Search Results (290)

Background/Objectives: Hypoglossal nerve palsy is a rare but disabling complication of general anesthesia, typically associated with tracheal intubation and head and neck surgery. This study evaluated the incidence, clinical characteristics, and potential mechanisms of postoperative tongue deviation after breast reconstruction and other surgeries performed under general anesthesia with orotracheal intubation. Methods: We retrospectively reviewed 240,646 consecutive general anesthetic procedures with orotracheal intubation performed at two tertiary hospitals between September 2011 and October 2025. Eighteen patients who developed new-onset postoperative tongue deviation were identified, and demographic features, surgical department, breast reconstruction status, anesthetic details, patient positioning, laterality of deviation, symptom duration, and recovery outcomes were analyzed. Results: Postoperative tongue deviation was documented in 18 patients, corresponding to an overall incidence of approximately 0.01%, most frequently after breast reconstruction (7/18, 38.9%), followed by vascular (27.8%), head and neck tumor (16.7%), neurosurgical (11.1%), and hepatobiliary–pancreatic surgery (5.6%). All seven breast-reconstruction cases occurred at the breast-cancer center hospital, corresponding to 0.31% of 2256 breast reconstructions. The median age was 58.0 years; 66.7% patients were female. Most patients (77.8%) achieved complete recovery, whereas 16.7% had residual deviation. Conclusions: Postoperative hypoglossal nerve palsy with tongue deviation is an exceptionally rare event after general anesthesia. In our two-center cohort, it was observed most frequently among patients undergoing breast reconstruction at one participating center; this pattern is confounded by institution-specific anesthetic and positioning practices and should not be interpreted as evidence that the procedure itself carries inherent risk. The findings are hypothesis-generating and suggest that prolonged operating time, repeated intraoperative position changes, and specific head-fixation and tube-fixation practices warrant prospective investigation. Meticulous head–neck alignment, careful tube fixation, and a structured postoperative cranial-nerve check (tongue-protrusion and voice-quality assessment in the recovery room and on postoperative day 1) may aid the early detection of this complication. Full article

Background: Recessive dystrophic epidermolysis bullosa (RDEB) is a rare inherited disorder characterized by extreme epithelial fragility and progressive cicatrization, frequently leading to severe ocular surface disease and early visual impairment. Surgical interventions such as ocular surface reconstruction (OSR) in childhood are often delayed because of anesthetic risks and concerns regarding recurrence. Consequently, the effectiveness of OSR, including amniotic membrane transplantation (AMT), and its impact on visual development remain poorly documented. Methods: We report a case series of two pediatric patients (three eyes) with genetically confirmed RDEB who underwent single-step OSR using AMT. Clinical outcomes, long-term visual acuity, perioperative management, and histopathological findings were evaluated. Results: Ocular manifestations included corneal epithelial damage, symblepharon, and pseudopterygium extending over the cornea. One patient underwent symblepharon lysis, superficial keratectomy, and AMT onto the bare sclera in the right eye at age 4 and in the left eye at age 8, both under intubated general anesthesia. The other patient underwent the same procedure in the right eye at age 6. Best spectacle-corrected visual acuity improved from ≤20/300 to 20/30 in all eyes, and pupillary zone clarity was maintained during the follow-up period (up to 6 years). Histopathology confirmed pseudopterygium with squamous metaplasia, goblet cell loss, and fibrovascular stroma. Safe general anesthesia was achieved through meticulous multidisciplinary perioperative planning involving anesthesiologists, dermatologists, and pediatricians. No systemic complications related to anesthesia or perioperative management were observed. Conclusions: Single-step OSR with on-lay AMT can restore and preserve visual function in pediatric RDEB. Early surgical intervention may prevent profound amblyopia and provide durable ocular surface stability. A multidisciplinary approach enables safe general anesthesia and perioperative management. Full article

In recent times, extracorporeal membrane oxygenation is increasingly employed in pregnant and postpartum patients with severe cardiopulmonary failure. This article presents two illustrative cases from our tertiary care center, highlighting the complexities of obstetric extracorporeal membrane oxygenation management. These cases are described within a synthesis of recent systematic reviews, registry data, and large case series focusing on maternal and fetal outcomes, extracorporeal membrane oxygenation modality impacts, timing of intervention, complication profiles, and anesthetic considerations. The concordance and contrasts between these cases and the existing literature underscore the evolving indications, improving survival rates, and critical perioperative management issues. Emphasis on multidisciplinary care and planning remains essential to optimize outcomes in this unique patient population. Full article

