Remimazolam was derived from its parent compound by adding an ester linkage into its structure, so that the drug becomes a substrate for ester metabolism. As a result, it undergoes organ independent ester hydrolysis, although the clinical benefits in terms of shorter recovery are not uniformly observed in clinical practice. Remimazolam is mainly tested in procedural sedation. In comparison to propofol, the current gold standard for procedural sedation, its proposed attractiveness is shorter wake-up times and a clear-headed recovery Its clear advantage over propofol is better hemodynamic stability, lack of pain on injection and availability of a reversal agent in the form of flumazenil. Data on patient and proceduralist’s satisfaction are lacking. Remimazolam is also used for induction and maintenance of general anesthesia in Japan (where it is approved for this purpose). In this scenario, it is not clear if it can achieve the same degree of lack of recall as propofol. The use of remimazolam in obstetrics, pediatrics and in high-risk population is an emerging area.

Gaucher Disease's (GD) pathophysiology generates anesthetic concerns in Total Hip joint Arthroplasty (THA), and due to its rareness, data on perioperative risks is scarce. This 22-year study at a large reference center addresses anesthetic management and perioperative outcomes in GD. This retrospective-cohort study assessed anesthetic success and safety in 30 THA patients, comparing them with a control-matched group. Data on clinical characteristics, perioperative events, and outcomes were collected. The primary outcome was difficult anesthesia-initiation incidence. Secondary outcomes were difficult intraoperative course and hemodynamic management, and the development of postoperative-complications. The age, sex, weight, body mass index, primary-to-revision hip arthroplasty ratio were similar in both groups. The mean age was 48±13 years. Ten arthroplasties were revision while twenty were primary. There was no significant difference at all-type anesthesia first initiation attempt success. No particular preference by staff anesthetists for general anesthesia or neuraxial procedures was observed. The GD group showed significantly higher mean intraoperative packed red blood cell units administered (0.73 vs 0.18);(p= 0.038)), higher intraoperative and postoperative platelet transfusion incidence (5/30 [16.7%] vs. 0/56 [0.00%];p=0.004) and (3/30 [10%] vs 0/56 [0%];p=0.040) and longer mean recovery-room length-of-stay (426±412 vs 175±140;p=0.004). Postoperative complications were not significantly different.

Background: Escalating climate change concerns have prompted the healthcare sector, particularly anaesthesia, to reassess its practices to align with environmental sustainability. Anesthetic gases like desflurane, sevoflurane, and isoflurane significantly impact the environment due to their high Global Warming Potentials (GWPs) and prolonged atmospheric lifetimes. This manuscript investigates these impacts and advocates for strategies to reduce the carbon footprint of anesthetic care while maintaining patient safety. Methods: We reviewed the environmental impacts of anesthetic gases and explored various strategies for sustainable anaesthesia. These strategies include adopting anesthetics with lower GWPs, enhancing recycling and waste reduction techniques, transitioning to intravenous anaesthesia, and implementing low-flow anaesthesia methods. We also examined barriers to these strategies, such as educational gaps, technological challenges, resistance to change, and policy limitations. Results: Adopting anesthetics with lower GWPs, such as sevoflurane over desflurane, and implementing low-flow anaesthesia can significantly reduce greenhouse gas emissions. Recycling and waste reduction techniques, though challenging, offer additional environmental benefits. Transitioning to intravenous anaesthesia can eliminate the direct GWP contributions from volatile anesthetic gases. However, these strategies require comprehensive education, advocacy for research and innovation, strategic change management, and supportive policies. Conclusions: Continuous monitoring and evaluation are crucial to ensure the effectiveness of sustainable practices in anaesthesia. Establishing robust Key Performance Indicators (KPIs) and utilizing advanced analytical tools will enable the anaesthesia community to adapt and refine practices. Collaborative efforts among clinicians, policymakers, and stakeholders are essential to significantly reduce the environmental impact of anaesthesia and promote ecological responsibility within healthcare.

Human epidemiologic studies and laboratory investigations in animal models suggest that exposure to general anesthetic agents (GAs) have harmful effects on brain development. The mechanism underlying this putative iatrogenic condition is not clear and there are currently no accepted strategies for prophylaxis or treatment. Recent evidence suggests that anesthetics might cause persistent deficits in synaptogenesis by disrupting key events in neurodevelopment. Using an in vitro model consisting of dissociated primary cultured mouse neurons we demonstrate abnormal pre- and post-synaptic marker expression after a clinically relevant isoflurane anesthesia exposure conducted during neuron development. We find that pharmacologic inhibition of the mechanistic target of rapamycin (mTOR) pathway can reverse the observed changes. Isoflurane exposure increases expression of phospho-S6, a marker of mTOR pathway activity, in a concentration-dependent fashion and this effect occurs throughout neuronal development. The mTOR 1 complex (mTORC1) and the mTOR 2 complex (mTORC2) branches of the pathway are both activated by isoflurane exposure and this is reversible with branch-specific inhibitors. Upregulation of mTOR is also seen with sevoflurane and propofol exposure, suggesting that this mechanism of developmental anesthetic neurotoxicity may occur with all the commonly used GAs in pediatric practice. We conclude that GAs disrupt the development of neurons during development by activating a well-defined neurodevelopmental disease pathway and that this phenotype can be reversed by pharmacologic inhibition.

