodilution and urine output obtained during and after infusion of 1–2 L of Ringer's solution over 30–60 min were collected from 61 patients undergoing surgery under general anesthesia and 106 volunteers matched with respect to the infusion volume and infusion time. Parameters describing fluid distribution in the anesthetized and awake subjects were compared by population volume kinetic analysis. Results: General anesthesia decreased the rate constant for urine output by 79% (flat recumbent), 91% (legs up) and 91% (head up), suggesting that laparoscopic surgery per se intensified the already strong anesthesia‐induced fluid retention. General anesthesia also decreased the rate constant governing the return of the distributed fluid to the plasma by 32%, 15%, and 70%, respectively. These results agree with laboratory data showing a depressive effect of anesthetic drugs on lymphatic pumping, and further suggest that the "legs up" position facilitates lymphatic flow, whereas the "head up" position slows this flow. Both Trendelenburg positions increased swelling of the "third fluid space". Conclusions: General anesthesia caused retention of infused fluid with preferential distribution to the extravascular space. Both Trendelenburg positions had a modifying influence on the kinetic adaptations that agreed with the gravitational forces inflicted by tilting to body. [ABSTRACT FROM AUTHOR]

Background: The current evidence on the use of laryngeal mask airway (LMA) as an airway management technique for general anesthesia (GA) during atrial fibrillation (AF) catheter ablation (CA) is insufficient. This study aims to compare the feasibility, safety, and clinical benefits of LMA and endotracheal intubation (ETI) for airway management in AF CA. Methods: One hundred fifty-two consecutive patients with AF who underwent CA under GA were included and divided into two groups based on different airway management methods (66 in the LMA group, 86 in the ETI group). After propensity score matching, a final analysis cohort of 132 patients was obtained to compare procedural parameters, adverse events, and prognosis between the two groups. Results: The LMA group exhibited significantly shorter total procedural time (p = 0.039), anesthesia induction time (p = 0.015), and recovery time (p = 0.006) compared to the ETI group. The mean arterial pressure (MAP) and heart rate were significantly lower in the LMA group during extubation and 1-min post-extubation (p < 0.05). Furthermore, the LMA group demonstrated lower MAP levels during intubation (p = 0.029). The incidences of intraoperative hypotension (p = 0.017) and bradycardia (p = 0.032) were significantly lower in the LMA group. The incidences of delayed recovery or delirium (p = 0.027), laryngeal or airway injury (p = 0.016), cough or bucking (p = 0.001), and sore throat (p < 0.001) were significantly lower in the LMA group. There were no statistically significant differences in catheter stability parameters and sinus rhythm maintenance rates between the two groups (p > 0.05). Conclusion: LMA is feasible, safe, and effective in AF CA as an optimized airway management technique for GA. [ABSTRACT FROM AUTHOR]

