Background:Effective postoperative analgesia is essential for optimizing recovery and patient satisfaction after inguinal hernia surgery. Therefore, we compared transdermal buprenorphine and fentanyl patches with conventional analgesia for pain control and quality of recovery-15 (QoR-15). Methods:In this prospective, randomized study 150 patients classified as American Society of Anesthesiologists (ASA) I-III scheduled for elective open inguinal hernia repair were randomized into three groups; (n=50 each) Group B (buprenorphine 10 µg/h patch), Group F (fentanyl 25 µg/h patch), and Group C (intravenous paracetamol and tramadol). Patches were applied 12 h preoperatively. The primary outcome was visual analog scale (VAS) pain score, assessed at 1, 6, 12, and 24 h. Secondary outcomes included QoR‑15 scores and rescue‑analgesic requirements. Statistical analysis was performed using the Kruskal-Wallis and Mann-Whitney U tests with Bonferroni correction. Results:Baseline demographic characteristics and perioperative hemodynamic parameters were comparable across groups. Median postoperative VAS scores at 6, 12, and 24 h were significantly lower in both transdermal groups than in the control group. QoR-15 scores at 24 h were 124 (122-125) (C), 127 (125-129) (F), and 133 (131-134) (B), at 48 h were 129 (128-130), 136 (134-138), and 137 (135-139) for Groups C, F, and B, respectively (P = 0.001). Conclusions:Transdermal buprenorphine and fentanyl provided effective postoperative analgesia and were associated with improved quality of recovery compared with standard analgesia. Buprenorphine showed a significant advantage over fentanyl in QoR-15 at 24 h, however, this difference was not significant at 48 h.
Background:Spontaneous intracranial hypotension (SIH) is a rare disorder characterized by cerebrospinal fluid loss and associated neurological effects, including coma. An epidural blood patch (EBP) is an established treatment, but procedural assessment often relies on patient feedback. In patients with impaired consciousness, an objective surrogate is needed. Case:A 40-year-old man with a newly identified intracranial lesion developed progressive cognitive decline with subsequent imaging demonstrating SIH. Despite medical and neurosurgical interventions, his neurological status continued to deteriorate. An EBP was performed based on clinical and radiographic findings. Given his comatose state and inability to provide verbal feedback, electromyography (EMG) with fluoroscopic guidance was used to assess procedural safety and efficacy. Following EMG-assisted EBP, the patient demonstrated progressive neurological improvement. Conclusions:This case highlights the utility of electromyography as an innovative adjunct in performing epidural blood patch in patients with compromised consciousness, offering an effective approach for managing severe spontaneous intracranial hypotension.
Background: Myoclonic epilepsy with ragged red fibers (MERRF) is a rare mitochondrial disorder caused by pathogenic mutations in mitochondrial DNA. Anesthetic management in these patients is challenging because, commonly used anesthetic agents may exacerbate mitochondrial dysfunction and increase the risk of perioperative respiratory, cardiac, and metabolic complications.Case: A 44-year-old woman with MERRF underwent a unilateral salpingo-oophorectomy. General anesthesia was induced applying low-dose midazolam, remifentanil and rocuronium, and maintained with desflurane and remifentanil. Perioperative management focused on minimizing metabolic stress through the maintenance of normothermia, avoidance of lactate-containing solutions, and close hemodynamic and respiratory monitoring. The intraoperative and immediate postoperative courses were uneventful.Conclusions: This case highlights that safe anesthetic care in patients with MERRF can be achieved through comprehensive preoperative evaluation, cautious selection and dosing of anesthetic agents, strict metabolic control, and perioperative monitoring. Hence, individualized anesthetic strategies are essential to optimize perioperative outcomes in patients with mitochondrial disorders.
