Background: Tracheostomy is commonly performed in intensive care units to secure the airway of patients requiring prolonged mechanical ventilation. Although the procedure may improve patient comfort and facilitate airway management, it is also associated with potential complications such as bleeding and infection. Optimal timing of tracheostomy remains controversial and is influenced by clinical severity, physician decision-making, patient and family preferences, and institutional resources.
Methods: This study included patients admitted to the intensive care unit of Kowsar Hospital, Sanandaj, Iran, between 2023 and 2024 who required prolonged mechanical ventilation. Participants were categorized into early (≤14 days) and late (>14 days) tracheostomy groups. Primary outcomes included one-month mortality and ventilator-associated pneumonia, while secondary outcomes comprised duration of mechanical ventilation, length of ICU and hospital stay, antibiotic exposure, chest radiographic findings, and arterial blood gas parameters, including pH and PCO₂.
Results: Patients who underwent early tracheostomy experienced significantly shorter hospital stays (25.4 vs. 32.2 days) and required fewer days of antibiotic therapy (7.5 vs. 14.3 days) compared with those in the late tracheostomy group. The total duration of mechanical ventilation was also reduced in the early group. No statistically significant differences were observed between the two groups with respect to one-month mortality or complications such as ventilator-associated pneumonia and fever.
Conclusion: Early tracheostomy was associated with improved clinical efficiency, reflected by reduced hospitalization duration, decreased antibiotic use, and shorter periods of mechanical ventilation, without an increase in mortality or procedure-related complications. These findings suggest that early tracheostomy represents a safe and cost-effective strategy for selected ICU patients requiring long-term ventilatory support.

Background: Sepsis and septic shock are life-threatening conditions. They occur when the body has an uncontrolled response to infection, often leading to problems in multiple organs and significant health issues. Even with improvements in critical care, survivors often deal with ongoing physical challenges, lower quality of life, and long-term disabilities. One widely used biomarker for systemic inflammation is C-reactive protein (CRP). It rises quickly after infection and tissue damage. While CRP is known to predict short-term mortality in sepsis, its impact on long-term recovery is still not well understood. This study aimed to find out if CRP levels at admission relate to physical activity in sepsis survivors one month after leaving the hospital. This is a crucial time when survivors are at high risk for readmission and functional decline.
Methods: In this cross-sectional study, we included 98 adult patients (ages 22 to 80) with sepsis or septic shock (SOFA score ≥3) admitted to Shariati Hospital ICU in Tehran, Iran, from February 2023 to March 2024. We excluded those with major health issues (like cancer) or pre-existing disabilities or who died during their hospital stay. We recorded admission CRP levels, SOFA scores, length of stay (LOS), and days on a ventilator. We assessed physical activity one month after discharge using an 8-item telephone questionnaire (score range: 0 to 32, with higher scores indicating better function), which looked at daily activities (such as walking, self-care, and housework). We used Pearson’s correlation and multivariate regression for analysis (SPSS v28; significance: p < 0.05).
Results: Among the 98 patients analyzed (54 males, 44 females; mean age 57.6 ± 16.5 years), the mean CRP level at admission was 85.5 ± 99.5 mg/L, while the mean physical activity score was 22.9 ± 9.7. We found a significant inverse correlation between admission CRP levels and physical activity scores (r = −0.337, p = 0.018). This means that higher CRP levels predicted poorer physical function. Longer use of the ventilator (r = −0.506, p < 0.001) and longer hospital stays (r = −0.396, p = 0.048) were also linked to lower physical activity. We did not find significant relationships between physical activity and SOFA score (r = −0.018, p = 0.901), ESR (r = 0.060, p= 0.683), age (r = −0.144, p = 0.325), or sex (p = 0.107).
Conclusion: Higher CRP levels at admission predict lower physical activity in sepsis survivors one month after discharge. This relationship also extends to longer mechanical ventilation and hospital stays. CRP may serve as an early marker to identify patients at high risk for targeted rehabilitation.