Abstract: this study aimed to evaluate the benefits of applying 5 cmH2O of CPAP using a pediatric helmet during the recovery phase from general anesthesia in brachycephalic dogs. Brachycephalic dogs undergoing various surgical procedures were included in the study, and a total of 64 subjects were randomly assigned to receive either standard oxygen supplementation (NO-CPAP group) or oxygen supplementation combined with CPAP (CPAP group). The study evaluated arterial blood pH, blood gas partial pressures of O2 and CO2, arterial blood O2 saturation, and related parameters during recovery. The dogs were monitored, and helmet tolerance was assessed using predefined criteria. Of the initially assessed 69 dogs, 64 were enrolled, 32 in the CPAP group and 32 in the NO-CPAP group. Fifteen dogs in the NO-CPAP group were excluded based on predetermined criteria. The CPAP group showed significant improvements in PaO2, PaO2/FiO2, P(A-a)O2, F-Shunt, and respiratory rate compared to the NO-CPAP group (p < 0.001). The incidence of reintubation and helmet intolerance was higher in the NO-CPAP group (18% and 15.6%, respectively) than in the CPAP group (0%). This study highlights the potential benefits of incorporating CPAP, delivered through a pediatric helmet, in the perioperative management of brachycephalic dogs. Keywords: Brachycephalic; dog; CPAP; oxygenation; anesthesia

Ketamine as an old - new drug has variety of clinical implications. In the last 30 years, ketamine has become popular for acute use in humans. Ketamine at standard doses is principally utilized for the induction and maintenance in surgical procedures. Beside its use in anesthesia and analgesia, recently studies had shown that ketamine find the place in the treatment of asthma, epilepsy, depression, bipolar affective disorders, alcohol and heroin addiction. Its mechanism of action is complex, but it mostly acts as a noncompetitive antagonist at the N-methyl-D-aspartate (NMDA) receptor. Ketamine is generally considered relatively secure and does not result in serious adverse effects when used at low doses and for short periods- Also, ketamine is known as a powerful psychostimulant. During the past decade, ketamine has been one of the commonly abused drug.

Anesthesia ensures the welfare of the animal, enables safe and effective procedures, and allows accurate data collection [1]. In clinical veterinary practice, proper training and expertise in anesthesia administration and monitoring are essential. Pigs are commonly used in medical and scientific research as models for studying various aspects of human health, physiology, and disease due to their physiological and anatomical similarities to humans [2–4]. Pigs are suitable experimental animals for many surgery techniques because they are similar in size to humans and have a short reproductive cycle. This makes them ideal for research concerning organ transplantation, cardiovascular surgery, and other procedures that require a large animal model. Pigs also have a similar anatomy to humans, which makes them a good choice for studying diseases and developing new treatments [5]. Sedation and premedication should be administered at the lowest dose to be effective with predictable results and reduced adverse effects, to ensure the safety of both the animal and the team involved in the procedure, with a fast onset and optimizing the induction and maintenance of anesthesia. The goal of induction is to achieve a safe and effective level of anesthesia that ensures the patient's safety and facilitates the research. Most of the time, inhalation anesthesia with endotracheal intubation is the ideal choice for maintenance., allowing efficient anesthetic management. The difficulties related to the endotracheal intubation of pigs can be overcome by knowing the anatomical peculiarities related to the species and the multiple methods cited in the literature. Effective analgesia tailored to the specific procedure, the pig's condition, and individual responses to medications should complete the maintenance and recovery protocols, reducing perioperative complications.

The field of anesthesia has always been at the forefront of innovation and technology, and the integration of Artificial Intelligence (AI) represents the next frontier in anesthesia care. The use of AI and its subtypes such as machine learning has the potential to improve efficiency, reduce costs, and improve patient outcomes. AI can assist with decision-making, but its primary advantage lies in empowering anesthesiologists to adopt a proactive approach to address clinical issues. However, further research and validation are needed to fully understand the benefits and limitations of these applications in clinical practice. Moreover, the ethical implications of AI in anesthesia must also be considered to ensure that patient safety and privacy are not compromised. This paper aims to provide a comprehensive overview of AI in anesthesia, including its current and potential applications, and the ethical considerations that must be considered to ensure the safe and effective use of the technology.

In this study, the effects of music therapy on anxiety for patients undergoing regional anaesthesia in an operating room was succinctly investigated. This investigation was largely based on the adapted Hospital Anxiety and Depression Score (HADS) and Spielberger State-Trait Anxiety Inventory (STAI-S), of patients undergoing regional anaesthesia in an operating room. A randomized control trial was performed on 90 patients due for surgery. The selected patients for regional anaesthesia were allocated to either the music therapy group who listened to music using headphones for the entire surgery or the no-treatment control group. Based on the findings, it has been conclusively demonstrated that music can decrease the patient's anxiety level. According to the socio-demographic evaluation, elderly patients have the highest stress hormones levels when compared to young patients. Although elderly patients are more likely to choose religious songs to help them relax, cortisol analysis revealed an increase in cortisol levels among the elderly compared with younger patients. As a result, music is especially important to be delivered to elderly patients. Nonetheless, there is no restriction against administering music to elderly patients because evidence from the Hospital Anxiety and Depression Score (HADS) and State-Trait Anxiety Inventory (STAI-S) has shown that music helps to shift their attention away from pain and complications and makes them feel tranquil. Similarly, the HADS and modified Spielberger STAI (STAI-S) analyses demonstrate a substantial outcome for both groups, with respondents responding positively. The study found that listening to music during regional anaesthesia might help people feel less worried.

Lombok earthquake that occurred in July 2018 has three large magnitude earthquakes that caused huge losses; 564 victims died, 1684 injured, 445 343 refugees, and 215 628 houses were damaged. The role of anesthesiology is very important to give prompt therapy for injured victims. This research gave an overview of the important role of Anesthesiologist and the selection of anesthesia techniques during the natural disasters’ victims’ management. This study was conducted by collecting data of all earthquake victims treated at the emergency room (ER) of RSUD NTB on August 6^th and 7^th 2018 and all victims operated during August 5 – 25^th 2018. All data were recorded, analyzed, and presented in descriptive form using frequency, pie chart, and bar diagrams. The result shown that the highest number of patients treated in ER are during the first seven days after the earthquake and reduced to several weeks. The majority of patients treated are trauma patients who need orthopedic surgery. Since limited number of anesthesiologist should be considered with the right selection of anesthesia techniques, so that the disaster preparedness could be prepared well and the disaster management could run well. General anesthesia was widely used than regional anesthesia, but the different is not significant. The type of regional anesthetic drug usually used is lidodex in combination with catapres. The role of anesthesiologist during disaster is important to handle a safe and optimal surgical condition.