Obstetric anesthesiologists have traditionally focused on providing effective labor analgesia and ensuring safe cesarean delivery. However, growing evidence suggests that anesthetic choices and childbirth experiences influence maternal mental health beyond the immediate intrapartum period. Postpartum depression (PPD) and postpartum post-traumatic stress disorder (PP-PTSD) are linked to impaired mother-infant bonding, reduced quality of life, and adverse long-term outcomes in mothers and children. Therefore, this review aimed to synthesize the current evidence on antenatal risk factors, delivery mode, anesthetic management, labor epidural analgesia (LEA), perioperative pharmacological prevention, and long-term outcomes, emphasizing the expanding role of obstetric anesthesiologists in postpartum mental health care. General anesthesia for cesarean delivery is linked to an increased risk of severe PPD and suicidality, although its relationship with PP-PTSD remains unclear. LEA does not appear to protect against PPD or PP-PTSD when assessed by binary exposure. Instead, the quality of pain relief, intraoperative pain, failed neuraxial anesthesia, and conversion to general anesthesia may be clinically relevant determinants of postpartum mental health. Perioperative ketamine and esketamine may help prevent the risk of early PPD following cesarean delivery, although evidence of sustained long-term benefits remains limited. These findings support an expanded role for obstetric anesthesiologists beyond intrapartum safety, including trauma-informed communication, optimized pain management, early identification of high-risk women, and prompt referral to multidisciplinary perinatal mental health care.
Safe and effective pediatric sedation depends on multiple factors, including the precise selection of sedative agents, provider expertise, availability of age-appropriate monitoring equipment, and the patients’ individual circumstances. These revised clinical practice guidelines, developed by the Korean Society of Pediatric Anesthesiologists, aim to promote safe and effective pediatric sedation across diverse clinical settings in Korea, thereby enhancing patient safety and standardizing care. These guidelines represent a comprehensive update to the first edition published in 2017, systematically revised through an expert consensus model to reflect the rapidly evolving clinical landscape. The revision prioritized clinical utility and consistency, incorporating the latest pharmacological and technological advancements, while optimizing the content for practical bedside use. Key recommendations cover the entire sedation continuum, including the identification of qualified providers, pre-sedation patient evaluation and fasting requirements, age-specific risk assessment, monitoring of the respiratory and cardiovascular systems, level of sedation, management of respiratory complications, and structured discharge criteria. These recommendations are intended to guide healthcare providers and guardians in sedation-related decision-making for various diagnostic and therapeutic procedures. Depending on the clinical needs and institutional limitations of the primary, secondary, and tertiary care facilities, sedation providers may apply these recommendations directly, adapt them to their specific environments, or use them as a foundational framework for internal protocols.
Hyaluronidase is an enzyme that degrades hyaluronic acid within the extracellular matrix, thereby increasing tissue permeability and facilitating the dispersion of injected agents. Hyaluronidase has been used as an adjunct in spinal interventions to improve drug delivery, enhance adhesiolysis, and overcome therapeutic limitations imposed by epidural fibrosis and scar tissue. This review summarizes the pharmacological properties, clinical evidence, safety considerations, and practical applications of hyaluronidase in spinal pain management. The available evidence suggests that hyaluronidase enhances the distribution of local anesthetics, corticosteroids, and other therapeutic agents within fibrotic or compartmentalized tissues. Clinical studies have demonstrated improved pain relief and functional outcomes when hyaluronidase was incorporated into lumbar interlaminar, caudal, and transforaminal epidural injections, particularly in patients with failed back surgery syndrome. However, evidence regarding its role in percutaneous epidural neuroplasty and adhesiolysis remains inconsistent, with some studies reporting sustained benefits, whereas others have not demonstrated significant independent effects beyond mechanical adhesiolysis. In trigger point injections for myofascial pain syndrome, hyaluronidase has been associated with a faster onset and longer duration of analgesia. Although generally well-tolerated, rare hypersensitivity reactions, including anaphylaxis, have been reported, necessitating careful patient selection and monitoring. Current evidence supports the use of hyaluronidase as a valuable adjunct rather than a stand-alone therapeutic option in selected spinal interventions. Future well-designed prospective studies are needed to clarify its independent therapeutic contribution, optimize dosing strategies, and establish evidence-based clinical guidelines for its use in interventional pain management.