Background: More than 60% children exhibit anxiety before undergoing an anesthetic‐surgical procedure, particularly among pre‐school paediatric patients. Oral midazolam can provide procedural sedation for children prior to anesthesia. However, extemporaneous solutions of midazolam are usually prepared from injectable drug solutions, leading to inconsistent efficacy due to variable preparation methods. Xiaoerjing® is the first commercially available oral formulation of midazolam for procedural sedation in children in China. Despite the recommended dosage range of 0.25–0.5 mg/kg, its effective dose is still largely unknown. Aim: To determine the 95% effective dose (ED95) of midazolam oral solution (Xiaoerjing®) for alleviating preoperative anxiety in children prior to mask induction of general anesthesia. Design: The study included 61 children between the ages of 1 and 6 years undergoing elective surgery under general anesthesia. The first patient received a single dose of 0.5 mg/kg midazolam oral solution, which was adjusted for subsequent patients using the biased coin design method based on their response to the previous dose. Doses were increased or decreased at the rate of 0.1 mg/kg. An effective response was defined as having a modified Ramsay sedation score ≥3a, separation anxiety score ≤2, and mask acceptance score ≤2 during inhalational anesthesia induction. Results: Fifty‐six children were included in the final analysis. Of those, sedation was successful in 50 patients, with a median separation time of 15 (IQR: 25) min. Midazolam oral solution has an ED95 of 0.8254 mg/kg (95% CI: 0.6915–0.8700 mg/kg) for relieving preoperative anxiety in children. No adverse events occurred following drug administration. Conclusion: Midazolam oral solution is a safe and effective medication for relieving preoperative anxiety in children. The ED95 of a single oral dose of midazolam oral solution is 0.8254 mg/kg (95% CI: 0.6915–0.8700 mg/kg). [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusions This quality improvement initiative is a continued pursuit to optimize outcomes by iteratively improving our opioid sparing anesthesia protocol for tonsillectomy with or without adenoidectomy at our pediatric ambulatory surgical center through data driven Plan‐Do‐Study‐Act cycles.From 1/2015 through 12/2023, our standardized tonsillectomy protocol underwent nine procedure‐specific perioperative Plan‐Do‐Study‐Act cycles, three procedure‐specific postoperative prescription Plan‐Do‐Study‐Act cycles, and four general ambulatory surgical center enhanced recovery Plan‐Do‐Study‐Act cycles. We analyzed data from the medical record using statistical process control charts. The primary outcome measure was the percent of patients requiring intravenous opioid in the post anesthesia care unit. Secondary outcomes included maximum post anesthesia care unit pain score, the percent of patients requiring treatment for nausea and/or vomiting in the post anesthesia care unit, and the number of postoperative opioid prescription dosages. Balancing measures were average post anesthesia care unit length of stay, percent of patients with prolonged Post Anesthesia Care Unit length of stay (>120 min), and 30‐day reoperation rate.A total of 5654 tonsillectomy with or without adenoidectomy cases were performed at our ambulatory surgical center from 2015 to 2023. The incidence of intravenous opioid administered in the post anesthesia care unit initially rose with opioid free anesthesia launch, but subsequently decreased below the target of 10%. Maximum post anesthesia care unit pain scores rose from mean 3.6 to 4.5, but subsequently returned to the baseline of 3.5, while the incidence of postoperative nausea and/or vomiting improved. The average post anesthesia care unit length of stay increased by 10 min with opioid free anesthesia; however, prolonged post anesthesia care unit stay and 30‐day reoperation rates were unchanged.The continued refinement of our opioid sparing anesthesia protocol has led to reduced perioperative and home opioid use, stable maximum post anesthesia care unit pain scores, and improved postoperative nausea and vomiting rates, with only a slight increase in mean post anesthesia care unit length of stay. [ABSTRACT FROM AUTHOR]

Purpose: Button battery nasal impactions pose serious risks due to complications and the need for prompt removal, yet research on interventions remains limited due to its rare occurrence. To delineate the clinical manifestations of nasal foreign bodies associated with button batteries and to explore treatment approaches focused on minimizing the reliance on general anesthesia and surgical interventions. Methods: This study focuses on 176 cases of children who received treatment for nasal cavity button battery impactions. It encompasses various factors including age, gender, battery location, impaction duration, methods of extraction, and associated complications. Results: The incidence of nasal button battery cases among nasal foreign body instances was 1.16%, with a majority being males (60.23%) aged 1–5 years (98.29%). Utilizing a specially designed nasal foreign body hook and following established treatment protocols enabled the successful outpatient management of the majority of cases. Only 12 cases (6.82%) necessitated removal under general anesthesia due to management challenges in an outpatient setting. Furthermore, our findings indicated no linear correlation between the duration of battery retention and the risk of nasal septal perforation, which was observed in 31 cases (17.61%). Conclusion: Nasal foreign bodies caused by button batteries in children demand urgent attention due to their potentially grave outcomes. Our research is directed towards enhancing diagnostic and therapeutic strategies to bolster the success rates of outpatient removal, curtail the duration of foreign body retention, and diminish the reliance on general anesthesia. [ABSTRACT FROM AUTHOR]