Although radiotherapy is a cornerstone in the management of several pediatric malignancies, its administration in children poses unique anesthetic challenges. Unlike adults, pediatric patients, particularly younger children, often require repeated sedation or general anesthesia to ensure immobility and reduce psychological distress during daily treatment sessions that may extend over several weeks. This narrative review summarizes current evidence on anesthetic strategies for children undergoing radiotherapy, focusing on clinical indications, pharmacological approaches, safety considerations, and organizational aspects. We discuss the main sedation and anesthesia techniques used in non-operating room anesthesia (NORA) settings, including deep sedation with midazolam, propofol, ketamine, and dexmedetomidine, as well as general anesthesia with laryngeal mask airway management. Particular attention is given to the cumulative effects of repeated anesthetic exposure, airway management challenges in remote radiation environments, and the risk of respiratory and hemodynamic complications. The review also highlights the importance of individualized, protocol-driven management, rapid recovery strategies, and continuous remote monitoring systems. Non-pharmacological interventions and audiovisual-assisted techniques are also discussed as potential strategies to reduce anesthesia requirements in selected patients. A multidisciplinary approach involving anesthesiologists, radiation oncologists, nurses, psychologists, and technical staff is essential to optimize safety, treatment adherence, and overall quality of care. Tailored anesthetic management, supported by standardized protocols and specialized pediatric expertise, remains crucial to balancing procedural efficacy with short- and long-term safety in this vulnerable population. Full article

Background: Frail patients undergoing hip and knee revision surgery represent a major anesthetic challenge because of advanced age and multiple comorbidities. Continuous spinal anesthesia (CSA) with titrated low-dose levobupivacaine may offer a potentially useful alternative to general anesthesia or single-shot spinal anesthesia in this high-risk population. Methods: A retrospective review was conducted of ASA II-III patients who underwent complex hip and knee revision surgeries between February and October 2024 under CSA. The technique was performed using a 25-gauge spinal catheter with incremental boluses of 0.25% levobupivacaine (2.5 mg). Hemodynamic parameters, including mean arterial pressure (MAP), stroke volume index (SVI), and cardiac index (CI), were continuously monitored using the EV1000 hemodynamic monitoring system. Postoperative complications were recorded. Results: 37 high-risk patients were included in the study. Catheter placement was successful in all patients, with no conversions to general anesthesia. MAP decreased by a mean of 14.6% after boluses (p < 0.05); 9 patients (24.3%) experienced reductions ≥ 20%, but all remained >65 mmHg and responded to fluid therapy. CI and SVI decreased by 10.1% and 10.5%, respectively (p < 0.05), without clinical instability. No major complications (neurological injury, infection, post-dural puncture headache) were observed. Conclusions: In this retrospective single-center experience, CSA with titrated low-dose levobupivacaine was feasible and associated with stable hemodynamic profiles and a low rate of complications in frail patients undergoing complex lower-limb revision surgery. However, given the absence of a control group and the limited sample size, these findings should be interpreted cautiously. Further prospective comparative studies are needed to better define the role of CSA in high-risk orthopedic patients. Full article

Background: Postoperative neurocognitive disorders (PND) are frequent complications in the elderly surgical patients, with aging recognized as a major risk factor. This study aimed to identify electrophysiological markers and establish an exploratory machine learning framework for PND-related vulnerability prediction using anesthetic electroencephalography (EEG) features in aged mice. Methods: Young and aged mice underwent laparotomy under isoflurane anesthesia with EEG recording. Neurocognitive performance was quantified by 16 standardized behavioral fractions. A semi-supervised K-means algorithm, anchored on young-surgery mice, stratified aged-surgery mice into PND and non-PND clusters. EEG dynamics during anesthesia maintenance and emergence were analyzed, and machine learning models were trained to predict PND from EEG features. Results: At baseline, neurocognitive function was comparable across groups. After anesthesia/surgery, aged mice exhibited selective spatial and contextual memory impairments, with two-thirds classified as PND. During emergence, PND mice displayed elevated δ power and reduced α and β ratios. A Multi-layer Perceptron classifier showed discriminatory performance for PND classification in one evaluation setting (AUC = 0.94). Conclusions: This study identifies emergence-related EEG features associated with postoperative neurocognitive vulnerability in aged mice and provides an exploratory machine learning framework for preclinical risk stratification. These findings support further mechanistic investigation and warrant future validation in human perioperative EEG datasets. Full article

