Background:Emergence agitation (EA) is a common postanesthetic problem in pediatric patients, particularly with sevoflurane anesthesia, and may lead to injury to patients, prolonged postanesthesia care unit (PACU) stay, and a risk of long-term maladaptive behavioral changes. Evidence regarding EA in nonpainful procedures such as magnetic resonance imaging (MRI) remains inconclusive. This study evaluated the effect of low-dose propofol at the end of sevoflurane anesthesia on EA in pediatric patients undergoing MRI. Methods:In this randomized controlled trial, 130 pediatric patients aged 2-8 years undergoing MRI under sevoflurane anesthesia with a laryngeal mask airway were enrolled. Patients were randomly assigned to receive either Group P (n = 61), receiving intravenous propofol 0.5 mg/kg, or Group N (n = 61), receiving normal saline at the end of anesthesia. EA was assessed using the Pediatric Anesthesia Emergence Delirium (PAED) scale, with EA defined as a score > 12 within the first 30 min of PACU stay. Primary analysis was performed on a per-protocol approach (n = 122), alongside a sensitivity analysis using the intention-to-treat approach (n = 130). Secondary outcomes included emergence time, PACU stay, adverse events, and requirement for EA rescue medication. Results:In the per-protocol analysis (n = 122), the incidence of EA was significantly lower in Group P compared with Group N (18.0% vs 39.3%; p = 0.01), with a relative risk of 0.46 (95% CI 0.25-0.85). Emergence time, PACU stay, adverse events, and requirement of EA rescue medication were comparable between the two groups. Conclusions:Administration of propofol at a dose of 0.5 mg/kg at the end of sevoflurane anesthesia significantly reduces EA in pediatric patients undergoing MRI without prolonging recovery or increasing adverse events. Further large-scale, multicenter studies are warranted to confirm efficacy and evaluate safety. Trial Registration: ClinicalTrials.gov identifier: NCT06218680.
Introduction:Videolaryngoscopes are widely utilized in daily clinical practice within anesthesiology and emergency medicine to enhance airway management techniques and promote patient safety. Among these devices, the C-MAC and McGrath videolaryngoscopes have been extensively evaluated in multiple studies to determine their relative efficacy. This systematic review aims to synthesize the findings of available research comparing the C-MAC and McGrath with respect to first-pass intubation success and intubation time, as well as to conduct a meta-analysis for statistical evaluation. Materials and Methods:A systematic review was performed using PubMed, Scopus, Cochrane Library, and Google Scholar in accordance with PRISMA guidelines. Eligible studies directly compared the C-MAC and McGrath videolaryngoscopes in adult clinical patients, simulated-patient clinical scenarios, or adult manikin-based airway models. Because these populations are methodologically and clinically heterogeneous, adult clinical patient studies were strictly separated from simulated-patient and manikin studies. Quantitative meta-analysis was restricted to adult clinical patient studies, whereas simulated-patient and manikin studies were summarized qualitatively. Studies were screened up to June 23, 2025, and assessed for bias with the Cochrane Risk of Bias 2.0 tool. Results are summarized in tables, and meta-analysis was conducted using R (meta-package, V4.4.1), focusing on first-pass intubation success and intubation time, displayed as forest plots. Certainty of evidence for the main outcomes was assessed using a GRADE-based approach, while publication bias and sensitivity analyses were also performed. Results:Nine studies met the inclusion criteria. The evidence base comprised six adult clinical patient studies and three manikin-based airway studies. Adult clinical patient studies and manikin-based studies were reported separately, and manikin datasets were not counted as clinical patients. Six adult clinical patient studies were included in the quantitative meta-analysis, whereas manikin-based studies were summarized qualitatively. No definitive superiority of either device was demonstrated for first-pass intubation success in adult clinical patients. C-MAC showed shorter intubation time in some analyses, but heterogeneity was substantial, and certainty of evidence was limited. Discussion:The available evidence should be interpreted cautiously because of clinical heterogeneity, differences in airway difficulty, operator experience, device blade configuration, and outcome definitions. Simulated-patient and manikin-based airway studies provide useful information on device handling and training but should not be interpreted as directly equivalent to adult clinical patient evidence.