Background: Postoperative thirst is one of the most intense, common and easily ignored subjective discomforts in patients after gynecological surgery. This study aimed to investigate whether early oral hydration on demand in the postanesthesia care unit (PACU) after gynecological laparoscopy under general anesthesia can appease postoperative thirst and increase patient comfort. Methods: Participants were randomized into the intervention and control groups. Patients in the intervention group were allowed to achieve early oral hydration on demand in the PACU if they were evaluated as fully conscious, with stable vital signs, grade 5 muscle strength, and well-recovered cough and swallowing reflex. However, the total amount of water intake throughout the entire study should not exceed 0.5mL/kg. During the study, the frequency of water intake, the total amount of water intake and adverse events were accurately recorded. The control group was managed according to the routine procedures and began to drink water 2 h after anesthesia. The intensity of thirst and subjective comfort in patients were assessed using the visual analog scale (VAS) when they entered and left the PACU. Results: No statistically significant differences were identified in age, height, weight, body mass index, pre-operative fasting time, duration of surgery, intraoperative fluid intake, intraoperative blood loss, intraoperative urine volume, and thirst intensity and subjective comfort scores between the groups before intervention (P > 0.05). After intervention, the VAS score for thirst intensity in the intervention group significantly decreased (P < 0.05), and the VAS score for subjective comfort in the intervention group significantly increased (P < 0.05). No adverse events were detected in both groups during the entire study. Conclusion: Early oral hydration on demand in the PACU can safely and effectively relieve postoperative thirst in patients, and improve patient comfort after gynecological laparoscopy. Trial registration: This single-center, prospective, randomized controlled trial was registered at the Chinese Clinical Trial Center on April 27, 2023. The registration number of this study is ChiCTR2300070985. [ABSTRACT FROM AUTHOR]

Background/aim: The most commonly prescribed anti-seizures medications (ASMs) for the treatment of epilepsy are currently topiramate, zonisamide, lacosamide, carbamazepine and levetiracetam. The objective of this study was to examine the correlation between preoperative, intraoperative, and postoperative metabolic acidosis and the use of ASMs prior to craniotomy operations. Materials and methods: This retrospective cross-sectional study evaluated patients who underwent intracranial surgery with craniotomy under general anaesthesia between May 2020 and April 2023 and used ASMs. The patients were classified into four groups based on the pharmacological mechanisms of action of the ASMs administered before intracranial surgery (Group-I, zonisamide or topiramate; Group-II, lacosamide; Group-III, carbamazepine; Group-IV, levetiracetam). Metabolic acidosis severity was defined based on base excess (BE) levels: mild (-3 to -5), moderate (-5 to -10), and severe (below − 10). The study investigated the correlation between ASMs and the severity of metabolic acidosis in preoperative, intraoperative, and postoperative blood gas measurements. Results: Out of 35 patients, 24 patients underwent intracranial surgery and 11 patients underwent epilepsy surgery. There were statistically significant differences in the severity of metabolic acidosis between preoperative (p < 0.001), intraoperative (p < 0.001) and postoperative (p = 0.01) groups. The preoperative mean BE of group-I was − 4.7, which was statistically lower than that of group-III (p = 0.01) and group-IV (p < 0.001). Intraoperatively and postoperatively, group-I had a mean BE of -7.5 and − 3.2, respectively, which was statistically lower than that of groups II (p = 0.007; p = 0.04), III (p = 0.002; p = 0.03), and IV (p < 0.001; p = 0.009). There was no statistically significant difference in BE between groups II, III and IV at all three time points. Group I had the lowest BE at all three time points. Intraoperative bicarbonate was administered to all patients in group I, whereas no intraoperative bicarbonate was required in the other groups. In group I, 50% of patients required postoperative intensive care. Conclusion: The use of ASMs in patients undergoing surgery is important in terms of mortality and morbidity. Topirimat and zonisamide are ASMs that can cause preoperative, intraoperative and postoperative metabolic acidosis. Patients receiving topirimat or zonisamide are particularly susceptible to metabolic acidosis. Special care should be taken in the management of anaesthesia in patients receiving these drugs, and monitoring of the perioperative metabolic status is essential. [ABSTRACT FROM AUTHOR]

