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.

Lumbar plexus blocks (LPBs) are routinely employed for analgesia in hip fracture surgery; however, a novel regional technique, the pericapsular nerve group (PENG) block, potentially offers comparable pain reduction while preserving motor function. Patients aged 45–90 years who underwent hip fracture surgery were allocated to receive either a PENG block or an LPB for analgesia. The primary outcome was the incidence of quadriceps motor block (defined as the paresis or paralysis of the knee extension) at 12 h postoperatively. The secondary outcomes included the performance time, the time to first analgesic requirement, postoperative intravenous (IV) fentanyl consumption, the ability to undergo physiotherapy at 24 and 48 h, complications, sensory and motor block assessments, postoperative numeric rating scale (NRS) pain scores, and patient outcome questionnaires. There was a significantly lower incidence of quadriceps motor block at 6 h (26.7% vs. 80.0%; p < 0.001) and at 12 h (20.0% vs. 56.7%; p = 0.010). The PENG block provided better preservation of the sensory block as well as better performance time (p < 0.001) and time to first analgesia requirement (p = 0.034), whereas the LPB resulted in lower postoperative IV fentanyl consumption at 24 h (p = 0.013). The PENG block demonstrated superiority over the LPB in preserving quadriceps strength and patient satisfaction without any substantial complications, despite higher opioid consumption within the first 24 h post-surgery.

(1) Background: Remifentanil is used for intraoperative pain control; however, it has several side effects, such as hypotension and opioid-induced hyperalgesia. We aimed to determine whether an intraoperative remifentanil infusion may increase postoperative opioid consumption in patients undergoing total knee arthroscopy (TKA) under femoral nerve block (FNB) in addition to general anesthesia. (2) Methods: We randomly assigned 66 patients who underwent total knee arthroplasty to the remifentanil (R) and control (C) groups. All patients underwent FNB and popliteal artery and posterior capsule of the knee (iPACK) block in addition to sevoflurane-based general anesthesia. Postoperative pain control was achieved using intravenous patient-controlled analgesia (IV-PCA) fentanyl. We recorded IV-PCA fentanyl consumption at various postoperative timepoints, numerical rating scale (NRS) scores, intraoperative changes in vital signs and index of nociception (qNOX), ephedrine consumption, postoperative side effects, satisfaction, and sleep quality. (3) Results: The primary outcome (the cumulative IV-PCA fentanyl usage within 48 h postoperatively) was significantly lower in the C group (541.1 ± 294.5 µg) than in the R group (717.5 ± 224.0 µg) (p < 0.001). The secondary outcome (the cumulative IV-PCA fentanyl usage within 12, 24, and 72 h) was lower in the C group than in the R group and the mean arterial pressure was lower in the R group than in the C group from immediately after tourniquet on to immediately after tourniquet off. The heart rate was lower in the R group from immediately after incision to immediately after irrigation. There was no significant between-group difference in the perioperative qNOX and NRS scores at rest and activity except for NRS scores at 72 h postoperatively. Ephedrine use was higher in the R group than in the C group (p = 0.003). There was no significant between-group difference in the incidence of postoperative nausea and vomiting, nor in the postoperative satisfaction and sleep quality. (4) Conclusions: Avoiding intraoperative remifentanil infusion may reduce total opioid consumption in patients undergoing FNB before TKA.

