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.

Background/Objectives: The anesthetic block of the sensory branches of the superficial cervical plexus (SCP) renders a specific area of the face, head, and anterior neck insensible and painless. Chronic pain in these areas can be difficult to diagnose and treat. In this report, we briefly review the existing evidence on the topic of the SCP block (SCPB) to set the context for our research. We then share our own clinical experience with the SCPB for managing chronic pain syndromes from both cancerous and non-cancerous etiologies. Methods: We first performed a comprehensive literature search and narrative review of clinical cases and studies that utilized the SCPB as an analgesic technique. We then conducted a retrospective case series of all patients who received a SCPB at our pain clinic since 2020. Results: Our literature review found only a few cases reported, with most of them focusing on acute painful emergencies and perioperative pain syndromes and only very few addressing chronic pain. In our pain clinic, 14 patients received one or more SCPBs for chronic pain management. In 42% of these cases, the pain was related to cancer. The most common areas of pain corresponded to the regions supplied by the transverse cervical and greater auricular nerves. The procedures were uneventful in all cases, and patients rated them as effective and worthwhile 71% of the time. Conclusions: Despite the lack of high-quality studies on SCPBs in pain management, the authors’ experience suggests that it is a valid minimally invasive alternative for managing chronic face, head and neck pain.

Background/Objectives: Airway management techniques, including mask ventilation and tracheal intubation, are vital across medical settings. However, these procedures can be challenging, especially when environmental conditions are less than ideal. This study explores how the height of the operating table affects the difficulty of surgical procedures involving mask ventilation and tracheal intubation. Methods: Twenty anesthesiologists participated in this study. We assessed the difficulty of procedures- such as mask ventilation, Macintosh laryngoscopy, and video laryngoscopy with McGRATH and AWS- on a four-level scale. The operating table’s height was adjusted at four points: operator's umbilicus, inferior margin of the 12th rib, xiphoid process, and nipple. Results: Mask ventilation was easiest at the operating table’s height aligned with the inferior margin of the 12th rib. Conversely, direct laryngoscopic exposure was perceived easier at higher table heights, with nipple height being optimal. McGRATH laryngoscopy showed consistent difficulty across table height, whereas AWS tended to be somewhat more difficult at greater heights. Conclusions: The optimal bed height for video laryngoscopy coincided with that for mask ventilation. Video laryngoscopy offers enhanced flexibility in optimal patient positioning compared to Macintosh laryngoscopy, contributing to its advantages in tracheal intubation procedures.

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.

Pain diagnosis remains a challenging task due to its subjective nature, the variability in pain expression among individuals, and the difficult assessment of the underlying biopsychosocial factors. In this complex scenario, artificial intelligence (AI) can offer the potential to enhance diagnostic accuracy, predict treatment outcomes, and personalize pain management strategies. This review aims at dissecting the current literature on computer-aided diagnosis methods. It also discusses how AI-driven diagnostic methods can be integrated into multimodal models that combine various data sources, such as facial expression analysis, neuroimaging, and physiological signals, with advanced AI techniques. Despite the significant advancements in AI technology, its widespread adoption in clinical settings faces crucial challenges. Ethical considerations related to patient privacy, biases, and lack of reliability and generalizability are the main issues. Furthermore, there is a need for high-quality real-word validation as well as the development of standardized protocols and policy rules to guide the implementation of these technologies in diverse clinical settings.

Introduction: Peripheral neuropathies are very common and occur due to multiple causes including diabetes, tuberculosis, vasculitis, thyroid disorders, immune mediated diseases, vitamin B12 deficiency and drugs. Drug induced peripheral neuropathy (DIPN) is potentially irreversible, resulting in sensory deficits and paraesthesia. DIPN due to anti-tubercular drugs is common and can be implicated on linezolid, cycloserine and isoniazid.Case: 40-year-old female, diabetic with MDR-TB presented with severe, sharp, burning pain in her lower limbs. The patient was on all longer acting ATT drug regimen and was suspected with drug induced peripheral neuropathy. Conclusion: Linezolid, is used in treatment of tuberculosis and one of the major side effects includes peripheral neuropathy which is usually quite severe, presenting predominantly with sensory symptoms. Cessation of linezolid and neuropathic pain medications reduced the pain of patient from VCPS 8-10 to 1-2. Treatment of DIPN can be challenging as adverse drug reactions while treating tuberculosis should be kept in mind. It also warrants earliest treatment by identification of the drug in disguise and timely discontinuation of the drug.

Background: The predictive value of changes in C-reactive protein (CRP), procalcitonin and leukocyte levels, which are commonly used in the diagnosis of infection in sepsis and septic shock, remains a topic of debate. This study aims to evaluate the effectiveness of changes in CRP, procalcitonin, and leukocyte counts on the prognosis of patients admitted to the intensive care unit (ICU) with a diagnosis of pneumosepsis and pneumonia-related septic shock, and to investigate whether any of these markers have a superior predictive value over the others in forecasting prognosis. Methods: The study analyzed the demographic data, Charlson Comorbidity Index score (CCIS), CURB-65 score (confusion, uremia, respiratory rate, BP, age ≥ 65 years), and Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores of 230 patients admitted to the ICU with a diagnosis of pneumosepsis and pneumonia-related septic shock between April 1, 2022, and December 31, 2023. The levels of CRP, procalcitonin, and leukocytes were also recorded and analyzed to assess their impact on 1-month and 3-month mortality outcomes. Results: According to multivariate logistic regression analysis, low BMI, male gender, high CCIS, CURB-65, and APACHE-II scores were found to be significantly associated with both 1-month and 3-month mortality (p<0.05). An elevated SOFA score was associated with 1-month mortality, while advanced age was related to 3-month mortality (p<0.05). Although there was no significant relationship between the first-day levels of leukocytes, CRP, and PCT and mortality, their levels on the third day were observed to be at their highest in both 1-month and 3-month mortality cases (p<0.05). Additionally, a concurrent increase in any two or all three of CRP, PCT, and leukocyte values was found to be higher in patients with 3-month mortality compared to those who survived (p=0.004). Discussion: Although PCT, CRP, and leukocyte values measured at the time of admission were not significantly associated with 1-month mortality in patients with pneumosepsis or pneumonia-related septic shock, the persistent elevation and concurrent increase of these values, along with male gender, advanced age, low BMI, and high CCIS, CURB-65, and APACHE-II scores, were found to be significantly associated with 3-month mortality.

The diagnosis of migraine is based on clear criteria outlined in the International Classification of Headache Disorders version 3 (ICHD-3). Notably, the criteria in ICHD-3 omit the location of migraine. There are increasing reports of migraine in the facial region.(1-3) Facial presentations of migraine are not easy to diagnose as they appear in the lower 2/3rd of the face, often in the maxillary sinus region, around the ear, the upper/lower jaws and teeth.(4) Moreover, the symptomatology of these facial representations of these headaches often resembles sinusitis and dental pathology. We will review these presentations, their diagnosis and possible pathophysiology.

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.

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.

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.

Introduction Emergency laparotomy is a surgical procedure associated with significantly higher mortality rates compared to elective surgeries. Awake laparotomy under neuraxial anaesthesia has recently emerged as a promising approach in abdominal surgery to improve patient outcomes. This study aims to evaluate the feasibility and potential benefits of using lumbar spinal anaesthesia as the primary anaesthetic technique in emergency laparotomies. Methods We conducted a case series involving 16 patients who underwent emergency laparotomy for bowel ischemia, perforation, or occlusion. Lumbar spinal anaesthesia was employed as the main anaes-thetic technique. We analysed patient demographics, clinical characteristics, intraoperative details, and postoperative outcomes. The primary outcome measures included the adequacy of postoper-ative pain control, the incidence of postoperative complications, and mortality rates. Results Among the 16 patients, adequate postoperative pain control was achieved, with only 2 patients requiring additional analgesia. Postoperative complications, including sepsis, wound dehiscence, and pneumonia, were observed in 7 patients (44%). The observed mortality rate was relatively low at 6% (1 patient). Notably, conversion to general anaesthesia was not necessary in any of the cases, and no early readmissions were reported. Discussion Our findings highlight the feasibility and potential benefits of using neuraxial anaesthesia in emergency laparotomies. The observed low mortality rate and the avoidance of conversion to general anaesthesia suggest that lumbar spinal anaesthesia may be a useful alternative in emer-gency settings. However, the occurrence of postoperative complications in 44% of patients indi-cates the need for cautious patient selection and close monitoring. Further research with larger sample sizes is warranted to fully elucidate the efficacy, safety, and potential impact of this tech-nique on patient outcomes in emergency laparotomies.

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.

Abstract Background: Occipital neuralgia is a debilitating condition and traditional treatments often provide limited or temporary relief. Recently, ultrasound-guided hydrodissection of the greater occipital nerve (GON) has emerged as a promising minimally invasive approach. Objectives: To describe two novel ultrasound-guided hydrodissection with 5% dextrose for GON and discuss their advantages, disadvantages, and considerations. Methods: Two case reports are presented. Case 1 describes a lateral decubitus approach for hydrodissecting the GON between the semispinalis capitis (SSC) and obliquus capitis inferior (OCI) muscles. Case 2 details a cranial-to-caudal approach for hydrodissecting the GON within the SSC and upper trapezius (UT) muscles when the GON pass through these two muscles. Results: Both patients experienced significant and sustained pain relief with improvements in function and quality of life. Conclusions: Ultrasound-guided GON hydrodissection using 5% dextrose is a promising treatment for occipital neuralgia. The lateral decubitus and cranial to caudal approaches provide additional options to address patient-specific anatomical considerations and preferences.

The severity and invasiveness of clinical outcomes from organic responses to trauma are influenced by individual, surgical and anesthetic factors. A stress response elicits neuroendocrine and immune reactions that may lead to multi-organ dysfunction. The degree of neuroinflammatory reflex activation from trauma can increase pro-inflammatory cytokine production, leading to endothelial dysfunction, glycocalyx damage, neutrophil activation and multisystem tissue destruction. A shift in patient treatment towards a neuroinflammatory perspective has prompted a new evaluation protocol for surgical patients, required to understand surgical pathogenesis and its link to chosen anesthesia-surgical methods. This study aims to provide a description of the mechanisms involved in the immune and neuroendocrine response and below is a summary of the main mediators, focusing on video laparoscopic surgeries, by examining its frequency usage by researchers. We performed a narrative review of data from databases like PubMed, MEDLINE, EMBASE, high-impact journals, and studies from the past decade that used inflammatory mediator analysis to compare anesthetic and surgical strategies. Results showed preference for certain biomarkers more sensitive to tissue trauma. These markers display distinct behaviors, temporal fluctuations and their dosages serve as a tool to measure and validate therapeutic approaches in perioperative systemic inflammation.

Abstract Objective: To assess wound infiltration with ropivacaine plus magnesium sulfate for pain relief following thyroid surgery. Background: Analgesia with local anesthetics following surgery is a critical element of alleviating postoperative pain. However, such strategies in neck surgery has not been a well-established practice. Methods: This prospective double-blind randomized study enrolled 68 patients who underwent thyroid surgery. Concerning the solution used for surgical wound infiltration the study participants were randomly allocated into three groups: 1) 100 mg of ropivacaine (Group R), 2) 100mg of ropivacaine plus magnesium sulfate 10mg/kg (Group RMg), and 3) normal saline which served as placebo (Group P). Pain perception both at rest and at movement, was measured using the Visual Analogue Scale (VAS) at 30 minutes, as well as 1, 2, 4, 6, 12, and 24 hours postoperatively. The total consumption of analgesics in morphine equivalents was also recorded. Moreover, adverse effects and patient satisfaction were recorded. Cortisol, TNF-α, and IL-6 levels were measured 30 minutes before infiltration, 6 hours and 24 hours postoperatively. Results: Demographics and clinical characteristics were similar between the groups. The VAS scores at rest and during movement were significantly lower in the RMg group compared to saline or ropivacaine groups. Total analgesic consumption was also significantly lower in the RMg group. No operational, wound or infiltration-related adverse effects were recorded in the study groups. Better overall satisfaction was obtained for the group RMg. Conclusions: Ropivacaine plus magnesium sulfate wound infiltration provided better pain control and analgesic effect was more significant, contributing to effective postoperative analgesia in patients undergoing thyroid surgery.

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.