The digital transformation of healthcare is advancing, leading to an increasing availability of clinical data for research. Perioperative big data initiatives were established to monitor treatment quality and benchmark outcomes. However, big data analyzes have long exceeded the status of pure quality surveillance instruments. Large retrospective studies nowadays often represent the first approach to new questions in clinical research and pave the way for more expensive and resource intensive prospective trials. As a consequence, utilization of big data in acute pain and regional anesthesia research considerably increased over the last decade. Multicentric clinical registries and administrative databases (e.g., healthcare claims databases) have collected millions of cases until today, on which basis several important research questions were approached. In acute pain research, big data was used to assess postoperative pain outcomes, opioid utilization, and the efficiency of multimodal pain management strategies. In regional anesthesia, adverse events and potential benefits of regional anesthesia on postoperative morbidity and mortality were evaluated. This article provides a narrative review on the growing importance of big data for research in acute postoperative pain and regional anesthesia.

Abstract: Background: Dental fear and uncooperative behavior can hinder dental treatment quality. Pediatric Procedural Sedation and Analgesia (PPSA) is used to facilitate treatment when coping capacity is exceeded. Out-of-hospital PPSA has been associated with more adverse outcomes compared to hospital-based settings. Updated Dutch PPSA guidelines recommending two anesthesiologists and a ventilator during out-of-hospital PPSA have increased costs and raised concerns about the accessibility to specialized high quality dental care for children in the Netherlands. Aim: This study aims to investigate the impact of the updated 2017 guideline on the occurrence rate of adverse events during PPSA, as recorded in the anesthesia complication database of twelve participating Dutch dental clinics, with adjustments made for age, weight, and duration of treatment. Method: Data of 25,872 children treated at 12 dental clinics performing out-of-hospital PPSA between 1997 and 2019 were analyzed. Eligible children were aged 2-18 with ASA classification I and II. A logistic two-level mixed-effects model is used to estimate the updated guideline’s impact on adverse events. Results: In the final model we analyzed the data of 21,759 children in nine dental clinics. The OR of the occurrence rate of an adverse event adjusted for age, weight, and duration of treatment was 0.75 (95% CI 0.64 – 0.89) after the implementation of the updated guideline, compared to before the updated guideline. This outcome was significant with a P=0.001, indicating a protective effect. The average odds per clinic of having an adverse event was 0.04 with a 3.81% chance. Conclusion: Our findings demonstrate a significant reduction in adverse events after the implementation of the updated guideline and highlight the importance of adherence to evidence-based guidelines in improving patient safety and the quality of care provided during pediatric procedural sedation and analgesia in out-of-hospital dental clinics. Our study underlines the necessity of considering the complex underlying mechanisms that play a role in the development and implementation of evidence-based practice and safety initiatives on the occurrence of adverse events.

Despite the advancements in evidence-based medicine, many hospitals still maintain high rates of patients undergoing prolonged preoperative fasting. The goal of this study is to determine the prevalence of prolonged fasting time among patients undergoing elective surgeries at a Brazilian university hospital and its associations with clinical and sociodemographic variables. This cross-sectional study was conducted between May and November 2019 and included patients of all ages undergoing elective surgeries. Out of the 293 patients analyzed, 64.2% were male, with ages ranging from 1 to 85 years, and 93.9% were classified as ASA I or II. The prevalence of preoperative fasting exceeding 8 hours was 89.4%. An average fasting time exceeding 11 hours was observed across all age groups. Patients who underwent procedures in the afternoon had an average fasting time that was 16% longer than those in the morning period (13.84 vs. 11.92, p<0.001). Surgery time (r=0.134, p<0.03) and anesthesia times (r=0.121, p<0.04) demonstrated a weak correlation with fasting time. Despite the international consensus on preoperative fasting time, our study demonstrated low adherence to current recommendations. Therefore, healthcare professionals should ensure the comprehension of fasting guidelines, and further studies should aim to identify effective solutions to mitigate prolonged fasting.

Anesthetic management for pregnant suffering from airway pathology poses unique challenges. The presence of bilateral vocal cord granuloma adds further complexity to the management, as it can potentially cause airway compromise and respiratory distress. This case presents a pregnant patient with bilateral vocal cord granuloma who underwent anesthesia using high-flow nasal cannula (HFNC) oxygenation and oxygen reserve index (ORi) monitoring. A 33-year-old pregnant woman, who had undergone intubation six month ago, experienced hoarseness and was ultimately diagnosed with bilateral granuloma. Due to the significant airway obstruction, neither intubation nor ventilation was feasible, thereby requiring a surgical intervention. Before the surgical removal, the patient’s oxygenation was ensured using HFNC oxygenation. After confirming sufficient oxygenation of the patient with ORi of 0.38, the operation commenced and as it lasted approximately 3 minutes, the patient was able to tolerate the brief period without additional oxygen supply. Post-surgical excision, mask bagging and HFNC oxygenation was resumed, driving ORi to 0.39, then the operation was resumed. Throughout the procedure, SpO2 remained above 98. The combination of HFNC and ORi ensured adequate oxygenation and allowed for early detection of hypoxemia during the procedure. This approach may be a good option for managing granuloma.

Background: There is a notable lack of protocols addressing extubation techniques in transoral robotic surgery (TORS) for obstructive sleep apnea (OSA). Methods. This retrospective cohort study enrolled patients who underwent TORS for OSA between March 2015 and December 2021 and were managed with different extubation approaches. The patients were divided into two groups: high-flow nasal cannula (HFNC) therapy and conventional oxygen therapy. The use of an airway exchange catheter (AEC) was investigated. Results: The only application of HFNC use versus conventional oxygen therapy led to a statistical reduction of extubation time (p=0.024); length of stay in the intensive care unit (ICU) and the episodes of desaturation below 95% were reduced, but data are non-statically significant. Similarly, the application of an AEC led to a reduction of extubation time in hours (p=0.008) and length of stay in the ICU (p=0.024). Conclusions: In patients with OSA who underwent TORS, the use of HFNC, with or without an AEC, resulted in a significant reduction in extubation time without major adverse events. Additionally, HFNC utilization may decrease desaturation episodes during extubation. Based on the findings of this preliminary investigation, the combination of HFNC and AEC emerges as a promising strategy for enhancing the safety and efficacy of extubation protocols in this patient population.