Background:The induction of general anesthesia with propofol often results in hypotension, which is primarily attributed to a decrease in the cardiac index (CI) among elderly patients. Norepinephrine (NE) is typically used to manage anesthesia-induced hypotension. We hypothesized that NE attenuates the reduction in CI while preserving blood pressure. Methods:In a randomized, double-blinded trial, 60 elderly patients undergoing elective major abdominal surgery under general anesthesia were randomly allocated to receive infusion of NE (6 µg/ml) (NE group) or saline (control [CT] group) during induction. CI was monitored using the FloTrac/Vigileo system, and the primary outcome was the change in CI (△CI) (△Value = value measured at the study time point-baseline value) at 10 min post-intubation (T10). Additionally, changes in systemic vascular resistance index (△SVRI) and mean arterial pressure (△MAP) were also evaluated for comparison. Results:In the NE group, the CI decreased from 3.9 to 2.9 L·min-1/m-2 at 10 min post-intubation (T10), whereas in the CT group, it declined from 3.7 to 2.6 L·min-1/m-2. After adjusting for propofol dosage per weight, the decreases in △CI (β = 0.63, 95% confidence interval [CI] 0.18 to 1.07; P = 0.006) and △MAP (β = 11.99, 95% CI 2.05 to 21.94; P = 0.018) at T10 were significantly less in the NE group compared to the CT group, whereas △SVRI did not show a significant difference between the two groups. From induction until 10 min post-intubation, the reductions in △CI, △MAP and stroke volume (△SV) were attenuated, and stroke volume variation was lower, while △SVRI and pulse rate (△PR) remained comparable between the NE and CT groups. Conclusions:Prophylactic infusion of NE effectively attenuated the decrease in △CI during propofol-induced anesthesia in elderly patients while maintaining MAP.
Background:Sugammadex has recently been approved globally for use in pediatric patients aged ≥ 2 years. This meta-analysis with trial sequential analysis (TSA) evaluated the efficacy and safety of sugammadex for reversal of neuromuscular blockade (NMB) in pediatric patients. Methods:PubMed, EMBASE, the Cochrane Library, Web of Science, Scopus, KoreaMed, and ClinicalTrials.gov were searched from inception to December 31, 2023. Randomized controlled trials (RCTs) evaluating sugammadex in pediatric patients were included. Efficacy outcomes were time to recovery to a train-of-four (TOF) ratio ≥ 0.9 and extubation time. Safety outcomes included overall post-anesthetic adverse events, bradycardia, tachycardia, postoperative nausea and vomiting (PONV), recurarization, and desaturation. Data were analyzed using RevMan, and TSA was performed using Copenhagen Trial Unit software. Results:A total of 21 RCTs (n=1,394 pediatric patients) were included in the study. Time to TOF ratio ≥ 0.9 was significantly shorter with sugammadex than with control (neostigmine or placebo) for both 2 mg/kg (mean difference [95% confidence interval], -6.03 [-7.85 to -4.21] min) and 4 mg/kg (-30.06 [-37.58 to -22.55] min). The extubation time was shorter with sugammadex (-14.26 [-17.22 to -11.30] min). The TSA for both efficacy outcomes indicated that the required information size had been reached, suggesting that additional trials are unlikely to change the efficacy conclusions. PONV, tachycardia, and desaturation occurred less frequently with sugammadex, whereas the overall post-anesthetic adverse events, recurarization, and bradycardia were comparable. Conclusions:Sugammadex was associated with faster and more effective reversal of rocuronium-induced NMB in pediatric patients.
Epigenetics, the study of heritable changes in gene expression that occur without altering the underlying DNA sequence, has emerged as an important conceptual framework for anesthesiology. The epigenome is organized into three mechanistic tiers: cytosine methylation in DNA, chemical modification of histone proteins, and gene regulation by non-coding RNA molecules. Unlike a relatively stable genome, epigenetic patterns vary between cell types, change throughout the lifespan, and are modifiable by environmental exposures, including surgical stress and anesthetic drugs. These properties make epigenetic mechanisms particularly relevant to several problems encountered in anesthetic practice. For example, interindividual variability in responses to analgesics and anesthetics, pathophysiology of chronic pain and opioid tolerance, immune dysregulation in critical illness, and long-term cognitive consequences of perioperative exposure in vulnerable populations. This review aimed to explore the fundamental concepts of epigenetics for anesthesiologists; established roles in disease conditions relevant to anesthesiology, including pain, neurodegeneration, and inflammation; and the key considerations for designing and interpreting epigenetic research in the perioperative context. Understanding the epigenome offers both a new lens through which to view the clinical phenomena encountered daily in anesthetic practice, and a potential avenue toward more individualized, mechanism-informed patient care.