Background: The transversus abdominis plane (TAP) block has gained increasing importance as a very effective pain relief in for caesarean section. This study aimed to compare bupivacaine (Group B), bupivacaine with dexmedetomidine (Group BD) and bupivacaine with dexamethasone (Group BDx) applied in ultrasound-guided TAP block in the treatment of CS postoperative pain. Material and Method: American Society of Anesthesiologists I and II pregnant women who underwent cesarean section were included in the study. Forty patients were admitted in each group. All patients were applied TAP block with ultrasound guidance by administering the medications of the group in which they were included. Results: Body mass index (BMI) and operation duration were higher in Group B (p*=0.01 and 0.004, respectively). Instant tramadol requirement and amount were higher in Group B at some of follow up times. Patient satisfaction scale were better in Group BD and Group BDx. Conclusion: TAP block significantly reduces pain after cesarean section, prolongs the time to first analgesic request, and reduces the need for additional opioid analgesics. The addition of adjuvant to the TAP block usually improves the postoperative clinical condition. However, some special conditions such as body mass index (BMI) may negatively affect the clinical situation. Comprehensive, standardized, randomized controlled studies are needed to compare results under different conditions.

The accurate identification of bacterial infections is critical for effective treatment in intensive care units (ICUs), yet current diagnostic methods face limitations in sensitivity and specificity, along-side cost and accessibility issues. Consequently, there's a pressing need for a marker that is economically feasible, rapid, and reliable. Presepsin (PSP), also known as soluble CD14 subtype (sCD14-ST), has emerged as a promising biomarker for early sepsis diagnosis. PSP, derived from soluble CD14, reflects the activation of monocytes/macrophages in response to bacterial infec-tions. It has shown potential as a marker of cellular immune response activation against patho-gens, with plasma concentrations increasing during bacterial infections and decreasing post-antibiotic treatment. Unlike traditional markers such as procalcitonin (PCT) and C-reactive protein (CRP), PSP specifically indicates monocyte/macrophage activation in bacterial infections. While limited studies in critical illness have explored PSP's role in sepsis, its diagnostic accuracy varies with threshold values, impacting sensitivity and specificity. Recent meta-analyses suggest PSP's diagnostic potential for sepsis, yet its standalone effectiveness in ICU infection management remains uncertain. This review provides a comprehensive overview of PSP's utility in ICU set-tings, including its diagnostic accuracy, prognostic value, therapeutic implications, challenges, and future directions.

Background: Electrical Impedance Tomography (EIT), combined with variable ventilation strate-gies and Artificial Intelligence (AI), is poised to revolutionize critical care by transitioning from reactive to predictive approaches. This integration aims to enhance patient outcomes through personalized interventions and real-time monitoring. Methods: This narrative review explores the principles and applications of EIT, variable ventilation, and AI in critical care. EIT’s impedance sensing creates dynamic images of internal physiology, aiding in the management of conditions like Acute Respiratory Distress Syndrome (ARDS). Variable ventilation mimics natural breathing variability to improve lung function and minimize ventilator-induced lung injury. AI enhances EIT through advanced image reconstruction techniques, neural networks, and digital twin technology, offering more accurate diagnostics and tailored therapeutic interventions. Conclu-sions: The confluence of EIT, variable ventilation, and AI represents a significant advancement in critical care, enabling a predictive, personalized approach. EIT provides real-time insights into lung function, guiding precise ventilation adjustments and therapeutic interventions. AI inte-gration enhances EIT's diagnostic capabilities, facilitating the development of personalized treatment plans. This synergy fosters interdisciplinary collaborations and sets the stage for in-novative research, ultimately improving patient outcomes and advancing the future of critical care.

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 prevalence of patients on buprenorphine therapy presenting for elective surgery has increased. Buprenorphine is a widely used medication for management of patients with chronic pain. It is also used for maintenance therapy for patients with a history of opioid use disorder (OUD). Due to lack of standardized protocol for managing patients on buprenorphine peri-operatively, we performed a retrospective analysis to compare pain score outcomes and post-operative opiate requirements between patients who continued versus discontinued buprenorphine. We identified 35 patients, 11 continued buprenorphine and 24 discontinued buprenorphine. The average Post-Anesthesia Care Unit (PACU) pain score was 7.54 for those who discontinued pre-operative buprenorphine and 5.59 for those who continued (P value 0.0339). The average post-operative Morphine Milligram Equivalent (MME) use was 86.13 for those who continued pre-operative buprenorphine and was 107.70 for those who discontinued buprenorphine (P value 0.6439). The results from our study correlate with several previous studies which showed lower PACU pain scores in patients who continued buprenorphine. There is a benefit of decreased pain post-operatively when pre-operative buprenorphine is continued and having a decrease in relapse in those with a history of OUD.

Background: The laryngeal mask airway Vision Mask (LMA VM) is a supraglottic airway device (SAD) with vision guidance system. The ideal head and neck position for direct laryngoscopy is known, but the ideal position for placing a LMA is not. The objective of this study is to evaluate and compare the optimal position for placement of a video laryngeal mask airway. Methods: This was a prospective observational, transversal and analytical study of 72 consecutive patients. In the same patient, laryngeal vision was first assessed with the head and neck in the sniffing position and then with the head in the neutral position. Procedures were filmed and performed by the same investigator. Assessment of the laryngeal view was performed using two classifications: modified Cormack-Lehane classification and Brimacombe classification. Device placement was considered adequate when the Cormack-Lehane rating was scored from 1 to 2 and the Brimacombe rating was from 2 to 4. Results: 72 patients were included in this study. In the assessment of the glottis using the Cormack Lehane classification for fiberoptic view, laryngeal visibility was adequate in 64 (88.89%) patients in the neutral position and in 65 (90,28%) patients in the sniffing position (p>0,05). In the fiberoptic view of the glottis, assessed using the Brimacombe classification, laryngeal visibility was adequate in 68 (93%) patients in the neutral position and in 69 (95%) patients in the sniffing position, (p>0,05). There was no statistically significant difference in the rate of success between the sniffing position (70 patients, 97.22% success rate) and the neutral position (67 patients, 93.06% success rate) during the first insertion attempt. Two patients required a second attempt in the sniffing position, while five patients required a second attempt in the neutral position. Conclusion: An adequate sniffing position did not result in a better glottic view than neutral position, and the number and type of additional maneuvers were equal in both positions.

Among nonsteroidal anti-inflammatory drugs, ibuprofen, diclofenac, and celecoxib have been frequently used in multimodal analgesia. Recent studies challenge the conventional theory that they exhibit activity and toxicity by acting on cyclooxygenase selectively. We compared their membrane interactions that may be associated with analgesic and gastrointestinal toxic effects. Biomimetic membranes suspended in buffers of different pH were prepared with 1-palmitoyl-2-oleoylphosphatidylcholine, sphingomyelin, and cholesterol to mimic neuronal membranes and with 1,2-dipalmitoylphosphatidylcholine to mimic gastrointestinal mucosae. The membrane interactivity was determined by measuring fluorescence polarization. At pH 7.4, the drugs interacted with neuro-mimetic membranes to decrease membrane fluidity at pharmacokinetically-relevant 0.5–100 μM. Celecoxib was most potent, followed by ibuprofen and diclofenac. At pH 4.0 and 2.5, however, the drugs increased the fluidity of 1,2-dipalmitoylphosphatidylcholine membranes at 0.1–1 mM corresponding to gastroduodenal lumen concentrations after administration. Their membrane fluidization was greater at gastric pH 2.5 than at duodenal pH 4.0. Low-micromolar ibuprofen, diclofenac, and celecoxib structure-specifically decrease neuronal membrane fluidity, which hypothetically could affect signal transmission of nociceptive sensory neurons. Under gastroduodenal acidic conditions, high-micromolar ibuprofen, diclofenac, and celecoxib induce fluidity increases of membranous phosphatidylcholines that are hypothetically associated with gastrointestinal toxic effects, which would enhance acid permeability of protective mucosal membranes.

The trigeminal nerve is responsible for innervating the periorbita. Ultrasound-guided trigeminal block is employed in humans for trigeminal neuralgia or periorbital surgery. There are no studies evaluating this block in dogs. This study aims to evaluate and compare two approaches (coronoid and temporal) of the trigeminal nerve block. We hypothesized superior staining with the coronoid approach. Thirteen dog heads were used. After a preliminary anatomical study, two ultrasound-guided injections per head (right and left, coronoid and temporal approach, randomly assigned), with an injectate volume of 0.15 mL cm-1 of cranial length were performed (iodate contrast and tissue dye mixture). The ultrasound probe was placed over the temporal region, visualizing the pterygopalatine fossa. For the temporal approach, the needle was advanced from the medial aspect of the temporal region in a dorsoventral direction. For the coronoid approach, it was advanced ventral to the zygomatic arch in a lateromedial direction. CT scans and dissections were conducted to assess and compare the position of the needle, spread of injectate, and nerve staining. No significant differences were found. Both approaches demonstrated effective interfascial distribution of injectate, with some minimal intracranial spread. Although the coronoid approach did not yield superior staining as hypothesized, it presents a viable alternative to the temporal approach. Studies in live animals are warranted to evaluate clinical efficacy and safety.

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.

.Bacground: Sepsis remains a major health challenge worldwide, characterized by a dysre-gulated host response to infection, leading to high mortality and morbidity in intensive care units (ICUs). The Fibrosis 4 (FIB-4) index, originally developed to assess liver fibrosis in hepatitis C patients, has recently been explored for its potential prognostic value in sepsis patients. Method: This study retrospectively analyzed 309 sepsis patients admitted to the Internal Me-dicine and Anaesthesia ICUs between December 12, 2021, and December 15, 2023, to inves-tigate the relationship between FIB-4 levels, Acute Physiology and Chronic Health Evaluation (APACHE), and Sequential Organ Failure Assessment (SOFA) and clinical outcomes. Results: The study found that higher FIB-4 measurements were statistically significantly asso-ciated with increased 28-day mortality, with a cut-off value of 4.9 providing a sensitivity of 54.92% and specificity of 74.25%. Logistic regression analysis indicated that elevated Conclusion:FIB-4 levels were a significant predictor of early mortality, suggesting that the FIB-4 index could serve as a valuable prognostic tool in assessing the severity and prognosis of sepsis patients.

Severe cancer pain significantly diminishes patients' quality of life, leading to increased reliance on caregivers. Although opioid analgesics are effective, they may induce opioid-induced bowel dysfunction (OIBD) with symptoms such as nausea, vomiting, drowsiness, and constipation. While controlled-release oxycodone is a viable option, its prolonged use can lead to opi-oid-induced constipation (OIC). Addressing this, a relative novel formulation - a fixed 2:1 ratio of oxycodone and naloxone in prolonged release - aims to provide analgesia while alleviating OIC. This review critically assesses the evidence on the efficacy, safety, and patient experience of ox-ycodone/naloxone prolonged release in managing severe cancer pain, emphasizing the necessity for a targeted approach in this patient population.

Background: Chronic lateral epicondylitis challenges the therapeutical approach; underlying mechanisms are incompletely understood; neuropathic pain and central and peripheral sensitization may explain the fact that botulinum toxin was found to play a role in pain and function management. Methods: We searched the literature for MeSH terms: lateral epicondylitis or synonyms and botulinum toxin. Results: We found 14 papers containing trials on botulinum toxin injection into the tendon or into the extensor muscles (particularly extensor carpi radialis brevis and extensor communis digitorum). We followed the administration pathways, doses, timing and side effects. Conclusion: With chronic course, the focus of the therapy shifts from the afflicted tendon to the inserting muscles, as muscle contracture may create a vicious loop to perpetuate and aggravate the disease. Doses, timing and side effects are discussed.

Background: Effective identification and management in the early stages of sepsis are critical for achieving positive outcomes. In this context, neutrophil activation status (NEUT-RI) emerges as a promising and easily interpretable parameter. This study aimed to assess the predictive value of NEUT-RI in diagnosing sepsis and to evaluate its prognostic significance in distinguishing 28-day mortality outcomes. Materials: The study is a secondary retrospective observational analysis. Clinical data upon ICU admission were collected. A control group of critically ill patients without sepsis criteria was included. Patients were divided into subgroups based on renal function for biomarker evaluation, with 28-day outcomes reported for septic and non-septic patients. Results: 200 patients were included in the study. A significant difference between the "septic" and "non-septic" groups was detected in the NEUT-RI plasma concentration (53.80 [49.65–59.05] vs. 48.00 [46.00–49.90], p< 0.001, respectively). NEUT-RI and PCT distinguished between not complicated sepsis and septic shock (PCT 1.71 [0.42 - 12.09] vs 32.59 [8.83 - 100.00], < 0.001 and NEUT-RI 51.50 [47.80 - 56.30] vs 56.20 [52.30 - 61.92], p=0.005). NEUT-RI, PCT and CRP values were significantly different in patients with “renal failure”. NEUT-RI and PCT at admission in ICU in septic group were higher in patients who died (58.80 [53.85-73.10] vs 53.05 [48.90-57.22], p=0.005 and 39.56 [17.39-83.72] vs 3.22 [0.59-32.32], p=0.002, respectively). Both NEUT-RI and PCT showed high negative predictive value and low positive predictive value. Conclusions: The inflammatory biomarkers assessed in this study offer valuable support in the early diagnosis of sepsis. NEUT-RI elevation appears particularly promising for early sepsis detection and severity discrimination upon admission

Introduction The monitoring of cerebral perfusion in patients with brain damage is a major clinical challenge. Monitoring cerebral oxygenation (rSO2) by NIRS was introduced at the turn of the 1980s, and many clinicians believed it was a valuable method for assessing cerebral perfusion and subsequent measures to optimize cerebral flow. The main problem of NIRS usage is the presence of the intermediate structures-skin, skull, meninges, cerebrospinal fluid-and their influence on the outcome of the test. Therefore, it seems that NIRS assessment performed on a patient during brain death attempts, can give an idea of the magnitude of the influence of these intermediate structures on the monitoring result. Case We present a retrospective analysis of cerebral oxygenation measurements of a patient undergoing a brain death diagnostic procedure. A clinical situation where the cerebral blood flow is stopped can give an idea of the specificity of the method, particularly the impact of the influence of intermediate structures on the monitoring outcome. In this case, the NIRS result is increased by the oxygenation of the patient before the apnoea test. The influence of chromophores in the tissues surrounding the CNS, reflections and scattering of the light wave spectrum have a very significant effect on the final result of cerebral saturation measurement. Discussion The majority of research observations describing changes in cerebral perfusion or its optimisation may be burdened by the problem described, i.e. the significant influence of measured oxygenation from intermediate structures. The specificity of NIRS to assess cerebral perfusion requires careful analysis. The therapeutic implications of monitoring cerebral oxygenation with NIRS are of great importance and, from the example presented and the literature provided, the method should be used with caution. It has been shown that in a patient with brain death, the result of NIRS oxygenation measurements depends on the surrounding structures of the brain.