Background and Objectives: Thrombocytopenia complicates 6.6–11.6% of pregnancies. While gestational thrombocytopenia (GT) is usually benign, etiologies such as immune thrombocytopenia (ITP), preeclampsia, and HELLP syndrome require individualized management. This study aimed to characterize the etiological spectrum, maternal peripartum hematologic outcomes, blood product utilization, and mode of delivery in a tertiary-center cohort of thrombocytopenic pregnancies and to assess whether platelet count should influence delivery mode decisions. Materials and Methods: This retrospective cohort study included 137 thrombocytopenic pregnant women at a tertiary center (2010–2019), categorized by etiology and severity. Peripartum hemoglobin, hematocrit, and platelet counts were compared between delivery groups. Blood product utilization was recorded and analyzed using t-test, ANOVA, chi-square, Fisher’s exact, and Fisher–Freeman–Halton tests; binary logistic regression was used for multivariable analysis. Results: GT (43.1%) and ITP (32.1%) were the most prevalent diagnoses; cesarean delivery rate was 52.6%. Postpartum Hb was higher in the vaginal delivery group (10.24 ± 1.28 vs. 9.80 ± 1.26 g/dL; p = 0.003), while platelet counts were paradoxically lower (p = 0.039). Platelet transfusion rates did not differ significantly between delivery modes (23.1% vs. 27.8%; p = 0.621). Severe thrombocytopenia required platelet transfusion in 92.6% of cases versus 11.6% (moderate) and 0% (mild) (p < 0.001). RBC transfusion was highest in gestational hypertensive disease (41.2%) versus GT (5.1%) and ITP (2.3%) (p < 0.001). General anesthesia was used in 75% of cesarean cases. Conclusions: Delivery mode in thrombocytopenic pregnancies should be guided by obstetric indications, not platelet count alone. Although postpartum platelet counts declined more steeply after vaginal delivery, this did not increase transfusion requirements. Gestational hypertensive disorders carried the greatest hemorrhagic burden, highlighting the need for etiology-specific multidisciplinary planning. The high general anesthesia rate warrants prospective institutional audit of anesthetic decision-making protocols to determine adherence to current neuraxial anesthesia thresholds. This study is limited to maternal peripartum hematologic outcomes; neonatal outcomes were not captured and should be addressed in future prospective research. Full article

