Background: The most severe complication of type 1 diabetes mellitus is diabetic ketoacidosis (DKA). Hypokalemia, a common electrolyte disturbance in DKA, can be life-threatening and often worsens during treatment. A significant clinical debate exists regarding the optimal route of potassium administration—central versus peripheral lines. Current guidelines recommend aggressive potassium replacement but lack consensus on the safest administration method. This study investigated the safety and complications of high-concentration peripheral potassium administration in pediatric DKA patients within an intensive care setting.
Methods: This observational study, conducted at the PICU of Bahrami Children's Hospital, enrolled 55 pediatric patients with DKA requiring high-concentration potassium supplementation (50, 60, or 70 mEq/L) through peripheral veins. Potassium chloride was administered in normal saline with dosing stratified by serum potassium levels checked every 2 hours. Primary analyses examined associations between infusion-related complications (phlebitis, pain, erythema, burning sensation) and potassium concentration, infusion duration, DKA severity, and patient characteristics.
Results: Among 55 patients (mean age: 8.7 ± 4.1 years; 52.7% male), 32 patients (58.2%) received 50 mEq/L, 21 patients (38.2%) received 60 mEq/L, and 2 patients (3.6%) received 70 mEq/L. Of these, 25 patients (45.5%) required infusion duration exceeding 6 hours. Hypokalemia occurred in 30.9% of patients, with higher prevalence in severe DKA (44.4%). A total of eight patients (14.5%) experienced a total of 10 infusion-related complications. These included one case of phlebitis (1.8%), five cases of injection site pain (9.1%), and four cases of burning sensation (7.3%). Infusion duration exceeding 6 hours significantly increased complication risk (OR: 5.7; 95% CI: 2.01-16.56; p=0.042), with combined high concentration and extended duration showing elevated risk (adjusted OR: 3.1; 95% CI: 1.86-5.24; p=0.003).
Conclusion: In pediatric DKA patients receiving care in the PICU setting, peripheral potassium infusion at concentrations up to 60 mEq/L demonstrates acceptable safety outcomes when administration duration remains under 6 hours and rigorous monitoring protocols are implemented. However, for infusions exceeding 6 hours, our findings suggest careful consideration of alternative approaches may be warranted, particularly at higher concentrations.

Background: A hernia is defined as the protrusion of an organ, tissue, or part of an organ through a structure that normally contains it. Inguinal hernias are a type of hernia that causes pain.
Methods: In this study, 62 individuals aged 4 to 18 years who met the inclusion criteria were enrolled. The tools used included a demographic characteristics form, a patient clinical characteristics form, and the Widder Scale questionnaire. After completing the questionnaires, data related to CPIP (likely an abbreviation for a pain assessment measure, but further information is needed for confirmation) and its influencing factors were entered into SPSS version 18 software and analyzed.
Results: According to the findings, out of 62 patients studied, 3 (4.8%) patients had CPIP, with the prevalence of CPIP being higher in men than in women. Also, none of the postoperative complications, including readmission, hydrocele, infection, and recurrence status, were observed in the patients. Also, regarding the duration of pain, it was shown that the pain of 36 patients was within the time range of up to one week, and the pain of 19 patients was within the time range of one week to one month.
Conclusion: It is essential to follow up on factors affecting CPIP in children undergoing hernia surgery on an ongoing basis or even one year after surgery.

Background: Cardiac catheterization is an essential procedure in managing pediatric congenital heart disease, providing a less invasive alternative to thoracotomy. However, adverse events remain a concern, especially in high-risk patients. The CRISP (Cardiac Risk in Pediatric) score, developed by the Congenital Cardiac Intervention Study Consortium (CCISC), predicts serious adverse events (SAEs) in pediatric cardiac catheterization. Despite its reliability, CRISP has not been implemented in Indonesia. This study evaluates its predictive ability at Dr. Wahidin Sudirohusodo Hospital, Makassar.
Methods: A prospective cross-sectional study was conducted from November 2024 to January 2025. Pediatric patients (<18 years) undergoing elective cardiac catheterization were assigned CRISP scores pre-procedure, and adverse events were recorded. The relationship between CRISP categories and SAE incidence was analyzed.
Results: Among 70 patients, the majority of patients were categorized as CRISP I (67.1%), followed by CRISP II (21.4%), CRISP III (5.7%), and CRISP IV (5.7%), with no CRISP V cases. There were 6 cases (8.6%) of serious adverse events identified, consisting of 4 cases (5.71%) of cardiac arrest and 2 cases (2.89%) of bleeding. A significant correlation was found between higher CRISP risk categories and SAE incidence (p < 0.001). SAEs occurred exclusively in CRISP III (50% incidence) and CRISP IV (100% incidence) patients.
Conclusion: The CRISP score effectively stratifies risk in pediatric cardiac catheterization. Higher CRISP categories correlate with increased SAE incidence, supporting its predictive validity. Routine CRISP implementation could enhance pre-procedural planning, risk mitigation, and patient safety in Indonesia. Further studies with larger sample sizes are recommended.