Effective perioperative pain control is essential for patient comfort and for optimizing surgical outcomes and the quality of recovery. Multimodal analgesic strategies have become a cornerstone of modern perioperative pain management. Although regional analgesia is widely used within this framework, the clinical utility of conventional local anesthetics remains limited by their relatively short duration of action. Continuous infusion techniques can sustain local anesthetic delivery; however, catheter-based systems have several device- and technique-related limitations. In response, sustained-release local anesthetic formulations have been developed to extend analgesia after a single administration. These formulations include liposomal preparations, polymer-based delivery systems, and hydrogel-based carriers. Liposomal bupivacaine uses a multivesicular delivery system that acts as a local drug depot and gradually releases the anesthetic at the injection site. Polymer-based systems that combine local anesthetics with anti-inflammatory agents enhance analgesia by modulating the local tissue environment. Hydrogel-based carriers, including thermoresponsive and hyaluronic acid-based platforms, provide sustained drug release through three-dimensional polymer networks while minimizing systemic exposure. Recent advances in these delivery platforms have expanded the clinical potential of sustained-release local anesthetic technologies. Nevertheless, widespread clinical adoption remains constrained by several challenges, including burst release, variability in release kinetics, high costs, and limited clinical evidence. Sustained-release local anesthetic systems may provide catheter-free, prolonged postoperative analgesia in accordance with the principles of enhanced recovery after surgery. As drug delivery technologies continue to evolve, sustained-release local anesthetic formulations are likely to play an increasingly important role in perioperative pain management.
BACKGROUND:Reports of remimazolam formulation-associated anaphylaxis are increasing as its use expands. Between 2023 and 2025, we identified two severe reactions among 1,592 patients who received remimazolam at our institution. CASE:A 65-year-old man with end-stage renal disease developed profound hypotension without cutaneous signs after induction with 10 mg of remimazolam and peri-induction cefazedone administration. Surgery was cancelled due to persistent hypotension. Serum tryptase at 6 h was 38.0 μg/L; however, delayed skin testing was negative. Subsequent propofol-based anesthesia without cefazedone re-administration was uneventful. A 50-year-old woman developed hypotension and facial flushing within 2 min of receiving 10 mg of remimazolam. Although serum tryptase levels remained within the normal range, delayed skin testing for remimazolam was positive. CONCLUSIONS:Diagnosis of remimazolam formulation-associated hypersensitivity may remain inconclusive when based on a single diagnostic test. Accurate evaluation requires integrating timed tryptase, delayed skin testing, and exposure history.
Background: Maternal satisfaction with anesthesia services is crucial, and an important factor affecting it is spinal needle pain. This study was designed to ascertain the effects of a topical spray of 10% lidocaine on spinal needle prick pain and its correlation with maternal satisfaction. Methods: One hundred ten patients receiving subarachnoid blockade prior to cesarean delivery were randomly allocated to two groups: group LIDO (2 puffs of topical 10% lidocaine spray) and group NS (2 puffs of normal saline spray) given 120 s prior to lumbar puncture, and finally data from 99 patients was analyzed. The primary outcome was maternal satisfaction score (1-5) at the end of surgery, and secondary outcomes were numeric rating scale (NRS) pain score during spinal needle puncture, physical response to pain (observer-assessed score, 0-4). Results: Maternal satisfaction did not differ significantly between the two groups (mean rank 50.76 vs. 49.26; median [1Q, 3Q]: 4 [4, 5] vs. 4 [4, 5], P = 0.767). Although both the NRS score and the physical response to spinal needle prick were significantly lower in the LIDO group compared to placebo (P < 0.001 for both), maternal satisfaction remained comparable between the groups. Conclusions: Topical 10% lidocaine spray is a feasible, economic, and effective intervention to alleviate pain during spinal needle prick in pregnant women. However, addressing spinal needle prick pain alone cannot improve maternal satisfaction and requires a multidimensional approach.