Background: Sellick’s maneuver is a well-known technique of cricoid pressure application that is practiced during rapid sequence induction to prevent regurgitation of gastric contents. The effectiveness of the cricoid pressure application has been often questioned with respect to the success of cricoid pressure application in preventing regurgitation and aspiration. The study aims to measure the outer anteroposterior(A-P) diameter of the esophagus visualized on ultrasound during the application of cricoid pressure in real time to assess its effectiveness.
Methods: 50 inpatients were enrolled as per inclusion and exclusion criteria. After obtaining informed consent, patients were examined with palpation and USG for identification of the cricoid and marked. As per institutional protocol, general anesthesia was induced. After administration of the induction agent, USG was placed over the cricoid in a slight oblique plane, and an uncompressed image of the esophagus was recorded as T1. An anesthesiologist trained in cricoid pressure application applied 30 N cricoid pressure with thumb and index finger. The anesthesiologist was not shown the image of the USG. The image after the application was recorded as T2. The compression was released after the recordings, and the case proceeded as per protocol. The images were analyzed for the anteroposterior diameter of the oesophagus visualized on cross-section, and values were taken.
Results: Appropriate statistical tests were used to obtain mean values of A-P diameter before and after compression. A-P value of 0.05 was considered significant. The oesophagus was visualized in 45/50 (95%) of individuals. In 45 patients, the oesophagus was visualized on the left side of the trachea in the groove behind the thyroid gland and trachea. In 27/45 (60%), there was occlusion of the oesophagus with cricoid pressure application. There was a significant change in the A-P diameter of the oesophageal lumen. In 18/45 (40%), occlusion was not observed.
Conclusion: In our study, the oesophagus as located on the lateral side of the trachea towards left. The cricoid pressure was effective in 60% of cases.

Background: Intertrochanteric femur fractures are prevalent orthopedic injury among the the geriatric population and demand adequate pain relief after surgery to improve recovery. While opioids are commonly used for analgesia, concerns about their side effects have led to increased interest in regional anesthesia techniques. The supra-inguinal (S-FICB) and infra-inguinal (I-FICB) fascia iliaca compartment blocks are two such approaches, but comparative studies on intertrochanteric fracture surgery are few. The present study was conducted to compare the efficacy and safety of the S-FICB approach with the I-FICB approach for postoperative pain management.
Methods: This single-center, prospective, randomized, double-blind clinical trial included 80 patients aged 55–75 years who underwent intertrochanteric femur fracture surgery. The participants were randomly divided to receive either S-FICB or I-FICB under real-time ultrasound guidance after spinal anesthesia. The main outcome measure was the pain index at rest and movement, based on the Numeric Rating Scale (NRS) score, which was compared at multiple intervals up to 24 hours. Secondary outcome measures included total morphine consumption over the 24-hour postoperative period, time to first request for morphine, and the occurrence of adverse effects.
Results: At 1, 4, 8, and 16 hours after surgery, patients in the S-FICB group experienced significantly lower pain scores, both at rest and during movement relative to the I-FICB group (P < 0.05), but not at 24 hours. Although the mean consumption of morphine was slightly lower in the S-FICB group (4.5 ± 1.2 mg) compared to the I-FICB group (5.2 ± 1.3 mg), the difference was not significant (P value > 0.05). Although the S-FICB group demonstrated a prolonged interval to initial morphine administration compared to the I-FICB group, this difference was not statistically significant (P value > 0.05). Patient satisfaction scores were significantly superior in the S-FICB group (P value < 0.05), while adverse events were similar between the groups.
Conclusion: In the early postoperative period, the S-FICB approach had better postoperative pain relief and greater patient satisfaction than I-FICB. However, there were no significant differences between groups in opioid use or the incidence of adverse effects.

Introduction: In geriatrics, general anesthesia can cause a high incidence of post-operative delirium (POD), reaching 3-61%, characterized by elevated interleukin-6 (IL-6) levels. Dexamethasone is often used as an adjunct in anesthesia to reduce cognitive impairment, but it can cause psychiatric symptoms. Cyclooxygenase-2 inhibitors such as parecoxib have been reported to inhibit post-surgical inflammation levels and improve neurological and neurocognitive disorders. However, there are no reports on the use of etoricoxib and its comparison with dexamethasone for these effects.