Awake craniotomy is a standard neurosurgical technique that enables real-time assessment of brain functions during tumor resection, with high success rates. Although highly effective, the procedure is associated with hemodynamic disturbances, including blood pressure variability and impaired cerebral perfusion, compromising intraoperative safety. A focused literature search of PubMed, Embase, and Google Scholar was performed to identify relevant studies on intraoperative hemodynamic management during awake craniotomy. Findings were synthesized narratively to summarize current evidence, highlight emerging strategies, and identify knowledge gaps. Hypertension (8%-34%) was the most common disturbance, often triggered by painful surgical stimuli or emergence from sedation, with repeat craniotomy, impaired autoregulation, and glioma pathology as additional risk factors. Hypotension (10%-11%) was linked to perioperative stroke and mortality. Cerebral hypoperfusion contributed to poor outcomes, with stroke up to 23% and neurological morbidity in 68% of patients. Preventive strategies, such as scalp blocks, individualized blood pressure targets, and the use of dexmedetomidine and midazolam, improved intraoperative stability, while short-acting agents, including esmolol and labetalol, were preferred for rapid control. Advanced monitoring modalities, including arterial lines, near-infrared spectroscopy, and cerebral autoregulation indices, enhance safety and support accurate functional mapping. Hemodynamic instability during awake craniotomy influences outcomes. Current evidence supports multimodal prevention, tailored blood pressure control, and short-acting pharmacological agents; practice variation and the lack of randomized trials limit standardization. Looking ahead, advanced monitoring and emerging AI systems may provide new opportunities to enhance cerebral protection and optimize patient safety. This review summarizes evidence on intraoperative hemodynamic control in awake craniotomy, emphasizing strategies that enable maximal safe resection while preserving neurological function.
To investigate the impact of preoperative zolpidem administration on early postoperative cognitive function in elderly patients with poor sleep quality, elderly patients undergoing gastrointestinal surgery with sleep disorders were enrolled and randomly allocated to two groups. The experimental group received 5 mg of oral zolpidem at bedtime for three consecutive nights preoperatively, whereas the control group was given a placebo. Data collected included patients' sleep quality after medication, demographic characteristics, intraoperative parameters, and the incidence of postoperative delirium (POD). Results showed that zolpidem effectively improved preoperative sleep quality in elderly patients. However, the preoperative administration of zolpidem did not yield a statistically significant reduction in the incidence of POD in this cohort, likely attributable to inadequate statistical power. Preoperative zolpidem intervention did not significantly reduce the incidence of POD in this population. Logistic multivariate regression analysis indicated that early POD was correlated with patient age, blood transfusion, postoperative pain, and the frequency of intraoperative hypotensive episodes; however, no significant association was observed between preoperative sleep quality and the recovery of early postoperative cognitive function. In conclusion, preoperative zolpidem intervention can safely and effectively enhance sleep quality in elderly patients undergoing gastrointestinal surgery. However, the observed effect size was smaller than anticipated (Cohen's h = 0.15), and the confidence interval for the difference in delirium incidence included both clinically meaningful benefit and harm. Therefore, we cannot draw definitive conclusions about whether short-term improvement in preoperative sleep quality reduces the incidence of early POD. These findings should be considered exploratory and require validation through larger, adequately powered multicenter prospective studies with objective sleep measures and longer intervention durations.
Background:Early postoperative cognitive trajectories following total arch replacement remain insufficiently characterized. This study evaluated serial postoperative recovery patterns with particular focus on cognitive performance during the first postoperative week. Methods:Adult patients undergoing elective total arch replacement were enrolled. Recovery was assessed using the Postoperative Quality of Recovery Scale (PostopQRS) at baseline within 14 days before surgery and postoperatively at 3 h and 1, 3, and 7 days after extubation. Cognitive recovery was evaluated according to the revised PostopQRS cognitive recovery algorithm. Recovery trajectories including other PostopQRS domains were summarized descriptively. Results:Forty-one patients were included in the final analysis. The mean (SD) age was 68.4 (10.4) years, and 31 patients (91%) were male. Cognitive recovery was observed in 23/41 (56.1%) of patients at 3 h after extubation, 26/41 (63.4%) at postoperative Day 1, 31/41 (75.6%) at postoperative Day 3, and 30/41 (73.2%) at postoperative Day 7. While physiological, emotive, and activities of daily living domains showed progressive improvement over time, nociceptive recovery remained incomplete throughout follow-up and was primarily driven by persistent pain rather than nausea. Conclusion:Cognitive recovery after total arch replacement improved gradually during the early postoperative period but remained incomplete in a substantial proportion of patients at postoperative Day 7. These findings highlight the heterogeneous nature of postoperative cognitive recovery and support the importance of serial cognitive assessment after complex aortic surgery.