BACKGROUND:Robot-assisted laparoscopic prostatectomy (RALP) with pneumoperitoneum and steep Trendelenburg positioning impairs ventilation and increases the risk of postoperative pulmonary complications (PPCs). Although positive end-expiratory pressure (PEEP) may reduce atelectasis, the optimal levels remain unclear. This study evaluated the effects of driving pressure (DP)-guided PEEP titration during RALP. METHODS:This single-center, randomized controlled trial enrolled adults undergoing RALP (American Society of Anesthesiologists < 3, without pulmonary disease) for either DP minimization-guided individualized PEEP (DP group) or fixed 5 cmH2O PEEP (control). DP was calculated as plateau pressure minus PEEP, with individualized PEEP determined using decremental titration. Atelectasis was quantified using modified lung ultrasound (LUS) score, incorporating B-lines and consolidations. Primary outcome was LUS score at end-Trendelenburg. Secondary outcomes included oxygenation and PPCs. RESULTS:Of 101 assessed, 63 completed analysis. The DP group (n=31) received higher individualized PEEP (median 8.0 cmH2O) during Trendelenburg than controls (5.0 cmH2O, n=32). In the DP group, mean DP was lower during Trendelenburg (19.0 ± 3.4 vs. 21.3 ± 4.7 cmH2O, P=0.035) and LUS score was significantly lower at the end-Trendelenburg (median [1Q, 3Q]: 9.0 [8.0, 11.5] vs. 11.0 [9.0, 13.0]; median difference, -2.0 [95% CI, -3.0 to 0.0]; P=0.032) and recovery (9.0 vs. 13.5, P<0.001). Intraoperative PaO2 during Trendelenburg was higher in the DP group (154.6 ± 33.1 vs. 133.3 ± 34.7 mmHg, P=0.015). PPCs and hospital stay were comparable between groups. CONCLUSIONS:DP-guided PEEP titration during RALP reduced lung de-aeration burden assessed by modified LUS score, though benefits did not translate to reduced PPCs.
Background: Low central venous pressure (CVP) and Pringle maneuver are commonly employed strategies to reduce bleeding during hepatic resection. Milrinone and terlipressin lower hepatic venous pressure and portal venous pressure (PVP), thereby reducing the risk of bleeding. This study compared the intraoperative blood loss between a combined infusion of milrinone and terlipressin, and terlipressin alone in patients undergoing elective hepatic resection. Methods: A total of 36 patients were randomized to the Milrinone and terlipressin or Terlipressin groups, who received infusions starting 30 min before the beginning of liver resection until the end of the surgery. The primary objective was to determine differences in blood loss between the two groups. Results: Thirty-four patients (17 in each group) were assessed by stratification into major and minor hepatic resections. The median (1Q, 3Q) intraoperative blood loss (in ml) was lower in Milrinone and terlipressin group than in Terlipressin group (570 [329, 880] vs. 824 [750, 1,146]; P = 0.046). In minor resections, milrinone and terlipressin had lower blood loss than terlipressin (373 [273, 556] vs. 798 [725, 1,230]; P = 0.015). There is no difference between the two groups in blood loss during major hepatic resection. The decreases in PVP and CVP at 30 min post-infusion were significant in the Milrinone and terlipressin group (P = 0.002 and P = 0.027, respectively). Conclusions: The combination of milrinone and terlipressin significantly reduces intraoperative blood loss, especially during minor hepatic resections.
Background: Effective perioperative analgesia is essential to prevent abrupt changes in cerebral blood flow following carotid endarterectomy (CEA). We aimed to evaluate whether multimodal analgesia, including intermediate cervical plexus block (CPB), reduces 24 h postoperative opioid consumption compared with local infiltration. Methods: This randomized, observer-blinded study included 40 patients undergoing CEA. Patients were randomly allocated to either the multimodal group (multimodal analgesia with intermediate CPB, n = 20) or the control group (local infiltration, n = 20). The primary outcome was 24 h intravenous (IV) opioid conversion to IV morphine equivalents. Secondary outcomes included pain scores at rest and during motion, time to first opioid use, hypertension incidence, antihypertensive use, postoperative nausea/vomiting, satisfaction with pain management, quality of first-night sleep, Korean version of the Quality of Recovery-15 (QoR-15K) scores, complications, cerebral hyperperfusion syndrome, and intraoperative analgesia nociception index values. Results: In the intention-to-treat analysis, 24 h postoperative opioid consumption was 13.3 (6.7, 20.0) mg and 10.0 (6.7, 13.3) mg in the control and multimodal groups, respectively, with no significant difference (P = 0.191). The multimodal group had significantly lower immediate postoperative pain at rest (P < 0.001) and during movement (P < 0.001), as well as longer time to first opioid use (P = 0.047) and higher QoR-15K scores (P = 0.004). No significant differences were observed in the other parameters. Conclusions: Multimodal analgesia with intermediate CPB did not reduce 24 h opioid consumption after CEA. However, it was associated with better early postoperative pain control and recovery scores.
