Background: Spinal fusion surgery, as one of the treatment options for back pain, often results in significant postoperative pain due to complexity and multiple incisions. Glutamate receptors such as NMDA are among the main receptors involved in this process, causing central hyperalgesia and sensitization and ultimately accelerating pain processing in the CNS. Therefore, NMDA receptor antagonists such as ketamine and magnesium sulfate can be considered as suitable options for treating pain caused by these surgeries. A prospective study was conducted to compare the effects of ketamine and magnesium sulfate on pain control in these patients. This double-blind clinical trial was performed on 72 patients undergoing fusion surgery, referred to the 5th Azar Medical & Educational Center of Gorgan in 2020-2022.
Methods: In group A, 50mg/kg of magnesium sulfate along with CVE=5 ml/kg was infused over 20 minutes, and then 500 mg/h of magnesium sulfate was given during and up to 48 hours after surgery. In group B, 0.5 mg/kg of ketamine was given as a bolus after patient positioning and 2 minutes before surgical incision, followed by 2.5 mcg/kg/h of ketamine during and up to 48 hours after surgery. Pain was evaluated using the NRS scale from admission to recovery up to 48 hours after surgery, and the amount of opioid consumption was recorded.
Results: Both ketamine and magnesium sulfate led to a significant reduction in pain during the first 48 hours after surgery (P value <0.0001). The speed of pain reduction in the first 6 hours was higher in women in the ketamine group and in men in the magnesium group, although the results were reversed in the second 6 hours. Pain assessment in opium addicts indicated the superiority of magnesium in the speed of pain reduction in patients during the first 12 hours. The amount of analgesic used during recovery was statistically similar in both groups (p=0.645), but during the 24 hours after surgery, the amount of opioid consumption used in the magnesium group was significantly lower (p=0.025). After 24 hours, none of the two groups needed analgesics. No severe side effects were observed in any of the patients in the two groups.
Conclusion: Magnesium sulfate not only works well with ketamine in controlling postoperative pain but can also perform better than ketamine in women and opioid addicts, leading to a reduction in the use of opioids and avoidance of ketamine's side effects. In addition to reducing pain and analgesic use, considering the benefits of magnesium in stabilizing hemodynamics and reducing anesthetic use, this drug can be a very suitable alternative to ketamine for a wider range of patients undergoing spinal surgery, including those with heart and mental illnesses.

Background: Nausea and vomiting are distressing symptoms that are commonly experienced during cesarean section and can also occur in the period following the procedure. Shivering is also common with spinal anesthesia. This study aimed to compare the effectiveness of ketamine and tramadol in preventing post-spinal shivering, nausea, and vomiting during cesarean section surgery.
Methods: This clinical trial study was conducted in 2025 on 108 pregnant mothers who were candidates for cesarean section under spinal anesthesia. The samples were selected at Arash Hospital using a convenience method and were randomly assigned to two groups: ketamine (53 people) and tramadol (52 people). The dose of ketamine was 0.25 mg/kg, and tramadol was 0.5 mg/kg. We measured the patient's vital signs (such as body temperature, blood pressure, and heart rate), vomiting status, nausea and shivering, and any other changes that may indicate the occurrence of nausea/vomiting or shivering.
Results: The mean age of the total cohort was 29.84 years, with no significant difference between the tramadol and ketamine groups. Weight, BMI, and NPO time were comparable between the two groups, confirming that they were well-balanced at baseline. Post-intervention outcomes showed significant differences between the two groups. The heart rate was significantly lower in the ketamine group compared to the tramadol group, and systolic blood pressure was higher in the ketamine group. Fever was slightly higher in the ketamine group. The rates of shivering in the tramadol and ketamine groups were 26.92% and 18.87%, respectively, which were not statistically significant. The rates of vomiting or nausea in the tramadol and ketamine groups were also reported to be 73.1% and 11.32%, respectively, which were significant (P<0.001). The use of rescue medications (pethidine/ephedrine and plasil/ondansetron) mirrored these findings, with significant differences between groups.
Conclusion: In conclusion, ketamine demonstrated favorable effects on hemodynamic stability, nausea/vomiting, and temperature regulation compared to tramadol, with significant differences observed in nausea/vomiting incidence.