Background and Objectives: ARNE score was developed for the prediction of difficult airway for both general and ENT surgery with a universal cut-off value. We tested the accuracy of this score in the case of laryngeal surgery and provided an insight of its combination with flexible laryngoscopy. Materials and Methods: This prospective pilot clinical study included 100 patients who were being scheduled for microscopic laryngeal surgery. We have calculated ARNE score for every patient and flexible laryngoscopy was provided preoperative. Difficult intubation was assessed according to intubation difficulty score (IDS). Results: A total of 33% patients had difficult intubation according to IDS. ARNE score showed to be accurate for prediction of difficult intubation in laryngology with P&lt;0.0001 and AUC 0.784. Flexible laryngoscopy showed to be an independent parameter with P&lt;0.0001 and AUC 0.766. We have defined a new cut-off value of 15.50 for laryngology, according to AUC curve. After the patients were divided in two groups, according to the new cut-off value and provided cut-off value, AUC improved to 0.707 from 0.619 respectively. Flexible laryngoscopy improved the prediction model of ARNE score to AUC 0.882 and of new cut-off value to AUC 0.833. Conclusions: It is recommended to use flexible laryngoscopy together with ARNE score in difficult airway prediction in patients with laryngeal pathology. Also, universally recommended cut-off value of 11 can not be effectively used in laryngology and a new cut-off value of 15.50 is recommended.

Palmitoylethanolamide (PEA) has been prescribed for neuropathic pain for several years. This study is mainly addressed to summarize what has been published on the topic in the last decades, and how appropriate the numerous prescriptions are. Among others, it examines the innovative EquiPEA^® patent, which aims to address obstacles encountered with conventional PEA formulations. EquiPEA^® seems to partially ameliorate the bioavailability and the targeted distribution. It seems to introduce novel advancements that have the potential to enhance the therapeutic effectiveness of PEA in terms of its anti-inflammatory, antioxidant, and analgesic properties. The deep literature analysis aims to examine the potential advantages of this innovative formulation, in the context of several pathological conditions that may benefit from this molecule. In particular, it investigates the potential enhanced bioavailability and targeted delivery system of EquiPEA^®. Also, it tries to understand if it can modernize the field of therapy based on PEA, thus offering a better treatment option for individuals with long-term inflammation, oxidative stress, and neuropathic or mixed pain with a neuropathic component. The study examines the possible impact of EquiPEA^® on personalized medicine strategies and its potential for translation into clinical practice. It analyses the possibilities that EquiPEA^® has in enhancing patient outcomes in a range of central nervous system and inflammatory conditions. This narrative review makes a valuable contribution to the ongoing comprehension of PEA therapy. It establishes a foundation for further exploration in research and potential uses in clinical settings.

There is an anecdotal impression that teenage patients report exaggerated postoperative pain scores that do not correlate with their actual level of pain. Nurse and parental perception of teenagers' pain can be complemented by knowledge of patient pain behavior, pain catastrophizing thoughts, anxiety, and mood level. Two hundred two patients completed the study: 56.4% female, 89.6% White, 5.4% Black, and 5% other race. Patient ages ranged from 11 to 17 years (mean = 13.8, SD = 1.9). The patient, the parent, and the nurse completed multiple questionnaires on day one after laparoscopic surgery to assess patient pain. Teenagers and parents (r=0.56) have a high level of agreement, and teenagers and nurses (r=0.47) have a moderate level of agreement on pain scores (p &lt;0.05). The correlation between patient APBQ (Adolescent Pain Behavior Questionnaire) and teenager VAS (Visual Analog Scale ) and between nurse APBQ and teenager VAS, while statistically significant (p &lt; 0.05), is weaker (r range = 0.14-0.17). There is a moderate correlation between teenagers' pain scores and their psychological assessments of anxiety, catastrophic thoughts, and mood (r range= 0.26 – 0.39; p &lt;0.05). A multi-modal evaluation of postoperative pain can be more informative than only assessing self-reported pain scores.

Vascular anomalies are a diverse group of abnormal blood vessel developments that can occur at birth or shortly afterward. Embolization and sclerotherapy have been utilized as a treatment option for these malformations but may cause moderate to severe pain. This study aims to evaluate the utilization of peripheral nerve blocks in opioid consumption, pain scores, and length of stay. A retrospective chart review was conducted at the UPMC Children's Hospital of Pittsburgh for all patients who underwent embolization and sclerotherapy between 2011 and 2020. Patient data was collected to compare opioid consumption, pain scores, and length of stay. Eight hundred fifty-four procedures were performed on 347 patients. The morphine milligram equivalent per kilogram mean ratio between groups was 0.9 (0.86, 0.95) with a p-value of &lt;0.001. The pain score mean ratio was –1.17 (–2.2, -0.1) and a p-value of 0.027. Length of stay had a mean ratio of 0.94 (0.4, 2) and a p-value of 0.875. By decreasing opioid consumption and postoperative pain scores, peripheral nerve blocks may have utility in patients undergoing embolization and sclerotherapy while not clinically increasing the length of stay for patients. Their use should be individualized and carefully discussed with the interventional radiologist.

Burn patients still represent an important challenge in critical care medicine today. These patients can develop significant neurological conditions up to intracranial hypertension, but as they find themselves hospitalized outside of neurocritical care and are often subjected to sedation for the complex management, they are sometimes underestimated. The aim of this study is to evaluate the feasibility of non-invasive methods for the early diagnosis of intracranial hypertension in these patients. In this prospective observational study, adult burn patients admitted to intensive care within the first 8 hours of the event were enrolled. These patients were studied through ultrasound measurement of optic nerve sheath diameter and intracranial vessel velocimetry with transcranial Doppler. In the 20 patients studied, no frankly pathological values were identified in the 3 different measurement stages (within 8 hours of the burn, then at 48 and 96 hours) and no correlations were identified between the measured values and the extension of the burn with the related risk of mortality. However, this study, one of a kind, demonstrates that these non-invasive methods are applicable to this specific patient population, and can represent an effective method for reducing the incidence of complications that are dangerous for survival.

Neuropathic pain is caused by a lesion or disease of the somatosensory system and is one of the most incapacitating pain types, representing a significant non met medical need. Due to the increase in research in the field and since innovative therapeutic strategies are required, namely in intractable neuropathic pain, neurostimulation has been used. Within this approaches, transcranial magnetic stimulation (TMS) that uses a transient magnetic field to produce electrical currents over the cortex emerges in the literature. Since this is an area in expansion and due to the putative role of TMS, we performed a bibliometric analysis in Scopus with the primary objective of identify the scientific production related to the use of TMS to manage neuropathic pain. The research had no restrictions and the analysis focused on the characteristics of the literature retrieved, scientific collaboration and main research topics from inception to July 6, 2023. A total of 474 articles were collected. A biggest co-occurrence between the terms “neuropathic pain” and “transcranial magnetic stimulation” was obtained. The journal “Clinical Neurophysiology” leads the Top 5 most productive sources. The United States is the most productive country with 50% of the documents being “review articles” followed by France with 56% of the documents being “original articles”. Lefaucheur, JP and Saitoh, Y are the two most influents authors. The most frequent type of documents was “original article”. This study allows to perform a general overview in the field of TMS application for neuropathic pain and is useful to establish future directions of research in this field.

Fibromyalgia is a complex and often misunderstood chronic pain disorder. It is characterized by widespread musculoskeletal pain, fatigue, and heightened sensitivity, and has evolved in diag-nostic criteria and understanding over the years. Initially met with skepticism, fibromyalgia is now recognized as a global health concern affecting millions of people, with a prevalence trans-cending demographic boundaries. The clinical features and diagnosis of fibromyalgia encompass a range of symptoms beyond pain, including sleep disturbances and cognitive difficulties. The study emphasizes the importance of a comprehensive evaluation for accurate diagnosis, considering the shift from tender point reliance to a more holistic approach. Etiology and pathophysiology involve genetic predisposition, neurotransmitter dysregulation, central sensitization, and immune system involvement. Risk factors such as gender, age, family history, and comorbid conditions contribute to susceptibility. The impact on quality of life is profound, affecting physical and social aspects, often accompanied by mood disorders. Management approaches include pharmacological interventions, non-pharmacological therapies, lifestyle modifications, and alternative treatments. The study also delves into emerging research, exploring advances in neurobiological understanding, brain imaging, genetic markers, glutamate modulation, cannabinoids, gut microbiome, and digital health tools for fibromyalgia manage-ment. Overall, this study provides a nuanced and up-to-date overview of the complexities sur-rounding fibromyalgia, aiming to enhance understanding and support for individuals grappling with this challenging condition.

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.

Anesthetics reduce cardiac functions and lower blood pressure (BP), potentially causing excessive BP reduction in dehydrated patients or those with heart conditions, such as coronary artery disease (CAD). Considering the increased prevalence of cardiovascular disease with age, anesthesiologists must be cautious about BP reduction during general anesthesia in older adults. In the present case, an undiagnosed CAD patient in a hypovolemic state experienced a significant systolic blood pressure drop to the 50s during propofol and sevoflurane anesthesia. Despite the use of vasopressors, excessive hypotension persisted, leading to anesthesia suspension. Subsequent cardiac examinations, including computed tomography heart angio and calcium score, and coronary angiogram, revealed a near total occlusion of the left main coronary artery and the formation of collateral circulation. After 5 days of hydration and anticoagulation medications and confirmation of normovolemic state, general anesthesia was attempted again and successfully induced; a normal BP was maintained throughout the surgery. Thus, it is important to conduct a thorough cardiac evaluation and maintain normovolemia for general anesthesia in older adults.

Comparing to males, females require much more morphine to produce comparable levels of analgesia, suggesting a difference in the endogenous hyperalgesia and analgesia modulation between sexes. Aside from hormones, emerging evidence suggests sex-differential intrinsic neural regulation of pain generation and maintenance. According to the International Association for the Study of Pain (IASP) and American College of Gastroenterology (ACG), up to 25 % of the population having visceral pain at any one time, and in the United States 10-15 percent of adults suffering from irritable bowel syndrome (IBS). Here we analyzed literatures on clinical reports of sex differences in visceral pain focusing on IBS, other form of bowel dysfunction and comorbidities, and summarized animal models that provided means to investigate the underlying molecular mechanisms in sexual dimorphism of visceral pain. Neurons and nonneuronal cells (glia and immune cells) in the peripheral and central nervous systems all contribute to sex-dependent nociception and nociplasticity in the painful signal processing. Emotion is another factor in pain perception and appears to have sexual dimorphism.