Background and Objectives: Postoperative nausea and vomiting (PONV) is a common adverse effect of general anesthesia, especially in middle ear surgery. Remimazolam is a newer benzodiazepine recently approved for use in general anesthesia. This study aimed to compare the incidence rate of PONV after tympanoplasty with mastoidectomy between using remimazolam and sevoflurane. Materials and Methods: This study included 80 patients undergoing elective tympanoplasty with mastoidectomy. The patients were randomly assigned to either the remimazolam or sevoflurane group. The primary outcome was the incidence rate of PONV 12 h after surgery. The secondary outcomes were the incidence rate of PONV 12–24 and 24–48 h after surgery, severity of PONV, incidence rate of vomiting, administration of rescue antiemetics, hemodynamic stability, and recovery profiles. Results: The incidence rate of PONV 0–12 h after tympanoplasty with mastoidectomy was significantly lower in the remimazolam group compared with that in the sevoflurane group (28.9 vs. 57.9%; p = 0.011). However, the incidence rate of delayed PONV did not differ between the two groups. PONV severity in the early periods after the surgery was significantly lower in the remimazolam group than in the sevoflurane group. The incidence rate of adverse hemodynamic events was lower in the remimazolam group than in the sevoflurane group, but there was no difference in the overall trends of hemodynamic data between the two groups. There was no difference in recovery profiles between the two groups. Conclusions: Remimazolam can significantly reduce the incidence rate of early PONV after tympanoplasty with mastoidectomy under general anesthesia.

Background Remimazolam is a novel benzodiazepine with fast onset and short half-life. We compared the effects of remimazolam and propofol on recovery profiles for general anesthesia in patients undergoing laparoscopic cholecystectomy. Methods We randomly assigned 108 patients to either a remimazolam (n=54) or propofol (n=54) group. Remimazolam and propofol were used for induction and maintanance of anesthesia. Following anesthesia, we recorded the time until an Aldrete score of 9 was achieved as the primary surrogate marker of complete recovery. The time to reach a Modified Observer’s Assessment of Alertness/Sedation (MOAA/S) score of 2 and the time from the end of anesthesia to eye opening time, recovery time of orientation, time to spontaneous breathing, extubation time, and the time required for analgesics were measured. Heart rate, blood pressure, and bispectral index were assessed before, during, and after pneumoperitoneum. Results We included 101 patients in the analysis. In the remimazolam group, it took longer to reach an Aldrete score of 9 after the drug infusion ended (P = 0.031). There was no difference in the time to reach MOAA/S 2 between the two groups. The time to eye opening, recovery time of orientation, and time required for analgesics were longer and heart rate was higher in the remimazolam group. Neither blood pressure, nor extubation time differed between groups. Conclusions Remimazolam and propofol provided safe induction and maintenance of anesthesia in patients undergoing laparoscopic cholecystectomy. The recovery time from anesthesia was longer than that with propofol. Fewer hemodynamic changes were observed with remimazolam, but further studies are needed.

The pericapsular nerve group (PENG) block targets the nerves innervating the anterior hip surface; however, few studies on this technique are currently available. We investigated the effects of the PENG block on postoperative opioid consumption after a hip surgery. This was a randomized, double-blind, placebo-controlled study conducted at a single institution. Fifty patients undergoing hip surgery were randomly allocated, 25 in each group, to receive a PENG block either using 25 mL of 0.5% ropivacaine (PENG group) or 25 mL of saline (control group). The primary outcome was the total opioid consumption 24 h postoperatively. The secondary outcomes were postoperative pain scores, time to first opioid demand, sensory block efficiency, quadriceps muscle strength, complications, and patient satisfaction. Compared with those in the control group, patients in the PENG group had a significantly lower total opioid consumption 24 h postoperatively (440.72 ± 242.20 μg vs. 611.07 ± 313.89 μg, P = 0.037) and significantly lower pain scores at 30 min postblock and 6 postoperatively ( P < 0.001 and P < 0.001 , respectively). The time to first opioid demand was significantly shorter in the control group than in the PENG group P < 0.001 . Sensory block effectiveness was better in the PENG group 30 min postblock and 6 and 12 h postoperatively than in the control group. Patient satisfaction was also better in the PENG group than in the control group. There were no differences in the other outcomes. The PENG block reduced the total opioid consumption in the first 24 h after hip surgery with no significant effects on quadriceps muscle strength and complication rate. This study was registered at the Korea Clinical Research Information Service (cris.nih.go.kr; Reg. No. KCT0006348) on July 16, 2021.