Background: Nasal bleeding is a common event during nasotracheal intubation. The present trial examined whether altering bevel orientation (upward, downward, right, or left) affects the likelihood of epistaxis, ease of intubation, and intraoperative outcomes.
Methods: In this triple-blind randomized controlled trial, 200 candidates for elective oral and maxillofacial procedures were randomized into four groups based on bevel orientation. The principal endpoint was the frequency and severity of epistaxis. Secondary endpoints included intubation time, difficulty score, hemodynamic responses, and oxygen saturation. Data were evaluated using chi-square, ANOVA, and Kruskal–Wallis tests (p<0.05).
Results: The incidence and grading of epistaxis, intubation time, and difficulty did not significantly differ between the four orientations. Hemodynamic and oxygenation parameters remained stable throughout. Lateral orientations showed a non-significant tendency toward less bleeding and smoother tube passage.
Conclusion: Bevel direction did not significantly influence bleeding or difficulty of nasotracheal intubation, although subtle clinical advantages were observed. Larger trials are needed to clarify the potential benefits.

Background: Postoperative pain following lumbosacral spine surgery is often intense and may hinder early recovery and ambulation. Caudal epidural analgesia using local anesthetics, particularly when combined with adjuvants, has shown potential in enhancing pain control. Dexmedetomidine which has a high affinity for α2-adrenergic receptors, may augment the analgesic effects of ropivacaine and extend its duration. To evaluate the effectiveness and safety of caudal epidural administration of ropivacaine alone versus ropivacaine combined with dexmedetomidine in patients undergoing lumbosacral spine surgery under general anesthesia.
Methods: A total of 60 adult patients (ASA I–II) scheduled for elective lumbosacral spine procedures were enrolled in this prospective, randomised, double-blind trial. Participants were assigned to two groups. One group received 20 mL of 0.2% ropivacaine, and another group received 18 mL of 0.2% ropivacaine with 2 mL of dexmedetomidine (1 µg/kg). Pain scores, time to first rescue analgesia, sedation levels, hemodynamic parameters, and adverse events were monitored. Statistical evaluation was carried out with SPSS version 21, with significance set at p < 0.05.
Results: Patients who received dexmedetomidine showed lower pain scores at 4, 8, and 12 hours after surgery. Their average duration of postoperative analgesia was also longer (23.00 ± 4.33 hours) when compared with the control group (15.13 ± 1.74 hours). Sedation profiles and intraoperative hemodynamics were largely similar in both groups. No clinically important adverse effects, such as hypotension, bradycardia, or respiratory compromise, were observed.
Conclusion: Incorporating dexmedetomidine into a caudal epidural block with ropivacaine provides more effective postoperative pain relief without significant side effects.

Background: This randomized controlled trial evaluated the analgesic effect of adding subcutaneous ketamine to bupivacaine in lumbar fusion surgery.
Methods: 46 adult patients were randomized to receive subcutaneous bupivacaine with or without ketamine before incision. Pain scores (VAS), time to first rescue analgesia, opioid use, extubation time, and patient satisfaction were assessed.
Results: The ketamine group had higher early postoperative pain (30 and 60 min; P < 0.05) but showed prolonged time to rescue analgesia (P = 0.037) and reduced opioid use (not statistically significant). Extubation time was significantly longer. Satisfaction scores were similar.
Conclusion: Subcutaneous ketamine delayed opioid use but increased early pain and extubation time. It may be considered in selected patients, pending further research.

Background: Ventilator-associated pneumonia (VAP) is a major source of morbidity and mortality in mechanically ventilated patients, with heterogeneous rates reported across Indonesian ICUs. Although evidence-based prevention bundles reduce VAP, real-world adherence is inconsistent. This study evaluated the association between VAP bundle compliance and VAP incidence among ICU patients at Wahidin Sudirohusodo Hospital in 2024.
Methods: We conducted a retrospective analytical study (January–December 2024) including adults ventilated ≥48 h with complete bundle documentation; patients with pre-existing pneumonia or incomplete records were excluded. VAP was defined by CDC criteria. Compliance with the five-element bundle (head-of-bed elevation, daily sedation interruption/readiness to extubate, stress-ulcer prophylaxis, DVT prophylaxis, and oral chlorhexidine) was recorded daily, calculated as a percentage, and categorized as 60% (3/5 elements), 80% (4/5), or 100% (5/5). Associations with VAP were analyzed statistically.
Results: Of the 385 patients who were on ventilators, 92 (23.9%) developed VAP. Of those, 52 (56.5%) died. The highest adherence was for head-of-bed elevation (91.5%), while the lowest was for DVT prevention (3.1%). In the VAP group (n=92), 65 subject manifested at 60% adherence (70.7%), 24 at 80% (26.1%), and 3 at 100% (3.3%). A higher level of adherence was significantly associated with a lower incidence of VAP (p = 0.001).
Conclusion: Higher adherence to the VAP preventive bundle is associated with a lower VAP rate. To increase bundle adherence and patient outcomes in ICU, targeted interventions are needed. These should include more staff training and regular audits, with an emphasis on DVT prevention and daily weaning.

