To determine the prevalence of disability-free survival (DFS) five years after elective non-cardiac surgery in older adults, and to identify preoperative factors associated with DFS using conventional statistical analyses and machine learning methods. In this prospective cohort study conducted at a single tertiary hospital in Japan, 2878 patients aged ≥55 years who underwent elective non-cardiac surgery under general anesthesia between 2016 and 2018 were enrolled and followed for 5 years. DFS was defined as survival without significant functional disability, assessed using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). Multivariable logistic regression and machine learning models were used to identify preoperative predictive factors. At 5 years after surgery, 80.6

Placental abruption complicated by intrauterine fetal demise (IUFD) is frequently associated with major obstetric hemorrhage, consumptive coagulopathy, and progressive maternal organ dysfunction. In such cases, vaginal delivery is generally preferred to avoid the additional bleeding risk of surgery, although cesarean delivery may become necessary if the maternal condition deteriorates. We report a case in which reassessment after induction of general anesthesia altered the planned mode of delivery and may have avoided laparotomy in a high-risk setting. In her late 20s primigravida at 30 + 3 weeks’ gestation presented with abdominal pain, vaginal bleeding, severe hypertension, and IUFD due to placental abruption. Laboratory findings showed severe coagulopathy, with platelet count = 78 × 103/μL, prothrombin time/international normalized ratio > 10, fibrinogen <30 mg/dL, and fibrin/fibrinogen degradation products >960 μg/mL, along with impaired renal function. Vaginal delivery was initially selected because less bleeding was expected than with cesarean delivery. However, labor failed to progress despite cervical ripening and oxytocin, while blood pressure remained uncontrolled and renal dysfunction worsened, prompting a decision for cesarean section under general anesthesia because neuraxial anesthesia was contraindicated. After induction, repeat vaginal examination demonstrated a cervical dilatation of 8 cm. Therefore, the delivery plan was changed, and vacuum-assisted vaginal delivery was completed under general anesthesia without major procedural complications. The patient required intensive postoperative monitoring for acute kidney injury and hemodynamic management but recovered without major complications and was discharged on postoperative day 10. This case highlights that, in carefully selected IUFD cases with severe coagulopathy, repeat vaginal assessment after induction but before incision may help identify a safer delivery route while preserving surgical readiness.

This study aimed to investigate whether CO₂ pneumoperitoneum and liver retraction affect predictive performance of the Marsh pharmacokinetic model for propofol target-controlled infusion (TCI) during laparoscopic or robot-assisted gastrectomy. Adult patients undergoing elective laparoscopic or robot-assisted gastrectomy were enrolled. Arterial blood samples were collected at predefined intraoperative time points, and plasma propofol concentration (Cp) was measured by high-performance liquid chromatography. Performance error (PE), median PE (MDPE), median absolute PE (MDAPE), wobble, and divergence were calculated. Associations between PE and procedural factors, time after anesthetic induction, and cardiac index (CI) were evaluated using linear mixed-effects models. Finally, an exploratory PE-correction equation was internally evaluated by leave-one-patient-out cross-validation. A total of 155 measurements from 16 patients were analyzed. The overall MDPE and MDAPE were 10.2 and 20.4

We report a rare fatal hyperthermic crisis likely precipitated by drug-induced fever in a muscular, obese patient with chronic high-level spinal cord injury (SCI). Shortly after antibiotic therapy was changed to meropenem, the patient developed severe agitation and hyperthermia exceeding 41 °C, accompanied by autonomic instability. Despite intensive management, including active cooling, intravenous fluids, and vasoactive support, the core temperature remained above 41 °C. Computed tomography revealed a low-density brainstem lesion consistent with infarction. The patient experienced respiratory arrest and died 4 h after admission to the ICU. This case underscores the complex interplay between drug-induced fever, impaired thermoregulation due to SCI, and heat-retentive body composition. This case highlights the risk of rapid and disproportionate temperature elevation in patients with high-level SCI, even in response to relatively minor fever-provoking stimuli, due to impaired thermoregulation. Early recognition and prompt intervention are crucial to prevent fatal hyperthermic crises in this vulnerable population.