To date, endotracheal tube (ETT) remains the mainstream for preterm infants receiving general anesthesia. We aim to compare the perioperative respiratory adverse events between using supraglottic airway device (SAD) and ETT in former preterm infants receiving general anesthesia. Former preterm infants below 52 weeks of postmenstrual age scheduled for herniorrhaphy were randomized to receive SAD or ETT for general anesthesia. Infants with severe congenital cardiopulmonary disease, prolonged oxygen or mechanical ventilation dependence, and recent respiratory tract infection were excluded. Muscle relaxant agents and opioids were avoided in this study. 40 infants were assigned into SAD or ETT groups. Infants in the SAD group had a much lower rate of intraoperative desaturation than those in the ETT group (21.1% vs. 73.7%, p = 0.003). Incidences of other intraoperative and postoperative 24-h respiratory adverse events were similar between groups, including laryngospasm/bronchospasm, cough and stridor during anesthesia, and postoperative apnea, bradycardia, and supplemental oxygen use. All participants were extubated successfully in the operation room. SAD is recommended in former preterm infants receiving general anesthesia for herniorrhaphy in their early infancy as it much decreases the incidence of intraoperative desaturation compared to ETT. [ABSTRACT FROM AUTHOR]

Background: This study aimed to determine the 50% effective dose of remimazolam co-administered with remifentanil for loss of consciousness in men and women as well as to investigate whether there are between-sex differences. Methods: Using a modified Dixon's up-and-down allocation approach, we sequentially enrolled male and female patients aged 19–60 years with American Society of Anesthesiologists class I or II who were scheduled for robotic surgery. For both sexes, the starting remimazolam dose was 0.15 mg/kg, with a step size of 0.05 mg/kg. After achievement of a target effect-site concentration 2.0 ng/ml of remifentanil, and administration of a bolus dose of remimazolam, we assessed whether adequate loss of consciousness (defined as a Modified Observer's Assessment of Alertness/Sedation scale score < 2 within 2 min) was achieved. Results: We included 22 male and 22 female patients. Based on Dixon's up-and-down method, the 50% effective dose of remimazolam (mean ± standard error) was 0.13 ± 0.01 mg/kg and 0.17 ± 0.01 mg/kg in the male and female groups, respectively (P = 0.34). Isotonic regression analysis revealed that the 95% effective dose (95% confidence interval) was 0.19 (0.18–0.20) mg/kg in the male group and 0.29 (0.29–0.30) mg/kg in the female group. Conclusions: There was no between-sex difference in the 50% effective dose of remimazolam for loss of consciousness; however, the 95% effective dose was significantly higher in female patients than in male patients. Trial registration: This study protocol was registered at Clinical Research Information Service (CRIS No. KCT0007951, 02/12/2022). [ABSTRACT FROM AUTHOR]

Introduction: The fragile brain includes both the developing brain in childhood and the deteriorating brain in elderly. While the effects of general anesthesia on the myelin sheath of developing brain have been well-documented, limited research has explored its impact on degenerating brain in elderly individuals. Methods: In our study, aged marmosets in control group were only anesthetized with 6--8% sevoflurane and 100% oxygen (2 L/min) for 1--2 min for anesthesia induction. In addition to anesthesia induction, the anesthesia group was exposed to a clinical concentration of sevoflurane (1.5--2%) for 6 h to maintain anesthesia. After anesthesia, scanning electron microscopy (SEM) and artificial intelligence-assisted image analysis were utilized to observe the effects of general anesthesia on the myelin sheath in prefrontal cortex (PFC) of aged marmosets. Results: Compared with the control group, our findings revealed no evidence that 6 h of sevoflurane general anesthesia altered the thickness of myelin sheath, the diameter of myelinated axons, and the g-ratio in prefrontal cortex of aged marmosets. Conclusion: Clinical concentration of sevoflurane may have no short-term effect on the myelin sheath in prefrontal cortex of aged marmosets. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to describe the successful identification and treatment of severe hyperkalemia, cardiac arrhythmia, rhabdomyolysis, and acute kidney injury (AKI) in a domestic cat that underwent general anesthesia for abdominal exploratory surgery. The definitive underlying cause remains unknown; however, a reaction to propofol is suspected. Case summary: A 6-month-old intact male domestic short-hair cat underwent general anesthesia and developed severe intraoperative rhabdomyolysis, hyperkalemia, ventricular fibrillation, and AKI during surgery despite a documented mild hypokalemia and normal creatinine before inducing anesthesia. Propofol was administered as part of the anesthetic protocol. The patient was resuscitated successfully and responded well to advanced medical intervention. The hyperkalemia and AKI were resolved within less than 24 h from surgery and rhabdomyolysis was resolved at the time of recheck 5 days later. New or unique information provided: While previously suspected in dogs, to the authors' knowledge, propofol-related infusion syndrome (PRIS) has not been reported in domestic cats. Veterinary professionals should be aware that drug-induced intraoperative rhabdomyolysis and hyperkalemia can develop unexpectedly and should remain a differential for acute cardiac arrhythmias or cardiac arrest and AKI. [ABSTRACT FROM AUTHOR]

