The management of brain tumors during pregnancy presents a complex clinical challenge, balancing maternal neurological needs with fetal safety. Awake craniotomy (AC) is a potential strategy to maximize tumor resection in eloquent areas while minimizing fetal anesthetic exposure, but the literature remains sparse. The objective of this review is to summarize the current evidence regarding the use of AC for brain tumors during pregnancy. Following PRISMA guidelines, a systematic search was conducted in PubMed, Scopus, Cochrane Library, and ScienceDirect databases for studies reporting on AC in pregnant patients. Data on clinical characteristics, anesthetic techniques, and maternal/fetal outcomes were extracted. Methodological quality was assessed using the Joanna Briggs Institute checklist for case reports. Eleven studies, comprising 11 patients, met the inclusion criteria. All were case reports or a small case series. AC was performed across all trimesters for various tumors, predominantly gliomas. Anesthetic techniques included both “awake throughout” and “asleep-awake-asleep” approaches, with dexmedetomidine and propofol being common agents. All cases reported successful surgical resections with positive fetal outcomes, resulting in the delivery of healthy infants. Short-term maternal neurological outcomes were generally favorable; however, long-term maternal prognosis was variable and dependent on the underlying tumor pathology. A multidisciplinary approach was highlighted as crucial for success. The available evidence, though limited to case reports, suggests that AC is a viable, effective option for carefully selected pregnant patients with brain tumors. However, the high potential for publication bias warrants caution, and larger, prospective studies are needed to establish definitive guidelines.
Background and Aims:Hypotension is a common adverse effect of spinal anesthesia and poses increased risks for patients with diabetes mellitus. While various tests exist for diagnosing diabetic autonomic neuropathy, dynamic pupillometry is a simple and cost-effective option. This study aimed to assess whether dynamic pupillometry can predict post-spinal hypotension in diabetic patients. Material and Methods:In this observational study, 75 patients with diabetes mellitus who were scheduled for surgery under spinal anesthesia underwent a pupillary examination the day prior. Both static and dynamic parameters were recorded. On the day of surgery, 3 ml of 0.5% hyperbaric bupivacaine was administered for spinal anesthesia, and instances of intraoperative hypotension and the use of vasopressors were noted. Results:Post-spinal hypotension occurred in 77% of the 75 patients studied, with 27 experiencing mild hypotension (20-30% drop in MAP) and 31 having severe hypotension (>30% drop). The severe hypotension group had a significantly lower baseline pupil radius (3.86 ± 0.52 mm) compared to the no hypotension group (4.37 ± 0.57 mm, P = 0.006). The area under the receiver operating characteristic curve for baseline pupil radius was 0.720, with a threshold of less than 4.01 mm showing 70.7% sensitivity and 70.6% specificity for predicting post-spinal hypotension. Conclusions:Baseline pupil radius measured using pupillometry may serve as a simple noninvasive marker to identify diabetic patients at risk of post-spinal hypotension.
Background and Aims:Peripheral arterial disease (PAD) impairs blood flow to the extremities, leading to symptoms that impair quality of life (QOL). Lumbar sympathectomy (LS) has shown potential in symptom management, particularly in cases where medical therapy or vascular bypass surgery fails. However, limited evidence compares the efficacy of LS in patients with and without prior vascular bypass surgery. This study evaluates the differential impact of LS on pain relief, analgesic consumption, and QOL in these subgroups. Material and Methods:A retrospective observational study was conducted involving 34 PAD patients who underwent fluoroscopy-guided LS between September 2023 and June 2024. Patients without prior vascular bypass surgery (Group L, n = 17) and with prior vascular bypass surgery (Group LB, n = 17) were assessed for pain using the Visual Analog Scale (VAS), analgesic consumption with the Overall Benefit of Analgesic Score (OBAS), and QOL via World Health Organization Quality of Life Brief Version (WHOQOL-BREF). OBAS is a 7-item patient self-report instrument that combines pain severity, opioid side effects, and treatment satisfaction in the past 24 h. We examined the sum of all WHOQOL-BREF items as the prespecified QOL measure (26 items; higher scores = better QOL). The four domains (Physical, Psychological, Social Relationships, and Environment) were not examined individually in the primary analysis to prevent multiplicity and because of the small sample size; results at the domain level, if examined, were considered exploratory and are not inferentially contrasted. Analysis of data was performed with descriptive statistics, paired and independent t-tests, Welch's t-tests, standardized effect sizes (Hedges' g and Cohen's dz), and repeated-measures Analysis of Variance test analysis of variance (ANOVA) with Greenhouse-Geisser correction; statistical significance was at P < 0.05. Results:Both groups showed significant improvements in VAS, OBAS, and QOL (P < 0.001). Patients in Group L experienced better immediate pain relief (VAS at 24 h: 3.29 vs. 4.29, P = 0.001) and sustained OBAS benefits over three months (P < 0.05). QOL improvements were comparable between groups in the long term. Conclusions:LS is effective in improving pain, reducing analgesic use, and enhancing QOL in PAD patients. Bypass-naïve patients demonstrated better immediate outcomes, suggesting tailored therapeutic benefits. Prospective studies are needed to confirm these findings.