Introduction: In recent years, platelets have been in short supply and high demand. Approximately one in five cardiac surgery patients require platelets. In our safety-net hospital, however, the incidence is over 40%. Renal dysfunction, long cardiopulmonary bypass (CPB) times, and absence of tranexamic acid (TXA) are common risk factors for requiring platelet transfusions. Methods: Our hypothesis was fewer platelets would be transfused within two hours after bypass under these three conditions: creatinine is low, predicted surgery duration is short, and TXA is uniformly administered. Our anesthesia department designed this retrospective before-and-after observational study when the surgery department decided to narrow preoperative criteria respective to these three elements. The Institutional Review Board of Louisiana State University Health Sciences Center Shreveport approved of the protocol and waived individual informed consent. We compared timing of platelet transfusions (within 7 days) in consecutive patients who had CPB during the first ninety days of 2022 to those in 2023 using t-tests in SAS 9.3. Confounders included age, weight, anticoagulants, gender, and the platelet counts and hemoglobin immediately prior to platelet transfusion. Secondary outcomes were postoperative day two creatinine and other components transfused. Results: Preoperatively creatinine tended to be higher in 2022 at 1.5 vs 1.1, reaching significance postoperatively at 1.9 vs 1.1 (p=0.02). Bypass times decreased from 174 to 124 minutes (p=0.06). TXA use increased from 18 of 28 to 26 of 29 patients. Platelet counts increased on bypass from 142 to 173 (p=0.06). Platelet and hemoglobin nadirs were higher (day 3: 8g/dL vs 8.8, p=0.04; 98 vs 138, p=0.005). Platelet units transfused per patient tended to increase (0.75+/-1 vs 0.93+/-1.5); if exposed, patients tended to receive more units (2.1+/-1.3 vs 2.5+/-1.4) sooner. Changes in transfusions for red cells were nonsignificant at 1.97 per patient to 1.21, cryoprecipitate 0.36 to 0.69, and FFP 0.93 to 0.83. Conclusions: This is the first study examining timing of platelet transfusions after bypass. In the present investigation, we measured platelet count during bypass and prothrombin hours after arrival in the intensive care. Platelets were often administered in sets of two because of scarce immediate supply, partly from lack of an agitator table. More importantly, these data support a need for point-of-care thromboelastograms intraoperatively, but the cost has been prohibitive. Some centers’ algorithms list triggers for transfusion by fibrinogen and prothrombin times, available immediately after separation from bypass.

A ganglion cyst is a benign fluid-filled sac that typically appears on the dorsal aspect of the wrist, arising idiopathically near the joint capsule or tendon sheath. Diagnosis is primarily clinical, with MRI and ultrasound serving as confirmation tools. Treatment options range from immobilization, aspiration, hydrossection, steroid or hyaluronidase injection, to surgical intervention. Although relatively uncommon, Dorsal Ganglion Cysts (DGC) can lead to Dorsal Wrist Impingement (DWI) syndrome. This syndrome results from the thickening of the wrist capsule due to overuse, injury, or repetitive activities. This thickening can lead to the compression of the extensor carpi radialis brevis (ECRB) tendon during wrist extension and produce tenderness around the lunate. In some refractory cases, MRI findings may show recurrent ganglion cysts, while in others, they may appear "normal." Consequently, the diagnosis remains clinical, and imaging is primarily employed to rule out secondary causes. Management strategies encompass rest, immobilization, occupational therapy, non-steroidal anti-inflammatory drugs (NSAIDs), cortisone injections, and, in certain instances, surgical intervention. Despite the clinical significance of these conditions, limited studies have explored their interrelationship. In this context, we present a rare case involving a 23-year-old female with recurrent DGC accompanied by DWI syndrome. Initially, the patient reported idiopathic left dorsal wrist pain localized around the tendon sheath. Her initial X-ray did not reveal any abnormalities, but MRI identified two ganglion cysts. A series of treatments were initiated, including left tendon sheath hydrossection, corticosteroid injections into the left wrist, and the excision of ganglion cysts from the left wrist. Furthermore, occupational therapy, oral Meloxicam, and Voltaren gel treatments were integrated into the management plan. Subsequent imaging confirmed the resolution of the cysts and an overall enhancement in the range of motion and wrist strength. However, the patient experienced only minimal pain relief, and pain was still elicited during end-range wrist extension and upon dorsal wrist palpation. An electromyography (EMG) test ordered to rule out neuropathic causes did not yield any conclusive results. Nonetheless, a repeat X-ray revealed mild soft tissue swelling on the dorsal side of the wrist, and a follow-up MRI detected ganglion cysts on the dorsal aspect of the lunate and the ECRB tendons. These findings indicated a re-accumulation of dorsal ganglion cysts with a concurrent dorsal impingement syndrome component. Consequently, the patient was referred to an orthopedic surgeon for evaluation and potential revision surgery. This unique case underscores the possibility of developing DWI Syndrome after the removal of a DGC. The diagnosis of this syndrome can be elusive, particularly when X-rays, MRIs, and EMGs yield negative results. Trauma, such as repeated hand surgery or recurrent ganglion cysts, may exacerbate wrist pain despite improvements in range of motion and strength. Special consideration should be given to patients who undergo surgical cyst excisions, as this procedure heightens the risk of recurrence and can irritate the tendon sheath. Collaborative efforts between Physical Medicine and Rehabilitation (PM&amp;R), Occupational Therapy (OT), and surgical teams may play a pivotal role in managing pain associated with these conditions. We propose that future research endeavors should focus on establishing guidelines for the management of this unique condition.

Chest trauma is one of the most serious and difficult injuries, with various complications that can lead to ventilation - perfusion (V/Q) mismatch and systemic hypoxia. We are presenting a case of 53 – year - old male with no comorbidities or chronic therapy, who was admitted to the Intensive Care Unit due to severe respiratory failure after chest trauma. He developed right - sided pneumothorax and then thoracic drain was placed. On admission, the patient was hemodynamically unstable and tachypneic. The patient was intubated and mechanically ventilated, febrile (38.9°C) and unconscious. A lung CT showed massive non-ventilated areas predominantly in the right lung. He was ventilated with PEEP of 10 cmH2O with a FiO2 of 0.6 – 0.8. Empirical broad-spectrum antimicrobial therapy was immediately initiated. Both high FiO2 and moderate PEEP were maintained and adjusted according to the current blood gas values and oxygen saturation. After Stenotrophomonas maltophilia was identified and treated with sulfamethoxazole/trimethoprim his general condition gradually improved, and he was weaned from mechanical ventilation. In conclusion, both ventilatory and antibiotic therapy were needed to improve oxygenation and outcome of the patient with pneumonia due to the resistant S. maltophilia with V/Q mismatch.

This narrative review aims to summarize evidence regarding the current utilization and future applications of neuromodulation in patients with headaches, with special attention paid to migraine and chronic cluster headache. We performed a narrative review of the literature to identify studies that detail the effectiveness of neuromodulation therapies in the treatment of headache syndromes. The literature was refined to predominantly focus on systematic reviews published in the last year that have the most robust reporting of research done on this topic. Patients with headache face several challenges, including medication overuse, cost burden, non-compliance to medications due to inability to tolerate side effects, or treatments that are ineffective. Neuromodulation is an emerging field that encompasses implantable and non-implantable technologies that intervene on the signaling and perception of pain. In recent years, this technology has been used as an analgesic, and has been shown to be effective for treatment-resistant headache, particularly when used in patients with migraine and chronic cluster headache.

Post-operative pain is the unpleasant sensory and emotional experience after surgery, its origin being both the inflammatory reaction induced by the surgical trauma on the abdominal wall, and the splanchnic pain, induced by the activation of nociceptors of the viscera, which are highly sensi-tive to distension, ischemia and inflammation. Nowadays, it is well recognized that there is a close relationship between the gut microbiome and pain perception, and that microbiome is highly af-fected by both anaesthesia and surgical manipulation. Thus, efforts to restore the disturbed micro-biome by supplementation with beneficial bacteria, namely probiotics, seems to be effective. In this article the knowledge gained mainly from experimental research on this topic is analyzed, the con-cluding message being that each probiotic strain works in its own way towards pain relief.

Regional anesthesia in postoperative pain management have developed in recent years, especially with the advent of fascial plane blocks. This study aims to compare the ultrasound-guided bilateral erector spinae plane block (ESPB) versus bilateral transversus abdominis plane block (TAPB) on postoperative analgesia after laparoscopic or robotic urologic surgery. This was a retrospective observational study; 97 patients (ESPB-group) received bilateral ultrasound-guided ESPB with 20 mL of ropivacaine 0.375% plus 0.5 mcg/kg of dexmedetomidine in each side at the level of T7-T9, and 93 patients (TAPB-group) received bilateral ultrasound-guided TAPB with ropivacaine 0.375% or 0.25%. The primary outcome was post-operative numeric rating scale (NRS) pain score, which was significantly lower in the ESPB-group on postoperative days 0, 2, and 3 (p=0.012, p=0.016 and p=0.004). Concerning the secondary outcomes, consumption of ropivacaine was significantly lower in ESPB-group (p<0.001) and the total amount of analgesic rescue doses was significantly lower in the ESPB-group than TAPB-group in postoperative days from 2 to 4 (1 vs 3, p>0.001). Incidence of postoperative nausea and vomiting was higher in the TAPB-group and no block related complications were observed. We conclude that ESPB provide better postoperative pain control with less consumption of local anesthetic and less total rescue analgesic therapies.

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.

Gabapentin (GBP), a GABA analogue, is primarily used as an anticonvulsant to treat partial seizures and neuropathic pain. While a majority of the side effects are associated with the nervous system, emerging evidence suggests a high risk for heart diseases in the patients taking GBP. In the present study, we used a preclinical model of rats to investigate (1) the acute cardiovascular responses to GBP (bolus i.v. injection, 50 mg/kg) and (2) the effects of chronic GBP treatment (i.p. 100 mg/kg/day x 7 days) on cardiovascular function and the myocardial proteome. Under isoflurane-anesthesia, rat blood pressure (BP), heart rate (HR), and left ventricular (LV) hemodynamics were measured using Millar pressure transducers. The LV myocardium and brain cortex were analyzed by proteomics, bioinformatics, and western blot to explore the molecular mechanisms underlying GBP-induced cardiac dysfunction. In experiment (1), we found that i.v. GBP significantly decreased BP, HR, maximal LV pressure, and maximal and minimal dP/dt, whereas it increased IRP-AdP/dt, Tau, systolic, diastolic, and cycle durations (*p < 0.05 and **p < 0.01 vs baseline; n = 4/group). In experiment (2), we found that chronic GBP treatment resulted in hypotension, bradycardia, and LV systolic dysfunction, with no change in plasma norepinephrine. In the myocardium, we identified 109 differentially expressed proteins involved in calcium pathways, cholesterol metabolism, and galactose metabolism. Particularly, we found that calmodulin, a key protein of intracellular calcium signaling, was significantly upregulated by GBP in the heart but not in the brain. In summary, we found that acute and chronic GBP treatments suppressed cardiovascular function in rats, which is attributed to abnormal calcium signaling in cardiomyocytes. These data reveal a novel side effect of GBP independent of the nervous system, providing important translational evidence to suggest that GBP can evoke adverse cardiovascular events by depression of myocardial function.

Introduction and Aims: COVID-19-associated invasive pulmonary aspergillosis (CAPA) is common and is associated with poor outcomes in critically ill patients. This prospective observational study aimed to explore the association between CAPA development and the incidence and prognosis of cytomegalovirus (CMV) reactivation in critically ill COVID-19 patients. Materials and Methods: We included all consecutive critically ill adult patients with confirmed COVID-19 infection who were admitted to three COVID-19 intensive care units (ICUs) in an Italian hospital from February 25, 2020, to May 8, 2022. A standardized procedure was employed for early detection of CAPA. Risk factors associated with CAPA and CMV reactivation and the association between CMV recurrence and mortality were estimated using adjusted Cox proportional hazard regression models. Results: CAPA occurred in 96 patients (16,6%) of the 579 patients analyzed. Among the CAPA population 40 (41,7%) patients developed CMV blood reactivation with a median time of 18 days (IQR 7-27). The CAPA+CMV group did not exhibit a significantly higher 90-day mortality rate (62.5% vs. 48.2%) than the CAPA alone group (p=0.166). The CAPA+CMV group had a longer ICU stay, fewer ventilation-free days, and a higher rate of secondary bacterial infections than the control group of CAPA alone. In the CAPA population, prior immunosuppression was the only independent risk factor for CMV reactivation (HR 2.33, 95% C.I. 1.21-4.48, p=0.011). Conclusions: In critically ill COVID-19 patients, CMV reactivation is common in those with a previous CAPA diagnosis. Basal immunosuppression before COVID-19 appeared to be the primary independent variable affecting CMV reactivation in patients with CAPA. Furthermore, the association of CAPA+CMV versus CAPA alone appears to impact ICU length of stay and secondary bacterial infections but not mortality.