Objective: To analyze the comparison between preoperative administration of dexamethasone and etoricoxib on IL-6 levels and POD in geriatric patients with general anesthesia.

Methods: This Randomized single-blind clinical trial study included 36 geriatric patients undergoing elective surgery who received therapy under general anesthesia were randomly divided into three groups: placebo (group P, n = 12), dexamethasone 10 mg (group D, n = 12), and etoricoxib 90 mg (group E, n = 12). IL-6 levels were measured preoperatively, 6 hours, and 24 hours postoperatively using the ELISA method. POD was measured using the Confusion Assessment Method (CAM) both preoperatively and 24 hours postoperatively.

Results: The incidence of POD at 24 hours postoperatively was significantly lower in group E compared to groups P and D (p < 0.05). Changes in IL-6 levels at 6 hours and 24 hours postoperatively were significantly lower in group E compared to groups P and D (p < 0.05). There was a significant relationship between IL-6 levels at 6 hours postoperatively and CAM (r = 0.481; p < 0.05), and there was a significant relationship between IL-6 levels at 24 hours postoperatively and CAM (r = 0.537; p < 0.05).

Conclusion: Preoperative treatment etoricoxib was more effective in suppressing IL-6 levels and the incidence of POD than dexamethasone and placebo.

Background: Extubation, the transition from controlled anesthesia to spontaneous breathing, is a critical perioperative phase associated with risks such as laryngospasm, bronchospasm, hemodynamic instability, desaturation, and arrhythmias. Smooth extubation, defined as the absence of coughing, straining, or airway obstruction, is vital for patient safety. Dexmedetomidine, a selective α2-adrenergic agonist with sedative, analgesic, and sympatholytic properties, provides stable conditions without respiratory depression, making it a promising agent for extubation. This study aimed to assess the impact of dexmedetomidine on hemodynamic stability and recovery responses during tracheal extubation. Objectives included evaluating the quality of extubation, the level of postoperative sedation, and drug-related adverse effects.
Methods: In this prospective, double-blind, randomized trial, 60 ASA I/II adult patients undergoing elective surgery under general anesthesia were allocated into two groups (n=30 each). Group D received dexmedetomidine 0.5 mcg/kg in 100 ml saline over 15 minutes, and Group N received 100 ml saline before extubation. Heart rate, blood pressure, mean arterial pressure, and saturation were recorded perioperatively. Extubation was assessed using the Extubation Quality Score (EQS), sedation with the Ramsay Sedation Score (RSS), and adverse events were documented.
Results: Both groups were demographically comparable. Group D had significantly lower hemodynamic responses, higher sedation (RSS 2.08 vs. 1.02; p<0.0001), and smoother extubation (EQS 1.18 vs. 1.84; p=0.0012). Bradycardia and sedation were more frequent in Group D, while nausea and vomiting occurred only in Group N.
Conclusion: Dexmedetomidine 0.5 mcg/kg before extubation improved hemodynamic stability, sedation, and extubation quality, though careful monitoring is required for bradycardia and hypotension.

Background: A common adverse event in pediatric patients after surgery is emergence delirium (ED), which manifests as agitation, disorientation, and changes in perception (such as hypersensitivity to stimuli) together with inconsolable crying and moaning. This study compared the efficacy of ketofol versus dexmedetomidine (DEX) in preventing ED in children undergoing squint surgeries.
Methods: This prospective, randomized, clinical double-blind study enrolled 52 children aged 2–6 years, of both sexes, undergoing squint surgery. Patients were divided into two equal groups. Five minutes after securing the airway, DEX was infused at 0.2 µg/kg/h in Group D, and Ketofol (1:4 ketamine to propofol) was infused at 80 µg/kg/min propofol and 20 µg/kg/min ketamine in Group K.
Results: The incidence of intraoperative bradycardia and hypotension was not substantially different between the two groups. There was no significant difference in heart rate, mean arterial blood pressure, or peripheral oxygen saturation between groups intraoperatively and postoperatively. PAED and FLACC scores were insignificantly different between the two groups. Postoperative rescue analgesia and rescue sedation showed insignificant differences between groups.
Conclusion: Ketofol and DEX are equally effective in preventing emergence delirium (ED) in children undergoing squint surgery while maintaining stable hemodynamics.