Background: Sore throat and hoarseness frequently occur following general anesthesia with tracheal intubation and are effectively reduced when dexamethasone is used prophylactically. Alchemilla vulgaris in glycerine (Neo Mucosal Activator®) suppresses inflammatory response, possibly relieving sore throat.Methods: We enrolled 94 patients (age ≥ 18 years) scheduled for thoracic surgery using double-lumen tube intubation. Before intubation, 0.2 mg/kg of dexamethasone was administered intravenously and 2 ml of normal saline was sprayed into the oropharyngeal cavity (Group D; n = 45), or 0.04 ml/kg normal saline was administered intravenously and 1 g of Neo Mucosal Activator® mixed with 1 ml of normal saline was sprayed into the oropharyngeal cavity (Group N; n = 43), in a double blind and prospectively randomized manner. Postoperative sore throat and hoarseness were recorded using a numeral rating scale and a 4-point scale to detect a change in voice quality following tracheal extubation (at 1, 6, and 24 h). The primary outcome was the incidence of sore throat at 24 h following surgery. The secondary outcomes were incidence and severity of sore throat and hoarseness.Results: There were no significant differences in the incidence of sore throat at 24 h following surgery (57.8% vs. 46.5%; P = 0.290) or in the incidence and intensity of sore throat and hoarseness at 1, 6, and 24 h following surgery between the groups. Conclusions: A. vulgaris in glycerine did not significantly differ from dexamethasone for preventing sore throat and hoarseness owing to intubation.

Background: Only a few studies have evaluated the differences between varying concentrations of a fixed dose of local anesthetics. This study was conducted to compare the effects of two different concentrations of a fixed dose of ropivacaine used in ultrasound-guided interscalene brachial plexus block. Methods: This prospective, randomized, double-blind study included 62 patients who underwent arthroscopic surgery under general anesthesia. The patients were randomly assigned to receive ultrasound-guided interscalene block with 75 mg of ropivacaine at one of two concentrations: 0.75% (10 ml; Group C) or 0.375% (20 ml; Group V). Time to onset of sensory blockade, degree of blockade, pulmonary function changes, analgesic duration of the interscalene block, postoperative opioid requirement within 24 h, postoperative pain scores, satisfaction, and incidence of complications were recorded. Results: Although the time to onset of sensory blockade was shorter for Group C (P = 0.015), successful blockade was achieved at 30 min after the interscalene block in both groups. The analgesic duration of the interscalene block was not significantly different between the groups. The amount of opioid used within 24 h after surgery was significantly reduced for Group V compared with Group C (P = 0.016). The rest of the parameters did not show any significant differences between the two groups. Conclusions: Compared with 10 ml of 0.75% ropivacaine, interscalene block with 20 ml of 0.375% ropivacaine could be effective for the reduction of postoperative opioid requirement within 24 h after surgery despite it might not prolong the analgesic duration.

Background: Gender and age are known factors that affect postoperative pain. The purpose of this study was to investigate the effect of gender and age on postoperative pain and analgesic consumptions after laparoscopic cholecystectomy. Methods: We studied 240 adult patients (120 female patients and 120 male patients) who underwent elective 3-port laparoscopic cholecystectomy under general anesthesia. The numerical rating scale (NRS) scores were assessed before surgery, when the patient arrived in the recovery room, and at 8, 16, and 24 h after surgery. Analgesic consumptions in the recovery room and at 24 h postoperatively were evaluated. We compared the NRS scores and quantity of analgesics between the gender groups and the age groups (20-45, 46-64, and ≥ 65 years old). Results: Compared to male patients, female patients had higher NRS scores (6 [5, 7] vs. 5 [4, 6]; P = 0.001) and required a higher dose of fentanyl (0.94 ± 0.47 μg/kg vs. 0.79 ± 0.41 μg/kg; P = 0.011) in the recovery room. The younger female patients (20-45 and 46-64 years old) required a higher dose of fentanyl than those older than 65 years of age in the recovery room. Conclusions: Female patients exhibit higher NRS scores and greater consumptions of analgesics than male patients immediately postoperatively. Younger female patients require more analgesics than elderly patients in the recovery room. Keywords: Age; Gender; Laparoscopic cholecystectomy; Postoperative pain