Background: Reflex Given the critical role of anatomical airway structures in tracheal intubation, this study aimed to predict the difficulty of mask ventilation and laryngoscopy using ultrasound-based airway evaluation criteria.
Methods: This cross-sectional study involved 205 patients undergoing tracheal intubation. During intubation evaluation based on the Cormack-Lehane classification, neck ultrasound was performed. The diagnostic value of neck sonographic parameters was assessed using receiver operating characteristic (ROC) analysis.
Results: According to the Cormack-Lehane classification, intubation was easy in 170 patients (82.9%) and difficult in 35 patients (17.1%). Ultrasound findings revealed statistically significant differences in all parameters, including neck circumference, between the easy and difficult intubation groups. All measured values were higher in the difficult intubation group.
Conclusion: The findings suggest that ultrasound is a useful, practical tool for predicting difficult intubation. However, due to study limitations such as the small sample size, further research is recommended.

Background: Vitamin D plays a vital role in bone metabolism, immune function, and overall health. Healthcare professionals, particularly those working indoors, may be at increased risk for deficiency due to limited sunlight exposure. This study aimed to evaluate serum vitamin D levels and explore associated factors among anesthesiology residents.
Methods: A retrospective cross-sectional study was conducted among 50 anesthesiology residents at Dr. Wahidin Sudirohusodo General Hospital in Makassar from January to February 2025. Data were collected through self-administered questionnaires and medical records. Serum 25-hydroxyvitamin D [25(OH)D] levels were used to determine vitamin D status. Statistical analysis was performed using SPSS version 26, with P values < 0.05 considered significant.
Results: Among the 50 participants, 76% were found to be vitamin D deficient. No significant associations were found between vitamin D levels and sex, age, or BMI. However, vitamin D deficiency was more common among residents with obesity and younger age groups. Vitamin D supplementation (p = 0.022) and duration of sunlight exposure (p = 0.029) showed significant associations with serum vitamin D levels. Dietary intake and comorbidities were not significantly related to vitamin D status.
Conclusion: A high prevalence of vitamin D deficiency was observed among anesthesiology residents, likely due to occupational limitations on sun exposure. Supplementation and regular sun exposure appear to be protective factors. Targeted strategies, including routine screening and preventive interventions, are recommended for at-risk healthcare workers.

Background: Non-cardiac surgery in patients with cardiovascular risk can lead to Spine surgery often leads to significant postoperative pain, inflammation, and hemodynamic instability, necessitating opioid use, which increases the risk of side effects. Dexmedetomidine (DEX) and magnesium sulfate (MgSO₄) are anesthetic adjuvants that may enhance recovery and reduce opioid consumption. This study aimed to compare the effects of DEX and MgSO₄ as an anesthetic adjuvant on interleukin-6 (IL-6) levels, hemodynamic stability, postoperative recovery, and opioid consumption in spine surgery.
Methods: A randomized controlled trial was performed on 24 patients undergoing spine surgery under general anesthesia. Participants were randomly divided into two groups: Group 1 received DEX (a 1 µg/kg bolus followed by a continuous infusion of 0.3–0.5 µg/kg/h), while Group 2 was given MgSO₄ (a 30–50 mg/kg bolus followed by an infusion of 10–20 mg/kg/h). Hemodynamic parameters, IL-6 levels (pre- and postoperatively), opioid use, and recovery outcomes were analyzed.
Results: IL-6 levels decreased significantly in both groups (p=0.001), with a greater reduction in the DEX group (-60.5 pg/dL vs. -24.9 pg/dL), though not statistically significant. Hemodynamic stability was comparable, but DEX provided better pulse rate control. Opioid consumption was lower in the DEX group at 24 and 48 hours postoperatively (p < 0.05). The DEX group also showed higher Aldrete scores (p<0.05) and shorter hospital stays (3.75 vs. 4.83 days, p<0.05).
Conclusion: DEX provides superior anti-inflammatory effects, hemodynamic stability, reduced opioid use, and improved recovery compared to MgSO₄ as an anesthetic adjuvant in spine surgery patients.