Unexpected preoperative surgery cancellations are one of the important problems in daily anesthesia practice. It's an even bigger problem if these cancellations happen in the operating room. Our aim was to draw attention to this issue and reveal the reasons. This prospective, cross-sectional study aimed to assess the prevalence and causes of elective surgery cancellations once patients are in the operating room. The study sample consisted of 7482 adult patients scheduled for elective surgeries and taken to the operating room. Sixty-seven patients whose surgeries were canceled were grouped into Group 1, while the remaining 7415 whose surgeries were completed were in Group 2. Patients were divided into two groups based on whether their surgeries were completed or canceled. Factors such as age, American Society of Anesthesiologists physical status, and surgical department were analyzed. Metrics involved comparisons between the two groups regarding age, American Society of Anesthesiologists physical status classification, surgical department, and timing of the surgery. The prevalence of elective surgery cancellations after patients were in the operating room was 0.9%. Group 1 was significantly older than Group 2 (p&lt;0.001). The proportion of patients classified as American Society of Anesthesiologists physical status III was higher in Group 1 (p&lt;0.001). The department with the highest cancellation rate was ophthalmology(2.5%), followed by general surgery(2.1%), urology(1.5%), and ear, nose, and throat(1.4%). Approximately 59.7% of cancellations were deemed potentially avoidable. The study suggests that many of these cancellations are potentially avoidable, underscoring the need for optimized surgical scheduling and patient assessment protocols.

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.

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.

In neonatal equines, pathologies involving umbilical structures are an important cause of morbidity, and surgical removal of urachal remnants is a common procedure in clinical practice. Surgery involving the ventral abdominal wall can cause substantial pain, leading to complications and prolonged recovery. The objectives of this study were to describe a two-point bilateral ultrasound-guided rectus sheath block at the level of the umbilicus and to evaluate the extent of dye distribution in foal cadavers. Ten foal cadavers were included in the study, in which a bilateral two-point ultrasound-guided rectus sheath block was performed—one injection cranially and a second one caudally to the umbilicus. The injectate consisted of a mixture of iodinated contrast medium and blue dye at a volume of 0.25 mL kg-1 per injection point (total 1 mL kg-1). After the injection, computer tomography and subsequent dissection of the ventral abdominal wall were performed. The extension of the contrast medium, the number of stained nerves, and contamination of the abdominal cavity were evaluated. The cranio-caudal extension of the contrast ranged from 0.8 to 1.4 centimeters per milliliter of injectate. The most commonly stained ventral branches of spinal nerves were thoracic (Th) nerves 16, 17, and 18 (95%, 85%, and 80% of the nerves, respectively). Abdominal contamination was found in 4 animals. The results suggest that the block could provide periumbilical analgesia. Further studies with different volumes of injectate and living animals are warranted.

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.

Background: Machine learning can analyze vast amounts of data and make predictions for events in the future. Our group created machine learning models for vital sign predictions. To transport the information of these predictions without numbers and numerical values and make them easily usable for human caregivers, we aimed to integrate them into the Philips Visual-Patient-avatar, an avatar-based visualization of patient monitoring. Methods: We conducted a computer-based simulation study with 70 participants in three European university hospitals. We validated the vital sign prediction visualizations by testing their identification by anesthesiologists and intensivists. Each prediction visualization consisted of a condition (e.g., blood pressure low) and an urgency (a visual indication of the timespan in which the condition is expected to occur). To obtain qualitative user feedback, we also conducted standardised interviews and derived statements that participants later rated in an online survey. Results: The mixed logistic regression model showed 77.9% (95%CI 73.2-82.0%) correct identification of prediction visualizations (i.e. condition and urgency both correctly identified) and 93.8% (95%CI 93.7-93.8%) for conditions only (i.e. without considering urgencies). Forty-nine of 70 participants completed the online survey. The online survey participants agreed that the prediction visualizations were fun to use (32/49, 65.3%), and that they could imagine working with them in the future (30/49, 61.2%). They also agreed that identifying the urgencies was difficult (32/49, 65.3%). Conclusions: This study found that care providers correctly identified >90% of the conditions (i.e. without considering urgencies). The accuracy of identification decreased when considering urgencies in addition to conditions. Therefore, in future development of the technology, we will focus on either only displaying conditions (without urgencies) or improve the visualizations of urgency to enhance usability for human users.

Background and Objectives: Botulinum toxin injections are commonly used for the treatment of spasticity. However, injection procedures are associated with pain and procedural anxiety. While pharmacological approaches are commonly used to reduce these, inno-vative technology might be considered as a potential non-pharmacological alternative. Given this context, immersive virtual reality (VR) has shown effectiveness in the man-agement of procedural pain[1]. Our retrospective pilot study aimed to assess the potential added value of virtual reality in the management of pain and anxiety during intra-muscular injections of botulinum toxin. Materials and Methods: Twenty-one adult patients receiving botulinum toxin injections were included. A numerical rating scale was used to assess pain and anxiety during the injection procedure. The patient reported the pain experienced during previous injections without VR before injection and the pain expe-rienced in the current procedure with VR after the end of the procedure. Level of satis-faction of VR experience, if they agreed to reuse VR for the subsequent toxin botulinum injection, and if they would recommend VR to other patients were assessed. Results: The use of virtual reality showed a decrease of 1.8 pain-related points compared to without technology. No significant improvement in the level of anxiety was reported. Patients were very satisfied by their VR experience (7.9 out of 10) and would agree to reuse VR in their next injection procedure (88%) and to recommend the use of VR in other patients (100%). Conclusion: VR was useful for managing procedural pain related to botulinum toxin injection in adults, with a high level of satisfaction reported by the patient. VR should be considered as a valuable alternative to pharmacological approach to manage procedural pain during Botulinum toxin injection in adults.

The 30-day postoperative outcome after elective endovascular aneurysm repair (EVAR) was evaluated and the possible predictors were identified. Demographics, medical history, laboratory values, length of hospitalization (LOH), intensive care unit (ICU) admission and 30-day complications, classified as major [major adverse cardiovascular events (MACE), acute kidney injury (AKI) and death of any cause] and minor [post-implantation syndrome (PIS), postoperative delirium (POD), urinary tract infection (UTI) and technical graft failure] were documented, respectively. We included 322 patients (median LOH 4 days). One-hundred and twenty one (37.5%) complications, mostly minor (n=103, 31.9%), were recorded. Eleven patients (3.4%) evolved MACE, 5 (1.6%) AKI and 2 patients (0.6%) died in ICU. Seventy-seven patients (23.9%) suffered from PIS, eleven from POD, 11 from UTI and 4 from technical graft failure. Multivariate logistic regression analysis revealed that aneurysm diameter (p=0.01) and past smoking (p=0.003) were predictors for postoperative complications. PAD was an independent predictor of MACE (p=0.003), preoperative neutrophil to lymphocyte ratio (NLR) value of AKI (p=0.003) and past smoking of PIS (p=0.008), respectively. Our study showed that 30-day morbidity after EVAR exceeded 35%. However, the majority of complications were classified as minor and the associated mortality was low. Aneurysm diameter and past smoking were independent predictors for postoperative outcome.

Adverse events associated with opioid use in palliative care have been extensively studied. However, predicting the occurrence of adverse events based on the specific opioid used remains unclear. This study aimed to comprehensively analyze the adverse events caused by µ receptor stimulation of opioids approved in Japan and investigate the tendencies of adverse event occur-rence among different opioids.We utilized the FDA Adverse Event Reporting System (FAERS) database to extract reported adverse events of opioids approved in Japan. Cluster analysis was performed on reporting odds ratios (RORs) of adverse event names among opioids to visualize relationships between opioids and adverse events, facilitating a comparative study of their clas-sifications.We calculated the RORs of adverse events for the target opioids. Based on these RORs, we performed a cluster analysis, which resulted in the classification of 11 target opioids into five distinct groups. we were able to comprehensively compare and examine the relationships between opioids and adverse events. This analysis helps in understanding and managing the risks and benefits of each drug in palliative care settings. By analyzing relationships between opioids and adverse events, clinicians can make informed decisions about opioid selection, dosage, and monitoring to maximize patient safety and comfort.

BACKGROUND: Few studies have examined the use of immunoassay urine drug testing of cancer patients in palliative care clinics. OBJECTIVES: We examined the frequency of immunoassay urine drug test (UDT) abnormalities and the factors associated with aberrancy at a safety-net hospital palliative medicine clinic. METHODS: A retrospective review of the electronic medical records of consecutive eligible patients seen at the outpatient palliative medicine clinic in a resource-limited safety net hospital system was conducted between September 1, 2015 and December 31, 2020. We collected longitudinal data on patient demographics, UDT findings, and potential predictors of aberrant results. RESULTS: Of the 913 patients in the study, 500 (55%) underwent UDT testing, with 455 (50%) having the testing within the first three visits. Among those tested within the first three visits, 125 (27%) had aberrant UDT results; 44 (35%) of these 125 patients were positive for cocaine. In a multivariable regression model analysis of predictors for aberrant UDT within the first 3 visits, non-Hispanic White race (odds ratio [OR]=2.13; 95% confidence interval [CI]: 1.03-4.38; p=0.04), history of illicit drug use (OR=3.57; CI: 1.78-7.13; p< 0.001), and history of marijuana use (OR=7.05; CI: 3.85-12.91; p< 0.001) were independent predictors of an aberrant UDT finding. CONCLUSION: Despite limitations of immunoassay UDT, it was able to detect aberrant drug taking behaviors in a significant number of patients seen at a safety net hospital palliative care clinic, including cocaine use. These findings support universal UDT monitoring and utility of immunoassay-based UDT in resource limited settings.

Blood gas analysis plays a central role in modern medicine. Advances in technology have expanded the range of available parameters and increased the complexity of their interpretation. By applying user-centered design principles, it is possible to reduce the cognitive load associated with interpreting blood gas analysis. In this international, multicenter study, we explored anesthesiologists' perspectives on Visual Blood, a novel visualization technique for presenting blood gas analysis results. We conducted interviews with participants following two computer-based simulation studies: the first utilizing Virtual Reality (VR) (50 participants) and the second without VR (70 participants). Employing the template approach, we identified key themes in the interview responses and formulated six statements, which were rated using Likert scales: from 1 (strongly disagree) to 5 (strongly agree) in an online questionnaire. The most frequently mentioned theme was the positive usability features of Visual Blood. The online survey revealed that participants found Visual Blood to be an intuitive method for interpreting blood gas analysis (median 4, IQR 4-4, p<0.001). Participants noted that minimal training was required to effectively learn how to interpret Visual Blood (median 4, IQR 4-4, p<0.001). However, adjustments are necessary to reduce visual overload (median 4, IQR 2-4, p<0.001). Overall, Visual Blood received a favorable response. The strengths and weaknesses derived from these data will help optimize future versions of Visual Blood to improve the presentation of blood gas analysis results.

This prospective study aimed to evaluate the ability of point-of-care Doppler ultrasound measurements of carotid-corrected flow time and changes in corrected carotid flow time (FTc) induced by volume expansion to predict fluid responsiveness in patients undergoing robot-assisted gynecological surgery in a modified head-down lithotomy position. FTc was measured using Doppler images of the common carotid artery before and after volume expansion. The stroke volume index at each time point was recorded using the MostCare instrument. Fluid responsiveness was defined as a stroke volume index ≥10% increase after volume expansion. Half (50%) of the 52 patients responded positively. The areas under the receiver operating characteristic curves measured to predict fluid responsiveness for the corrected carotid flow time and changes in the FTc were 0.82 [95% confidence interval:0.705–0.937; P &lt; 0.0001] and 0.67 (95% confidence interval:0.520–0.815; P &lt; 0.05), respectively. The optimal cut-off value for the FTc and the change in FTc were 356.5 ms and 19.5 ms, respectively. FTc is a more reliable predictor of fluid responsiveness than FTc induced by volume expansion in gynecological patients undergoing robot-assisted laparoscopic surgery in the modified head-down lithotomy position.

In the Emergency Department (ED), pain is one of the symptoms that is most frequently reported, making it one of the most significant issues for the emergency physician, but is frequently under treated. Intravenous (IV), oral (PO), and intramuscular (IM) delivery are the standard methods for administering acute pain relief. Firstly, we compared the safety and efficacy of IN analgesia to other conventional routes of analgesia to assess if IN analgesia may be an alternative for the management of acute pain in ED. Secondary, we analyzed the incidence and severity of adverse events (AEs) and rescue analgesia required. We performed a systematic review-based keywords in Pubmed/Medline, Scopus, EMBASE, the Cochrane Library and Controlled Trials Register finding only twenty randomized Clinical trials eligible in the timeline 1992-2022. A total of 2098 patients were analyzed and compared to intravenous analgesia showing no statistical difference in adverse effects. In addition, intranasal analgesia also has a rapid onset and quick absorption. Fentanyl and ketamine are two intranasal drugs that appear promising and may be taken simply and safely while providing effective pain relief. IN is simple to administer, non-invasive, rapid onset and quick absorption; it might be a viable choice in a variety of situations to reduce patient suffering or delays in pain management. Analgesia needs to be tailored to each patient's features and type of pain: IN Fentanyl and Ketamine look promising and may be administered easily and safely while providing effective pain relief.