Background: Dysfunction of ventriculoperitoneal (VP) shunts can lead to decreased levels of consciousness. We report a case of delayed emergence from anesthesia due to the malfunction of a VP shunt during neurosurgery in the prone position. Case presentation: A 75-year-old male with a history of VP shunt for a fourth ventricle obstruction underwent cerebral vascular anastomosis in the prone position. His preoperative level of consciousness was clear. The surgery under general anesthesia was completed without any particular issues. After discontinuation of anesthesia, the patient did not awaken for over an hour. Postoperative CT revealed exacerbated hydrocephalus, likely from VP shunt occlusion. After pumping the reservoir of the VP shunt, the patient regained consciousness. He was extubated and discharged from ICU on the second postoperative day with no neurological issues. Conclusion: For surgical patients with a VP shunt, anesthesia management must consider the risk of shunt malfunction due to patient positioning. [ABSTRACT FROM AUTHOR]

Post-induction hypotension (PIH) is a common and potentially serious complication of general anesthesia. This meta-analysis (Prospero registration number: CRD42024566321) aimed to evaluate the predictive efficacy of the perfusion index (PI) for PIH in patients undergoing general anesthesia. A comprehensive literature search was performed using multiple electronic databases (Google Scholar, EMBASE, Cochrane Library, and MEDLINE). Studies involving adult patients undergoing general anesthesia, with the PI measured before anesthesia induction and reporting PIH incidence, were included. The primary outcome was the diagnostic accuracy of the PI in predicting the probability of PIH. The secondary outcome was the pooled PIH incidence. Eight studies with 678 patients were included. The pooled incidence of PIH was 44.8% (95% confidence interval [CI]: 29.9%–60.8%). The combined sensitivity and specificity of the PI for predicting PIH were 0.84 (95% CI: 0.65–0.94) and 0.82 (95% CI: 0.70–0.90), respectively. The summary receiver operating characteristic (sROC) analysis revealed an area under curve of 0.89 (95% CI: 0.86–0.92). The Deek's funnel plot asymmetry test indicated no significant publication bias. The PI demonstrates high predictive efficacy for PIH in patients undergoing general anesthesia, indicating that it can be a valuable tool for identifying those at risk of PIH. [ABSTRACT FROM AUTHOR]