Background: Caesarean section is associated with postoperative pain that results in patient dissatisfaction and necessitates the use of various analgesics. In this study, the effect of gabapentin on post-Caesarean-section pain relief was evaluated.
Methods: A total of 50 parturients undergoing spinal anesthesia for cesarean section were randomly assigned into intervention and control groups in this randomized clinical trial between 2022 and 2023. Patients in the case group received gabapentin 300 mg capsules one hour before surgery, while the control group received an identical placebo. The postoperative pain intensity and need for analgesics, as well as nausea, vomiting, and drowsiness, were evaluated at 0, 6, 12, and 24 hours after surgery.
Results: The mean age of patients in the gabapentin and placebo groups was 26.42±6.15 and 26.5±65.91, respectively (P=0.34). A significant difference was found in postoperative pain intensity and the need for analgesics between the case and control groups at zero (P=0.001 and P=0.003), six (P=0.007 and P=0.002), 12 (P=0.005 and P=0.001), and 24 (P=0.004 and P=0.021) hours after surgery. No significant differences were seen in the rates of nausea, vomiting, and drowsiness between the two groups at the different time points (P>0.05).
Conclusion: According to our findings, prescribing gabapentin 300mg before a cesarean section effectively reduces postoperative pain severity and the need for analgesics. This dose is also safe for the neonate.

Background: In perioperative care, patient satisfaction is a key quality indicator; however, very little information exists on anesthetic-specific satisfaction among cardiac surgery ICU patients. Patients admitted to the cardiac surgery intensive care unit (ICU) were evaluated in this study for their level of satisfaction.
Methods: Between 2019 and 2020, this cross-sectional analytical research included 186 consecutive adult patients undergoing open-heart surgery at Golestan Hospital, Ahvaz, Iran. The verified Evaluation du Vécu de l'Anesthésie Générale (EVAN-G) scale (score range: 0-100) measured anesthesia satisfaction 48 hours post-extubation. Multivariable linear regression identified predictors of satisfaction.
Results: The mean satisfaction score was 73.8 ± 14.2. High satisfaction (≥80) was reported by 52.7% (n=98). Significant predictors included: Preoperative anxiety therapy (β=8.6, p=0.003), Effective pain control (VAS<4) (β=12.1, p<0.001), Clinician communication quality (β=9.3, p<0.001) and, Absence of PONV (β=7.2, p=0.011). The regression model accounted for 63% of satisfaction variation (R²=0.63, p<0.001).
Conclusion: Modified variables linked with anesthesia satisfaction in patients in a cardiac ICU are active communication, pain management, and preoperative counseling.

Background: Postoperative cognitive dysfunction (POCD) is a major concern in anesthesia, leading to increased morbidity and longer hospital stays. Our study aimed to evaluate the efficacy of target-controlled infusion (TCI) dexmedetomidine in reducing the incidence of POCD following laparotomy surgery.
Methods: A single-blinded, randomized controlled trial involving 107 patients aged >18 years old undergoing laparotomy surgery was conducted. Patients were randomly assigned to 54 patients in Group D (TCI dexmedetomidine with a target plasma of 1 ng/ml) and 53 patients in Group I (sevoflurane at 0.8% concentration).
Results: Our study showed subjects whose anesthesia was maintained by TCI dexmedetomidine had a lower chance of developing POCD (p=0.043) and experienced less pain at 12 hours (p=0.049) and 24 hours (p=0.049) in the postoperative period, compared to the control group. There were no significant differences between both groups in intraoperative MAP (p=0.290) and HR (p=0.453).
Conclusion: Maintaining anesthesia using Conox®-guided TCI dexmedetomidine reduces the incidence of POCD and postoperative pain in laparotomy patients who underwent general anesthesia.

Background: Magnetic resonance imaging (MRI) is widely used for diagnosing various diseases. This technique may lead to an elevation in temperature within the targeted imaging area, while intravenous anesthetics may induce hypothermia, particularly in pediatrics. The impact of different anesthetics on core body temperature in children undergoing such procedures has been partially explored with agents such as propofol and ketamine; however, findings associated with dexmedetomidine remain contentious. Therefore, this study aimed to investigate the influence of dexmedetomidine and ketamine on core body temperature in the pediatric population during MRI procedures.
Methods: This study was a prospective, randomized, double-blind clinical trial conducted on children aged 6 months to 10 years who underwent MRI and anesthesia at Mofid Hospital (Tehran, Iran) in 2025. Patients were randomly assigned to receive ketamine and dexmedetomidine for performing an MRI. Demographic, hemodynamic, and sedation data were compared between the two groups. The significance level was considered less than 0.05.
Results: Twenty-six pediatrics were assessed in each group receiving dexmedetomidine and ketamine. The sedation scores did not demonstrate significant differences between the two groups (P value: 0.55). Dexmedetomidine exhibited significantly lower heart rates (P value: 0.001) and core body temperatures (P value: 0.02).
Conclusion: Dexmedetomidine significantly reduces heart rate and core body temperature compared to ketamine in pediatrics undergoing MRI.