BACKGROUND:The coronavirus disease 2019 (COVID-19) pandemic has profoundly influenced surgical practice and perioperative care, but its impact on postoperative pneumonia incidence remains unclear. METHODS:We conducted a retrospective cohort study using the Observational Medical Outcomes Partnership-Common Data Model databases from 17 Korean hospitals. Based on the inpatient surgery date, patients were classified into prepandemic (January 2018-December 2019) and postpandemic groups (January 2020-December 2021). Postoperative pneumonia was identified within 30 days after surgery. Logistic regression analysis assessed the independent effects of the pandemic, age, anesthetic technique, and their interaction. RESULTS:The overall incidence of postoperative pneumonia per 10,000 persons changed slightly from 12.38 prepandemic to 12.99 postpandemic (+4.94%). Younger patients (< 70 years) demonstrated decreased incidence (8.47→7.97, -5.81%), whereas older patients (≥ 70 years) demonstrated increased incidence (28.97→31.97, +10.36%). Considerable interhospital variation was observed, with some hospitals reporting increases exceeding 100%, while others reporting declines exceeding 80%. Overall postoperative pneumonia risk was similar between the pre- and postpandemic periods (odds ratio [OR], 0.893; 95% confidence interval [CI], 0.787-1.015). Older age (≥ 70 years) was strongly associated with higher risk (OR, 2.816; 95% CI, 2.383-3.328), and a significant postpandemic×age interaction indicated that older patients were disproportionately affected (OR, 1.385; 95% CI, 1.145-1.675). CONCLUSIONS:The COVID-19 pandemic did not substantially change the overall incidence of postoperative pneumonia, although variations existed across hospitals and age groups. Older age remained the strongest risk factor. Further studies are warranted to clarify the underlying causes and optimize perioperative infection control.
Background: We compared the quality of recovery (QoR) between total intravenous anesthesia using remimazolam and propofol in older patients undergoing laparoscopic abdominal surgeries.Methods: A total of 120 patients (aged ≥ 60 years) undergoing laparoscopic gastric or colorectal surgery were randomized to the remimazolam or propofol group. Continuous remimazolam/propofol infusion and target-controlled remifentanil infusion were performed. Recovery was evaluated using the Korean version of the Quality of Recovery-15 (QoR-15K) questionnaire. The primary outcome was the QoR-15K score on postoperative day (POD) 3. Secondary outcomes included the QoR-15K score on POD 1; perioperative mean arterial pressure and heart rate; times to eye opening, extubation, and full recovery; post-anesthetic care unit (PACU) adverse events; postoperative delirium; and duration of hospitalization.Results: The total QoR-15K scores over time did not make differences significantly between the groups. Total QoR-15K scores on POD 3 (112.0 [96.0, 119.0] vs. 104.0 [84.8, 120.5], P = 0.481) and POD 1 (80.0 [62.0, 97.0] vs. 78.0 [60.8, 95.3], P = 0.635) were comparable between the groups. The MAP and HR were significantly higher in the remimazolam group. The times to extubation (12.0 [11.0, 15.0] vs. 10.5 [9.0, 12.3] min, P = 0.003) and full recovery (13.0 [9.0, 16.0] vs. 11.5 [8.0, 14.0] min, P = 0.045) were notably longer in the remimazolam group. The incidence of adverse events in the PACU and postoperative delirium, and duration of hospitalization were comparable between the groups.Conclusions: Remimazolam yielded a similar QoR as propofol in older patients undergoing laparoscopic abdominal surgeries.