Background: This study aims to comprehend the levels of dry mouth and thirst in patients after general anesthesia, and to identify the factors influencing them. Methods: The study included all patients transferred to the Post Anesthesia Care Unit (PACU) at the Second Affiliated Hospital of Dalian Medical University between August 2021 and November 2021 after undergoing general anesthesia. A thirst numeric rating scale was utilized to conduct surveys, enabling the assessment of thirst incidence and intensity. Statistical analysis was performed to explore patient thirst levels and the associated factors. Results: The study revealed a thirst incidence rate of 50.8%. Among the thirst intensity ratings, 71.4% of patients experienced mild thirst, 23.0% reported moderate thirst, and 5.6% expressed severe thirst. Single-factor statistical analysis of potential risk factors among the enrolled cases indicated that gender, history of coronary heart disease, surgical duration, intraoperative fluid volume, intraoperative blood loss, intraoperative urine output, and different surgical departments were linked to post-anesthetic thirst in patients undergoing general anesthesia. Multifactorial Logistic regression analysis highlighted age, gender, history of coronary heart disease, fasting duration, and intraoperative fluid volume as independent risk factors for post-anesthetic thirst in patients undergoing general anesthesia. Moreover, age, gender, history of coronary heart disease, and intraoperative fluid volume were also identified as risk factors for varying degrees of thirst. Conclusion: The incidence and intensity of post-anesthetic thirst after general anesthesia are relatively high. Their occurrence is closely associated with age, gender, history of coronary heart disease, fasting duration, and intraoperative fluid volume. [ABSTRACT FROM AUTHOR]

Background: Remifentanil, an ultra-short-acting µ-opioid receptor agonist, is commonly used for anesthetic management due to excellent adjustability. Remifentanil is known to cause sinus bradycardia, however, because it has a direct negative chronotropic effect on the cardiac conduction system and there is an indirect negative chronotropic effect via the parasympathetic nervous system. Case presentation: An 8-year-old Japanese boy was diagnosed with acute hydrocephalus due to a brain tumor in the fourth ventricle and underwent emergency surgery. Imaging examination showed brainstem compression. Endoscopic third ventriculostomy and ventriculoperitoneal shunt surgery were scheduled. Remifentanil was started during induction of general anesthesia, but electrocardiogram showed sinus bradycardia, then Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was immediately discontinued, and we administered atropine sulfate. Complete atrioventricular block was restored to sinus rhythm. When remifentanil was restarted, however, the electrocardiogram again showed sinus bradycardia, Wenckebach-type atrioventricular block, and then complete atrioventricular block. Remifentanil was again immediately discontinued, we administered adrenaline, and then complete atrioventricular block was restored to sinus rhythm. Fentanyl was used instead of remifentanil with continuous infusion of dopamine. There has since been no further occurrence of complete atrioventricular block. Conclusions: This is the first known case of complete atrioventricular block in a pediatric patient with increased intracranial pressure seemingly caused by administration of remifentanil. [ABSTRACT FROM AUTHOR]

Background: The skin-prick and intradermal tests are the main diagnostic methods used to identify the causative agent in patients with suspected perioperative anaphylaxis. Although the intradermal test is more sensitive than the skin-prick test, multiple intradermal injections can be painful for children. Here, we present the case of a child with autism and suspected perioperative anaphylaxis. The causative agent was successfully identified using the intradermal test under general anesthesia. Case presentation: An 8-year-old boy with autism developed anaphylaxis during general anesthesia for the fourth cleft lip and palate surgery. An allergic workout was performed, but both the skin-prick and basophil activation tests for suspected causative agents yielded negative results. The patient was afraid of multiple injections, and an intradermal test was performed under general anesthesia by anesthesiologists and allergists. Piperacillin was confirmed as the causative agent, and subsequent surgery using the same anesthetic agents without piperacillin was uneventful. Conclusions: Concerted efforts should be made to identify the causative agent for diagnosing perioperative anaphylaxis. [ABSTRACT FROM AUTHOR]