Background: Cardiopulmonary bypass (CPB) and aortic cross-clamping are essential components of many cardiac surgical procedures. However, prolonged durations have been linked to adverse outcomes, including delayed recovery and increased intensive care unit (ICU) resource utilization. Understanding their impact is critical for improving perioperative management and optimizing patient outcomes.
We aimed to assess how cardiopulmonary bypass time (CPBT) and aortic cross-clamp time (ACCT) affect the length of ICU stay in patients undergoing elective cardiac surgery.
Methods: Our study was retrospective clinical study which conducted at Nasiriya Heart Center, Iraq, between September 2023 and September 2024. A total of 100 patients (aged 18–65 years) who underwent elective cardiac surgery were included. Demographic data, type of surgery, admission and discharge dates, and intraoperative variables (CPBT and ACCT) were collected. Associations between CPBT, ACCT, and ICU stay were analysed by using suitable statistical approaches.
Results: Of the 100 patients, 47% were male and 53% female, with a mean age of 44 years. The mean CPBT was 112.6 ± 44.2 minutes, and the mean ACCT was 69.0 ± 34.5 minutes. Gender showed no significant effect on ICU stay. In contrast, both prolonged CPBT and ACCT were significantly associated with longer ICU stays (P = 0.047 and P = 0.005, respectively).
Conclusion: Extended CPBT and ACCT are significant predictors of prolonged ICU stay after cardiac surgery. Strategies to minimize intraoperative times may help reduce postoperative ICU occupancy and improve overall resource allocation in cardiac surgical care.

Background: Drug-related problems (DRPs) are highly prevalent among critically ill patients in intensive care units (ICUs) and may negatively influence clinical outcomes. Pharmacist-led interventions play a pivotal role in detecting and resolving DRPs; however, their implementation and acceptance vary across healthcare systems.
Methods: This cross-sectional, descriptive-analytical study was conducted in the ICUs of Al-Zahra Hospital, Isfahan, Iran, during the second half of 2024. Adult patients admitted for more than 24 hours were evaluated for DRPs using Cipolle’s classification system. Data were obtained from medical charts, direct observation, and patient assessments. The severity of DRPs was graded using the NCC-MERP index, and pharmacist interventions as well as their acceptance by physicians were documented.
Results: A total of 100 patients were enrolled (60% male; mean age, 55.1 ± 18.1 years). A total of 324 DRPs were identified from 1,682 reviewed medication orders (mean of 3.24 DRPs per patient, with a median of 16.8 medication items received per patient). The most frequent categories were dosage too low (n = 68), ineffective drug therapy (n = 64), unnecessary drug therapy (n = 39), and dosage too high (n = 45). The most frequently implicated drugs were pantoprazole, acetaminophen (Apotel), vitamins and supplements, and broad-spectrum antibiotics including meropenem, vancomycin, and ceftazidime. Although 83% of drug-related problems (DRPs) caused no immediate harm, 18% led to actual patient harm. Clinical pharmacists offered several recommendations; however, only 18% of these were accepted by physicians.
Conclusion: Drug-related problems are very common among ICU patients, with dosing errors and unnecessary treatments being the most frequent types. The involvement of clinical pharmacists is essential for early detection and prevention, but the low rate of acceptance of their recommendations highlights the need for stronger interdisciplinary collaboration. Evidence from both international studies and Iranian research points to similar challenges, supporting the integration of clinical pharmacists into ICU teams as a key strategy to improve patient safety and treatment outcomes.