Background and Aims: The traditional approach to combined lumbar and sacral plexus block require multiple injections with the patient in the lateral or prone position. We designed a study to compare the novel single puncture, dual injection, anterior approach targeting the branches of the lumbosacral plexus versus lumbar epidural for postoperative analgesia. Material and Methods: The present study enrolled 134 adult patients scheduled for unilateral lower limb orthopedic surgery under combined spinal epidural anesthesia without epidural activation. Study participants were randomly assigned to either group B (lumbosacral plexus block) or group E (lumbar epidural). Postoperatively, patients in group ‘B’ received the ultrasound-guided single puncture, dual injection, block via anterior approach targeting the branches of the ipsilateral lumbosacral plexus, while patients in group ‘E’ received lumbar epidural. All patients received patient-controlled epidural analgesia (PCEA). The primary objective of the study was to compare postoperative analgesia as assessed by numerical rating scale (NRS) score at predefined time points (0, 1, 3, 6, 12, 18, and 24 h) between groups. The secondary objectives were the comparison of sensory block, motor block, rescue analgesic requirement, complications, and patient satisfaction. Results: Patients in group B had significantly lower median (quartile) NRS scores (at rest and movement) at predefined time points compared to patients in group E (P-value < 0.001). The median PCEA pump boluses attempted and delivered were significantly lower in group B (P-value < 0.001), and a lesser number of patients required rescue analgesia in group B than in group E (P-value < 0.001). Group B had fewer patients with hypotension and PONV and a significantly higher median satisfaction score than group E (P < 0.001). Conclusions: The ultrasound-guided single puncture, dual injection, anterior approach targeting branches of the lumbosacral plexus provides better postoperative analgesia and is as safe as epidural analgesia.
Background and Aims: A brachial plexus injury (BPI) with phrenic nerve involvement causes hemidiaphragm paresis and subclinical respiratory problems. Surgical traction and anesthetic agents employed during brachial plexus repair may further worsen diaphragm function, complicating extubation and increasing postoperative pulmonary complication (PPC) risk. Point-of-care ultrasound (POCUS) provides rapid, bedside assessment of diaphragm function but has not been evaluated in BPI repair surgery. Hence, this study evaluated the role of perioperative diaphragmatic POCUS (PDPOCUS) for determining PPC incidence as the primary objective in BPI repair surgeries with preexisting chronic hemidiaphragm paresis. Secondary objectives included assessment of diaphragm dysfunction contributing to PPC. Material and Methods: This prospective observational study recruited 60 patients with chronic hemidiaphragm paresis undergoing BPI repair surgeries under propofol-dexmedetomidine total intravenous anesthesia (TIVA) without muscle relaxants. PDPOCUS was employed to measure diaphragm excursion (DE), diaphragm thickness (DT), and diaphragm thickness fraction (DTF) bilaterally and to compare between the two sides and preoperative versus postoperative values. PPCs were followed till 3 postoperative days. Results: All 60 patients exhibited lower diaphragm parameters in the affected side than the normal side (P < 0.05) (100% diaphragm dysfunction incidence) except for DT during expiration preoperatively, reflecting paresis. Postoperatively, the normal hemidiaphragm showed a significant fall in DE during deep breathing (P = 0.042), DT during inspiration (P = 0.001), and DTF (P = 0.031) but remained near normal, implying no new dysfunction. Only two patients desaturated postoperatively within 24 hours and required oxygen support, indicating 3.33% incidence of PPC. Conclusions: PDPOCUS reliably assesses perioperative diaphragmatic dysfunction in brachial plexus repair surgeries with preexisting hemidiaphragm paresis. PPC incidence is low with propofol-dexmedetomidine TIVA and meticulous microsurgical techniques, which preserve diaphragm integrity and promote safe extubation under POCUS guidance, despite chronic paresis, but large trials are needed.