Background: The current evidence on the safe use of supraglottic airway for pediatric laparoscopic surgeries is limited. Although i-gel has been successfully used in adult laparoscopic surgeries, to our knowledge, no studies have compared it to the endotracheal tube (ETT) in pediatric laparoscopic surgeries. This study evaluated the effectiveness of i-gel over ETT with regards to the respiratory and hemodynamic parameters during pediatric laparoscopic surgeries. Methods: A total of 60 pediatric patients undergoing elective laparoscopic surgeries were randomly allocated to either the i-gel or ETT groups. Anesthetics used included ketamine, sevoflurane, and rocuronium. The primary outcome measured was the peak airway pressure (PAP) and the secondary outcomes measured were leak fraction, end-tidal CO2, respiratory rate, insertion time, heart rate, blood pressure and perioperative complications. Results: The PAP during surgeries was higher in the ETT group than in the i-gel group. There were no statistically significant differences in the leak fraction, end-tidal CO2, and respiratory rate. The i-gel group had a shorter insertion time compared with the ETT group. The changes in heart rate were comparable in both groups. However, systolic and diastolic pressures were higher in the ETT group following intubation, before and after the creation of pneumoperitoneum. The incidence of perioperative complications was similar in both groups. Conclusions: The i-gel provided adequate ventilation with lower PAP compared with ETT. In addition, it provided minimal hemodynamic changes compared with ETT. Therefore, the i-gel may provide a suitable alternative to ETT in pediatric laparoscopic surgeries. Keywords: Intubation; intratracheal; I-gel; Laparoscopy; Pediatrics

CHARGE syndrome is a rare genetic disorder with CHD7 gene mutation. CHARGE is an acronym for coloboma (C), heart disease (H), atresia of choanae (A), retardation of growth (R), genitourinary malformation (G), and ear abnormalities (E). Patients with CHARGE syndrome need to undergo many surgeries due to their various congenital anomalies. Since airway abnormalities frequently accompany CHARGE syndrome, general anesthesia remains a challenge. Here we report a case of difficult intubation in a 35-month-old boy with CHARGE syndrome during general anesthesia and the experience of successful intubation using D-blade of C-MAC® video laryngoscope. Keywords: Airway management; CHARGE syndrome; Laryngoscope; Pediatrics

Background The supraglottic airway device is an appropriate alternative to tracheal intubation in laparoscopic surgery. We compared the Baska MaskⓇ with i-gelⓇ by measuring the oropharyngeal leak pressure (OLP) and hemodynamic and respiratory parameters during laparoscopic cholecystectomy. Methods A total of 97 patients were randomly allocated to either i-gel group (n = 49) or Baska Mask group (n = 48). Insertion time, number of insertion attempts, fiber-optic view of the glottis, and OLP were recorded. Heart rate, mean arterial pressure, peak airway pressure (PAP), lung compliance, and perioperative complications were assessed before, during, and after pneumoperitoneum. Results There were no significant differences between the two groups regarding demographic data, insertion time, fiber-optic view of the glottis, and the use of airway manipulation. The OLP was higher in the Baska Mask group than in the i-gel group (29.6 ± 6.8 cmH2O and 26.7 ± 4.5 cmH2O, respectively; P = 0.014). Heart rate, mean arterial pressure, PAP, and lung compliance were not significantly different between the groups. The incidence of perioperative complications was small and not statistically significant. Conclusions Both the i-gel and Baska Mask provided a satisfactory airway during laparoscopic cholecystectomy. Compared with the i-gel, the Baska Mask demonstrated a higher OLP.