Consciousness has been proposed to be supported by electrophysiological patterns poised at criticality, a dynamical regime which exhibits adaptive computational properties, maximally complex patterns and divergent sensitivity to perturbation. Here, we investigate dynamical properties of the resting-state electroencephalogram (EEG) of healthy subjects undergoing general anesthesia with propofol, xenon or ketamine. Importantly, all participants were unresponsive under anesthesia, while consciousness was retained only during ketamine anesthesia (in the form of vivid dreams), enabling an experimental dissociation between unresponsiveness and unconsciousness. For each condition, we measure (i) avalanche criticality, (ii) chaoticity, and (iii) criticality-related metrics, revealing that states of unconsciousness are characterized by a distancing from both avalanche criticality and the edge of chaos. We then ask whether these same dynamical properties are predictive of the perturbational complexity index (PCI), a TMS-based measure that has shown remarkably high sensitivity in detecting consciousness independently of behavior. We successfully predict individual subjects' PCI values with considerably high accuracy from resting-state EEG dynamical properties alone. Our results establish a firm link between perturbational complexity and criticality, and provide further evidence that criticality is a necessary condition for the emergence of consciousness. An EEG study demonstrates that dynamical properties of resting-state EEG mark (un)consciousness under propofol, xenon and ketamine anesthesia and are able to predict the TMS-derived perturbational complexity index (PCI) in healthy adults. [ABSTRACT FROM AUTHOR]

Background: Severe pain occurs after cardiac surgery in the sternum and chest tubes sites. Although analgesia targeting the sternum is often prioritized, the analgesia of the drain site is sometimes overlooked. This study of patients undergoing coronary artery bypass grafting (CABG) aimed to provide optimized analgesia for both the sternum and the chest tubes area by combining parasternal block (PSB) and serratus anterior plane block (SAPB). Methods: Ethics committee approval (E.Kurul-E2-24-6176, 07/02/2024) was received for the study. Then, the trial was registered on www.clinicaltrials.gov (https://clinicaltrials.gov/) under the identifier NCT05427955 on 17/03/2024. Twenty patients between the ages of 18–80, with ASA physical status classification II-III, undergoing coronary artery bypass grafting CABG with sternotomy, were included. While the patients were under general anesthesia, PSB was performed through the second and fourth intercostal spaces, and SAPB was performed over the sixth rib. The primary outcome was VAS (Visual Analog Scale) during the first 12 h after extubation. The secondary outcomes were intraoperative remifentanil consumption and block-related side effects. Results: The average age of the patients was 64 years. Five patients were female, and 15 were male. For the sternum area, only one patient had resting VAS scores of 4, while the VAS scores for resting for the other patients were below 4. For chest tubes area, only two patients had resting VAS scores of 4 or above, while the resting VAS scores for the other patients were below 4. The patients' intraoperative remifentanil consumption averaged 2.05 mg. No side effects related to analgesic protocol were observed in any of the patients. Conclusions: In this preliminary study where PSB and SAPB were combined in patients undergoing CABG, effective analgesia was achieved for the sternum and chest tubes area. [ABSTRACT FROM AUTHOR]

General anesthesia can impact a patient's memory and cognition by influencing hippocampal function. The CA1 and dentate gyrus (DG), serving as the primary efferent and gateway of the hippocampal trisynaptic circuit facilitating cognitive learning and memory functions, exhibit significant differences in cellular composition, molecular makeup, and responses to various stimuli. However, the effects of isoflurane-induced general anesthesia on CA1 and DG neuronal activity in mice are not well understood. In this study, utilizing electrophysiological recordings, we examined neuronal population dynamics and single-unit activity (SUA) of CA1 and DG in freely behaving mice during natural sleep and general anesthesia. Our findings reveal that isoflurane anesthesia shifts local field potential (LFP) to delta frequency and reduces the firing rate of SUA in both CA1 and DG, compared to wakefulness. Additionally, the firing rates of DG neurons are significantly lower than CA1 neurons during isoflurane anesthesia, and the recovery of theta power is slower in DG than in CA1 during the transition from anesthesia to wakefulness, indicating a stronger and more prolonged impact of isoflurane anesthesia on DG. This work presents a suitable approach for studying brain activities during general anesthesia and provides evidence for distinct effects of isoflurane anesthesia on hippocampal subregions. [ABSTRACT FROM AUTHOR]