Background:Emergence agitation (EA) is a phenomenon commonly occurring in otorhinolaryngology surgery. It may increase the risk of injury and prolong recovery. Dexmedetomidine is the standard preventive agent, but limited due to its high cost, limited accessibility, extubation time, and incidence of bradycardia and hypotension. Magnesium sulphate (MgSO4) is considered a potential alternative but is there is insufficient research available. This study aimed to compare the effectiveness of intravenous MgSO4 and dexmedetomidine in reducing EA. Methods:This study is a multicentered, double-blinded, randomized controlled trial involving 64 adult patients undergoing otorhinolaryngology surgery. They were divided into two groups in a 1:1 ratio, with one group receiving MgSO4 20 mg/kgBW/h and another receiving dexmedetomidine 0.5 μg/kgBW/h from induction until the procedure ends. We measured the proportion of EA, onset, and duration of EA, intraoperative ephedrine dose, perioperative heart rate and mean arterial pressure (MAP), pain scores, perioperative fentanyl use, intraoperative sevoflurane use, and extubation time. Results:The proportion of EA was not significantly different between the MgSO4 and dexmedetomidine groups (12.5% vs. 15.6%, p > 0.05). No differences in the severity, onset and duration of EA. The reduction of MAP and heart rate were greater in the dexmedetomidine group. The intraoperative ephedrine was significantly lower in the MgSO4 group (0 vs. 5 mg, p < 0.05). No significant differences in fentanyl and sevoflurane use, postoperative pain scores, and extubation time. Conclusion:Intravenous MgSO4 and dexmedetomidine showed no statistically significant difference in the incidence of EA in adult patients undergoing otorhinolaryngologic surgery. Trial Registration: ClinicalTrials.gov: NCT07544173.
Background:The prevalence of hypertension is high. However, hypertensive patients often remain undiagnosed or poorly controlled, posing challenges for anesthesiologists before surgery. Although well-established guidelines have been proposed, some uncertainties remain. This study aimed to test the hypothesis that the closer the preoperative blood pressure (BP) is to normal, the lower the incidence of unfavorable postoperative outcomes in hypertensive patients using data from 2016 onward. Methods:Medical records of adult patients under general anesthesia for surgery at 68 hospitals in Japan between 2016 and 2021 were reviewed. In accordance with World Health Organization criteria, patients were categorized based on their maximum BP recorded the day before surgery into five groups: true normotension, controlled hypertension (patients with prior diagnosis and/or treatment of hypertension), and Stages 1, 2, and 3 hypertension groups. Postoperative mortality rates and incidence of unfavorable outcomes, including ischemic heart disease, cerebrovascular disease, aortic dissection, and acute renal failure, were compared using multivariable logistic regression analysis. Results:Data from 272,594 patients (either sex, aged between 20 and 106 years) were analyzed, excluding those undergoing cardiac, brain, and obstetric surgery. Mortality did not differ significantly between the four hypertension groups and the true normotension group. Compared with the true normotension group, the odds of ischemic heart disease were higher in the controlled, Stage 2, and Stage 3 hypertension groups. The odds of cerebrovascular disease and acute renal failure increased with hypertension stage, whereas the odds of aortic dissection were elevated only in Stage 3 hypertension. Conclusions:Our results showed that the closer preoperative BP was to normal, the better the postoperative outcomes for cerebrovascular disease and acute renal failure, but not for mortality, ischemic heart disease, or aortic dissection. Since the risk in the controlled hypertension group was higher than initially expected, our hypothesis was rejected.
Background:Explicit recall during general anesthesia is rare; however, experimental and clinical evidence suggests that auditory stimuli may sometimes be processed at an implicit or unconscious level. Routine intraoperative conversations differ from structured therapeutic suggestions; nevertheless, they form part of the auditory environment surrounding anesthetized patients. This study aimed to assess operating room professionals' awareness of possible unconscious auditory perception related to intraoperative conversations during general anesthesia, their previous educational exposure, and their professional attitudes. Methods:In this cross-sectional survey, an anonymous 19-item online questionnaire was distributed to operating room health professionals in Türkiye through professional communication networks. Descriptive statistics were reported as n (%). A study-specific 9-item exploratory Awareness/Professional Attitude Index was calculated with two items reverse-coded, and internal consistency was assessed using Cronbach's alpha. Between-group comparisons were performed using the Mann-Whitney U test and the Kruskal-Wallis test. A p value < 0.05 was considered statistically significant. Results:A total of 251 responses were analyzed, and 96.4% of participants reported that they were actively working in the operating room. Most participants agreed that intraoperative communication should remain within appropriate professional boundaries (97.2%) and that awareness-oriented education on this topic is needed (88.0%). However, 74.5% reported that they had not received formal education on this topic, and only 19.5% reported exposure to related scientific education or activities. The study-specific exploratory Awareness/Professional Attitude Index was 3.61 ± 0.67 and showed high internal consistency (Cronbach's alpha = 0.83). Index scores were higher in women than in men (3.76 vs 3.43; p < 0.001) and differed across professional groups (p = 0.001) and experience groups (p = 0.023). These findings indicate a gap between the perceived importance of communication around anesthetized patients and formal educational exposure. Conclusions:Operating room professionals reported substantial awareness of the importance of intraoperative conversations in the context of possible unconscious auditory perception during general anesthesia. However, formal educational exposure to this topic was limited. These descriptive findings do not demonstrate effects on patient outcomes; however, they identify an awareness-education gap and support awareness-oriented education, clearer communication norms around anesthetized patients, and further research using standardized measurement approaches, as well as observational or interventional designs. Trial registration: ClinicalTrials.gov, NCT07396727. Registration date: September 26, 2025.