Background: Cardiopulmonary bypass (CPB) is an essential technique for cardiac surgery but significantly increases the risk of perioperative neurological complications. Electroencephalography (EEG) enables real-time monitoring of brain function and provides sensitive biomarkers for early detection of cerebral injury. However, a systematic synthesis of how CPB-related physiological, pharmacological, and technical factors influence EEG signals, and how these insights can be integrated into clinical decision-making, is still lacking. Objective: To systematically review the effects of temperature management, mean arterial pressure (MAP), hemodilution, anesthetic agents, embolization, and systemic inflammatory response during CPB on EEG parameters (including frequency bands, Bispectral Index (BIS), quantitative EEG metrics such as burst suppression ratio (BSR), spectral edge frequency (SEF), etc.), and to evaluate the associations between EEG changes and postoperative delirium (POD) and stroke. Methods: Following the PRISMA 2020 guidelines, we searched PubMed, Web of Science, and related databases for original English-language articles published between February 1974 and September 2025. Inclusion criteria: adult patients (≥18 years) undergoing cardiac surgery with CPB and intraoperative EEG monitoring (raw or processed). Exclusion criteria: reviews, case reports, animal studies, pediatric populations, and articles with inaccessible full texts. Two reviewers independently screened the literature and extracted data; a narrative synthesis was performed. Results: Fifty-one studies were included. Main findings: (1) Hypothermia: BIS decreases linearly with temperature (≈1.12 units/°C); electrocerebral silence occurs during deep hypothermic circulatory arrest; EEG recovery dynamics during rewarming predict POD. (2) MAP and cerebral perfusion: The rate of MAP decline (≥0.66 mmHg/s) is a stronger predictor of EEG abnormalities than the absolute MAP value; under fixed pump flow, some patients exhibit coexisting cerebral overperfusion and metabolic suppression. (3) Hemodilution: Maintaining hemoglobin ≥9.4 g/dL prevents EEG slowing; a drop below 9.2 g/dL significantly increases the risk of slowing. A ≥10% decrease in regional cerebral oxygen saturation (rSO₂) is associated with a 1.5-fold increased risk of burst suppression. (4) Anesthetic agents: Propofol maintains flow-metabolism coupling, and BSR reflects deep anesthesia better than BIS; sevoflurane and isoflurane impair autoregulation and suppress EEG. (5) Embolization and inflammation: EEG epileptiform discharges increase the risk of POD five-fold; a decrease in LIR predicts stroke (AUC 0.771) and POD (AUC 0.779); persistent EEG changes increase the risk of POD 2.65-fold. Conclusions: CPB-related factors affect EEG signals through distinct mechanisms, and specific EEG patterns (slowing, burst suppression, asymmetry, epileptiform discharges) are significantly associated with postoperative neurological complications. Multimodal monitoring (EEG + cerebral oximetry + hemodynamics) with clear intervention thresholds facilitates individualized brain protection. Future interventional studies using real-time EEG feedback are needed to confirm improvements in long-term neurological outcomes. Full article

Post-reperfusion syndrome (PRS) remains a critical complication in living donor liver transplantation (LDLT). While sevoflurane is recognized for its organ-protective properties, the impact of the donor’s anesthetic choice on recipient outcomes has not been clearly established. This study evaluated whether donor sevoflurane anesthesia reduces the incidence of PRS in recipients compared to desflurane. We retrospectively analyzed 5006 adult LDLT recipients whose donors received either sevoflurane or desflurane. Propensity score matching was employed to minimize selection bias, resulting in 941 matched pairs. The incidence of PRS was significantly lower in the sevoflurane group (64.0%) compared to the desflurane group (71.8%; p < 0.001). Multivariable logistic regression identified donor sevoflurane as an independent protective factor against PRS (odds ratio 0.47; 95% confidence interval 0.41–0.55; p < 0.001). Furthermore, recipients in the sevoflurane group exhibited significantly lower rates of prolonged intensive care unit stay, along with superior recovery of liver enzymes and inflammatory markers. Our findings suggest a potential association between donor sevoflurane anesthesia and more favorable early recipient outcomes, including a reduced incidence of PRS and enhanced recovery. Full article

Background/Objectives: An effective inferior alveolar nerve block (IANB) is critical for mandibular third molar surgery, especially for novice student operators who face steep learning curves. This study compared the clinical efficacy and safety of 4% articaine, 2% lidocaine, and 2% mepivacaine in an undergraduate setting. Methods: A prospective observational study was conducted with 189 patients undergoing third molar surgery performed by dental students. Patients received either 4% articaine (n = 69), 2% lidocaine (n = 61), or 2% mepivacaine (n = 59). Anesthetic efficacy was evaluated using a two-stage assessment comprising Vincent’s sign (Stage 1) and profound surgical anesthesia (Stage 2). Intra- and postoperative pain, anesthetic volume, surgical duration, and postoperative complications were recorded and compared among anesthetic groups. Results: Baseline demographics, impaction patterns, and difficulty indices did not differ significantly among groups. Stage 2 profound success rate was significantly higher with articaine (76.8%) than with lidocaine (55.7%) and mepivacaine (61.0%) (p = 0.031). Articaine was also associated with a longer duration of anesthesia (261.7 vs. 164.6 and 192.6 min; p < 0.001), a lower total anesthetic volume (2.1 vs. 2.4 and 2.3 mL; p = 0.007), and significantly lower intraoperative pain scores (14.3 vs. 31.0 and 29.8 mm on the Heft–Parker VAS pain scale (HPS); p < 0.001). Postoperative pain through Day 7 and complication rates were comparable among anesthetics, with no serious adverse events reported. Conclusions: Within the limitations of this observational study, four percent articaine was associated with higher profound IANB success rates and lower intraoperative pain observed in this cohort. These observed associations with higher success and tissue diffusion properties may mitigate the impact of novice technical variability within this cohort. Full article