Background: Spinal anesthetic has improved perioperative care for lower-limb procedures. However, sympathetic blocking can induce considerable hemodynamic instability. While fluid preloading and vasopressors are established preventive interventions, dexamethasone and ondansetron, employed as antiemetics, have lately been studied for their cardiovascular-stabilizing effects. This study compares the effects of preoperative intravenous dexamethasone (8 mg) and ondansetron (8 mg) on hemodynamic stability and postoperative nausea and vomiting during spinal anesthesia.
Methods: 192 ASA I-II patients undergoing elective lower-limb orthopedic surgery under spinal anesthesia at Alkafeel Hospital in Karbala from 2nd September, 2022, to 3rd November, 2024, were assigned to four groups: dexamethasone (Group D), ondansetron (Group O), combination (Group B), and control (Group C). MAP, HR, and SpO₂ incidences of nausea and vomiting were measured at 5, 10, 15, 30, and 60 minutes after spinal block.
Results: MAP and HR did not differ significantly between groups (p = 0.326 and 0.458, respectively). At 5 minutes, Group B had greater MAP (p = 0.001) and HR (p = 0.030) than Group C. No significant differences in SpO₂ levels were seen (p > 0.05). The incidence of nausea was lowest in Group B (2.1%), compared to Group C (14.6%) (p = 0.009). Vomiting occurred in all groups, with zero incidences in Group B.
Conclusion: Combining dexamethasone and ondansetron before lower-limb surgery under spinal anesthesia improved cardiovascular stability and reduced nausea.

Background: Acute Respiratory Distress Syndrome (ARDS) is associated with an increased risk of stress-related mucosal disease (SRMD) due to hypoxemia, systemic inflammation, and prolonged mechanical ventilation. Stress ulcer prophylaxis is routinely administered in the intensive care unit (ICU), most commonly using proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs). Although PPIs provide more potent gastric acid suppression, their use has been associated with a higher risk of infection, and evidence regarding their superiority over H2RAs remains inconclusive. This study aimed to compare the efficacy of PPIs and H2RAs in maintaining gastric pH and preventing stress ulcers in mechanically ventilated patients with ARDS.
Methods: This single-blind randomized controlled trial included 40 adult patients diagnosed with ARDS who required mechanical ventilation. Participants were randomly assigned to receive either intravenous omeprazole 40 mg once daily (PPI group) or intravenous ranitidine 50 mg every 12 hours (H2RA group) for three days. Gastric pH was measured at baseline (day 1) and on day 4 using nasogastric aspirates.
Results: The PPI group demonstrated a statistically significant increase in gastric pH from day 1 to day 4 (p = 0.012), whereas no significant change was observed in the H2RA group (p = 0.528). The between-group comparison showed a significant difference in pH changes over time (p = 0.024), with the PPI group exhibiting a mean increase of 0.65 ± 0.99, while the H2RA group showed a mean decrease of 0.18 ± 1.21. However, there were no significant differences between groups in absolute gastric pH values on day 1 (p = 0.265) or day 4 (p = 0.117), nor in the incidence of stress ulcers (p = 1.000). ARDS severity did not differ significantly between groups on day 1 or day 4 (p = 0.058 and p = 0.655, respectively), and the proportion of patients with worsening ARDS severity was also comparable (30% vs. 15%, p = 0.451).
Conclusion: Both PPIs and H2RAs were effective for stress ulcer prophylaxis in mechanically ventilated ARDS patients, with similarly low rates of stress ulcer bleeding. Although PPIs resulted in a greater increase in gastric pH, this did not translate into superior clinical outcomes. Therefore, the choice between PPIs and H2RAs should consider not only their acid-suppressive effects but also potential adverse events, including infection risk.