Objectives: Commonly, general anesthesia (GA) with endotracheal intubation is the standard anesthesiology approach in gynecological laparoscopic surgery; neuraxial anesthesia (NA) can also be used, but its application is very low and limited to few indications. This study assessed NA feasibility for almost all kinds of gynecologic laparoscopies. Materials and Methods: Data on laparoscopic surgeries performed under NA were collected retrospectively. A total of 76 patients had laparoscopic interventions at the Donatello Clinic in Florence, Italy, between October 2019 and August 2022. Adnexectomies, ovarian cyst enucleations, multiple myomectomies, total hysterectomies, radical hysterectomies with sentinel lymph-node biopsies, and complete excisions of endometriosis and adhesiolysis were performed under regional anesthesia. All procedures but 1 were completed with no change from NA. Results: All cases but 1 were completed under NA. There were (1) spontaneously breathing patients; (2) no pulmonary complications; (3) satisfactory muscle relaxation; (4) fast postoperative bowel function recovery; (5) reduced postoperative pain; (6) reduced postoperative narcotics use; and (6) absence of postoperative nausea and vomiting. Conclusions: These procedures appear to comprise the largest series of complex gynecologic laparoscopies performed under NA reported in the literature. Preliminary data seems to support the concept that this approach might be feasible and safe in selected and motivated patients, but further research is needed to confirm these encouraging data. (J GYNECOL SURG 20XX:000) [ABSTRACT FROM AUTHOR]

Background: Endovascular thrombectomy (EVT) has been proven as the standard treatment for acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). However, the ideal anesthetic strategy during EVT still remains unclear. Therefore, this systematic review and meta-analysis aimed to determine the optimal anesthetic modality for patients with AIS undergoing EVT based on current randomized controlled trials (RCTs). Methods: The databases Medline (via PubMed), EMBASE, Web of Science, and the Cochrane Library were searched for RCTs comparing general anesthesia (GA) and conscious sedation (CS) in AIS patients undergoing EVT. The primary outcome was a favorable functional outcome at 90 days postintervention. Data analysis was conducted using the Review Manager software (RevMan V.5.3). Results: Eight RCTs involving 1199 patients were included. There was no significant difference between GA and CS group in the rate of functional independence (risk ratio (RR) = 1.10, 95% confidence interval (CI) = 0.96 to 1.25; p = 0.17; I 2 = 30%). Compared with the CS group, the GA group attained a higher successful recanalization rate (RR = 1.14, 95% CI = 1.08 to 1.20; p < 0.00001; I 2 = 17%). In addition, patients in the GA were associated with a higher rate of hypotension (RR = 1.87, 95% CI = 1.44 to 2.41; p < 0.00001; I 2 = 66%) and a higher incidence of pneumonia (RR = 1.38, 95% CI = 1.05 to 1.8; p = 0.02; I 2 = 37%). Conclusion: For AIS patients receiving EVT, the choice of anesthetic modality did not influence the 3-month neurological outcome while GA is superior to CS in terms of successful reperfusion rate. Moreover, the patients in the GA group were at a higher risk of developing hypotension and pneumonia. Further studies are required to provide more sufficient evidence. [ABSTRACT FROM AUTHOR]

Background: Tracheal intubation in the Sellick and Trendelenburg position (ST position) can prevent pulmonary aspiration but increase the difficulty of tracheal intubation. We compared tracheal intubation using video and direct laryngoscopy in the ST position with direct laryngoscopy in the supine sniffing position to evaluate the overall intubation performance. Methods: One hundred and twenty patients were randomly assigned to three groups: direct laryngoscope in the supine sniffing position (control), direct laryngoscope in the ST position (ST direct), and video laryngoscope in the ST position (ST video). The primary outcome was the intubation time; secondary outcomes included the first attempt success rate of tracheal intubation, intubation difficulty scale score, operator's subjective assessment of intubation difficulty, and modified Cormack–Lehane grades. Results: The median intubation times were greater in the ST direct (36.0 s) and video (34.5 s) than the control (28.0 s) groups. The first attempt success rate decreased in the ST direct (77.5%) but not the video (95.0%) group compared with the control group (100%). Conclusions: The challenges of tracheal intubation in the ST position, aimed at reducing the risk of pulmonary aspiration, can be mitigated by using a video laryngoscope, despite slightly longer intubation times. [ABSTRACT FROM AUTHOR]