RATIONALEPatients frequently report relief from dyspnea following chest drain removal, even in the absence of pain, suggesting that negative intrapleural pressure may independently impair respiratory mechanics.OBJECTIVESThe objective of this study was to investigate the effect of chest drainage on respiratory mechanics using a thoracic experimental model that excludes the confounding influence of pain.METHODSA thoracic model with a sealed container and a 1-L anesthesia bag was used to simulate spontaneous and volume-controlled ventilation. Chest drainage levels (0-5 cm H2O) were applied, and tidal volumes, intrathoracic pressures and transpulmonary pressures were recorded.MEASUREMENTS AND MAIN RESULTSDuring spontaneous breathing, tidal volumes declined with increasing drainage, despite constant inspiratory effort, producing higher transpulmonary pressures. Mandatory ventilation maintained set tidal volumes, but airway and transpulmonary pressures increased proportionally. Visual inspection confirmed baseline lung expansion with drainage.CONCLUSIONSChest drainage restricts spontaneous breathing capacity, increasing inspiratory effort and potentially contributing to dyspnea. Drainage itself can compromise respiratory mechanics independently of pain. JUSTIFICATIONLes patients signalent fr & eacute;quemment un soulagement de la dyspn & eacute;e apr & egrave;s l'ablation du drain thoracique, m & ecirc;me en l'absence de douleur, ce qui porte & agrave; croire que la pression intrapleurale n & eacute;gative peut alt & eacute;rer la m & eacute;canique respiratoire de mani & egrave;re ind & eacute;pendante.OBJECTIFSExaminer l'effet du drainage thoracique sur la m & eacute;canique respiratoire & agrave; l'aide d'un mod & egrave;le exp & eacute;rimental thoracique excluant l'influence confondante de la douleur.M & Eacute;THODESUn mod & egrave;le thoracique constitu & eacute; d'un r & eacute;cipient herm & eacute;tique et d'un ballon d'anesth & eacute;sie de 1 L a & eacute;t & eacute; utilis & eacute; pour simuler une ventilation spontan & eacute;e et contr & ocirc;l & eacute;e en volume. Des niveaux de drainage thoracique (0-5 cm H2O) ont & eacute;t & eacute; appliqu & eacute;s et les volumes courants ainsi que les pressions intrathoraciques et transpulmonaires ont & eacute;t & eacute; enregistr & eacute;s.MESURES ET PRINCIPAUX R & Eacute;SULTATSAu cours de la respiration spontan & eacute;e, les volumes courants ont diminu & eacute; avec l'augmentation du drainage, malgr & eacute; un effort inspiratoire constant, ce qui a entra & icirc;n & eacute; une augmentation des pressions transpulmonaires. La ventilation contr & ocirc;l & eacute;e a maintenu les volumes courants fix & eacute;s, mais les pressions des voies a & eacute;riennes et les pressions transpulmonaires ont augment & eacute; proportionnellement. L'inspection visuelle a confirm & eacute; l'expansion pulmonaire initiale en pr & eacute;sence de drainage.CONCLUSIONSLe drainage thoracique restreint la capacit & eacute; ventilatoire spontan & eacute;e, augmente l'effort inspiratoire et pourrait contribuer & agrave; la dyspn & eacute;e. Le drainage en lui-m & ecirc;me peut compromettre la m & eacute;canique respiratoire ind & eacute;pendamment de la douleur.

Alcohol-based antiseptic solutions are widely used for preoperative skin preparation but may rarely cause surgical fires. We report a case of surgical drape ignition during transumbilical laparoscopic surgery in a woman in her late 30s. A fire occurred shortly after starting to use an electrosurgical unit following additional disinfection of the umbilicus with an alcohol-based chlorhexidine solution. When additional disinfection is performed, care should be taken to ensure that the antiseptic is completely dry before proceeding. Under specific circumstances, alcohol-free antiseptic solutions may be considered as an alternative.

One-lung ventilation (OLV) in infants is technically demanding and is typically reported from high-volume centers. We describe here perioperative management using OLV in a 6-month-old, 3.5-kg infant undergoing resection of a large emphysematous lung lesion at a low-volume center. Due to limited institutional experiences and anticipated airway challenges, the anesthetic strategy prioritized structured decision-making, predefined withdrawal criteria, and anesthesiologist-led multidisciplinary briefings and simulations. The key elements included planned apneic oxygenation using nasal high-flow oxygen and preparation of alternative confirmation methods. During surgery, bronchial blocker dislodgement required deviation from the initial plan; however, shared situational awareness and open communication enabled flexible adaptation and maintenance of stable ventilation. This case highlights that in rare, high-risk pediatric airway management, non-technical skills-including planning, communication, and team coordination-may play a critical role in ensuring patient safety, particularly in low-volume settings.

Sedation is essential in intensive care units (ICUs) for invasive procedures and mechanical ventilation; however, commonly used agents are limited by hemodynamic instability, delayed recovery of consciousness, and delirium. Remimazolam, an ultra-short-acting benzodiazepine, introduced in 2020, is rapid metabolized by hepatic carboxylesterase 1 and enables predictable recovery after prolonged administration, suggesting potential advantages for sedation in critical illness despite limited ICU-specific evidence. A narrative review was conducted based on evidence derived from randomized controlled trials, meta-analyses, and observational studies, which indicated that remimazolam provides sedation efficacy comparable to that of conventional hypnotics across surgical anesthesia, procedural sedation, and ICU settings. Multiple meta-analyses have suggested that remimazolam is associated with favorable hemodynamic tolerance and does not increase the incidence of postoperative or ICU delirium compared with propofol or other sedative agents. Delirium risk appears to be more strongly influenced by patient severity, surgical characteristics, and sedation depth than by hypnotic choice alone, although the heterogeneity across studies may partly reflect differences in delirium diagnostic tools. In ICU patients requiring mechanical ventilation, remimazolam demonstrated safety and efficacy comparable to those of propofol or midazolam, with acceptable hemodynamic stability and no consistent signs of increased mortality. Several studies have also suggested that the predictable recovery profile associated with flumazenil may facilitate ventilator weaning or recovery of consciousness, although the interpretation of recovery outcomes requires caution, particularly in studies involving routine flumazenil administration. Pharmacokinetic data in ICU populations remain limited but suggest preserved dose linearity with reduced clearance in patients with severe hepatic dysfunction. Remimazolam may be a promising sedative option for critically ill patients, offering a predictable recovery and generally favorable hemodynamic profiles. However, its optimal role in ICU sedation requires confirmation through high-quality international multicenter studies, particularly regarding prolonged mechanical ventilation, neurocognitive outcomes, and cost-effectiveness.