Background: The aim of this study was to identify the poor prognostic factors associated with acute dyspnea in medical emergencies.
Methods: A retrospective descriptive and analytical study conducted over a 12-month period (January 2022 to December 2022) in the medical emergency department of the Centre Hospitalier Universitaire de Treichville. All patients admitted to the medical emergency department for dyspnea during the study period were included.
Results: Prevalence was 7%. The mean age was 49 years, with a standard deviation of 16 years. The sex ratio was 1.08. Comorbidities were dominated by arterial hypertension (30.5%) and diabetes (14.7%). The majority of patients had NYHA stage 4 dyspnea (40%). Vital signs revealed arterial hypotension (45.5%), tachycardia (43.75%), tachypnea (66.9%), desaturation (52.2%), and disturbed consciousness (28.3%). The etiological diagnosis was dominated by bacterial pneumonia (35%), covid-19 pneumonia (22.4%), heart failure (21.7%), and pulmonary tuberculosis (13%). The mean time to therapeutic management was 3 hours and 23 minutes. Oxygen therapy was used in all patients. The average length of stay in the medical emergency department was 4 days ± 2 days. Mortality was 29% and was statistically associated with the existence of comorbidities (heart disease, arterial hypertension, tuberculosis, and diabetes), tachycardia (HR greater than 120 bpm), arterial hypotension (MAP less than 60 mmhg), tachypnea (respiratory rate greater than 30 cycles per minute), saturation less than 80%, and impaired consciousness (Glasgow score less than 14).
Conclusion: Dyspnea is responsible for a significant mortality rate. Several poor prognostic factors have been identified. Management of these factors could reduce mortality.

Background: Circumcision is one of the most frequently performed pediatric surgeries. Effective perioperative analgesia is essential to minimize pain, reduce stress responses, and facilitate early recovery. This study aimed to compare the analgesic efficacy, hemodynamic effects, and recovery outcomes of ropivacaine versus bupivacaine in penile nerve block among children undergoing circumcision.
Methods: In this quasi-randomized clinical trial conducted at Bahrami Children’s Hospital (Tehran, Iran) from November 2024 to January 2025, 66 male children aged 3 months to 3 years (ASA I–II) scheduled for elective circumcision were consecutively enrolled. Based on sequential allocation, participants received either 0.2% ropivacaine (Group R) or 0.25% bupivacaine (Group B) at 0.2 mL/kg for dorsal penile block. Hemodynamic parameters were recorded at key perioperative time points. Pain was assessed using the FLACC scale, and recovery time and fentanyl consumption were documented.
Results: Group R demonstrated significantly lower heart rates and higher systolic blood pressure at post-induction, post-incision, and end-of-surgery time points (p < 0.05). The need for intraoperative fentanyl was lower in group B (24.2% vs. 66.7%, p < 0.001), while postoperative FLACC scores were lower in Group R (p = 0.024). Recovery time was significantly shorter in the ropivacaine group (p < 0.001). No adverse events occurred.
Conclusion: Both drugs (ropivacaine and bupivacaine) were safe and effective. Ropivacaine provided better analgesia and faster postoperative recovery, while bupivacaine reduced intraoperative opioid use. These findings suggest that drugs should be selected based on individual clinical preferences.

Background: Spinal anesthesia is a very commonly used procedure in modern-day anesthesia practice. Today most of the lower limb surgeries are performed under spinal anesthesia. Midazolam, dexmedetomidine, and fentanyl are common intravenous adjuvants used during anesthesia to allay anxiety and sedation. The aim of this study was to compare the effects of intravenous dexmedetomidine-midazolam versus fentanyl-midazolam in terms of analgesic characteristics, sedation, and adverse effects.
Methods: This is a randomized prospective study that included 35 patients in each group, posted for lower limb orthopedic surgery. Intravenous dexmedetomidine, fentanyl, and midazolam were administered after subarachnoid block. Data for sedation, analgesia, hemodynamic parameters, and adverse effects were recorded.
Results: RR for FM group showed significant intra-group variability in RR across perioperative stages (p<0.05), whereas the DM group maintained greater respiratory stability (p=0.243). HR for DM group exhibited significantly lower intraoperative and postoperative HR compared to FM group (p<0.001), with notable within-group changes, unlike the FM group. MAP for both groups remained stable over time (DM: p= 0.283, FM: p= 0.260), although the FM group had slightly higher values in the postoperative recovery phase. Sedation (RSS): DM produced deeper and more sustained sedation intraoperatively and postoperatively (p<0.001), while FM showed quicker sedation decline. Patient satisfaction was significantly higher in the DM group (VAS: 3.0 vs. 4.0, p= 0.001), although surgeon satisfaction did not differ notably. Adverse events were rare and comparable, though hypotension was more frequent in the DM group (22.9% vs. 8.6%).
Conclusion: Dexmedetomidine plus midazolam provided superior sedation quality and patient satisfaction, with more stable cardiopulmonary parameters during orthopedic surgery under spinal anesthesia. Despite a slightly higher rate of hypotension, DM appears to offer a more favorable sedative profile compared to fentanyl plus midazolam.