Background and Clinical Significance: Needle fracture during inferior alveolar nerve block is a rare complication, but it can nevertheless result in serious complications, especially when the fragment migrates into deep anatomical spaces like the pterygomandibular region. Accurate localization and safe retrieval are vital in preventing infection, chronic pain, neurovascular injury, and long-term functional impairment. Case Presentation: We present a case of a 27-year-old patient who had a fractured needle fragment from a local anesthetic procedure retained in the left pterygomandibular space. Cone beam computed tomography (CBCT) was carried out to verify the presence of the metallic foreign body and to define its exact three-dimensional position in relation to adjacent bone and soft tissue landmarks. The approach was transoral, and the surgery was done under general anesthesia. During the surgery C-arm fluoroscopy was used to help guide localization and retrieval, along with the help of radiopaque reference markers to assist in determining the trajectory. The fragment was removed without any issue. After the surgery, the patient’s condition improved well, and he showed no signs of functional deficits. Conclusions: The management of broken needle fragments in the pterygomandibular space can be safely and effectively done using a combination of preoperative CBCT and intraoperative C-arm guidance. This technique allows for exact location determination, minimizes unnecessary dissection of the tissue, and will make the surgery safer in complicated areas. Full article

Background: Acute kidney injury (AKI) is a frequent and severe complication after liver transplantation (LT), occurring in 30–60% of cases. It increases mortality, prolongs hospital stay, and increases the risk of chronic kidney disease. Intraoperative, modifiable anesthetic factors play a key preventive role. This systematic review synthesizes the overall prevalence of AKI and examines the evidence linking intraoperative anesthetic management to AKI after LT, emphasizing modifiable factors that may inform future perioperative strategies. Methods: We conducted a systematic, computerized search on PubMed, EMBASE, Cochrane Library, and Scopus from January 2004 to November 16, 2025, following a registered protocol on PROSPERO (ID: CRD420250580749). Randomized controlled trials (RCTs) and cohort studies assessing intraoperative predictors of AKI were considered eligible for inclusion. The primary outcome was the incidence of post-LT AKI. Intraoperative factors associated with post-LT AKI, including intraoperative hypotension, fluid therapy, transfusion strategies, and the use of vasopressors and/or inotropic agents, were also assessed. Results: A total of 50 studies (8 RCTs and 42 cohort studies) involving 22,434 patients were included. The pooled incidence of post-LT AKI from observational studies was 41% (95% CI 36–46%). Across the included studies, intraoperative hemodynamic instability, excessive or unbalanced fluid administration, liberal transfusion practices, and suboptimal use of vasopressors were consistently associated with an increased risk of post-transplant AKI. Conclusions: AKI after LT is mainly influenced by modifiable perioperative factors. Prevention relies on maintaining stable hemodynamics, careful fluid and transfusion management, and avoiding intraoperative hypotension. Prompt and adequate vasopressor support appeared protective. A multimodal, personalized, kidney-protective approach is essential for improving post-transplant outcomes. Full article

Objective: The objective of this study was to evaluate the efficacy of a ropivacaine-loaded poloxamer 407 (P407)-based thermosensitive hydrogel applied at the subfascial site compared with a continuous local anesthetic delivery system using a catheter for postoperative pain control after cesarean section (CS), in combination with standard intravenous patient-controlled analgesia (IV-PCA). Methods: This single-center, prospective randomized controlled trial included 72 pregnant women undergoing CS between April and October 2025. Participants were randomly assigned to receive either ropivacaine hydrogel or catheter-based ropivacaine infusion, both in conjunction with IV-PCA. Primary outcomes included numeric rating scale (NRS) pain scores at 3, 6, 12, 24, and 48 h postoperatively. Secondary outcomes included the time to first NSAID request and the cumulative use of rescue NSAIDs. Results: There were no significant differences in baseline characteristics between the groups. NRS pain scores did not differ significantly at any time point, although they varied significantly over time within each group. The hydrogel group showed a statistically significant delay in the time to first NSAID request (6.3 ± 5.1 h vs. 5.0 ± 6.1 h, p = 0.049) and higher cumulative NSAID use (2.4 ± 1.7 vs. 1.6 ± 1.2, p = 0.035). No serious complications were observed in either group. Conclusion: The ropivacaine hydrogel provided postoperative pain control comparable to that of the continuous catheter system, with no statistically significant differences in NRS scores observed between groups. Given its ease of use, absence of catheter-related concerns, and substantially lower total anesthetic dose, the P407-based hydrogel may represent a practical and patient-friendly alternative for post-cesarean analgesia. Full article