Laparoscopic bariatric surgery is associated with specific analgesic challenges because opioid-related adverse effects may be especially relevant in patients with obesity, obstructive sleep apnea, and cardiometabolic comorbidities. Inadequate perioperative analgesia in this population may impair early mobilization and functional recovery, while excessive opioid use increases the risk of respiratory depression, postoperative nausea and vomiting (PONV), and prolonged hospital stay. This narrative review synthesizes and critically appraises contemporary evidence on intravenous lidocaine, dexmedetomidine, opioid-free or opioid-sparing anesthesia, and enhanced recovery after surgery (ERAS)-based perioperative strategies in adult patients undergoing laparoscopic bariatric surgery. A structured literature search was conducted in PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library from January 2018 to May 2026. A total of 41 studies were included, comprising randomized controlled trials, observational studies, pharmacokinetic investigations, systematic reviews, meta-analyses, and ERAS implementation studies. Methodological quality was appraised using RoB 2.0, ROBINS-I, and AMSTAR-2 according to study design. Evidence for intravenous lidocaine remains heterogeneous and appears dependent on dosing strategy, infusion duration, and perioperative context; its antiemetic and anti-inflammatory effects may be more consistent than its analgesic benefit when infusion is limited to the intraoperative period. Dexmedetomidine has been associated with reductions in perioperative opioid exposure and PONV through alpha-2-mediated sympatholysis and opioid-sparing mechanisms, although effects on pain scores are variable and hemodynamic monitoring is required. Opioid-free or opioid-sparing strategies may reduce opioid exposure and PONV, but superiority over conventional anesthesia for pain control or length of stay is inconsistent, and protocol heterogeneity limits generalizability. ERAS pathways represent the most comprehensive and evidence-supported framework for perioperative optimization, with benefit proportional to adherence and independent of any single pharmacologic agent. These pharmacologic strategies are best understood as mechanism-based adjuncts to be selectively integrated within high-adherence ERAS programs, not as universal standalone interventions. Rigorous multicenter randomized trials with standardized dosing, detailed ERAS adherence reporting, patient-centered outcome measures, and subgroup analyses by procedure type, OSA status, and PONV risk are needed.
Background:Patients with hypertrophic obstructive cardiomyopathy (HOCM) undergoing minimally invasive modified Morrow procedure may be vulnerable to postoperative pulmonary dysfunction. During cardiopulmonary bypass (CPB), lung-protective ventilation has been proposed, but the optimal inspired oxygen concentration under this strategy remains unclear. This study aimed to compare different inspired oxygen concentrations under a fixed lung-protective ventilation strategy during CPB. Methods:This was a prospective clinical observation study involving 97 patients scheduled for modified Morrow procedures via a small right axillary incision between January 2023 and November 2023 at a single center. Patients were randomized to receive CPB ventilation with FiO2 of 30%, 50%, or 100% under a standardized ultra-low-tidal-volumelung-protective strategy. The primary outcomes included the Horowitz Index (HI = PaO2/FiO2), respiratory index (RI = P(A-a)O2/PaO2), and alveolar-arterial oxygen pressure difference [P(A-a)O2] at six different time points within the first 24 h postoperatively, as well as postoperative pulmonary complications. Secondary outcomes included plasma levels of inflammatory cytokines, endothelial glycocalyx (eGC) components, and measures of postoperative rehabilitation and other complications. Results:There were no significant differences in terms of postoperative complications and rehabilitation among the three groups with different inspired oxygen concentrations under a fixed lung-protective ventilation strategy during CPB. Compared with the 100% FiO2 group, the 30% FiO2 group exhibited higher HI at 6 h and 24 h postoperatively with lower P(A-a)O2 at 18 h and 24 h postoperatively and a lower RI at 24 h postoperatively. In addition, the 30% FiO2 group showed lower plasma levels of inflammatory cytokines and eGC. Conclusion:These findings indicate that the use of 30% 100% FiO2 group with ultra-low tidal volume ventilation during CPB in patients undergoing a modified Morrow procedure via a small right axillary incision was safe and associated with improved early postoperative oxygenation and attenuated inflammatory response. Trial Registration: Chinese Clinical Trial Registry: ChiCTR2400084443.