Breast cancer is the most common malignant disease in women. Preclinical studies have confirmed that the local anesthetic levobupivacaine has a cytotoxic effect on breast cancer cells. We examined whether postoperative wound infiltration with levobupivacaine influences survival in 120 patients who were operated on for breast cancer and underwent quadrantectomy or mastectomy with axillary lymph node dissection. Groups with continuous levobupivacaine wound infiltration, bolus wound infiltration, and diclofenac analgesia were compared. Long-term outcomes examined were quality of life, shoulder disability, and hand grip strength (HGS) after one year, and survival after 5 and 10 years. Groups that had infiltration analgesia had better shoulder function compared to diclofenac after one year. Levobupivacaine PCA group had the best preserved HGS after 1 year (P=0.022). The most significant predictor of the 5-year outcome was HGS (P=0.03). Although the best survival after 5 and 10 years was registered in the bolus levobupivacaine group, statistical significance was not reached (P=0.36). The extent of the disease at the time of surgery is the most important predictor of long-term survival. A larger prospective clinical study could better confirm the effect of levobupivacaine wound infiltration on outcomes after breast cancer surgery observed in this pilot study. Trial number NCT05829707

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.

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.

TBI is one of the most common causes of death and long term damage to health worldwide. The approved guidelines for patients with TBI include standards of treatment. However, there is lack of guidelines for monitoring or neuroprotective treatment. Cerebrolysin is a drug with a proven beneficial effect on treatment outcome in patients with TBI. There are also reports of the beneficial effect of Amantadine. Studies on the use of additional neuromonitoring are also published with increasing frequency. We decided to investigate how the result of treatment changed with the administration of Cerebrolysin and Amantadine and with additional neuromonitoring. In an observational study, we collected data on 56 patients. After the statistical analysis, it could be shown, that Cerebrolysin monotherapy increases Glasgow Outcome Scale (GOS) among our patients and it was found to interact significantly with Amantadine and neuromonitoring approach in the group of severe TBI. In conclusion, it is worth considering a multimodal approach to the treatment and monitoring of patients with TBI. However, more randomized studies are needed to confirm the method of monitoring or conducting neuroprotective therapy in patients with TBI.

Pulmonary aspiration is a serious anaesthetic complication with morbidity and up to 9% of all anaesthesia-related mortality. Aspiration risk is especially focused on fastening time. We aimed to evaluate the prevalence of 'risky stomach' defined by ultrasound imagine of solid contents and/or calculated gastric fluid volume >1.25 mL/kg in elective surgery also comparing this definition with the 0-2 qualitative rating scale used for "empty/risky stomach". This prospective study has 97 patients aged 2-18. Ultrasonographic evaluations of the gastric antrum content is scaled with qualitative assessment in supine and right lateral decubitus (RLD) position. Gastric volume was calculated. In our study, stomach content and volume were evaluated by ultrasound in 97% of children and 5.2% had Grade 2 antrum. In RLD position, antral CSA was 2.36 cm², and the median gastric volume was 0.46 mL/kg. In patients with grade 0 antrum has moderate and positive correlation between antral CSA and BMI, and strong and positive correlation between antral CSA and age like grade 1 antrum. We showed that 0.1%-4.7% of elective children had gastric fluid volumes of >1.25 mL/kg as "risky stomach". Ultrasound for gastric contents could be used routine practice to determine pulmonary aspiration risk in emergency and elective procedures.

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.

Background: The clinical impact of vasopressin in hemorrhagic shock remains largely unknown. Objective: This systematic review and meta-analysis was designed to investigate the effects of vasopressin receptor agonists during the resuscitation of hemorrhagic shock. Methods: A systematic search of PubMed (MEDLINE), Scopus, and PubMed Central was conducted for relevant articles. Preclinical (animal) and clinical studies were included. The primary objective was to investigate the correlation of vasopressin receptor agonist use with mortality and various hemodynamic parameters. Results: Data extraction was possible in 13 animal studies and two clinical studies. Differences in risk of mortality between patients who received a vasopressin receptor agonist were not statistically significant when compared to those who were not treated with such agents [RR (95%CI): 1.17 (0.67, 2.08); p=0.562; I2 = 50%]. The available data were insufficient to conduct a meta-analysis assessing the effect of vasopressin receptor agonists on hemodynamics. Drawing safe conclusions from animal studies was challenging, due to significant heterogeneity in terms of species and dosage of vasopressin receptor agonists across studies. Conclusions: Differences in risk of mortality between patients who received a vasopressin receptor agonist were not statistically significant when compared to those who were not treated with such agents after hemorrhagic shock.

Pain is frequently reported during cancer disease, and still remains poorly controlled in 40% of patients. Recent developments in oncology have helped to better control pain. Targeted treatments may cure cancer disease and significantly increase survival. Thereby, a novel population of patients (cancer survivors) has emerged, also enduring chronic pain (27.6% moderate to severe pain). The present review discuss the different options currently available to manage pain in (former) cancer patients in the light of progress made in the last decade. Major progress in the field are recent development of a chronic cancer pain taxonomy now included in International Classification of Diseases (ICD-11) and update of WHO analgesic ladder. Until recently, cancer pain management has mostly relied on pharmacotherapy, opioids being considered as mainstay. The opioids crisis has prompted the reassessment of opioids use, both in cancer patients and cancer survivors. The review focuses on the current utilization of opioids, on the neuropathic pain component often neglected and on techniques and non-pharmacological strategies available which help to personalize patient’s treatment. Cancer pain management is now closer to the management of chronic non-cancer pain i.e. “an integrative pain care” aiming to improve patient’s quality of life.

Background : Our objectives were to investigate the incidence of elevated methemoglobin level among COVID-19 patients at intensive care unit. The correlation of methaemoglobinemia with mortality and some haematological parameters was also tested. Methods: The diagosis of coronavirus -19 infection was confirmed by RT-PCR. The quantitative method for determination of methemoglobin was it’s cyanide derivative by spectrophotometry. The reference range was less than 2 percent. Results: There were altogether 46 patients (11 male, 35 female) included. Their median age value was 70 y. ( 29 – 89). The methemoglobin median value was 4,3%. 15 of 46 patients died. The methemoglobin median value of departed patients was 8 % , and 2,5% was among survivors. ( P= 0,001) 19 patients were blood transfused. Their methemoglobin median was 11 % , otherwise the non transfused patients presented 2,7 % methemoglobin median. ( p= 0,001). We performed two binary logistic regression calculation, in order to judge the elevated methemoglobin level as an independent risk factor for the mortality. The predictor of methaemoglobin was 0,062 the constant -1,266 the odds ratio 1,06. The other binary logistic regression tested the fact of transfusion for the mortality. Predictor of transfusion 1,1474, constant -1,2527 odds ratio 3,15 There was no significant correlation between methemoglobin and CRP level. Discussion: The methemoglobin is not able to transport oxygen. It’s association with mortality is discussed by some papers.There are several hypothesis in the literature to explain it’s occurrence in COVID-19. The role of coronavirus proteins as oxydative agents was mentioned. The importance of enzyme defect is emphasized. The impact of reactive oxygen free radicals in inflammation is also probable. Some papers mentioned applying local anesthetics and azythromycin as a risk. The role of transfusion is obscure, because the methemoglobin can be elevated in blood conserves during storage. Conclusion: Testing the methemoglobin seems to be important, but the pathomechanism needs further research.. The traceability and standardization of different measurement methods at intensive care units is the key for defining it’s pathogenetic role.

Purpose: To reassess the results of former meta-analyses focusing on the relationship between novel HES preparations (130/0.4 and 130/0.42) and acute kidney injury. Previous meta-analyses are based on studies referring to partially or fully unpublished data or data from abstracts only. Methods: The studies included in the former meta-analyses were scrutinized by the authors independently. We completed a critical analysis of the literature, including the strengths, weaknesses and modifiers of the studies when assessing products, formulations and outcomes. Results: Both the published large studies and meta-analyses show significant bias in the context of the deleterious effect of 6% 130/0.4-0.42 HES. Without (1) detailed hemodynamic data, (2) the exclusion of other nephrotoxic events and (3) a properly performed evaluation of the dose-effect relationship; the AKI-inducing property of 6% HES 130/0.4 or 0.42 could not be accounted as evidence. The administration of HES is safe and effective if the recommended dose is respected. Conclusion: Our review suggests that there is questionable evidence for the deteriorating renal effect of these products. Further well-designed, randomized and controlled trials are needed. Further conclusions formulated for resource-rich environments should not be extended to more resource-scarce environments without proper qualifiers provided.

Background: Chronic, non-cancer pain represents a serious public health and economic issue affecting approximately 20% of the global population. Chronic pain can affect many aspects of patient’s lives, including mental health, employment, and relationships. Current medical management is largely focussed on investigating and managing acute pain. Patients and clinicians are now increasingly aware of the potential benefits of combined treatments or complex interventions in alleviating chronic pain. These approaches include both physical interventions, such as exercise or yoga, as well as psychological support including cognitive behavioural therapy (CBT) and talking therapies. Methods: This study used network meta-analyses to explore the prevalence of complex interventions in pain management, and the effects of these interventions on quality of life, using outcome measures including intensity of chronic pain, assessment of functional disability and participant’s psychological state. Results: Psychological interventions were associated with improvements in pain intensity and depression. Exercise and manipulation technique-based treatments provided a statistically significant reduction in pain intensity. This effect was enhanced when exercise and CBT were combined. Mensendieck somatocognitive therapy (MSCT) plus standard gynaecological treatment (STGT) treatments appeared to have a better effect on chronic pain than multimodal exercise plus CBT treatment. Combined MSCT and STGT treatment, and multimodal exercise plus CBT treatments, reduced pain intensity, whilst MSCT+STGT treatments had a slightly better effect than exercise plus CBT treatment.Conclusions: Complex interventions have become more popular with patients as the risks associated with other interventions including surgery and pharmacological management have become better understood. These interventions can have a significant positive effect both on the physical and psychological health of patients. The analysis presented in this study suggests that further work is warranted in this area and that additional studies are required, both in more geographically diverse locations, and with larger cohorts.

Thermoregulation is important for maintaining homeostasis of our body. It can be easily broken under anesthesia. An appropriate method to measure the core body temperature is needed, especially for elderly patients because the efficiency of thermoregulation gradually decreases with age. The aim of this study was to examine the accuracy and feasibility of using of SpotOn® sensor in lower extremity orthopedic surgery in elderly patients aged over 80 years by comparing a SpotOn® sensor with two other reliable minimal-invasive methods: a tympanic membrane thermometer and a bladder thermometer. This study enrolled 45 patients aged over 80 years who were scheduled to undergo a lower extremity surgery. Body temperature was measured using a SpotOn® sensor, tympanic membrane thermometer and bladder thermometer. Agreements between the SpotOn® sensor and the other two methods were assessed using Bland and Altman plots for repeated measures adjusted for unequal numbers of measurements per patient. Compared with TempBladder, bias and limits of agreement for TempZHF were 0.07℃ ± 0.58℃. Compared with TempTympanic, bias and limits of agreement for TempZHF were -0.28℃ ± 0.61℃. 3M SpotOn® sensor using ZHF method for patients aged over 80 years undergoing lower extremity surgery shows feasible measurement value and sensitivity.

Objective: To describe the proportion of patients undergoing major abdominal surgery who develop postoperative hypothermia, and the variables associated with its occurrence. Material and Methods: We conducted a prospective cohort study in a tertiary care referral hospital in Mexico City to describe the incidence of perioperative hypothermia and factors associated with postoperative hypothermia. A repeated measures ANOVA model was used to compare preoperative, intraoperative, and postoperative temperatures. Potential variables associated with hypothermia were evaluated with a logistic regression analysis. Results: A total of 110 patients were included in the analysis. Of them, 61% (n=67) were women. The mean age was 56.7 years (SD: 16.3, range: 75). The most frequently involved organ on which surgery was performed was kidney or urinary tract (21.8%), followed by large bowel (14.5%) and exploratory laparotomy (14.5%). The incidence of postoperative hypothermia in patients undergoing major abdominal surgery was 57.3%, while preoperative and intraoperative hypothermia occurred in 55.5% and 79.1%, respectively. Age over 60 years was the only variable associated with postoperative hypothermia after multivariable adjustment for sex, age, and time surgery (OR=18.4, 95% CI:3.79-89.6, p<0.0001). Conclusion: Increasing age was the only variable associated with postoperative hypothermia in patients undergoing major abdominal surgery.

Objective: This systematic review and meta-analysis compared the patient-reported outcomes of intra-articular facet joint injections of normal saline and selected active substances to identify a more effective agent for treating subacute and chronic low back pain (LBP). Methods: The PubMed, Embase, Scopus, Web of Science, and CENTRAL databases were searched for randomized controlled trials and observational studies published in English. A research quality assessment was performed using ROB2 and ROBINS-I. A meta-analysis was conducted using a random-effects model, and the mean differences (MD) with 95% confidence intervals (CI) in efficacy outcomes, including pain, numbness, disability, and quality of life, were assessed. Results: Of the 2,467 potential studies, three were included (247 patients). The active substances and normal saline had similar therapeutic effects on pain within 1 h, after 1-1.5 months, and after 3-6 months, with MD and 95% CI of 2.43 and -11.61 to 16.50, -0.63 and -7.97 to 6.72, and 1.90 and -16.03 to 19.83, respectively, as well as the quality of life after 1 and 6 months. Conclusion: The short- and long-term clinical effects of intra-articular facet joint injections of normal saline are comparable to those of other active substances in patients with LBP.