Lidocaine hydrochloride (HCl) 2% with 1:100,000 epinephrine (LW/E) is widely used to prevent pain during dental procedures and has been associated with injection sting, jittering effects, slow onset, and a bitter aftertaste. Since LW/E’s introduction in 1948, no significant modifications have been proposed. This study aims to design and characterize an improved dental lidocaine HCl injectable formulation without epinephrine (LW/O/E) via buffers, sweeteners, and amino acids. LW/O/E injections were prepared with pH and osmolality values of 6.5 – 7.0 and 590-610 mOsm/kg. Using the electronic tongue (ETongue), the LW/O/E injectable formulations were characterized for viscosity, injectability, and taste analysis. The results were compared with the LW/E control. In vivo efficacy and anesthetic duration of the samples were measured through radiant heat tail-flick latency (RHTFL) and hot plate (HP) tests and local toxicity was assessed after a single intra-oral injection in Sprague Dawley rats (SDR). The viscosity and injectability values of the LW/O/E samples were found to be comparable to the LW/E injection. ETongue taste analysis showed an improvement in bitterness reduction of the LW/O/E samples compared to the LW/E formulation. Toxicity studies of samples in SDR showed minor and transient signs of erythema/eschar and edema. Anesthetic duration via RHTFL and HP paw withdrawal latency time in SDR were found to be comparable for the LW/O/E Sample 3A and the LW/E injection (p<0.05). In conclusion, the buffered, higher osmolality and reduced bitterness developed LW/O/E formulation (Sample 3A) could be considered a promising alternative to the LW/E formulation for dental use.

Introduction. Anesthesia is widely used in various fields of dentistry to reduce patient discomfort when the treatment would be painful. The dentist may need to infiltrate the anesthetic into multiple locations and this is usually done with the same needle which passes through the soft tissues several times to distribute the anesthetic solution over a larger area. The present study aims to evaluate, through a morphological analysis under a scanning electron microscope (SEM), how the beveled tip of a 30G needle, used to inject anesthetic several times into different areas of the vestibular mucosa, changes. Materials and methods. 30G needles with two different brands were tested, in vivo used for a variable number of sequential injections from 1 to 6 on 192 patients. The specimens were analyzed under SEM observation to evaluate any deformations induced by contact with the vestibular soft tissues. Results. The amount of deformation, measured along the axis parallel to the needle, was proportional to the number of injections. The protrusion of deformations, measured on an axis perpendicular to the needle, were maximum on the needles used 3 times. For the needles used 4,5 and 6 injections, no further increase in deformations was noted. Conclusion. From the data it seems that the tested needles are not produced to withstand multiple injections consequently after the first injection on soft tissues, they undergo a deformation which could increase the risk of injury to the mucosa itself or to nerves and vessels with which they come into contact. It would be advisable to use the single needle for a reduced number of injections.

Objective: This prospective study investigated the feasibility performing laparoscopic pelvic surgery in spinal anesthesia and analyzed their intraoperative side effects like pain and nausea and vomitus of 915 patients. Methods: Implementation and performance of laparoscopic surgery under local anes-thesia of 915 patients out of a total of 3212, who underwent laparoscopic pelvic surgery in spinal anesthesia, were analyzed in relation to BMI (Body Mass Index), obesity, pain during surgery and amount of intraperitoneal mmHg CO2 gas pressure and surgical complications. Results: BMI > 30, intraabdominal adhesions, increased duration of the operation, bleeding and increased intraperitoneal CO2 pressure were statistically significant as the main causes of pain during laparoscopic surgery in spinal anesthesia. Under-weight patients, on the other hand, had less pain when intra-abdominal pressure in-creased compared to those of normal weight. The appearance of pain, nausea and vomitus occurred in 10,3% and was easy to manage and treat. It did not affect the sur-geon's work and the course of the operation. Conclusion: In view of these observations, we are proposing spinal anesthesia for lap-aroscopic surgery as the first choice in those patients, who have no contraindications. In our knowledge this clinical study constitutes the largest clinical observations and dataset that applies spinal anesthesia in laparoscopic pelvic surgery.

The definition of patients with Special Needs (SN) is used in the literature to refer to individuals with mental and physical disorders for whom the usual perioperative pathways are not applicable due to lack of cooperation, regardless of age. Studies in the literature recognize the appropriateness of general anesthesia for performing day surgery dental care in this type of patient. The present retrospective, single-center, observational study involved 41 uncooperative patients aged between 3 and 17 undergoing dental surgery under general anesthesia. The main objective was to assess the possible incidence of difficult airway management, understood as difficulty ventilating and/or intubating the patient. A secondary objective was to highlight the influence of general anesthesia on patient outcomes by testing the incidence of perioperative complications. Tracheal intubation was successfully completed in all of the patients considered, and in no case did the patient have to be woken up because of difficulty in airway management. No perioperative complications attributable to anesthesia were found in any patients. From the present experience, it can be concluded that general anesthesia is a suitable option for performing dental care in pediatric subjects with special needs, and that although the peculiar peri-operative management of these patients might increase the risk of possible anesthesia-related side effects, no complications have been encountered in any case.

Background: The NOL system (PMD-200™ Nociception Monitor; Medasense Ltd, Israel) is used for real-time detection of physiological nociception in anesthetized patients by assessing varia-bles indicative of sympathetic activity, such as photoplethysmography, skin conductance, pe-ripheral temperature, and accelerometry, which are quantified into a "NOL" index. This index is more sensitive than traditional clinical parameters in estimating pain and stress responses. While its effectiveness in general anesthesia is well-documented, its efficacy in epidural anes-thesia needs investigation. Methods: This retrospective study analyzed NOL index dynamics compared to conventional pa-rameters after epidural administration of a local anesthetic during abdominal surgeries. After Ethics Committee approval and DRKS registration, 119 NOL measurements were retrospectively analyzed following thoracic epidural catheter administration. NOL values were assessed at 0, 1, 3, and 5 minutes post-application and compared to heart rate, blood pressure, and bispectral in-dex dynamics. Results: This studys showed a significant decrease in NOL values post-local anesthetic admin-istration, unlike classical clinical parameters. Higher doses of local anesthetics led to a signifi-cant, dose-dependent decrease in NOL index. Conclusions: This study is the first to demonstrate the NOL-Index's effectiveness in assessing nociceptive effects post-epidural administration, showing its superiority over conventional pa-rameters and sensitivity to dose variations.