Background:Enhanced recovery after surgery (ERAS) is a current concept in surgery that has excellent short-term outcomes. Currently, no standardized ERAS protocol exists for total hip replacement (THR). So, we conducted this study to assess the efficacy of ultrasound-guided erector spinae plane block (ESPB) with dexmedetomidine as an additive in comparison with intrathecal morphine (ITM) for ERAS after THR in Cairo University hospitals. Methods:Our randomized controlled study included 70 patients. The patients were randomly allocated to the M group or E group. M group patients received 5 mL of subcutaneous lidocaine 1% and then 3.5 mL of hyperbaric bupivacaine 0.5% with 0.1 mg of morphine in 0.25 mL of normal saline intrathecally. E group patients received ESPB with dexmedetomidine as an additive on the side of surgery and then 3.5 mL of hyperbaric bupivacaine 0.5% with 0.25 mL of normal saline intrathecally. The primary outcome was the time of the first successful walking trial for 10 steps with a walker. Secondary outcomes were postoperative pain score, total morphine consumption, duration of hospital stay, patient satisfaction, and incidence of complications (hypotension, bradycardia, pruritus, nausea, vomiting, and urine retention). Results:The mean time of a successful walking trial with a walker of the E group was 12.69 ± 2.42 h which is decreased significantly in comparison to the M group (19.71 ± 3.11 h), with a mean difference of 7.0 (95% CI 8.81-5.2) hours, with a very large effect size (Cohen's d = 2.51), and p value < 0.001. The mean number of failed walking trials in the E group (1.11 ± 0.4 trials) decreased to a statistically significant value in comparison to the mean number of failed walking trials in the M group (2.29 ± 0.52 trials), with a mean difference of 1.18 (95% CI 0.96-1.4) trials, and p value < 0.001. Duration of hospital stay after surgery was, on average, 33.9% lower in E group in comparison to M group (1.66 ± 0.59 and 2.51 ± 0.51 days, respectively) with a large effect size (Cohen's d = 1.54) and p value < 0.001. There was no significant difference regarding the mean time of the first morphine dose in M and E groups (16.8 ± 4.78 h and 18.86 ± 4.63 h, respectively) and p value = 0.072. Total morphine consumption in the first 24 h was insignificantly higher in the M group than in the E group (7.36 ± 2.97 mg and 5.76 ± 2.88 mg, respectively), with a mean difference of -1.6 (95% CI -2.99 to -0.2) mg and p value = 0.025. The patient satisfaction score was better in the E Group than in the M Group. The number of patients with complete satisfaction was more in the E group (24 [68.6%]) than in the M group (10 [28.6%]) and p value < 0.001. The rate of complications was higher in the M Group than in E Group (56.19% vs. 22.86%, respectively, with an odds ratio of 4.01 (95% CI, 1.43-11.25) and p value = 0.008. Conclusion:ESPB with dexmedetomidine as an additive enhances early mobilization after THR better than ITM with about a 34% decrease in the duration of hospital stay and a lower rate of complications. Trial Registration: ClinicalTrials.gov Protocol Registration and Results System: NCT06621849.
Opioid‐free anesthesia (OFA) has been proposed as a strategy to reduce opioid exposure and opioid‐related adverse events in laparoscopic surgery. However, evidence from randomized trials remains heterogeneous regarding pain control, postoperative nausea and vomiting (PONV), and opioid consumption. We performed a systematic review and meta‐analysis of randomized controlled trials (RCTs) comparing OFA with opioid‐based anesthesia (OBA) in adult patients undergoing elective laparoscopic surgery. Primary outcomes included postoperative pain scores (0–10 scale), PONV, and 24‐h opioid consumption. Secondary outcomes included hemodynamic events, recovery quality, and hospital length of stay. Sixteen RCTs ( n = 1322) were included. OFA reduced PONV by approximately 40% (RR 0.60; 95% confidence interval [CI] 0.48–0.75) and modestly decreased postoperative opioid use by 6.4 mg morphine equivalents (95% CI −9.1 to −3.7). Pain scores during the first 24 h were similar between OFA and OBA (MD −0.3 on a 0–10 scale; 95% CI −0.7 to +0.1). Hemodynamic instability (bradycardia and hypotension) occurred more frequently with dexmedetomidine‐based regimens but was transient and clinically manageable. No differences were observed in recovery time or hospital length of stay. OFA provides clinically meaningful reductions in PONV and opioid exposure without compromising postoperative analgesia. These findings support OFA as a safe and effective alternative to OBA in laparoscopic surgery and a potential component of enhanced recovery pathways.