Background: Ventilator-Associated Pneumonia (VAP) is a common complication in mechanically ventilated ICU patients and is associated with bacterial colonization in the oral cavity. Poor oral hygiene can increase the risk of bacterial aspiration into the lower airway. Various oral hygiene agents such as chlorhexidine, povidone iodine 1%, and fluoride toothpaste are used to prevent this colonization, but their effectiveness is still variable. This study aimed to compare these three agents on tracheal microorganism growth and antibiotic resistance profile in mechanically ventilated patients.
Methods: This single-blind randomized clinical trial included 45 ICU patients on mechanical ventilation at Dr. Wahidin Sudirohusodo Hospital, Makassar. Subjects were allocated into three groups to receive oral hygiene using chlorhexidine 0.12%, povidone iodine 1%, or fluoride toothpaste twice daily for five days. Tracheal aspirates were collected at baseline (before intervention), Day 3, and Day 5 to assess microbial colony counts and antibiotic susceptibility profiles.
Results: The chlorhexidine group showed the most significant reduction in tracheal microorganism colony counts from 1833.33  566.5 to 1226.7  461.7 CFU/mL on day 5 (p < 0.001), compared to povidone iodine and fluoride. The highest antibiotic resistance was found in Acinetobacter baumannii and Pseudomonas aeruginosa. The chlorhexidine group also had the lowest number of multiresistant isolates.
Conclusion: Among the evaluated oral hygiene agents, chlorhexidine 0.12% was the most effective in reducing tracheal microbial colonization and showed a lower tendency for antibiotic resistance development. It is recommended as a superior oral care agent for preventing VAP in mechanically ventilated ICU patients.

Background: Effective management of postoperative pain in breast cancer surgery is crucial to enhance recovery and quality of life. Regional anesthesia techniques such as Pecs II and Serratus Anterior Plane Block (SAPB) have emerged as alternatives to systemic opioids. To compare the efficacy of single-shot Pecs II block and SAPB in terms of acute and long-term (up-to 2 months) postoperative analgesia following modified radical mastectomy.
Methods: A single-blind, randomized controlled trial was conducted on 46 ASA I-II female patients undergoing MRM, assigned to either Pecs II block (Group P) or SAPB (Group S), each with 30 mL of 0.25% bupivacaine. Numerical Rating Scale (NRS) scores at rest and during movement were recorded perioperatively and during 60-day follow-up. Secondary outcomes included time to first rescue analgesia, number of rescue analgesics in 48 hours, and adverse effects.
Results: Both blocks provided comparable acute pain relief in the first 48 hours (p>0.05). Group P showed significantly lower NRS scores at 15, 30, and 60 days at rest and on movement (p<0.05), indicating better long-term analgesia. There was no significant difference in rescue analgesic requirements or adverse effects.
Conclusion: Both Pecs II and SAPB offer effective acute postoperative pain control following MRM, while Pecs II provides superior long-term analgesia.

Background: Hysterectomy often triggers a systemic inflammatory response, increasing biomarkers like C-reactive protein (CRP) and the neutrophil-lymphocyte ratio (NLR), which can delay recovery and raise complication risks. Ketamine, a common anesthetic, possesses anti-inflammatory properties that may modulate this postoperative response. This study aimed to further examine the effects of ketamine on CRP and NLR levels in patients undergoing hysterectomy.
Methods: This double-blind randomized clinical trial included 28 adult female patients (ASA I–II) undergoing elective abdominal hysterectomy under epidural anesthesia. Patients were randomized to receive either 0.5 mg/kg intravenous ketamine (intervention group) or no ketamine (control group). Serum CRP and NLR were measured preoperatively and at 8 and 24 hours postoperatively. The visual analog scale was used to evaluate pain level, data were processed with the appropriate statistical test, and a p-value < 0.05 is considered significant.
Results: Our study discovers that intravenous ketamine reduced postoperative inflammatory markers significantly. Postoperative measurements at 8 and 24 ours proved that the ketamine group had lower CRP and NLR levels significantly (p<0.05). Patients receiving ketamine showed a non-significant reduction in VAS pain scores compared with controls. No participant in either group needed additional opioids for pain control.
Conclusion: Intravenous ketamine decreased postoperative inflammatory response significantly in hysterectomy patients receiving epidural anesthesia, as proved by lower CRP and NLR.  Ketamine seemed to improve patient comfort by lowering pain intensity. Combining epidural anesthesia with ketamine may be a viable strategy to suppress inflammation and enhance recovery after hysterectomy.