Tracheostomy is increasingly performed in children for upper airway anomalies. Here, an 18-month-old child (height 84.1 cm, weight 12.5 kg) presented to the emergency department with dyspnea, stridor, and chest retraction. However, exploration of the airways using a bronchoscope failed due to subglottic stenosis. Therefore, a surgical tracheostomy was successfully performed with manual mask ventilation. However, pneumomediastinum was found in the postoperative chest radiograph. Although an oxygen saturation of 99% was initially maintained, oxygen saturation levels dropped, due to sudden dyspnea, after 3 hours. A chest radiograph taken at this time revealed a left tension pneumothorax and small right pneumothorax. Despite a needle thoracostomy, the pneumothorax was aggravated, and cardiac arrest occurred. Cardiopulmonary-cerebral resuscitation was performed, but the patient was declared dead 30 minutes later. This study highlights the fatal complications that can occur in children during tracheostomy. Therefore, close monitoring, immediate suspicion, recognition, and aggressive management may avoid fatal outcomes.

A 72-year-old man underwent spinal anesthesia for artificial urinary sphincter placement for urinary incontinence. After the block level was confirmed below T6, 1 g of cefotetan, which had not shown any reaction on skin test, was administered as a prophylactic antibiotic. The patient began complaining of chest discomfort and dyspnea shortly after injection. ST elevation appeared on the electrocardiogram and the patient’s pulse could not be palpated. Accordingly, cardiopulmonary resuscitation was performed for 5 minutes; the patient recovered spontaneous circulation. The patient was diagnosed as experienced coronary artery spasm by coronary angiography with spasm test. Because coronary artery spasm can also develop in patients with no history of coronary artery disease and under spinal anesthesia, careful observation, suspicion of coronary artery spasm and prompt response to hemodynamic and electrocardiogram changes are necessary. Keywords: Conduction anesthesia; Coronary vasospasm; Heart arrest; Spinal anesthesia

Background The i-gel™ (i-gel) and Laryngeal Mask Airway Supreme™ (LMA Supreme) have been safely used in children. We compared the airway performance of the i-gel and LMA Supreme in infants undergoing general anesthesia. Methods Sixty infants with American Society of Anesthesiologists physical status I or II were randomly assigned to place either the i-gel or the LMA Supreme. The size 1 or 1.5 of each airway was selected by the weight of infants. The primary outcome variable was oropharyngeal leak pressure (OLP). We also assessed insertion success rate, insertion time, fiberoptic view of the larynx, airway quality, airway manipulations, and perioperative complications. Results Demographic data did not differ between the two groups. Insertion success rate was similar in both groups. OLP for the i-gel (26.0 ± 3.8 cmH2O) was higher than for the LMA Supreme (23.7 ± 3.2 cmH2O) (P = 0.016). Insertion time for the i-gel (16.4 ± 2.8 s) was shorter than for the LMA Supreme (18.5 ± 2.7 s) (P = 0.002). There were no differences in fiberoptic view of the larynx, airway quality, airway manipulations, and complications between the two groups. Conclusions This study demonstrated that the i-gel and LMA Supreme provided a similar performance of airway in infants. Compared with the LMA Supreme, the i-gel provided shorter insertion time and higher OLP in infants.

Sevoflurane, which has low solubility in blood, facilitates rapid induction and recovery. Sevoflurane is metabolized to hexafluoroisopropanol by cytochrome P450. Hexafluoroisopropanol has significantly less protein binding capability, does not accumulate and rapidly undergoes phase II biotransformation to form Hexafluoroisopropanol glucuronide, which is mostly excreted in the urine within 12 hours. Thus, the hepatotoxic potential of sevoflurane has been considered very low. However, there are many reports about hepatic toxicity after sevoflurane anesthesia. We report a case of a 21-year-old male who had high levels of aspartate transaminase and alanine transaminase with crushing injuries and had low hepatic dysfunction after 29 sevoflurane anesthesia treatments within three months. Keywords: Hepatotoxicity; Sevoflurane