Background:Laryngoscopy and endotracheal intubation evoke significant hemodynamic responses, particularly in patients undergoing coronary artery bypass grafting (CABG) who have compromised cardiac reserves. This study aimed to compare the hemodynamic effects of the C-MAC video laryngoscope (VL) with those of the conventional Macintosh laryngoscope (MC) in patients undergoing elective CABG. Methods:This randomized controlled trial included 86 patients scheduled for elective CABG, who were randomly assigned to intubation with either the MC group or the C-MAC VL group. Hemodynamic parameters, including heart rate, systolic, diastolic, and mean arterial pressures, were recorded at five time points (prelaryngoscopy baseline to 10 min postintubation). Secondary outcomes included the intubation success rate, duration of laryngoscopy and intubation, glottic visualization, and complications. Results:Two-way repeated measures ANOVA revealed no significant group effect or group-by-time interaction for any hemodynamic variable (all p > 0.05), confirming equivalent hemodynamic profiles across all time points. A significant time effect was observed for all variables (all p < 0.001). First-attempt intubation success was 88.4% (VL) versus 74.4% (MC) (p = 0.166). The C-MAC provided significantly better glottic visualization (modified CL grade, p < 0.001). No major complications occurred in either group. Conclusion:In patients undergoing CABG, C-MAC VL and conventional MC result in similar hemodynamic responses. The choice of laryngoscope may be guided by airway considerations and operator experience rather than anticipated cardiovascular effects. Trial Registration: Clinicaltrials.gov_identifier: NCT04433884.
Background:Pain after cardiac implantable electronic device (CIED) implantation remains clinically relevant and may increase postoperative analgesic requirements. Ultrasound-guided pectoral nerve block has shown benefit in anterior chest wall procedures, but evidence during CIED implantation, particularly in Asian populations with relatively lower body mass index (BMI), remains limited. This study aimed to evaluate the efficacy and safety of ultrasound-guided pectoral nerve block for postoperative analgesia during CIED implantation and to explore clinical factors associated with rescue analgesic use. Methods:In this prospective randomized controlled trial, 660 patients undergoing CIED implantation were randomly assigned to a pectoral nerve block group or a standard-care group, with 330 patients in each group. Postoperative pain intensity was assessed using the numeric rating scale (NRS) at 1, 2, 4, 24, and 48 h after the procedure. Longitudinal NRS trajectories were analyzed using a linear mixed-effects model for repeated measures. Rescue analgesic use, length of hospital stay, and adverse events were compared between groups. Univariable and multivariable logistic regression analyses were performed as exploratory analyses to identify factors associated with rescue analgesic requirement. Results:Procedural characteristics were comparable between groups, including procedure type, device type, procedure duration, and implant laterality. Longitudinal analysis demonstrated significantly lower postoperative NRS scores over time in the pectoral nerve block group. Pain scores were consistently lower in the block group than in the control group at 1 h (0.87 ± 0.51 vs. 2.50 ± 0.78), 2 h (1.33 ± 0.55 vs. 4.37 ± 0.89), 4 h (2.00 ± 0.83 vs. 4.37 ± 0.93), 24 h (2.27 ± 0.91 vs. 4.57 ± 0.90), and 48 h (2.03 ± 0.67 vs. 3.67 ± 0.99) (all p < 0.001). The proportion of patients requiring rescue analgesics was significantly lower in the pectoral nerve block group than in the control group (7.58% vs. 16.67%, p = 0.001). Length of hospital stay and adverse event rates were comparable between groups. In exploratory multivariable analysis, higher BMI and higher glycated hemoglobin were independently associated with greater rescue analgesic use, whereas pectoral nerve block was independently associated with a lower likelihood of rescue analgesic requirement. Conclusions:Ultrasound-guided pectoral nerve block significantly improved postoperative analgesia and reduced rescue analgesic use in patients undergoing CIED implantation without increasing adverse events. These findings support its use as an effective perioperative analgesic strategy in an Asian cohort with a relatively lower BMI profile and suggest that BMI-related variation in analgesic requirement may remain clinically relevant even in such populations. Trial Registration: ClinicalTrials.gov; identifier: NCT04931693.
Background:Effective postoperative analgesia is essential after laparoscopic appendectomy. This randomized, double-blind controlled study compared the analgesic efficacy of ultrasound-guided erector spinae plane block (ESP) and the transversus abdominis plane block (TAP). Methods:This randomized, double-blind controlled study included 72 adult patients undergoing laparoscopic appendectomy. The primary outcome was the 24 h postoperative Numerical Rating Scale (NRS) pain score. Secondary outcomes included time to first rescue analgesia, total 24 h pethidine consumption, intraoperative fentanyl requirements, and adverse events. Patients were randomized to receive either an ultrasound-guided erector spinae plane block or a transversus abdominis plane block. Results:The erector spinae plane block group demonstrated significantly lower postoperative pain scores (mean difference -0.8 to -1.4), longer time to first rescue analgesia (mean difference 1.6 hours; 95% CI: 1.2-2.0), and reduced 24-hour pethidine consumption (mean difference -43.1 mg; 95% CI: -54.0 to -32.1). No major complications occurred. Conclusion:The erector spinae plane block provides superior postoperative analgesia after laparoscopic appendectomy and supports its inclusion in multimodal analgesic pathways. Trial Registration: ClinicalTrials.gov: NCT06220513.