Background: Laparoscopic sleeve gastrectomy (LSG) is a cornerstone of bariatric surgery, requiring optimized anesthesia to ensure patient safety and postoperative recovery. Total Intravenous Anesthesia (TIVA) and inhalational anesthesia are commonly employed, yet their comparative efficacy in LSG remains underexplored. This study evaluates TIVA versus Inhalational Anesthesia in LSG, focusing on recovery time, hospital length of stay (LOS), postoperative nausea and vomiting (PONV), pain scores, and adverse events.
Methods: A randomized clinical trial (RCT) was conducted on 70 patients undergoing LSG between January 2024 and June 2025. The study data were collected in general operating rooms by an anesthesia assistant and colleagues at the Imam Khomaini Hospital Complex of tehran. Patients were randomly assigned to TIVA (n=35) or inhalational (n=35) groups using a computer-generated randomization sequence.
Primary outcomes included recovery time, LOS, and PONV incidence. Secondary outcomes included Visual Analog Scale (VAS) pain scores at 15, 30, 45, and 60 minutes post-surgery and adverse events (hypotension, bradycardia). Data were analyzed using t-tests for continuous variables and chi-square tests for categorical variables, with significance set at p<0.05.
Results: TIVA significantly reduced recovery time (21.1 ± 15.2 vs. 34.6 ± 20.3 minutes, p<0.05) and PONV incidence (20% vs. 34.5%, p<0.01) compared to inhalational anesthesia. VAS scores were lower in the TIVA group at 15 minutes (5.2 ± 1.8 vs. 6.8 ± 1.5, p<0.05) and 30 minutes (5.0 ± 1.7 vs. 6.5 ± 1.6, p<0.05), with no significant differences at 45 or 60 minutes. LOS was comparable (2.4 ± 0.7 vs. 2.7 ± 0.9 days, p=0.15). Subgroup analyses showed TIVA’s superior recovery time in women (p<0.05) and the 30-40 age group (p<0.05). Adverse events were similar between groups.
Conclusion: TIVA offers faster recovery and lower PONV rates compared to inhalational anesthesia in LSG, particularly in women and patients aged 30-40 years. These findings advocate for TIVA as a preferred anesthetic strategy in LSG to enhance postoperative outcomes.

Background: The study aimed to examine the relationship between weekly working hours and burnout syndrome among operating room nurses, focusing on the three core dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment.
Methods: The study involved 121 operating room nurses at Dr. M. Djamil General Hospital, Padang. The data were gathered by means of the Maslach Burnout Inventory (MBI) and analyzed using Pearson Correlation and Multiple Linear Regression.  
Results: Emotional exhaustion was significantly associated with burnout levels (p = 0.007), whereas depersonalization and personal accomplishment did not show statistically significant effects. A weak but significant negative correlation was identified between working hours and personal accomplishment (r = –0.183, p = 0.044).
Conclusion: Emotional exhaustion emerged as the most influential factor in predicting burnout among operating room nurses. Emotional fatigue interventions and psychological support system reinforcement are suggested for reducing burnout risk among them.

Background: Accurate confirmation of endotracheal tube (ETT) placement is essential to ensure adequate ventilation and prevent life-threatening complications in pediatric anesthesia. Traditional methods such as auscultation and capnography have inherent limitations. Point-of-care ultrasound (POCUS) has recently emerged as a rapid and reliable alternative. This study aimed to compare the diagnostic accuracy of ultrasound and finger palpation for ETT placement confirmation in children undergoing general anesthesia.
Methods: In this diagnostic accuracy clinical trial, 60 children aged 3–6 years (ASA I–II) scheduled for elective surgery were enrolled. Following standardized tracheal intubation, both ultrasound and finger palpation were performed sequentially by independent blinded operators. Fiberoptic bronchoscopy served as the reference standard. Diagnostic indices, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated. Secondary outcomes included operator confidence (5-point Likert scale) and time to confirmation.
Results: Ultrasound achieved higher sensitivity (92.5%) and specificity (71.4%) compared with finger palpation (79.2% and 100%, respectively). The PPV and NPV for ultrasound were 96.1% and 55.6%, whereas those for palpation were 100% and 38.9%. Operator confidence was significantly greater with ultrasound (4.37 ± 0.74) than with palpation (3.45 ± 1.03; p < 0.001). The mean confirmation time was also shorter using ultrasound (16.12 ± 1.55 s) than palpation (20.95 ± 1.88 s; p < 0.001). No complications occurred.
Conclusion: Tracheal ultrasonography provides a rapid, highly sensitive, and non-invasive way of verifying the proper placement of the endotracheal tube (ETT) in children, which is much more accurate and rapid than finger palpation. While finger palpation is a simple bedside technique with an ideal specificity, its low sensitivity makes it less useful as a sole diagnostic tool. The incorporation of ultrasonography into the usual management of the pediatric airway may have the potential of enhancing patient safety.