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.

Abstract: (1) Background: Minimally-invasive sacroiliac joint (SIJ) fusion is the preferred surgical intervention to treat chronically severe pain associated with SIJ degeneration and dysfunction. (2) Methods: This paper details the ten-step surgical procedure associated with the postero-inferior approach using the PsiF™DNA Sacroiliac Joint Fusion System. (3) Results: The posterior surgical approach with an inferior operative trajectory (postero-inferior) utilizes easily identifiable landmarks to provide the safest, most direct access to the articular joint space for transfixing device placement. Implanting the device through the subchondral bone, provides maximum fixation and stabilization of the joint by utilizing an optimal amount of cortical bone-implant interface. Approaching the joint from the inferior trajectory also places the implant perpendicular to the S1 endplate at a “pivot point” near the sacral axis of rotation, which addresses the most significant motion of the joint. (4) Conclusions: Further observational data from real-world clinical use are encouraged to further validate this procedure as the surgical preference for minimally-invasive SIJ fusion.

Chronic pain is a source of major alterations in quality of life. It represents significant costs for health systems, and reduces the competitiveness of the working population. Vulnerability can drive the incidence of chronic pain, through its influence on modifiable risk factors, and reduced utilization of health care systems. But vulnerability can also be the consequence of a chronic pain: illness can push people into precariousness. We analysed the factors associated with pain intensity among vulnerable persons with a chronic condition, in five European countries (N=1,364). Pain was, among the whole set of variables, the main predictor of sleep problems, fatigue, depression, self-perceived health, physical and mental quality of life. This is in line with other studies showing the major impact of pain on an individual’s health and life. Multivariable analyses, adjusting for the whole set of variables, showed that women had more intense pain, as well as participants with a lower education level. These results confirm the social component in the complex etiology of pain and clearly plaid in favor of integrated care, taking into account individual characteristics and environment.

The survival rate of extracorporeal life support (ECLS) remains overall at 60 %. Research and development is slow, partly due to the lack of sophisticated experimental models. This publication introduces a dedicated rodent oxygenator (“RatOx”) and shows preliminary in vitro classification tests. The RatOx has an adaptable fiber module size for various rodent models. Gas transfer performance over the fiber module for different blood flows and fiber module sizes were tested according to DIN EN ISO 7199.At the maximum possible amount of effective fiber surface and a blood flow of 100 ml/min, the oxygenator performance has been tested to a maximum of 6.27 ml O2/min and 8.2 ml CO2/min, respectively. The priming volume for this the largest fiber module is 5.4 ml, while the smallest possible configuration with a single fiber mat layer has 1.1 ml of priming volume. The novel RatOx ECLS system has been evaluated in-vitro to comply to a high degree with all predefined functionality criteria for rodent sized animal models. We intend for the RatOx to become a standard testing platform for scientific studies on ECLS therapy and technology.

Background: The hypothesis is that a hypoxic-hyperoxic preconditioning (HHP) is associated with a protective effect on myocardial function by reducing endothelial damage and a beneficial effect on postoperative outcome in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Methods: Patients (n=120) were randomly assigned to an HHP and a control group. A safe inhaled oxygen fraction for the hypoxic preconditioning phase (10-14% oxygen for 10 minutes) was determined by measuring the anaerobic threshold. At hyperoxic phase, 75-80% oxygen fraction was used during 30 minutes. Results: The cumulative frequency of postoperative complications was 14 (23.3%) in the HHP vs 23 (41.1%), p=0.041. The nitrate decreased after surgery by up to 20% in the HHP group and up to 38% in the control group. Endothelin-1 and nitric oxide metabolites were stable in HHP but remained low more than 24 h in control group. The endothelial damage markers appeared to be predictors of postoperative complications. Conclusion: The HHP with individual parameters based on the anaerobic threshold is a safe procedure, it can reduce the frequency of postoperative complications. The endothelial damage markers appeared to be predictors of postoperative complications.

Abstract: Background: Non-invasive acquistion of beat-to-beat pulse transit time (PTT) via piezoelectric/piezocapacitive sensors (PES/PCS) may expand perioperative hemodynamic monitoring. This study evaluated the ability for PTT via PES/PCS to correlate with systolic, diastolic, and mean invasive blood pressure (SBPIBP, DBPIBP, and MAPIBP) and to detect SBPIBP fluctuations. Methods: PES/PCS and IBP measurements were performed in 20 patients undergoing abdominal, urological, and cardiac surgery. A Pearson’s correlation analysis (r) between 1/PTT and IBP was performed. The predictive ability of 1/PTT with changes in SBPIBP was determined by area under the curve (reported as AUC, sensitivity, specificity). Results: Significant correlations between 1/PTT and SBPIBP were found for PES (r=0.64) and PCS (r=0.55) (p<0.01), as well as MAPIBP/DBPIBP for PES (r=0.6/0.55) and PCS (r=0.5/0.45) (p<0.05). A 7% decrease in 1/PTTPES predicted a 30% SBPIBP decrease(0.82, 0.76, 0.76), while a 5.6% increase predicted a 30% SBPIBP increase (0.75, 0.7, 0.68). A 6.6% decrease in 1/PTTPCS detected a 30% SBPIBP decrease (0.81, 0.72, 0.8), while a 4.8% 1/PTTPCS increase detected a 30% SBPIBP increase (0.73, 0.64, 0.68). Conclusions: Non-invasive beat-to-beat PTT via PES/PCS demonstrated significant correlations with IBP and detected significant changes in SBPIBP. Thus PES/PCS as a novel sensor technology may augment intraoperative hemodynamic monitoring during major surgery.

Introduction The Pericapsular Nerve Group (PENG) block is a novel technique that allows for analgesia of the anterior hip capsule via the articular branches of the accessory obturator nerve and femoral nerve, which have a significant role in the innervation of the hip capsule. PENG blockade is effective in both adult and pediatric patients. However, there are no studies in the available literature on patients under five years of age. Herein, we describe our experience with two pediatric patients with hip dysplasia. Purpose This study aimed to evaluate the analgesic effect of the pericapsular nerves group (PENG) in small children undergoing hip surgery. Patients and methods This study included two patients, aged 2 and 4 years old, who qualified for hip surgery. General or spinal anesthesia with the addition of a PENG block was performed. During the procedure, the basic hemodynamic parameters were monitored. After the surgery, the patients received 15mg/kg-1 iv paracetamol every 6 hours to prevent rebound pain. The pain was assessed using the FALCC score. The 15mg/kg-1 metamizole was administered if the FLACC score was 3. In the FLACC score 4, the application of 0,2mg/kg-1 Nalpain was ordered. Results The patient's hemodynamic parameters were stable and within normal range. FLACC scores from all patients ranged from 0 and 3 in the first 24 h period. One patient required metamizole 12 hours after surgery. No evidence of block complications was observed. Conclusions This case series showed that PENG block provided adequate postoperative analgesia and assured opioid-free pain management. However, we are convinced that future randomized, controlled trials are needed in this field.

Background: Chronic Back Pain due to Facet Joint Syndrome is a common and debilitating con-dition. Advances in regenerative medicine have shown that Autologous Unmodified Adipose Tissue-Derived Regenerative Cells (ADRC) provide several beneficial effects [1,2]. These regen-erative cells can differentiate into various tissues [3] and exhibit a strong anti-inflammatory po-tential. ADRCs can be obtained from a small amount of fatty tissue derived from the patient´s abdominal fat. Methods: We report long-term results of 37 patients (age 31-78 years, mean 62.5) suffering from “Facet Joint Syndrome” The pathology was confirmed by clinical, radiological examinations and fluoroscopically guided test injections. Then liposuction was performed. 50-100 cc of fat were harvested. To recover stem cells from adipose tissue, we use the CE-certified Transpose RT™ system from InGeneron GmbH. The cells were then injected under fluoroscopic control in the periarticular fat. Follow-up examinations were performed at one week 1 and 5 years. Results: Every patient reported improved VAS pain at any follow-up (1 week, 1, and 5 years) with ADRCs compared to the baseline. Conclusion: Our observational data indicate that facet joint syndrome patients treated with unmodified adipose tissue-derived regenerative cells experience improved quality of life in the long term.

The effects of morphine (MOR) and dexmedetomidine (DEX) on the MAC of isoflurane were measured in rats chronically treated with the synthetic cannabinoid WIN 55,212-2 (WIN55). Methods: The MAC of isoflurane was determined in 32 male rats from expiratory samples at the time of tail clamping. The effects of morphine (MAC(ISO+MOR)) and dexmedetomidine (MAC(ISO+DEX)) on the MAC of isoflurane in untreated rats and rats treated for 21 days with WIN 55,212-2 (MAC(ISO+WIN55+MOR)) and (MAC(ISO+WIN55+DEX)) were measured. Prior to the administration of morphine and dexmedetomidine, the MAC of the isoflurane was measured in both untreated rats (MAC(ISO)) and those treated with WIN 55,212-2 (MAC(ISO+WIN55)). Results: The minimum alveolar concentration was measured as 1.32 ± 0.06 in the MAC(ISO) group and 1.69 ± 0.09 in the MAC(ISO+WIN55) group. The MAC of the MAC(ISO+MOR) group was 0.97 ± 0.02 (26% less than the control group, MAC(ISO)). MAC was measured as 1.55 ± 0.08 in the MAC(ISO+WIN55+MOR) group (8% less than the MAC(ISO+WIN55) group), 0.68 ± 0.10 in the MAC(ISO+DEX) group (48% less than the control group, MAC(ISO)), and 0.67 ± 0.08 in the MAC(ISO+WIN55+DEX) group (60% less than the MAC(ISO+WIN55) group). Conclusions: The administration of WIN 55,212-2 for 21 days increases the MAC of isoflurane in rats. The sparing effect on isoflurane of morphine decreases in rats chronically treated with the synthetic cannabinoid, WIN 55,212-2. Dexmedetomidine increases its sparing effect on the minimum alveolar concentration of isoflurane in rats chronically treated with WIN 55,212-2.

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently prescribed drugs for cancer pain. We used Delphi methodology to evaluate the opinions of clinicians on NSAIDs and paracetamol, with a specific focus on their safety profile. Consensus was reached on 7 statements. High level of consensus was reached regarding use of NSAIDs and gastrointestinal, cardiovascular, and renal risk in patients taking low-dose aspirin and assessment of liver function during long-term treatment with paracetamol. Consensus was also reached that assessment and monitoring of eGFR is important in the elderly being administered NSAIDs. It was further agreed that NSAIDs can often play a key role in association with opioids in treatment of cancer pain and that paracetamol is the analgesic of first choice for patients with mild chronic pain. When NSAIDs are administered in combination with steroids, it was agreed that the risk of gastrointestinal damage is increased since steroids delay the healing of ulcers, and that paracetamol can be used during pregnancy and does not affect the health of the fetus. This Delphi study highlights that there is a poor agreement on how these drugs are routinely prescribed. However, the consensus was reached for 7 key statements and may represent a valid contribution to daily practice.

The thoracic surgery has increased drastically in recent years, especially in the light of the severe outbreak of 2019 novel coronavirus disease (COVID-19). Routine “passive” chest computed tomography (CT) screening of inpatients detects some pulmonary diseases requiring thoracic surgeries timely. As an essential device for thoracic anesthesia, the double-lumen tube (DLT) is particularly important for anesthesia and surgery. With the continuous upgrading of the DLTs and the widespread use of the fiberoptic bronchoscopy (FOB), the position of DLT in thoracic surgery is gradually becoming more stable and easier to observe or adjust. However, the DLT malposition still occurs during transferring patients from supine to lateral position in thoracic surgery, which leads to lung isolation failure and hypoxemia during one-lung ventilation (OLV). Recently some innovative DLTs or improved intervention methods have shown good results in reducing the incidence of DLT malposition. This review aims to summarize the recent studies of the incidence of left-sided DLT malposition, the reasons and effects of malposition, and summarize current methods for reducing DLT malposition and prospects for possible approaches. Meanwhile, we use bibliometric analysis to summarize the research trends and hot spots of the DLT research.