Background and aims: For many surgical procedures, spinal anesthesia is a reliable and efficient anesthetic approach. Numerous drugs have been reported to be administered to intrathecal local anesthetics as adjuvants to increase the efficacy of spinal anesthesia. There is little evidence of the effect of intrathecal dexmedetomidine on pain scores and the consumption of analgesia postoperatively. Methods: After obtaining ethical approval, demographical and clinical data of patients who underwent surgical procedures under spinal anesthesia with intrathecal dexmedetomidine or fentanyl was collected and analyzed. Results: In this study with 96 patients, intrathecal dexmedetomidine (group D) resulted in significantly lower post-operative pain scores compared to intrathecal fentanyl (group F) (p=0.000). Across various surgical types, including Orthopedic, General, Urology, and Obs/Gyne procedures, group D consistently displayed reduced pain scores (p&lt;0.001). The number of patients who needed post-operative analgesia was significantly higher in group (F) than in group (D) (40 vs 23, p=0.002). Conclusion: Compared to fentanyl, intrathecal dexmedetomidine as an adjuvant to local anesthesia was found to lower post-operative pain scores and decrease the need for post-operative analgesia.

Modern anesthesia continues to be impacted in new and unforeseen ways by digital technology. Combining portability and versatility, mobile applications or “apps” provide a multitude of ways to enhance anesthetic and peri-operative care. Research suggests that uptake of apps into anesthetic practice is becoming increasingly routine, especially amongst younger anesthetists brought up in the digital age. Despite this enthusiasm, there remains no consensus in how apps are safely and efficiently integrated into anesthetic practice. This review summarizes the most popular forms of app usage in anesthesia currently and explores the challenges and opportunities inherent in implementing app use in anesthesia, with an emphasis on a practical approach for the modern anesthetist.

Objective: This prospective study aimed to compare the efficacy of caudal block (CB) and inguinal block (IB) for providing additional analgesia during unilateral orchidopexy. Methods: Seventy-two boys aged &lt;48 months, classified as ASA I/II, were assigned into CB (n=37) and IB (n=34) groups. Outcome measures included intra- and postoperative analgesic requirements, pain scores, and administration duration. Additional intraoperative analgesia was administered for a 10% increase in heart rate, while postoperative pain was assessed using the Children's and Infants Postoperative Pain Scale (CHIPPS), with scores &gt;4 prompting supplementary analgesia. Monitoring extended for 24 hours post-surgery. Results: CB significantly reduced the need for intraoperative (p&lt;0.001) and early postoperative (p=0.008) analgesia compared to IB. Although the CB group exhibited a slightly higher but non-significant analgesic requirement on the ward. No clinically relevant side effects were observed in either group. Conclusion: Both CB and IB are effective and safe methods for providing regional analgesia during orchidopexy. CB demonstrated superior efficacy intraoperatively and in the early postoperative period, while IB may offer advantages in the later recovery phase. However, additional analgesia is often required for orchidopexy, particularly in outpatient settings.

The aim of this prospective, randomized, clinical study was to evaluate the use of the pleth variability index (PVi) to guide the rate of intra-operative fluid therapy as compared with a traditional fixed fluid rate approach in ASA 1-2 dogs undergoing surgery. Twenty-seven dogs meet the inclusion criteria and were randomly assigned to conventional fluid management group (CFM, n = 12) or PVi-guided group (PVi, n = 15). The CFM group received a fixed rate of 5 ml kg-1 h-1 of crystalloid solution, while in the PVi group the rate was continuously adjusted based on PVi: PVi &lt; 14% = 3 ml kg-1 h-1; 14% ≤ PVi ≥ 20% = ml kg-1 h-1; PVi &gt; 20% = 15 ml kg-1 h-1. Hypotension (MAP &lt; 65 mmHg) was managed in CFM with maximum two fluid boluses (5 ml kg-1 in 10 minutes) and in case of no response dobutamine (1-3 mcg kg-1 min-1) was administered. In the PVi group treatment of hypotension was similar except when PVi &gt; 14% when dobutamine was directly initiated. The total fluid amount was significantly lower in PVI group (0.056 ± 0.027 ml kg-1 min-1) vs. CFM group (0.132 ± 0.115 ml kg-1 min-1), and hypotension incidence was lower (p = 0.023) in PVi group (0%) vs. CFM group (41%). Mean arterial pressure (MAP) was significantly higher during surgery in the PVi group. Dobutamine was never administered in both groups. Preliminary data suggest that PVi may be considered a potential target to guide fluid therapy in dogs; larger studies are needed, especially in cases of cardiovascular instability.

Worldwide, the prevalence of surgery under general anaesthesia has increased significantly, on one hand because of modern anaesthetic and pain control techniques, and on the other hand because of better diagnosis and increased complexity of surgical technique. Together with the development of new concepts in the surgical field, the attention of researchers and clinicians turned to minimizing the impact of surgical trauma and offering minimal invasive procedures. This fact is due to the recent discoveries in the field of cellular and molecular mechanisms, that have revealed a systemic inflammatory and pro-oxidative impact that not only lasts in the perioperative period, but also impacts the long term, contributing to more difficult recovery, increased morbidity, and mortality, and finally a negative financial impact. Detailed molecular and cellular analysis have shown an overproduction of inflammatory and pro-oxidative species, that are responsible for an augmentation of the systemic inflammatory status and more difficult postoperative recovery. Moreover, it was shown that there are a series of changes in certain epigenetic structures, the most important being the microRNAs. Based on these findings, a series of modern, targeted therapeutic approaches have been proposed, with the final goal of blocking these mechanisms and reducing the redox state. Recent studies carried out had a positive clinical impact regarding antioxidant therapy and have shown that it can be used in the perioperative period with beneficial clinical impact. This review describes and details the most important molecular and cellular mechanisms that impact the surgical patient undergoing general anaesthesia, and it presents a series of antioxidant therapies that can reduce systemic inflammation.