Introduction: Severe traumatic brain injury (sTBI) frequently coexists with polytrauma and often necessitates damage control neurosurgery (DCNS), where rapid decompression and temporary stabilization take precedence over definitive reconstruction. Within this context, anesthetic management must balance cerebral protection with ongoing resuscitation, yet high-quality DCNS-specific evidence remains limited. Materials and Methods: A comprehensive search of PubMed, Scopus, and Google Scholar (2015–2025) was conducted using MeSH terms and keywords related to neurotrauma, anesthesia, intracranial pressure, and perioperative management. Studies were included if they examined anesthetic or hemodynamic strategies in severe TBI or DCNS and reported relevant clinical or physiologic outcomes. Results: Nineteen articles addressing perioperative strategies for optimizing DCNS outcomes were analyzed. Discussion: Preoperative care emphasizes hemodynamic stabilization and permissive hypertension, damage control resuscitation including massive transfusion protocols, optimization of cerebral perfusion pressure (CPP) and neuromonitoring, and the use of hyperosmolar therapy. Transexamic acid can be used in sTBI safely but with unclear improvement in outcomes. Intraoperatively, propofol-based total intravenous anesthesia is generally preferred over volatile agents due to favorable effects on intracranial pressure (ICP), cerebral blood flow (CBF), autoregulation, and emergence. While historically contraindicated, ketamine and etomidate are now increasingly used as hemodynamically protective induction agents. Analgesic and sedative strategies prioritize dexmedetomidine and carefully titrated opioids to minimize respiratory depression and reduce postoperative complications. CPP and ICP-directed management relies on individualized blood pressure targets, vasopressor selection, lung-protective ventilation, and strict temperature control. Conclusions: Emerging evidence has suggested the benefit of DCNS for patient survival. Overall, perioperative care is guided largely by physiology and extrapolation, highlighting the need for standardized protocols. Full article

Background: Chronic pain following thoracotomy remains a common and clinically significant complication that adversely affects functional recovery and quality of life. Despite advances in perioperative analgesic techniques, chronic post-thoracotomy pain continues to be under-recognized and insufficiently managed in routine clinical practice. In this study, we aimed to determine the incidence of chronic pain after thoracotomy and evaluate its impact on daily activities and postoperative pain management behaviors. Methods: This retrospective observational study was conducted after institutional ethics committee approval was received (approval no. 2023/61). Patients aged ≥15 years who underwent thoracotomy between 15 June 2022 and 15 June 2023 and had undergone an operation at least three months prior to the study were included. Patients who underwent video-assisted thoracoscopic surgery were excluded. Demographic, surgical, anesthetic, and postoperative analgesia data were obtained from medical records. Patients were contacted by telephone to assess pain intensity using a Numeric Rating Scale (NRS), functional impact on daily activities, and analgesic medication use. The primary outcome was the incidence of chronic post-thoracotomy pain, defined as pain persisting beyond three months and reported at the time of the interview. Results: A total of 56 patients were included in the analysis. Chronic pain was reported by 55.4% of the patients. Pain that interfered with daily activities and required medication use was reported by 51.5% of the patients. Thirty-three patients (57.9%) reported an NRS score > 3 during movement. Among patients with chronic pain, 64.7% reported self-medication without physician consultation, whereas only 11.8% sought medical advice for pain management. Conclusions: Chronic pain remains highly prevalent after thoracotomy and substantially interferes with daily functioning. A considerable proportion of patients self-manage their pain without medical supervision, underscoring the need for structured postoperative follow-up, early identification of high-risk patients, and individualized multimodal analgesic strategies to reduce the burden of chronic post-thoracotomy pain. Full article