Background: Managing intracranial pressure and brain swelling during supratentorial brain tumor surgery often involves hyperosmolar solutions like hypertonic saline and mannitol. However, using these solutions alongside hydroxyethyl starch (HES) could potentially affect blood clotting. This study aimed to compare the impact of hypertonic saline and mannitol, when combined with HES, on blood coagulation in patients undergoing these surgeries.

Materials and Methods: This clinical trial compared 20% mannitol and 3% hypertonic saline in patients undergoing brain tumor surgery. Patients were divided into two groups, each receiving one of these osmotic agents along with hydroxyethyl starch. The study focused on assessing any blood clotting abnormalities.

Results: The study included 30 patients (15 in each group). Their initial characteristics were similar. The study found no significant differences in blood coagulation tests between the groups. Additionally, osmolality levels and measures of brain tension were comparable in both groups. There were also no significant differences in intraoperative hemodynamic parameters.

Conclusion: Both hypertonic saline and mannitol, when used with HES, effectively manage intracranial pressure without significantly affecting blood clotting during supratentorial tumor surgeries. Further research is needed to refine fluid management strategies and minimize potential clotting risks in these procedures.

Background: Different studies investigated strategies to prevent perioperative bleeding in cardiac surgeries. The use of fibrinogen concentrate is one of these efforts. In this study, we will investigate the efficacy and proper dosage of fibrinogen concentrate as a prophylactic adjuvant for reducing postoperative bleeding in patients with normal blood fibrinogen under coronary artery bypass grafting (CABG) surgery.
Methods: Patients with preoperative normal plasma fibrinogen levels were randomly divided into two groups (15 patients in each). At the final stage of cardiac surgery and after reversal of heparin, the first group received 2gr of fibrinogen IV concentrate in 15 minutes, while the other group received the same volume of placebo. In each patient, postoperative haematocrit percentage, intraoperative and postoperative administered blood products, and postoperative drainage amount were collected.
Results: Although in the study group, the postoperative amount of plasma fibrinogen increased compared to preoperative and decreased in the control group, but this change was not statistically significant. Also there wasn’t any significant difference in terms of blood drainage and blood product consumption.
Conclusion: We did not find evidence of a significant difference in the change of fibrinogen blood level before and after the operation, the amount of drainage, and the consumption of blood products in the fibrinogen and placebo groups.

Background: COVID-19 patients requiring invasive mechanical ventilation represent the most severe cases with high mortality rates. This study aimed to analyze survival outcomes and identify prognostic factors in a cohort of invasive mechanically ventilated COVID-19 patients in Iran.
Methods: In this retrospective cohort study, we analyzed 639 adult COVID-19 patients who underwent invasive mechanical ventilation at Al-Zahra Hospital's ICUs in Isfahan. Survival analysis and Cox regression models were used to identify factors associated with mortality.
Results: Among 639 mechanically ventilated patients, mortality was 87.9%. The mean age was 63.01±16.4 years. 59.8% of participants were male. Hypertension (42.6%), diabetes (33.8%), and cardiovascular disease (25.0%) were the most prevalent comorbidities. The overall median survival time was 35 days. Cox regression analysis identified significant mortality predictors, including male sex (HR=3.489, 95% CI: 1.150-10.585), age (HR=1.064, 95% CI: 1.024-1.106), cardiovascular disease (HR=1.445, 95% CI: 1.096-1.905), higher APACHE IV score (HR=1.028, 95% CI: 1.005-1.051), and delayed mechanical ventilation after disease onset (HR=1.111, 95% CI: 1.031-1.196).
Conclusion: COVID-19 patients with invasive mechanical ventilation demonstrated high mortality rates. Older age, male sex, cardiovascular disease, higher APACHE IV score, and delayed mechanical ventilation after symptom onset were significant predictors of mortality. These findings highlight the importance of timely intervention in high-risk patients and may help optimize resource allocation during future pandemic waves.

Background: Pulmonary compliance measurement is a critical component of monitoring mechanically ventilated patients with respiratory failure. The traditional method calculates compliance by dividing delivered tidal volume by the resultant airway pressure (plateau pressure minus positive end-expiratory pressure [PEEP]). However, this approach requires intermittent ventilator disconnection, limiting its frequency. A novel method using multiple linear regression (MLR) analysis of continuous pressure and flow waveforms enables breath-to-breath compliance measurement without disrupting ventilation. This study compares pulmonary compliance values obtained by MLR and traditional methods.
Methods: In this clinical study, pulmonary compliance was measured and compared in consecutive mechanically ventilated patients using both traditional and MLR methods. MLR-derived compliance was obtained using the ventilator’s integrated monitoring function, while traditional compliance was calculated as tidal volume divided by (plateau pressure – PEEP).
Results: Among 200 enrolled patients, the two methods showed strong correlation (*r* = 0.9, *p* < 0.01). However, MLR-derived compliance values were consistently lower than those from the traditional method (44.74 ± 21.78 mL/cmH₂O vs. 57.95 ± 26.64 mL/cmH₂O, *p* < 0.01).
Conclusion: MLR is a reliable alternative for continuous pulmonary compliance monitoring, though its systematically lower values—likely reflecting dynamic rather than static compliance—may necessitate a correction factor. The method’s ability to provide breath-to-breath measurements offers significant clinical advantages over traditional intermittent assessments.