The operating room in a cardiothoracic surgical case is a complex environment, with multiple handoffs often required by staffing changes, and can be variable from program to program. This study was done to characterize what types of practitioners provide anesthesia during cardiac operations to determine the variability in this aspect of care. A survey was sent out via a list serve of members of the cardiac surgical team. Responses from 40 programs from a variety of countries showed variability across every dimension requested of the cardiac anesthesia team. Given that anesthesia is proven to have influence on the outcome of cardiac procedures, this study indicates the opportunity to further study how this variability influences outcomes, and to identify best practices.

The question of what generates conscious experience has mesmerized thinkers since the dawn of humanity, yet its origins remain a mystery. The topic of consciousness has gained traction in recent years, thanks to the development of large language models that now arguably pass the Turing test, an operational test for intelligence. However, intelligence and consciousness are not related in obvious ways, as anyone who suffers from a bad toothache can attest - pain generates intense feelings and absorbs all our conscious awareness yet nothing particularly intelligent is going on. Still, in the hard sciences, this topic is frequently met with skepticism because to date no protocol to measure the content or intensity of conscious experiences in an observer-independent manner has been agreed upon. Here we present a novel proposal: Conscious experience arises whenever a quantum mechanical superposition forms. Our proposal has several implications: First, it suggests that the structure of the superposition determines the qualia of the experience. Second, quantum entanglement naturally solves the binding problem, ensuring the unity of phenomenal experience. Finally, a moment of agency may coincide with the formation of a superposition state. We outline a research program to experimentally test our conjecture via a sequence of quantum biology experiments. Applying these ideas opens up the possibility of expanding human experience through brain-quantum computer interfaces.

Anxiety is a complex emotional state that can arise from the anticipation of a threatening event, and preoperative anxiety is a common experience among adult patients undergoing surgery. In adult patients, the incidence of preoperative anxiety varies widely across different surgical groups, and it can result in a variety of psychophysiological responses and problems. Despite its negative impact, preoperative anxiety often receives insufficient attention in clinical practice. To improve pain management strategies, there is a need for further research on personalized approaches that take into account various factors that contribute to an individual's pain experience. These personalized approaches could involve developing tools to identify individuals who are more likely to experience increased pain and may require additional analgesia. To address this, regular assessments of anxiety levels should be conducted during preoperative visits, and counseling should be provided to patients with high levels of anxiety. Identifying and addressing preoperative anxiety in a timely manner can help reduce its incidence and potential consequences.

Ovariectomy appears to be the best method to control the density of wild ungulate populations. The aim of the present study was to compare two surgical approaches, via the flank and midline, in mouflon’s ovariectomy in field conditions. Twenty female mouflons were enrolled in the study. The animals were divided randomly in two groups, Group F animals were gonadectomized via flank approach, while Group A animals were sterilized via linea alba access. The parameters evaluated were duration of surgery, duration of anaesthesia, recovery time, intra- and post-operative complications, intra-operative nociception and pain in the post-operative period. There were no intra- and post-operative complications. The evaluated parameters showed a very similar trend in both groups. Both techniques are found to be effective and safe in execution.

Philips Visual Patient Avatar represents an alternative method of patient monitoring that, according to computer-based simulation studies, enhances diagnostic accuracy, confidence and reduces workload. After its clinical integration, we assessed pediatric anesthesia providers' perspectives on this technology. This is a single-center qualitative study, conducted at the University Hospital Zurich using in-depth individual interviews. We aimed to identify the advantages and limitations of Visual Patient Avatar in pediatric anesthesia and to assess children and parents' reactions from caregivers' perspective. Thematic analysis was used to identify the dominant themes. Fourteen members of the institution's pediatric anesthesia team were interviewed. The most prevalent themes were: children's positive reactions towards the Visual Patient Avatar (92.9%) and enhanced speed in problem identification (71.4%). Additionally, 50% of participants reported finding the Visual Patient Avatar useful for diverting children's attention during anesthesia induction, and 50% suggested that its vital sign thresholds should be adaptable for different age groups. The study revealed that the Visual Patient Avatar was recognized as a valuable tool in pediatric anesthesia, enabling prompt identification of underlying issues and receiving positive feedback from both children and parents. The most commonly voiced wish for improvement in the study was the ability to customize the Visual Patient Avatar's thresholds for different age groups.

Spinal Cord Stimulation (SCS) is an effective and validated treatment to address chronic refractory neuropathic pain in Persistent Spinal Pain Syndrome-Type 2 (PSPS-T2) patients. Surgical SCS lead placement is traditionally performed under general anesthesia due to its invasiveness. In parallel, recent works have suggested that Awake Anesthesia (AA), consisting in Target Controlled Intra-Veinous Anesthesia (TCIVA), could be an interesting tool to optimize lead anatomical placement using patient intra-operative feedback. We hypothesized that combining AA with Minimal Invasive Surgery (MIS) could improve SCS outcomes. The goal of this study was to evaluate SCS lead performance (defined by the area of pain adequately covered by paraesthesia generated via SCS), using an intraoperative objective quantitative mapping tool, and secondarily to assess pain relief, functional improvement and change in quality of life with a composite score. We analyzed data from a prospective multicenter study (ESTIMET) to compare the outcomes of 115 patients implanted with MIS under AA (MISAA group) or General Anesthesia (MISGA group), or by Laminectomy under General Anesthesia (LGA group). All in all, MISAA appears to show significantly better performance in terms of patient pain coverage, as well as improved secondary outcomes. One step further, our results suggest that MISAA combined with intra-operative hypnosis could potentialize patient intraoperative cooperation and could be proposed as a personalized package offered to PSPS-T2 patients eligible for SCS implantation in highly dedicated neuromodulation centers.