Chronic inflammation and oxidative stress play a critical role in conditions such as atherosclerosis, metabolic syndrome, and diabetic nephropathy. Telmisartan is a unique long-acting ARB due to its dual mechanism of action. In addition to blocking the AT1R, it acts as a partial agonist for peroxisome proliferator-activated receptor-gamma (PPAR-γ). It is also characterized by high lipophilicity compared to other drugs in its class, facilitating tissue penetration into the central nervous system. The objective of this narrative review is to bridge the gap between murine models of oxidative stress and inflammation and human clinical outcomes across the cardiovascular, renal, hepatic, neurological, and autoimmune systems. Across extensive human clinical trials and murine models, telmisartan demonstrates unique potential as a multi-system anti-inflammatory and antioxidant agent that actively suppresses pro-apoptotic and fibrotic cascades. Beyond these systemic effects, telmisartan confers localized vascular benefits by actively stabilizing coronary plaques and suppressing cardiac inflammation. While its cardiovascular and renal benefits are the most widely investigated, it also demonstrates profound extra-cardiac efficacy. In particular, telmisartan improves neuroinflammation in neurodegenerative diseases, metabolic profiles in hepatic steatosis, and protects against gastrointestinal and musculoskeletal inflammation. But its protective effects are limited for established HIV fibrosis and severe primary autoimmune conditions like psoriasis. In conclusion, telmisartan is a cardiometabolic and immunomodulatory drug, extending the clinical use beyond hypertension.

Background: Cerebral hypoperfusion is a major cause of brain ischemia, both global and focal. In focal ischemia, there are three main zones: the ischemic core, which undergoes permanent damage; the penumbra, which remains salvageable; and the area with normal perfusion. A decrease in blood flow and disruption of cerebral autoregulation can convert the penumbra into an infarct if reperfusion is not promptly achieved. The penlucida region represents tissue capable of spontaneous recovery without intervention, whereas the penumbra requires immediate action to preserve neuronal viability. Neuronal injury in ischemia primarily results from energy production failure due to impaired oxidative phosphorylation, increased intracellular calcium, excessive glutamate release, and the formation of free radicals that lead to excitotoxicity and cell death through necrosis and apoptosis. Resuscitation of the penumbra–penlucida area aims to restore perfusion and oxygenation before irreversible damage occurs through the application of the neuroanesthetic-based ABCDE principles (airway, breathing, circulation, disability, exposure). Maintaining airway patency, oxygenation, normocapnic ventilation, and adequate cerebral perfusion pressure (CPP) are key to preserving collateral blood flow. Hypotension, hypoxia, hyperthermia, hypoglycemia and hyperglycemia must be avoided as they accelerate infarct progression. Anesthetic agents play a protective role by reducing cerebral metabolism, although careful monitoring of blood pressure is still necessary to prevent relative hypotension. Thus, the application of neuroanesthetic principles in penumbra–penlucida resuscitation aims to maintain cerebral perfusion, oxygenation, and metabolic stability to prevent the transformation of reversible tissue into a permanent infarct.

Background: Patients undergoing neuraxial anesthesia remain conscious during surgery and may experience perioperative anxiety and psychological distress. Virtual reality (VR) has been proposed as a non-pharmacological strategy to improve patient experience. This scoping review aims to map current evidence on VR effects on psychological and experiential outcomes in adults undergoing neuraxial anesthesia.
Methods: This scoping review was conducted in accordance with PRISMA-ScR guidelines. PubMed, Scopus, Web of Science, and Embase were searched up to November 2025. Studies investigating the use of virtual reality among adult patients receiving neuraxial anesthesia in the operating room were included. Information regarding study design, characteristics of the VR intervention, and reported outcomes was collected and summarized narratively.
Results: 13 studies involving 1,127 participants were identified, including 12 randomized controlled trials and one matched retrospective cohort study. Most interventions employed immersive VR during the intraoperative period. Anxiety and stress were the outcomes most frequently assessed, and a large proportion of studies reported significant reductions in anxiety following VR use. Evidence regarding pain reduction was variable and showed limited and inconsistent benefits across studies. Patient satisfaction and comfort were generally improved, whereas findings related to sedative requirements were mixed, with several studies reporting reduced sedative use.
Conclusion: VR appears to be a useful adjunct for enhancing perioperative patient experiences, especially with respect to anxiety reduction and patient satisfaction in adults undergoing neuraxial anesthesia. However, evidence concerning pain outcomes and medication use remains inconclusive, emphasizing the importance of conducting well-designed studies with standardized outcome measures.