Background: Lumboperitoneal (LP) shunting is an effective and less invasive treatment for normal pressure hydrocephalus (NPH). However, degenerative spinal changes, such as lumbar spinal stenosis, which are common in elderly patients, can complicate lumbar puncture and increase the risk of neurological complications. We report a case in which LP shunt placement failed due to severe lumbar spinal stenosis, highlighting the need for careful preoperative assessment of the spine. Case Presentation: An 80-year-old man presented with gait disturbance and physical debilitation. Magnetic resonance imaging (MRI) revealed ventricular enlargement, and a cerebrospinal fluid tap test resulted in symptomatic improvement; therefore, LP shunting was planned. Because lumbar puncture was unsuccessful, a ventriculoperitoneal shunt was performed instead. Postoperatively, the patient developed lower extremity pain, and an MRI revealed spinal stenosis from L2 to L5. Minimally invasive lumbar decompression was subsequently performed, resulting in symptom improvement and independent ambulation. Conclusion: Although LP shunting is generally safe, spinal stenosis may obstruct cerebrospinal fluid flow and reduce its effectiveness. Preoperative MRI evaluation of the spine is essential to guide puncture strategy, anticipate technical difficulties, and minimize complications in elderly patients.

In ultrasound-guided needle insertion, continuous needle visualization is crucial for accurate needle placement, particularly for beginners. Novice operators may have difficulty maintaining the spatial relationship between the needle trajectory and the ultrasound imaging plane during freehand needle insertion. To address this educational challenge, we developed a detachable flat plate that can be attached to the needle shaft as a visual and tactile reference to assist alignment with the ultrasound imaging plane. The present study aimed to evaluate this plate's potential utility as an educational aid for novices performing both in-plane and out-of-plane techniques. This simulation-based randomized exploratory study included 32 practitioners who had no prior experience performing ultrasound-guided puncture. The participants were assigned to either the intervention group or the control group. In the intervention group, a custom-made flat plate was attached to the needle to assist alignment with the ultrasound imaging plane. After watching a brief video explaining how to do the procedure, the participants performed puncture tasks on a gelatin phantom at three probe positions—at the apex and at locations 45° to either side of the apex—using both in-plane and out-of-plane techniques. The primary endpoint was needle visualization during in-plane puncture at the right 45° position, assessed on a 5-point scale by a blinded evaluator. In addition, participants rated the ease of needle visualization using a 100-mm visual analogue scale. Of the 39 individuals assessed for eligibility, 32 were included in the analysis (16 in the control group and 16 in the intervention group). All participants were right-handed except for one left-handed individual in the control group. The distributions of sex and participant background (medical students or nurses) were comparable between the two groups. No significant difference in objective needle-visualization scores was observed between the intervention and control groups (p = 0.0516), whereas self-assessed ease of needle visualization was significantly higher in the intervention group (p = 0.0157). In subgroup analysis within the intervention group, angled in-plane puncture showed a tendency toward higher objective and subjective scores, with no such tendency observed for the out-of-plane technique. Our needle-mounted guide improved subjective assessments of needle visualization and showed potential benefits during angled in-plane puncture. These findings suggest that the guide may help novice practitioners maintain alignment between the needle and the ultrasound imaging plane. Further evaluation in more homogeneous and standardized novice populations is required to assess the educational value and potential clinical applications of the device.

Parkinson's disease is a common neurodegenerative disorder that often affects airway and respiratory function. Although upper airway obstruction following general anesthesia is well documented, we report a rare case of respiratory arrest that occurred prior to anesthesia induction. A 74-year-old woman with Parkinson's disease, receiving levodopa/carbidopa and rotigotine, was scheduled to undergo left mastectomy. Her medications were continued until just before anesthesia. Upon entering the operating room, she appeared to be experiencing the wearing-off phenomenon. Insertion of a peripheral intravenous line exacerbated her rigidity and precipitated respiratory arrest, rendering mask ventilation impossible. Rocuronium and remimazolam enabled effective mask ventilation, although her percutaneous oxygen saturation dropped to 49 %. This case highlights the importance of heightened vigilance in Parkinson's disease patients during the wearing-off phenomenon. Anesthesiologists play a central role in the perioperative management of Parkinson's disease patients and must ensure appropriate medication continuity and preparedness for sudden symptom exacerbation.