Background: Infection with multidrug-resistant Acinetobacter baumannii has a high mortality rate. Some studies support the use of combination therapy with rifampin and colistin in the treatment of resistant Acinetobacter baumannii, but there is concern about the liver toxicity of high doses of rifampin in critically ill patients. Critically ill patients are more susceptible to liver side effects of drugs. The present cross-sectional study seeks to investigate the hepatic safety of rifampicin at a 1200 mg daily dose in combination with colistin.
Methods: Following the acquisition of approval from the hospital's ethics committee, a cross-sectional study was conducted to assess the prevalence of hepatotoxicity associated with a daily dosage of 1200 mg of rifampicin. Patients who were treated with a rifampicin-colistin regimen and were admitted to the ICUs of Sina Hospital between April 2017 and February 2021 were identified for this study. Patients were screened for drug-related liver complications using the updated Roussel Uclaf Causality Assessment Method (RUCAM). Then the data was assessed using the SPSS software.
Results: 60 patients were included in this study with an average age of 51.76 years. 40 patients (66.66%) were male and 20 (33.33%) were female. The studied patients had a mean weight of 72.56 kg, and their average rifampicin dose (based on their body weight) was 17.03 mg/kg. Results of ANOVA and Chi-square tests indicated that the values of main hepatic parameters like baseline aspartate aminotransferase (AST) (with a mean and standard deviation (SD) of 84.27±68.30), baseline Alanine transaminase (ALT) (with a mean and SD of 86.27±75.25), and baseline total Bilirubin (TBIL) (with a mean and SD of 1.16±0.788) were significantly related to the occurrence of drug-induced hepatotoxicity (P≤0.001).
Conclusion: Critically ill patients take many drugs, some of which are categorized as hepatotoxic drugs and increase the risk of hepatic complications depending on the patient's underlying diseases. Results indicated that patients with elevated baselines of AST, ALT, and TBIL were more likely to suffer from drug-induced liver injury (DILI). It seems that a 1200 mg daily dose of rifampicin has a safe hepatic profile until meeting normal hepatic baseline requirements.

Background: Diabetes mellitus in subjects of coronary artery bypass grafting (CABG) surgery is associated with increased morbidity and mortality. Therefore, in recent years, glycemic monitoring and control have been the focus of clinical research. This study aimed to determine the impact of insulin glargine on the management of blood glucose during the perioperative period of on-pump coronary artery bypass graft in diabetic patients.
Methods: In a randomized clinical trial, 80 patients with type 2 diabetes, candidates for elective CABG with a cardiopulmonary pump, were randomly separated into two groups. The intervention group received 0.2 units/kg of insulin glargine 2 hours before induction of anesthesia plus usual care. The control group received usual care. Usual care included injection of regular insulin before, during, and after surgery in accordance with a changed Van den Berghe code. Blood glucose (BG) level, ICU and hospital length of stay (LOS), creatinine, white blood cell count (WBC), and postoperative complications, including infection and dehiscence, were evaluated between two groups.
Results: The BG of patients upon entrance (p=0.04), 16 (p=0.01), 20 (p=0.01), and 24 (p=0.01) hours after admission to the ICU was significantly lower in the intervention than in the control group. There was a significant difference in the average BG levels at different times (p<0.001), so the highest and lowest BG levels were observed 4 and 20 hours after ICU administration in the intervention group and 4 hours and immediately after ICU admission in the control group. Average creatinine (p=0.01), regular insulin used until the end of the first day after surgery (p=0.01), ICU length of stay (LOS) (p=0.009), and hospital LOS (p=0.001) were significantly lower in the intervention group than the controls.
Conclusion: Insulin glargine plus regular insulin is able to maintain BG at a controlled level up to 24 hours after surgery. It also showed significant control over postoperative complications. This study revealed the therapeutic effectiveness of both insulin glargine and regular insulin in achieving adequate BG control for type 2 diabetes patients during the critical postoperative period of on-pump CABG.