Critical airway incidents in children are among common anesthetic concerns. Due to limited apnea tolerance, any delay in airway management can quickly lead to severe complications. Unique pediatric anatomical features such as a large epiglottis, narrowed subglottic space, prominent occiput, elevated larynx position, and enlarged tongue can heighten the risk of airway obstruction. In this report, we presented a case of compromised airway due to a parapharyngeal mass in a 7-year-old patient, managed without complications.

Intracranial arteriovenous malformation (AVM) is a rare cerebrovascular abnormality that may cause bleeding, seizures, or neurological deficits. Treatment options, including surgery, embolization, and radiosurgery, are based on lesion size, location, and symptoms. In neurosurgery, Enhanced Recovery After Surgery (ERAS) aims to reduce pain, accelerate recovery, and shorten hospitalization. Opioid-Free Anesthesia (OFA), as part of ERAS, minimizes opioid-related complications and supports faster postoperative recovery. A 43-year-old woman presented with seizures and decreased consciousness. Angiography revealed an AVM in the right lateral parietooccipital region, classified as Spetzler Martin Supplementary Grade VI. She underwent craniotomy and AVM resection under OFA. Induction included dexmedetomidine loading at 0.7 mcg/kg for 10 minutes, followed by 0.2–0.5 mcg/kg/h maintenance. Anesthesia was maintained with target-controlled infusion (TCI) propofol in Schnider mode, effect-site concentration 3–5 mcg/mL. Lidocaine 90 mg and rocuronium 30 mg were also administered. Postoperative analgesia consisted of paracetamol 500 mg every 6 hours, ibuprofen, and dexmedetomidine infusion 0.2 mcg/kg/h. Multimodal anesthesia using dexmedetomidine, propofol, rocuronium, and lidocaine effectively replaced opioids, maintaining stable hemodynamics and adequate anesthesia. The combination of propofol and dexmedetomidine provided sedation, hypnosis, and analgesia, facilitating early extubation. The patient experienced rapid recovery without postoperative nausea or vomiting. AVM resection in a 43-year-old woman was successfully performed under OFA, with stable intraoperative conditions and no postoperative complications or neurological deficits. This case demonstrates the feasibility and effectiveness of OFA in complex neurosurgical procedures, supporting its broader application in clinical anesthesia practice.

Snakebite envenomation is a medical emergency with potentially fatal systemic complications. We report a case of a 32-year-old male patient who presented to the Emergency Department with a complaint of a snakebite on his right ear. On arrival, he didn’t have signs of bleeding, fever, or swelling. Two hours after admission, the patient developed cardiac arrest and required mechanical ventilation. Although resuscitation was successful, the patient’s condition deteriorated, with progressive neurological and motor deficits, despite unremarkable findings on head CT scans and chest X-rays. Given progressive neurological and motoric deficits, hemoperfusion was initiated six hours post-envenomation as an adjunctive therapy. The procedure lasted six hours using a standard hemoperfusion cartridge. The patient demonstrated significant neurological recovery within 22 hours post-procedure, and he was successfully extubated on day 4. This case highlights the potential role of hemoperfusion as an adjuvant treatment in managing venomous snakebite envenomation, especially in places with limited species-specific antivenom availability. Early recognition of systemic complications and timely initiation of hemoperfusion may improve neurological outcomes in critically envenomed patients.

Although varicella-zoster virus (VZV) infection is typically self-limiting in immunocompetent individuals, this case underscores its rare but fatal potential when complicated by appendicitis, hepatitis, and pneumonia. The rapid progression to septic shock in a healthy young adult makes this report novel and clinically significant. An 18-year-old previously healthy Iranian woman underwent an appendectomy, after which she developed diffuse varicella-like skin lesions. Polymerase chain reaction of peripheral blood confirmed VZV viremia. During hospitalization, she developed pneumonia, hepatitis, and septic shock requiring intensive care. Despite aggressive treatment, including intravenous acyclovir, broad-spectrum antibiotics, and hemodynamic support, she died from multiorgan failure seven days after admission. This case demonstrates that even common, typically benign infections (e.g., chickenpox) and routine surgical conditions (e.g., appendicitis) can culminate in fatal systemic complications in immunocompetent patients. Clinicians should maintain a high index of suspicion for atypical VZV presentations in adults, as early antiviral therapy may improve outcomes.