Introduction:Anesthetic complications related to difficult airways in obese patients are very common, necessitating the need for an ideal method of awake intubation, either airway block anesthesia or topical anesthesia. The Aim of This Work:To compare topical airway anesthesia with airway nerve block for ease of awake intubation, with the C-MAC video laryngoscope device employed in difficult intubation anticipated in patients undergoing bariatric surgery. Ease of intubation has been assessed by comparing gag reflex, cough reflex, patient comfort, and other factors. Patients and Methods:This study has been conducted on 80 obese patients undergoing bariatric surgery, where 40 patients received airway nerve block Group LA and 40 patients received topical anesthesia by the method of spray as you go for anesthetizing the airway using 10% lidocaine spray Group T, in addition to conscious sedation before video-assisted laryngoscopy. Result:Group LA showed better airway conditions with decreased cough and gag reflexes, and more patients were intubated at the first attempt than in Group T. Intubation time and need for a rescue airway were less in Group LA. Patient comfort and experience, by recall absence and lower Visual Analog Scale (VAS) scores, were better for Group LA in comparison with Group T. Adverse events in terms of heart rate (HR), elevated mean blood pressure (MAP), and desaturation episodes were more common in Group T. Conclusion:This study concluded that ultrasound-guided airway nerve blocks provided shorter intubation time, significantly superior airway conditions, and more stable hemodynamic and oxygenation profiles compared to topical lidocaine spray, with fewer airway-related complications, reduced need for rescue interventions, and higher overall comfort with no recall of the procedure. Trial Registration: ClinicalTrials.gov identifier: NCT07069686.
Objective:The primary aim was to compare the efficacy of the quadratus lumborum (QL) block with alternative fascial plane blocks for postoperative analgesia following hysterectomy, while secondary aims were to compare total 24-h analgesic consumption, postoperative pain scores at different time intervals, and the incidence of postoperative nausea and vomiting (PONV) between the QL block and comparator groups. Methods:Electronic databases were systematically searched for studies that compared bilateral ultrasound-guided single-injection QL block to no block or other fascial plane blocks in hysterectomy surgeries. The QL block was compared with other fascial plane blocks, including transversus abdominis plane (TAP), oblique subcostal TAP (OSTAP), erector spinae plane (ESP), and combined TAP with ilioinguinal/iliohypogastric nerve block. The methodological quality of the included studies was assessed using the RoB 2.0 risk-of-bias tool. All outcomes were pooled using the Mantel-Haenszel method and random-effect model. Results:After screening 946 relevant articles, 15 RCTs were included in this meta-analysis. The QL block significantly prolonged the time to first rescue analgesic request compared to the TAP block in the abdominal hysterectomy subgroup (MD 244.77 [95% CI: 191.98 to 297.56], I 2 = 89%; GRADE evidence-"high") and the laparoscopic hysterectomy subgroup (MD 443.15 [95% CI: 56.37 to 829.93], I 2 = 98%; GRADE evidence-"high"). Regarding the 24-h total analgesic requirement, the QL block significantly reduced its consumption than the TAP block in both the abdominal (MD -2.64 [95% CI: -4.19 to -1.09], I 2 = 93%; GRADE evidence-"moderate") and the laparoscopic hysterectomy subgroup (MD -6.65 [95% CI: -7.39 to -5.91], I 2 = NA due to n = 1; GRADE evidence-"moderate"). The risk of PONV did not differ significantly between the QL block and placebo in abdominal hysterectomy (RR 2.48 [95% CI: 0.50 to -12.35], I 2 = 0%; GRADE evidence: "moderate") and laparoscopic hysterectomy arm (RR 0.78 [95% CI: 0.50 to -1.22], I 2 = 44%; GRADE evidence: "moderate"). The QL block did not show significant difference in risk of PONV than the TAP block across both the abdominal (RR 0.59 [95% CI: 0.25 to 1.40], I 2 = 0%; GRADE evidence: "moderate") and laparoscopic hysterectomy subgroups (RR 0.86 [95% CI: 0.30 to 2.45], I 2 = 0%; GRADE evidence: "moderate"). Conclusion:The QL block provides superior postoperative analgesia compared with the TAP block in patients undergoing abdominal and laparoscopic hysterectomy.