Background: Acute postoperative pain following modified radical mastectomy (MRM) remains a significant clinical problem, affecting patients’ quality of life. Opioid-based anesthesia (OBA), while effective for analgesia, is associated with adverse effects, including increased interleukin-6 (IL-6) levels, and the higher the IL-6 levels, the higher the likelihood of breast cancer recurrence. Opioid-free anesthesia (OFA) has emerged as a potential alternative to mitigate these effects. This study aimed to compare the impact of OBA and OFA on intraoperative hemodynamic stability, IL-6 levels, postoperative pain degree, and total postoperative opioid requirements.
Methods: This was a single-blind randomized clinical trial involving 30 patients undergoing MRM, allocated into two groups: Group I received OBA, and Group II received OFA. Parameters assessed included intraoperative hemodynamic changes, serum IL-6 levels, postoperative pain degree, and total postoperative opioid requirements.
Results: The OFA group had significantly lower IL-6 levels at 24 hours post-surgery. The OFA group also demonstrated more stable intraoperative hemodynamics, significantly lower postoperative pain degree, and reduced postoperative opioid (fentanyl) requirements compared to the OBA group.
Conclusion: OFA is better than OBA in modified radical mastectomy surgery. OFA significantly reduced IL-6 levels as a marker of inflammation, resulted in lower recurrence of breast cancer, reduced the degree of postoperative pain, maintained hemodynamic stability during the procedure, and reduced postoperative opioid requirements. These findings suggest that OFA is a more effective and safe anesthetic option in controlling pain and surgical stress response.

Background: The incidence of postoperative delirium (POD) in geriatric patients is aged 3-61%. The combined effects of inflammatory factors and depth of anesthesia can affect neurotransmitters and receptors in the central nervous system that affect POD. To analyze the relationship between depth of anesthesia and IL-6 with the incidence of POD in geriatric patients undergoing general anesthesia.
Methods: A prospective cohort study was conducted in geriatric patients undergoing general anesthesia. Patients were divided into two groups based on the bispectral index (BIS): BIS 40-45 and BIS 51-60. POD was measured using the Confusion Assessment Method (CAM) and Mini-Mental State Exam (MMSE) 24 hours postoperatively. Serum IL-6 measurements were also performed before and 24 hours postoperatively.
Results: A total of 22 patients were collected with the results that the MMSE score decreased insignificantly at 24 hours postoperatively, and there was no difference in MMSE scores based on BIS (p > 0.05). The depth of anesthesia was significantly associated with CAM (p < 0.05). Delirium incidence was more frequent in BIS 40-45. IL-6 levels increased significantly at 24 hours postoperatively (p < 0.05). IL-6 levels were not significantly associated with MMSE and CAM scores (p > 0.05).
Conclusion: BIS 40-45 has the potential to be a predictor of POD in geriatric patients with general anesthesia.

Background: Accurate assessment of volume status in cases with acutely decompensated heart failure (ADHF) is crucial for prognostication and management. While brain natriuretic peptide (pro-BNP) and echocardiographic inferior vena cava (IVC) diameter are commonly used surrogate markers, their combined prognostic value has not been thoroughly established.
Methods: This prospective cohort study included 100 adults with ADHF and reduced ejection fraction (EF <40%). Pro-BNP levels and IVC diameter were assessed on admission and after 72 hours. The primary outcome was in-hospital mortality; secondary outcomes included complications and 30-day cardiovascular mortality. Repeated measures ANOVA, ROC analysis, and correlation testing were performed to evaluate predictive value.
Results: In-hospital mortality occurred in 21% of cases. Pro-BNP levels were significantly higher in non-survivors both on admission (median: 11,542 pg/mL vs. 6,350 pg/mL, p<0.001) and after 72 hours (3,695 pg/mL vs. 3,029 pg/mL, p<0.001). Similarly, IVC diameter was significantly greater in the mortality group at both time points (2.85 cm vs. 2.2 cm on admission, p<0.001; 2.15 cm vs. 1.9 cm after 72 hours, p=0.004). ROC analysis revealed strong predictive power for in-hospital mortality with admission Pro-BNP >8,856 pg/mL (AUC=0.89) and IVC diameter >2.55 cm (AUC=0.81). A combined model incorporating both parameters at admission yielded the highest diagnostic accuracy (AUC=0.89; NPV=95.4%).
Conclusion: Pro-BNP and IVC diameter are independent yet complementary predictors of in-hospital mortality in ADHF. Combined early assessment significantly enhances risk stratification and may guide intensive monitoring and therapeutic strategies.