This study investigates job satisfaction, burnout, and well-being among first-generation migrant physicians in anesthesia and intensive care medicine in Germany, comparing them to their native German counterparts. Utilizing a cross-sectional survey design, the study collected data from 513 physicians, 110 of whom identified as having a migration background. Job satisfaction was measured using the German version of the Warr-Cook-Wall (WCW) Job Satisfaction Scale, burnout was assessed with the Copenhagen Burnout Inventory (CBI), and well-being was evaluated using the WHO-5 Well-Being Index. The job satisfaction ratings revealed no significant differences between migrant and German physicians in most dimensions, including physical workload, freedom to choose work methods, satisfaction with colleagues, responsibility, income, skill utilization, and variety in work tasks. However, migrant physicians reported significantly higher satisfaction with recognition received for their work and lower dissatisfaction with working hours. Burnout assessments showed that migrant physicians experienced higher psychological strain, perceiving every work hour as more exhausting and having significantly less energy for family and friends. Notably, migrant physicians reported higher difficulty and frustration in working with patients. Well-being ratings indicated that migrant physicians felt less energetic and active but found their daily life more filled with interesting activities. The findings underscore the unique challenges faced by migrant physicians, particularly in terms of recognition and patient-related burnout. These results highlight the need for targeted interventions to support migrant physicians, including cultural competence training and flexible working hours to enhance their job satisfaction and overall well-being. Addressing these issues is crucial for maintaining the quality of patient care and the occupational health of migrant physicians in Germany.

Sleep is still considered a mystery, despite intense scientific investigation. Here we present the first complete biological theory of sleep. The role of sleep is to restore the optimal homeostatic state, which is essential for tissue performance and health. Non-rapid eye movement sleep (NREMS) restores cortical and most other brain neurons, via relaxed global activity managed by thalamocortical circuits. The role of REM sleep is to restore acetylcholine (ACh) neurons, which support focused responses and hence cannot participate in global oscillations. Sleep enhances learning and memory via state restoration and ACh-affected paths. NREMS induces a lack of consciousness because global synchronous activity prevents focused responses, which are essential for consciousness. Dreams result from focused neural firing during sharp-wave ripples and REMS, and have a sense of reality because they involve the same neurons representing focused perceptual responses during wake. Anesthetics utilize a variety of mechanisms that prevent focused responses.

Considerable attention has recently been given to the contribution of greenhouse gas (GHG) emissions of the healthcare sector to climate change, which represents 4-6% of emissions worldwide. GHGs used in medical practice are regularly released into the atmosphere and contribute to elevation in global temperatures that produce detrimental effects on the environment and human health. Consequently, a comprehensive assessment of their global warming potential (GWP) characteristics and clinical uses, many of which have evaded scrutiny from policy makers due to their medical necessity, is needed. Of major interest are volatile anesthetics, analgesics, and inhalers, as well as fluorinated gases used as tamponades in retinal detachment surgery. In this review, we compare estimates of these gases’ GHG emissions in metric tons CO₂ equivalent (MTCO₂e) and their relative GWP. Notably, the anesthetics desflurane and nitrous oxide contribute the most emissions out of the major medical GHGs, equivalent to driving 12 million gasoline-powered cars annually in the US. Retinal tamponade gases have markedly high GWP up to 23,500 times compared to CO₂ and long atmospheric lifetimes up to 10,000 years, thus bearing the potential to contribute to climate change long-term. This review provides the basis for discussions on examining the environmental impacts of medical gases with high GWP, determining whether alternatives may be available, and reducing emissions while maintaining or even improving patient care.

In solid cancer surgery, oxidative stress (OS) is of particular interest because both the malignancy itself and the surgical intervention are major contributors to the modulation of OS levels. This study aimed to investigate the effects of solid cancer surgery on OS levels. Because solid cancer is often accompanied by intense cell death, the study specifically focused on the pathway leading to uric acid formation, (i.e. adenosine deaminase (ADA) and xanthine oxidase (XO). Ische-mia-modified albumin (IMA), a recognized marker of oxidative stress, and plasma redox poten-tial (RP) were also measured. Thirty-six patients undergoing major solid cancer surgery (median age 68 years (58-76), 23 men and 13 women) and thirty controls (62 years (51-80)) were included. During the surgical procedure, serum ADA levels did not change significantly (10.4 International Units (IU) (6.9 – 13.7) vs. 8 IU (6 – 12); p = 0.47). In contrast, XO (IU), IMA (Arbitrary Units(AU)) and redox potential (mV) decreased significantly (22.5 IU (11 – 63) vs. 8.4 IU (5 – 27); p = 0.0041, 89 AU (69 – 105) vs. 74 AU (66 – 80); p = 0.01 and 98 mV (78 – 118) vs. 79 mV (65 – 101); p = 0.033). The correlation between XO and IMA or redox potential was positive (Spearman’s r = 0.32 ; p = 0.007, and r = 0.58; p < 0.001, respectively). XO was negatively correlated with ADA (r = -0.26; p = 0.03). Redox potential was positively correlated with IMA (r = 0.26; p = 0.04) and nega-tively correlated with ADA (r = -0.25 ;p = 0.04). We found that a major source of OS in solid cancer could be the result of an increase in xanthine oxidase activity and that the global effect of solid cancer surgery is a significant decrease in OS levels. We also found that ADA and XO were inversely correlate, suggesting the existence of a negative retrocontrol between the production of free radicals and the production of their sub-strate. Finally, our study highlights the potential value of XO inhibitors as adjuvant therapy in solid tumor surgery.

Aims: The aim of our work was to demonstrate the possibility, in carefully selected cases, to perform operations under local anesthesia with a benefit to the patient and savings for national health care. Method: 123 patients with breast cancer underwent quadrantectomy or wide tumorectomy and sentinel lymph node removal under local anesthesia in out-patient surgery. Results: Of the 123 patients, 9 had micro-metastases and 4 had macro-metastases and only three of this had metastasis in other lymph nodes. Conclusions: Our results demonstrate that it is possible in selected cases to operate on breast cancer in out-patient surgery, with an advantage for the patient and savings for national health care.

In cardiac surgery, post-sternotomy pain is a significant issue, peaking within 48 hours and requiring proper analgesia for both acute relief and to avoid chronicization. Opioids are commonly used for pain management post-surgery but pose risks like adverse effects and dependency. Post-cardiac surgery pain can stem from various sources - somatic, visceral, and neuropathic, making opioid reliance a concern. Multimodal analgesia, combining different medications and regional anesthesia techniques, is increasingly recommended to decrease opioid use and its related problems. Strategies include acetaminophen, gabapentinoids, NMDA antagonists, alpha-2 agonists, intravenous lidocaine, anti-inflammatory drugs, and regional anesthesia. Implementing these approaches can enhance pain control, lessen opioid reliance, and improve cardiac surgery outcomes. The ERAS® Cardiac Society strongly advocates for an opioid-sparing multimodal approach to benefit patient recovery by reducing complications and enhancing satisfaction. This review aims to consolidate current evidence to assist healthcare providers in customizing pain management for patients post-cardiac surgery, emphasizing reduced opioid use and optimizing the recovery process.