Background: Nosocomial infections increase morbidity, mortality, and healthcare costs in intensive care units (ICUs). The study aimed to describe the epidemiological profile and outcomes of nosocomial infections in an ICU in sub-Saharan Africa.
Methods: It was a retrospective and analytical study from January 1st, 2013, to December 31st, 2021, in the intensive care unit of Cocody University Hospital, Abidjan, Côte d’Ivoire. All patients hospitalized for at least 48 hours in the ICU or in the referring department were included.
Results: Among 5330 admissions, 325 patients developed a nosocomial infection (6.1%). Of these, 52% acquired the infection before ICU admission and 48% during their ICU stay. The mean age of the patients was 40 years with a standard deviation of 21 years, and the male-to-female ratio was 1.25. Neurological disorders were the most frequent underlying conditions. Nosocomial pneumonia was the most common infection (49.7%), followed by urinary tract infection (44.2%), bacteremia (37.0%), and other infections (11.1%). Gram-negative bacilli were predominant (79.9%), followed by Gram-positive infections (15.4%) and yeasts (4.7%). The most frequently isolated germs were Pseudomonas aeruginosa, Klebsiella pneumoniae, and E. coli. The overall mortality rate was 77.2%. Poor prognostic factors included mechanical ventilation, deep coma, and ventilator-associated pneumonia (VAP).
Conclusion: Nosocomial infections most frequently complicated neurological conditions and were predominantly pulmonary. Pseudomonas aeruginosa was the leading causative pathogen. These infections were responsible of high mortality.

Background: The integration of artificial intelligence (AI) and machine learning (ML) technologies in anesthesiology has emerged as a transformative force in perioperative medicine. This narrative review synthesizes current evidence on AI applications across the perioperative continuum. The objective is to provide a comprehensive overview of AI applications in anesthesiology, examining current implementations, clinical outcomes, and future directions across preoperative assessment, intraoperative monitoring, drug delivery, postoperative care, and clinical documentation.
Methods: A systematic literature search was performed across several databases for peer-reviewed publications on AI applications in anesthesiology from 2015 to June, 2025. If the papers were peer reviewed and come from quality journals. Sixty-six papers from reputable peer-reviewed medical journals of high quality were selected for analysis.
Results: The use of AI-based applications for anesthesiology can be summarized into 5 specific domains: predictive modeling to predict surgical risk assessment, real-time monitoring systems that measure anesthesia depth, automated drug delivery systems (and devices), postoperative complication prediction after surgery, and natural language processing (NLP) to assess clinical documentation. Recent advances show better patient outcomes, clinical decision-making and operational efficiency.
Conclusion: AI technology holds substantial potential to enhance anesthesiology practice along the entire perioperative continuum. Although some challenges need to be addressed in respect of clinical integration and validation, we believe that there is sufficient evidence to justify undertaking further development work with a view towards implementation of AI-assisted anesthesia care.

Tetralogy of Fallot (TOF) is becoming the most common cyanotic congenital heart disease, so there are many considerations for anesthesia and perioperative management, and also comorbidities such as laryngomalacia and microcephaly make its management quite challenging. This case report describes the perioperative and intensive care management of a patient undergoing total correction of TOF with a large ASD, complicated by postoperative atelectasis, pneumonia, and ventricular tachyarrhythmia. A 1-year-11-month-old boy with a weight of 10.2 kg was diagnosed with TOF + large secundum ASD, with a history of cyanotic spells, malnutrition, and laryngomalacia. Baseline SpO₂ was 85% on room air, and echocardiography shows severe infundibular pulmonary stenosis (PG 94 mmHg). The patient underwent total correction, including pulmonary valve-sparing infundibulectomy, patch closure of VSD and ASD, and tricuspid commissuroplasty, with intraoperative TEE monitoring. He developed ventricular tachycardia after cross-clamp removal, successfully treated with DC shock and amiodarone infusion. Postoperatively, he required prolonged mechanical ventilation and reintubation due to atelectasis and nosocomial pneumonia. This case highlights the importance of meticulous hemodynamic and airway management in TOF with comorbidities. Multidisciplinary care, intraoperative TEE guidance, and early recognition of postoperative complications contributed to a favorable outcome.