Background and Aims:Central venous cannulation in neonates and infants is technically challenging due to small vessel size and vein collapsibility. Although ultrasound-guided (USG) internal jugular vein (IJV) cannulation is commonly used, supraclavicular in-plane brachiocephalic vein (BCV) cannulation has emerged as a newer approach with several advantages because of its straighter course, larger diameter, and reduced collapsibility. The aim of this study was to compare the USG-guided in-plane IJV vs supraclavicular in-plane BCV cannulation in neonates and infants. Material and Methods:This prospective randomized controlled trial (RCT) was commenced after obtaining institutional ethical clearance (EC/OA-67/2022) and registered with CTRI (REF/2023/08/071780). A total of 80 neonates and infants satisfying the eligibility criteria were included for this study, with 40 each being randomly allotted either to group A (USG in-plane right IJV cannulation) or group B (USG supraclavicular in-plane left BCV cannulation). Written informed parental consent was obtained for all the participants. The primary outcome was 1st attempt success rate. Secondary outcomes included cannulation time, number of attempts, overall success rate, and complications. Results:First-attempt success rate was higher in BCV than in the IJV group (95% vs 77.50%, P value = 0.02) (95% CI: 3.2-31.8). Cannulation time was less in the BCV group (50.70 ± 58.51 secs vs 86.63 ± 60.19 secs: P value < 0. 008) (95% CI: -62.5 to -9.3) as compared to the IJV group. Overall success rate was slightly higher in the BCV group (100% vs 97.50%, P value = 0.31) (95% CI: -2.4% to 7.4%) along with a reduced number of attempts (1.08 ± 0.35 vs 1.30 ± 0.65, P value = 0.057) (95% CI: -0.45 to 0.01). No immediate or late complications (within 48 hours) were observed in both the groups. Conclusions:USG in-plane left BCV cannulation improved first-attempt success rate and cannulation time as compared to in-plane right IJV cannulation with a reduced number of attempts. Brachiocephalic central venous cannulation may have advantages over IJV access, especially in critically ill neonates and infants, making it a feasible and safe alternative to IJV.
Maternal cardiac arrest is a life-threatening event with both obstetric and non-obstetric causes, requiring rapid, pregnancy-specific resuscitation. Physiological changes in pregnancy reduce the effectiveness of standard Cardiopulmonary resuscitation, necessitating modifications to advanced cardiac life support (ACLS). This review aims to highlight key causes, resuscitation adaptations, and the critical role of perimortem cesarean delivery (PMCD) in improving maternal and fetal outcomes. A structured literature search was conducted across PubMed, Scopus, Google Scholar, and Web of Science using relevant keywords. Studies were screened by title/abstract followed by full-text review, and articles focusing on clinical aspects, techniques, outcomes, and guidelines of PMCD were included, with emphasis on recent high-quality evidence. The literature search included peer-reviewed publications from 2000 to 2025, comprising original research articles, case reports, and guideline documents. Resuscitation follows standard American Heart Association (AHA) basic life support (BLS)/ ACLS with key modifications: provide left uterine displacement (LUD) (15-30° tilt) after 20 weeks to relieve aortocaval compression; secure airway early due to difficult airway and rapid desaturation; perform chest compressions slightly higher on the sternum; use upper-extremity/central venous access; and apply standard defibrillation and drug protocols. If PMCD is performed within 5 min of cardiac arrest, it significantly improves maternal return of spontaneous circulation (ROSC) and increases the likelihood of favorable fetal survival and neurological outcomes. Maternal cardiac arrest requires prompt, pregnancy-specific modifications to standard resuscitation to optimize outcomes. Early uterine displacement, effective airway management, and adherence to ACLS protocols are critical, while timely PMCD within 4-5 min significantly improves maternal hemodynamics and enhances both maternal and fetal survival.
Background and Aims: Neuraxial anesthesia is a core anesthetic skill, but traditional patient-based teaching carries ethical and safety concerns. Simulation-based training offers a structured, risk-free environment for novices to gain competence before performing procedures on patients. This study aimed to compare the subarachnoid block simulation performance of novice postgraduate students of anesthesiology after spinal mannequin-based and conventional didactic methods of teaching. Material and Methods: This study included 50 novice anesthesia residents who were randomly assigned to Group A and Group B. Group A received mannequin-based instruction, while Group B received didactic instruction. They were then assessed on patients for the number of successful first needle passes or redirections, time taken to successfully perform neuraxial anesthesia/analgesia, total number of attempts, complications, number of needle bone contacts, and ease of landmark palpation of space. Results: Twenty novices in group A (n = 25) successfully performed spinal anesthesia on the first attempt as compared to 7 (n = 25) in group B (P = 0.001). Patients in group A had a lower number of needle bone contacts as compared to group B (6 vs 19, P = 0.002). Also, the procedural time was much less in group A (127 ± 66.4 seconds) as compared to group B (173 ± 68.9) (P = 0.01). Conclusions: Novices trained on mannequins had higher successful first pass attempts, fewer procedural errors, and shorter procedural times. Mannequin-based stimulation teaching should be considered for training all novices in subarachnoid block.