Abstract: Background: Pain management is one of the main parts of treatments for Temporomandibular Disorders (TMDs). However, there is still a lack of high-quality evidence that compare the overall effects of these non-surgical treatments. The objective of this systematic review is to identify the most potential treatment protocol in dealing with pain caused by TMDs through a mixed comparison of interventions based on network meta-analysis. Methods: A systematic review and network meta-analysis of studies identified by searching PubMed, Embase, Medline, Ovid, and CINAHL. All the included studies should have characteristics that: (1) participants with TMDs of any age; (2) non-surgical treatments; (3) score of Visual Analog Scale (VAS) as the outcome measure; (4) randomized controlled trials. The Cochrane Bias Assessment Toll was used to assess the bias, the CINeMA website was applied to rate the confidence of evidence, and ADDIS software was used to conduct the network meta-analysis. Results: 46 studies were included in this review. The agreement between authors reached a kappa value of 0.78. The results of the network meta-analysis showed that wearable therapy devices are more likely to be the best choice for reducing the pain of patients with myogenic TMDs, whereas a combination of platelet-rich plasma injection and wearable therapy devices is more likely to be the best choice for reducing the pain in a long term after treatment for patients with mix-type TMDs. Moreover, the application of therapy equipment has the most potential in reducing pain in a long term after treatment for patients with articular TMDs. Discussion: Wearable devices have a great potential for pain syndrome caused by TMDs, the mechanism might come from a biomechanical perspective. However, the overall confidence rating of evidence is low. Studies with high quality are still needed in the future. Other: The PROSPERO Registration Number of this systematic review is CRD42021253442.

Background. In a cannot ventilate cannot intubate situation, careful preoxygenation with high FiO₂ allowing subsequent apneic oxygenation can be life-saving. The best position for an oxygen supply line within the human airway at which oxygen insufflation is more effective than standard preoxygenation with a face mask, or comparably effective as intratracheal insufflation, is unknown. Methods. In this experimental study, we compared effectiveness of preoxygenation by placing an oxygen cannula at the nose entrance, through the nose at the soft palatine, or at the base of tongue; as control we used ambient air. We connected a fully preoxygenated test lung on one side to an oximeter with a flow rate of 200ml/min simulating oxygen consumption of a normal adult, and on the other side to the trachea of an anatomically correctly shaped airway manikin over a 20 min observation period five times for each cannula placement in random order. Results. Oxygen percentage in the test lung dropped from 100% in all groups to 53±1% in the ambient air control group, to 87±2% in the nasal cannula group, to 96±2% in the soft palatine group, while it remained at 99±1% in the base of tongue group (p=0.003 for soft palatine vs base of tongue; and p<0.001 between all other groups). Conclusions. When simulating apneic oxygenation in a preoxygenated manikin, oxygen insufflation at the base of tongue kept oxygen percentage at baseline values of 99% demonstrating a complete block for ambient air flowing into the manikin’s airway. Oxygen insufflation at the soft palatine or insufflation via nasal cannula were less effective in regard of this effect.

The therapeutic effects of volatile anesthetics on mental diseases, particularly schizophrenia, have gained considerable interest. Although isoflurane is a commonly used volatile anesthetic, there’s no more evidence that it could work on treating schizophrenia. Here, we discovered that inhaling isoflurane at low concentrations might reverse the behavioral phenotypes of schizophrenia caused by MK801, such as hyperlocomotion, pre-pulse inhibition impairment, and working memory loss. Isoflurane also helped recovering adult neurogenesis and synaptic plasticity impairments in the dentate gyrus (DG) induced by MK801. To better understand the mechanism, we discovered that isoflurane could reverse the reduction of parvalbumin (PV)-positive GABAergic interneuron (PVI) number and the aberration of NRG1-ErbB4 signaling in the DG; however, isoflurane could not reverse the schizophrenia-related phenotypes caused by PVI ablation, indicating that PVI are necessary for the therapeutic effect of isoflurane. Interestingly, isoflurane could reverse phenotypes caused by blocking PVIs GABA release in the DG, indicating the therapeutic impact is independent of PVI GABA release. Our research revealed that isoflurane might be used to treat schizophrenia, possibly through PVI in the DG.

Background: Once a widely used analgesic in the United States (US), meperidine offered an alternative to other opioids as a pain reliever. However, within the last two decades, meperidine has gone from a drug to be utilized only when patients exhibit atypical reactions to opioids (e.g., morphine and hydromorphone) to being taken off the World Health Organization List of Essential Medications and receiving strong recommendations for the overall avoidance. The aim of this study was to identify changes in meperidine distribution in the US and regional disparities as reported to the Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (DEA ARCOS) and Medicaid. Methods: Data related to the meperidine distribution was obtained through ARCOS (2001 –2021) and Medicaid public use files (2016 –2021). Heat maps were used to visualize regional disparities in distribution by state. States outside a 95% confidence interval were statistically significant. Results: Meperidine distribution between 2001 and 2021 decreased by 97.4% (R=.-97, P &lt; .0001). There was a 34-fold state-level difference in meperidine distribution between Arkansas (16.8 mg/10 persons) and Connecticut (0.5 mg/ 10 persons) in 2020. Meperidine distribution in 2020 was elevated in Arkansas, Mississippi, and Alabama. In 2021, Meperidine distribution was highest in Arkansas ( 1.67 /10 persons) and lowest in Connecticut (0.08 /10 persons). Total prescriptions of meperidine as reported by Medicaid decreased by 73.8% (R= -0.67, P = 0.045) between 2016 and 2021. Conclusion: We observed a decrease in the overall distribution of meperidine in the past two decades with similar recent declines in prescribing to Medicaid enrollees. The shortage of some parenteral formulations is an important contributor to these declines. This data may reflect plans to phase out the use of this opioid, especially in the many situations where preferred opioids are available.

Up to 56% of patients develop chronic postsurgical pain (CPSP) after coronary artery bypass grafting (CABG). CPSP can affect patients’ moods and decrease daily activities. The primary aim of this study was to investigate CPSP severity in patients following off-pump (OP)-CABG using the Neuropathic Pain Symptom Inventory (NPSI). This was a prospective cohort study conducted in a cardiac surgery department of a teaching hospital. Patients undergoing OP-CABG were enrolled in an erector spinae plane block (ESPB) group (n = 27) or a control (CON) group (n = 24). Before the induction of general anesthesia, ESPB was performed on both sides under ultrasound guidance using 0.375% ropivacaine. The secondary outcomes included cumulative oxycodone consumption, acute pain intensity, mechanical ventilation time, hospital length of stay, and postoperative complications. CPSP intensity was lower in the ESPB group than in the CON group 1, 3, and 6 months postsurgery (p < 0.001). Significant between-group differences were also observed in other outcomes, including postoperative pain severity, opioid consumption, mechanical ventilation time, and hospital length of stay in favor of the ESPB group. Preemptive ESPB appears to decrease the risk of CPSP development in patients undergoing OP-CABG. Reduced acute pain severity and shorter mechanical ventilation times and hospital stays should improve patients’ satisfaction and reduce perioperative complications.

Global anaesthesia workforce limitations contribute to emigration of skilled anaesthesiologists from lower- to higher-income countries, jeopardizing workforce balance and patient outcomes in Pakistan. This study aims to explore challenges experienced by anaesthesiologists in Punjab, Pakistan’s most populous province, and necessary changes to encourage their retention. We conducted a qualitative study to examine perspectives of anaesthesiologists who chose to serve in Pakistan. We drew data from semi-structured interviews conducted with 25 purposively-sampled consultant anaesthesiologists. We analysed data thematically and distinguished the practice hurdles faced by anaesthesiologists in public and private hospitals of Punjab. The main reasons to work abroad could be broadly categorized under two inductive themes, i.e. practice hurdles in public and private sector. Both had distinct issues which compromised the number and quality of anaesthesia workforce in the country. The key outcomes were workplace security, promotion/incentive issues and gender inequalities in the government sector. The private sector had improper salaries and facilities, anaesthesiologist’s dependency on surgeons for getting work and lack of out-of-theatre practice which minimise the scope and earnings of anaesthesiologist within the country. There is a need to overcome surgeon dependency and hospital manipulation by fixing salary percentages for each surgical case and encouraging direct patient-anaesthesiologist relationships.

A 57-year-old male with a history of hyperlipidemia and mild pulmonary hypertension presented for a left inguinal hernia repair. Preoperative electrocardiogram showed severe right axis deviation at 177 degrees and abnormal repolarization. Right ventricular hypertrophy secondary to pulmonary hypertension was the primary differential but was quickly ruled out due to the patient being asymptomatic and having great exercise tolerance. Dextrocardia was also ruled out due to normal progression on the precordial leads. The simultaneous severe right axis deviations of P, R, and T waves raised suspicion for erroneous lead placement. The repeat electrocardiogram confirmed the diagnosis.

Acute low back pain (LBP) stands as a leading cause of activity limitation and work absenteeism, and its associated healthcare expenditures are expected to become substantial when acute LBP develops into a chronic and even refractory condition. Therefore, early intervention is crucial to prevent progression to chronic pain whose management is particularly challenging and for which the most effective pharmacological therapy is still controversial. Current guideline treatment recommendations vary and are mostly driven by expertise with opinion differing across different interventions. Thus, it is difficult to formulate evidence-based guidance when relatively few randomized clinical trials did explore the diagnosis and management of LBP while employing different selection criteria, statistical analyses, and outcome measurements. This narrative review aims to provide a critical appraisal of current acute LBP management by discussing the unmet needs and areas of improvement from bench-to-bedside and proposes multimodal analgesia as the way forward to attain an effective and prolonged pain relief and functional recovery in patients with acute LBP.

Worldwide, one of the main causes of death among young adults is multiple trauma. In these pa-tients hemorrhagic shock represents the leading cause for worsening of the clinical status and for increased morbidity and mortality. This is due to a multifactorial complex involving cellular, bi-ological, and biophysical mechanisms. The most important mechanisms affecting clinical out-come are oxidative stress, the augmentation of pro-inflammatory status, immune deficiency, dis-ruptions in the coagulation cascade, imbalances in electrolyte and acid-base homeostasis. Poly-trauma patients in hemorrhagic shock need adequate fluid management to ensure hemodynamic stability that must consider not only the maintenance of adequate blood pressure, but also the ad-equate oxygenation of tissues for optimal cellular function. In the current clinical practice, fluid resuscitation in polytrauma patients uses a variety of widely studied pharmacological products, such as crystalloids, colloids, blood transfusions, and the infusion of other blood products. Alt-hough these products exist, an agreement was not reached on a standard administration protocol that could be generally applied for all patients. Moreover, numerous studies have reported a se-ries of adverse events related to fluid resuscitation and to the inadequate use of these products. This review aims at describing the impact the administration of all the solutions used in fluid re-suscitation might have on the cellular and pathophysiological mechanisms in the case of poly-trauma patients suffering from hemorrhagic shock.

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.

Introduction: The effect of halogenated drugs as cardioprotectors in cardiac surgery has been evaluated in several studies. However, the possibility that there is a protective role at renal level, triggered by their use, is currently under study. Aortic valve replacement and coronary revascularization are the most frequent surgeries in cardiac surgery. Our research evaluates the effect of desflurane compared to propofol in aortic valve replacement surgery at renal level; including its administration during extracorporeal circulation. Method: Quasi-experimental prospective study performed on 60 patients, divided into 2 groups according to the drug used in intraoperative aortic valve replacement surgery. In group 1 propofol was used as a hypnotic during surgery, in group 2 desflurane was used. Differences in kidney damage measured through the urinary NGAL marker were evaluated. Other markers of renal function and myocardial damage and the need for inotropic support during the first 48 hours were also measured. Results: There were significant variations in the values ​​of urinary NGAL and creatinine regarding to basal values ​​in the propofol group, but not in the desflurane group, in which there were no differences in the hemodynamic parameters and myocardial damage. Conclusion: the use of desflurane during aortic valve replacement surgery produced better renal preservation than propofol.

Interventional management of neuropathic pain (NP) is available to the many patients who do not attain satisfactory outcomes with pharmacotherapy, but evidence supporting this is sparse and fragmented. We attempted to summarize and critically appraise the existing data to identify strategies that yield maximum benefit, orient clinicians, and identify areas that merit further investigation. A two-round Delphi survey that involved pain clinic specialists with experience in the research and management of NP was done over an ad hoc 26-item questionnaire prepared by the authors. Consensus on each statement was defined as either at least 80% endorsement or rejection after the second round. Thirty-five and 29 panelists participated in the first and second round, respectively. Consensus was reached in 20 out of 26 statements. There is sufficient basis to treat postherpetic neuralgias and complex regional pain syndromes with progressive levels of invasiveness and failed back surgery syndrome with neuromodulation. Radiculopathies and localized NP could be treated with peripheral blocks and neuromodulation, or pulsed radiofrequency. Non-ablative radiofrequency and non-paresthetic neuromodulation are efficacious and better tolerated than ablative and suprathreshold procedures. A graded approach, from least to most invasive interventions has the potential to improve outcomes in many patients with common refractory NP conditions. Preliminary promising data warrant further research on new indications, and technical advances might enhance the safety and efficacy of current and future therapies.