Background There are few information about the differences of the effective dose (ED) of cisatracurium between the adult and the elderly. We investigated the ED and the onset time of cisatracurium in the adults and the elderly. Methods We studied two hundred patients of the adults aged 20 through 64 years and the elderly aged ≥ 65 years, with American Society of Anesthesiologists physical status I or II. Each 100 patients with 20 patients of each dose group, randomly selected from 30, 40, 50, 60 or 70 µg/kg of cisatracurium, were randomly allocated to the adults and the elderly groups. We recorded the 0.1 Hz single twitch responses of the adductor pollicis and the onset times to maximal blockade. The magnitude of muscle relaxation was recorded by using an acceleromyography. The effect of cisatracurium on single twitch was calculated as percent reduction. After converting each drug dose into logarithm and percent reduction of the muscle reduction into probit, the EDs representing the muscle relaxation effects of 5%, 25%, 50%, 75% and 95% were estimated using the linear regression analysis. Results No significant differences were found in age, weight, height, or body mass index within or between the groups. The ED50 and ED95 of the adult group were 35.39 and 59.58 µg/kg. The ED50 and ED95 of the elderly group were 34.89 and 55.50 µg/kg, respectively. The onset times were 375.4 ± 76.9 seconds in the adult group and 369.1 ± 70.0 seconds in the elderly group. Conclusions The ED and the onset time were not significantly different between the adult and the elderly.

Background: The clinical features of spinal anesthesia may differ between young and old patients because of the anatomical and physiological changes that occur with an increase in age. This study was performed retrospectively to compare the clinical aspects of spinal anesthesia between the non-elderly and elderly patients. Methods: We investigated the medical records of 1,180 adult patients who received spinal anesthesia during a one-year period. They were divided into two groups on the basis of 65 years of age; the non-elderly patient group (Y group, n = 813) versus the elderly patient group (E group, n = 367). Pre-, intra-, and postoperative data related to spinal anesthesia were collected. The data about satisfaction and causes of dissatisfaction with the procedure were evaluated. Results: There were significant differences between the two groups in terms of age, height, and weight, except for sex. Significantly more than two attempts at spinal puncture were performed in the E group (37.6%) than in the Y group (21.4%). There were no statistically significant differences in perioperative complications after spinal anesthesia between the two groups. There were no significant differences in the reported causes of dissatisfaction between the two groups. The rate of wanting to undergo spinal anesthesia in the future was 96.4% in the Y group and 97.5% in the E group, which showed no statistically significant difference. Conclusions: Although the elderly patients had to undergo more spinal puncture attempts, more than 90% of the elderly patients were satisfied with spinal anesthesia and wanted to undergo spinal anesthesia again for similar surgeries in the future. Keywords: Elderly patient; Spinal anesthesia

Background Sore throat and hoarseness are common complications after general anesthesia with tracheal intubation. The position for patients can affect the incidence of postoperative sore throat (POST) by causing displacement of the endotracheal tube. This study investigated the prophylactic effect of dexamethasone in prone position surgeries. Methods One hundred-fifty patients undergoing lumbar spine surgery (18-75 yr) were randomly allocated into the normal saline group (group P, n = 50), dexamethasone 0.1 mg/kg group (group D1, n = 50) or dexamethasone 0.2 mg/kg group (group D2, n = 50). The incidence and severity of POST, hoarseness, and cough were measured using direct interview at 1, 6, and 24 h after tracheal extubation. The severity of POST, hoarseness, and cough were graded using a 4-point scale. Results At 1, 6, and 24 h after extubation, the incidence of sore throat was significantly lower in group D1 (1 h; P = 0.015, 6 h; P < 0.001, 24 h; P = 0.038) and group D2 (1 h; P < 0.001, 6 h; P < 0.001, 24 h; P = 0.017) compared to group P. There were less number of patients in the groups D1 and D2 than group P suffering from moderate grade of POST at 1, 24 h after extubation. The incidence of hoarseness at 1, 6, and 24 h after extubation was significantly lower in groups D2 than group P (P < 0.001). There were no significant differences in the incidence of cough among the three groups. Conclusions The prophylactic use of dexamethasone 0.1 mg/kg and 0.2 mg/kg in prone surgery reduces the incidence of postoperative sore throat and dexamethasone 0.2 mg/kg decreases the incidence of hoarseness.