Background and Aims: The proportion of older adults with frailty undergoing total hip arthroplasty (THA) has increased significantly against the backdrop of the rapidly aging population. However, the benefits of ciprofol in this population have not been widely investigated. Material and Methods: We conducted a single-center, prospective, double-blind, randomized controlled trial. From October 2024 to July 2025, this study was conducted at a large, university-affiliated tertiary care hospital. After obtaining ethical approval, 78 older adults with frailty undergoing hip arthroplasty scheduled for elective laparoscopic surgery were enrolled. Using a randomized numerical table method, they were classified into either the ciprofol group (Group A) or the propofol group (Group B), with 39 patients in each group. Cardiac output (CO) and the mean arterial pressure (MAP) were recorded at eight intraoperative time points from T0 to T7, in addition to the use of intraoperative vasoactive drugs, postoperative awakening time, extubation time, postoperative complications, and length of hospitalization. Results: At T2 (preintubation) and T3 (immediately postintubation), MAP and CO in the ciprofol group were significantly higher than those in the propofol group (P < 0.05). Furthermore, the use of intraoperative vasoactive drugs was significantly lower in Group A. No significant differences were observed between these groups in postoperative awakening time, extubation time, the length of hospitalization, and complications. Conclusions: Ciprofol shows comparable efficacy as propofol for the induction and maintenance of anesthesia during THA in older adults with frailty. Furthermore, ciprofol yields a better perioperative hemodynamic profile and causes fewer adverse effects.
Chronic spinal pain markedly impairs function and quality of life. Dextrose prolotherapy is a potential treatment thought to induce a controlled inflammatory response, promote connective-tissue repair, enhance spinal stability, and modulate nociceptive signaling. This systematic review synthesised current evidence on its effectiveness and safety. A systematic search was performed in PubMed, ScienceDirect, SpringerLink, and the Cochrane Library up to June 2025. Eligible studies included randomized controlled trials (RCTs), prospective cohort studies, and prospective case series (≥10 patients) reporting outcomes on pain, physical function, quality of life, or adverse events. Risk of bias was assessed using Joanna Briggs Institute tools for nonrandomized studies and the Cochrane Risk of Bias 2 tool for RCTs. Twelve studies were included (six case series, two cohort studies, one quasi-experimental study, and three RCTs), involving chronic low back pain, sacroiliac joint pain, discogenic pain, coccydynia, failed back surgery syndrome, and lumbar disc herniation. Most studies reported pain reduction; intra-articular injections of 25%-50% dextrose were associated with analgesia lasting 6-24 months, whereas 5% epidural dextrose provided rapid relief in radicular pain. Improvements in physical function and quality of life were also reported, with no major complications. Overall, dextrose prolotherapy appears safe and potentially effective for chronic spinal pain, particularly in refractory cases, although outcomes may depend on patient selection, dextrose concentration, and injection technique.
Background and Aims: Nasotracheal intubation is commonly used in maxillofacial surgeries but often causes complications, with epistaxis being the most frequent. Selecting the more patent nostril and appropriate tube size can help reduce bleeding. Flexible nasal endoscopy (FNE) is traditionally used for this assessment but is invasive. Virtual nasal endoscopy (VNE), a non-invasive imaging technique, may offer an alternative. This randomized controlled study aimed to compare the incidence of epistaxis during nasotracheal intubation when guided by VNE vs FNE. Material and Methods: Sixty-four patients were enrolled. Preoperatively, VNE using OsiriX Lite software identified the more patent nostril and endotracheal tube (ETT) size. On surgery day, FNE was performed to assess the same. Patients were randomized into Group V (virtual) or Group E (endoscopy), with nostril side and Ring-Adair-Elwyn (RAE) tube size chosen accordingly. Incidence and severity of epistaxis during laryngoscopy and before throat packing, ease and time of insertion, manipulations, and number of attempts were recorded. Results: The incidence and severity of epistaxis were significantly less in group V than group E at laryngoscopy (18.8% vs 59.4%, P < 0.001) and during throat packing (31.2% vs 84.4%, P < 0.001). The time taken for ETT insertion, tube impingement, and manipulations was also significantly reduced in group V. Conclusion: Our study showed that the incidence of epistaxis was significantly less in VNE than in FNE-guided intubation.