Perioperative acute pain management in pediatric patients is essential to reduce complications. Adenoidectomy-Tonsillectomy are surgical procedures requiring pain control, and risk minimization for postoperative bleeding, nausea, and vomiting. Despite their known secondary effects, the use of opioid analgesics remains preponderant in pediatric perioperative management. We present an updated review on perioperative pain management in children and describe the development and implementation of a multimodal analgesia protocol aimed to improve patients’ pain management while consistently reducing opioids use. Information from relevant articles was summarized, then compared to our clinical needs. Learnings were used to create and implement a multimodal analgesia protocol to be used in patients 3-9 years-old undergoing adenoidectomy/tonsillectomy. Analgesic strategies have emerged to reduce or avoid the use of opioids. Among these strategies, combining different non-opioid analgesics (Ibuprofen, Paracetamol, Metamizole) has been shown to be an effective and safe pharmacological strategy when implemented as part of postoperative multimodal analgesia protocols. Significant evidence associating the use of NSAIDs with a bigger risk of postoperative bleeding does not exist. Multimodal and preventive analgesia has shown to provide significantly more effective analgesia than some opioid regimens. Ibuprofen offers highly effective analgesia for postoperative pain, particularly when combined with acetaminophen.

Abstract: Laryngoscopy for tracheal intubation has been developed for many decades. Among various conventional laryngoscopes, videolaryngoscopes (VL) have been applied in different patient populations, including difficult airways. The safety and effectiveness of VL have been repeatedly studied in both normal and difficult airways. The superiority of VL then has been observed and is advocated as the standard of care. In contrast to laryngoscopy, the development of video-assisted intubating stylet (VS, also named as styletubation) has been noticed two dec-ades ago. Since then, sporadic clinical experiences of use have appeared in literature. In this re-view article, we presented our vast use experiences of the styletubation (more than 55,000 pa-tients since 2016). We found this technique is swift (the time to intubate: from 3 s to 10 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satis-faction and fast learning curve for the novice trainees) in both normal and difficult airway sce-narios. We therefore propose styletubation technique can be feasibly applied as universal rou-tine use for tracheal intubation.

Patients who have undergone surgery in early life may be at elevated risk for neuropathic pain in later life. The risk factors for this susceptibility are not fully understood. Here, we used a mouse chronic pain model to test the hypothesis that early exposure to general anesthetic (GA) causes cellular and molecular alterations in dorsal spinal cord (DSC) and dorsal root ganglion (DRG) that produces a predisposition to neuropathic pain via an upregulation of the mammalian target of the rapamycin (mTOR) signaling pathway. Mice were exposed to isoflurane at postnatal day 7 (P7) and underwent spared nerve injury at P28 which causes chronic pain. Selected groups were treated with rapamycin, an mTOR inhibitor, for eight weeks. Behavioral tests show early isoflurane exposure enhances susceptibility to chronic pain, and rapamycin treatment improves outcomes. Immunohistochemistry, Western blotting, and q-PCR indicates that isoflurane upregulates mTOR expression and neural activity in DSC and DRG. Accompanying upregulation of mTOR and rapamycin-reversible changes in chronic pain-associated markers, including N-cadherin, cAMP response element-binding protein (CREB), purinergic P2Y12 receptor, glial fibrillary acidic protein (GFAP) in DSC; and connexin 43, phospho-extracellular signal-regulated kinase (p-ERK), GFAP, Iba1 in DRG, were observed. We conclude that early GA exposure alters the development of pain circuits such that mice are subsequently more vulnerable to chronic neuropathic pain states.

One of the most important pieces of equipment used in labs in culturing populations of fruit flies (Drosophila sp.) is that of the “CO₂ gas plate”, which is used to anesthesize individuals during “fly-pushing”. This piece of equipment consists of a box with a porous top into which carbon-dioxide is pumped. Flies placed on its surface are left immobilized, permitting the sorting, categorizing and/or counting of flies during population culturing and experimental assays. Unfortunately, commercially available gas plates are typically expensive. Here, we describe a new design for a gas plate that can be easily produced using a 3D printer and a laser cutter, which we are making freely available to the fly community.

Direct laryngoscope and videolaryngoscope are the dominant endotracheal intubation tools. Styletubation technique (using a video-assisted intubating stylet) has shown its advantages regarding in short intubation time, high success rate, less stimulation, and operator’s satisfaction. The learning curve can be steep but easy to overcome if the technical pitfalls could be avoided. Conditions make styletubation challenging include secretions/blood, short/stiff neck, restricted mouth opening and cervical spine mobility, anatomical abnormalities over head and neck regions, and obesity, etc. In this clinical report, we present the effectiveness and efficiency of routine use of the styletubation for tracheal intubation in a super-super obese patient (BMI 103 kg/m2) undergoing bariatric surgery with laparoscopic sleeve gastrectomy.

The aim of this case-series report article is to provide a new topical view of the styletubation (video intubating stylet technique) in obese patients undergoing bariatric surgeries. In contrast to various conventional direct laryngoscopes (DLs), videolaryngoscopes (VLs) have been applied in such obese population with potentially difficult airway populations. The safety and effectiveness of VLs have been repeatedly studied and the superiority of VLs then has been observed and is advocated as a routine use. In this article, among our vast use experiences of the styletubation (more than 54,998 patients since 2016) for routine tracheal intubation, we present such unique experience to apply such intubating technique in obese patient undergoing bariatric surgery. Consistent with the experiences applied in other patient populations, we found the styletubation technique to be swift (the time to intubate from 5 s to 24 s), smooth (first-attempt success rate: 100%), safe (no airway complications), and easy (high subjective satisfaction). The learning curve can be steep but is easily overcome if technical pitfalls are avoided. We, therefore, propose that the styletubation technique can be feasibly applied for tracheal intubation in obese patients undergoing bariatric surgery.