Study design:The study was an interventional, randomized, prospective comparative clinical trial on 60 patients scheduled for lumbar fixation surgery. Study aim:The study goal was to justify the effectiveness of combined continuous caudal epidural with general anesthesia compared to general anesthesia alone as analgesia for lumbar fixation patients. Overview of Literature:Pain control during the intraoperative and postoperative period for spine surgeries is crucial. Much literature had proved that caudal analgesia is an acceptable alternative approach for intraoperative and postoperative analgesia.Methods: 60 patients were equally allocated to two groups: Group A (Study group) and Group B (Control group). For Group A patients', general anesthesia induction was followed by fluoroscopic-guided caudal epidural catheter insertion. Thirty patients of Group B received general anesthesia only. Various parameters were assessed, including postoperative pain and hemodynamic parameters, time to rescue analgesia, estimated blood loss, surgeon satisfaction with the surgical field, total intraoperative and postoperative narcotics, and common postoperative complications of caudal epidural. Results:The intraoperative heart rate and mean blood pressure showed significant differences. Group A showed a significantly lower intraoperative fentanyl dose. Group A patients had nonsignificant lower blood loss and higher surgeon satisfaction with the surgical field. Postoperative numeric pain scale was significantly lower in the study group. Study group had significant less frequent postoperative morphine need and significant lower total 6-h morphine dose. The rate of requesting the morphine first rescue dose was significantly later and lower in the study group. There was a significant less frequent sedation, in addition to a significant less frequent nausea and vomiting in the study group. Conclusions:Combined continuous caudal epidural with general anesthesia had lower intraoperative fentanyl dose and postoperative morphine dose, with overall lower opioid requirements and better pain control. Trial Registration: Clinical trial.gov.identifier; NCT06929611.
Aim:The aim of this study is to compare the effect of intranasal and oral midazolam administered for premedication to children of preschool age on hemodynamic parameters, sedation, and separation from parents. Method:A prospective, randomized, single-blind design was adopted, including 60 children aged 2-6 years scheduled for elective surgery under general anesthesia. Participants were randomly assigned into two equal groups using a sealed-envelope randomization technique (Group O, n = 30, 0.5 mg/kg oral midazolam; Group N, n = 30, 0.25 mg/kg intranasal midazolam). The study drug was administered 20 min prior to induction of anesthesia. Vital signs and sedation score levels were recorded every 5 min. At the end of the 20th minute, the separation from parents score was assessed and recorded. Assessments were completed by an anesthesiologist who did not know the method of administration for premedication. Results:There were no statistically significant differences between the two groups in terms of mean age, sex, height, and weight. In Group N, 11/30 (36%) of patients had different types of nasal irritation identified. In both groups, sedation score values examined in the 10th minute were significantly high compared to the initial values. No statistical significance was observed for the other values. There was no statistically significant difference observed for the mean separation from parents scores in Group N and Group O examined in the 20th minute (p > 0.05). Conclusion:In our study, 0.25 mg/kg intranasal midazolam and 0.5 mg/kg oral midazolam, administered to children from 2 to 6 years for premedication, were effective methods, with no significant differences between the two kinds of administration in terms of sedation or separation from parents. Due to the nasal irritation emerging in patients with nasal administration, oral midazolam was evaluated as a more preferable method. Trial Registration: ClinicalTrials.gov: NCT07021755.
Purpose:Regional anesthesia techniques are crucial for optimizing pain management after hip arthroplasty. The pericapsular nerve group (PENG) block represents a novel approach targeting specific neural structures for hip joint innervation. Objective:To evaluate the efficacy of PENG block compared to suprainguinal fascia iliaca compartment block (S-FICB) in adult patients undergoing hip arthroplasty, focusing on postoperative opioid consumption, pain scores, and mobilization time. Methods:We conducted a systematic review following PRISMA guidelines, searching PubMed and Scopus databases through October 2025. Only randomized controlled trials comparing PENG block with S-FICB were included. Risk of bias was assessed using the revised Cochrane tool. Meta-analysis employed random effects modeling, with evidence strength evaluated using GRADE methodology. Results:Five randomized controlled trials (824 patients) were included. PENG block significantly reduced 24-h opioid consumption compared to S-FICB (MD -3.85 mg, 95% CI -6.61 to -1.09, p = 0.006, I 2 = 87%), improved pain scores (MD -0.74, 95% CI -1.28 to -0.19, p = 0.008, I 2 = 74%), and shortened time to mobilization (MD -6.94 h, 95% CI -8.96 to -4.93, p < 0.00001, I 2 = 0%). Trial sequential analysis demonstrated robust evidence for mobilization time, with qualified support for analgesic outcomes due to incomplete information size and heterogeneity. Evidence certainty was high for mobilization time and moderate for opioid consumption and pain scores. Conclusions:PENG block provides statistically significant reductions in opioid consumption and pain scores, with robust and clinically meaningful earlier mobilization compared to S-FICB in patients undergoing hip arthroplasty. These findings support incorporating PENG block into multimodal enhanced recovery pathways, though heterogeneity in analgesic outcomes warrants cautious interpretation.