Unintentional extubation during prone-position surgery is a rare but critical airway emergency in anesthetic practice. We report a case of a 41-year-old obese female with predictors of a difficult airway undergoing elective lumbar laminectomy. Intraoperative dislodgement of the endotracheal tube, likely due to inadequate fixation, was promptly identified. Prone mask ventilation with an oropharyngeal airway maintained oxygenation until safe repositioning and reintubation were achieved. This case highlights the importance of rapid recognition, effective prone ventilation, and coordinated team response in managing airway emergencies in non-supine positions to optimize patient outcomes.

Neuraxial anesthesia is widely used in obstetric practice due to its well-established benefits for both maternal and fetal outcomes. While spinal anesthesia is more commonly employed, epidural anesthesia remains a valuable alternative, especially when prolonged surgical duration is anticipated. Complications from epidural anesthesia are uncommon, with catheter fracture representing an exceedingly rare occurrence. Because of its rarity, this complication presents unique diagnostic and management challenges. This report details the case of a retained epidural catheter fragment in a parturient undergoing elective repeat cesarean section. During epidural placement, an inadvertent dural puncture occurred, followed by difficulty threading the catheter. Upon withdrawal, the catheter tip was found to be missing, prompting abandonment of the epidural technique and conversion to spinal anesthesia. Postoperatively, serial neurologic examinations revealed no deficits or signs of infection. Magnetic resonance imaging and ultrasound failed to localize the retained fragment, leading to a decision for conservative management. This report emphasizes comprehensive clinical and imaging evaluations in determining the suitable approach to a retained epidural catheter fragment. When a patient is asymptomatic with no radiologic evidence of a neuraxial fragment, observation with close follow-up is acceptable. On the other hand, when a patient develops symptoms or there is evidence of fragment retention within the spinal canal, surgical exploration may be necessary. Due to the risk for complications in the future, full disclosure, thorough documentation, and long-term monitoring are indispensable.

Airway management in pediatric patients with craniofacial anomalies can be unpredictable, particularly when syndromic features are subtle or masked. We report the case of a 2-year-old boy (20 kg) posted for orchidopexy, whose preoperative airway assessment was limited by irritability, and whose dysmorphic features resembled those of his parents, masking suspicion of an underlying syndrome. Induction was carried out uneventfully, but intubation attempts with 4.5 mm and bougie-guided 4.0 mm endotracheal tubes failed. Placement of an i-gel size 2 initially secured ventilation, though progressive hypercarbia ensued, with end-tidal carbon dioxide (EtCO₂) rising to 75 mmHg. Video laryngoscopy subsequently revealed a markedly anterior larynx, severe supraglottic edema, and a ranula-like swelling. Administration of hydrocortisone and dexamethasone was followed by successful intubation with a bougie-guided 3.5 mm tube, after which ventilation normalized, and the remainder of anesthesia was uneventful. This case highlights the importance of anticipating hidden syndromic airway challenges, recognizing the limitations of supraglottic devices in the setting of edema, and relying on early video laryngoscopy, smaller tube selection, corticosteroids, and advanced adjuncts to ensure safe outcomes.

  Hypoglycemia is an under-recognized cause of intraoperative tachyarrhythmias because autonomic warning signs are obscured under general anesthesia. We report a 52-year-old male with type 2 diabetes mellitus who developed ventricular tachycardia and persistent tachycardia immediately after induction for endoscopic combined intrarenal surgery. Despite adequate anesthetic depth and stable hemodynamics, the arrhythmia did not respond to lignocaine. Point-of-care glucose testing revealed severe hypoglycemia (44 mg/dL), and dextrose administration rapidly normalized the heart rate. Opioid-induced alterations in glucose metabolism and diabetic autonomic neuropathy likely contributed. This case underscores the need to consider hypoglycemia in the differential diagnosis of unexplained intraoperative tachycardia in diabetic patients and to perform early glucose assessment.