Background: The objective of this work had been to identify the minimum effective and safest dosage of intrathecal hyperbaric prilocaine 2% in combination with 25 µg of fentanyl necessary for day-case lower abdominal and urologic procedures.
Methods: This randomized, parallel-group, double-blind clinical study included 45 individuals, aged 65 to 80 years, of both sex, planned for elective day-case lower abdomen or urologic surgeries. Patients were randomly placed in three groups. All groups were administered 25 µg of fentanyl (0.5 mL) with intrathecal prilocaine 2%, with dosages of 30 mg (1.5 mL) for group P1, 40 mg (2 mL) for group P2, and 50 mg (2.5 mL) for group P3.
Results: The time length of motor blockage and complete regression of sensory block were considerably prolonged in group P3 contrasted to groups P1 and P2. Intraoperative SBP and MAP were substantially elevated at 15, 30, 45, and 60 minutes in group P1 contrasted to group P3. The length of stay in the post-anaesthesia care unit (PACU) was markedly reduced in groups P1 and P2 compared to P3. Hypotension and bradycardia exhibited no significant differences across all groups
Conclusion: In elderly individuals having lower abdominal and urologic surgery, a low dose of prilocaine combined with fentanyl yields a reduced duration of block and a shorter PACU stay, along with improved hemodynamic stability, compared to a higher dose of prilocaine with fentanyl.

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: Breast cancer can lead to pain and reduced comfort in individuals and affect their lives. Therefore, planning to maintain or improve the level of comfort and pain management in these patients with training focused on virtual reality seems necessary. Therefore, the present study aimed to investigate the effect of using virtual reality on pain and comfort in breast cancer patients undergoing chemotherapy in Zahedan.
Methods: This randomized clinical trial was conducted on 90 patients undergoing chemotherapy at Khatam Al-Anbiya Hospital in Zahedan. Participants were randomly assigned to two intervention groups (n=45) and control groups (n=45). The intervention group used Samsung Gear VR in the first 15 minutes of chemotherapy, while the control group did not receive any intervention. Data collection included the McGill Pain Questionnaire (MPQ) and the Hospital Comfort Questionnaire (HCQ), which were administered before and after chemotherapy. Data were analyzed using SPSS 21 software with paired and independent t-tests.
Results: The mean pain score in the intervention group decreased significantly after using VR (pre: 42.00 ± 12.99, post: 30.77 ± 11.6, p=0.0001), while no significant change was observed in the control group (p>0.05). Similarly, the comfort level in the VR group improved significantly compared to the control group (p<0.05).
Conclusion: The use of virtual reality significantly reduced pain and increased comfort in chemotherapy patients. Implementing VR as a non-pharmacological method in pain management protocols can improve the quality of life and treatment experience of cancer patients.

Background: Intrauterine adhesion (IUA) typically occurs as a result of intrauterine trauma associated with a surgical procedure. This study aimed to assess the prevalence and risk factors of postoperative adhesions following repeated cesarean sections.
Methods: In this registry-based study, data collection tools included a standardized registry checklist and the American Fertility Society (AFS) classification system for assessing IUA. The diagnosis of IUA was confirmed by an obstetrician-gynecologist, and the AFS scoring was performed by trained researchers responsible for completing the registry data. This study specifically focused on patients who were admitted to the Intensive Care Unit (ICU) of Ayatollah Taleghani Hospital in Ilam following their second cesarean delivery (CD). Within a defined timeframe, the incidence of IUA among these ICU-admitted patients was evaluated. The collected data were subsequently analyzed using SPSS statistical software.
Results: According to the findings, out of 121 hospitalized patients, 35 (28.92%) patients were diagnosed with IUA. Out of 35 patients, 15 (42.9%) patients were in Stage I (mild), 13 (37.1%) patients were in Stage II (moderate), and 7 (20%) patients were in Stage III (severe). also, there was no difference between any of the variables in Table 1 and the stage of adhesions (P>0.05).
Conclusion: Given that the rate of IUA has been significant, it is recommended that necessary preventive and therapeutic interventions be implemented to reduce its incidence, contributing factors, and related complications.

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: 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: 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.

Background: Postoperative cognitive dysfunction (POCD) is a relatively common and troubling issue, especially in older adults undergoing surgery. Bispectral index (BIS) monitoring enables anesthesiologists to assess anesthetic depth in real time and adjust dosing accordingly. In this article, we summarize the current evidence on BIS-guided anesthesia in reducing the incidence and severity of POCD in adult surgical patients.
Methods: A structured search was conducted in PubMed and Scopus databases to identify randomized controlled trials, observational studies, and meta-analyses published between 2000 and 2024.
Results: Clinical trials and meta-analyses suggest that BIS monitoring reduces anesthetic exposure, shortens recovery time, and is associated with lower POCD rates. Mechanisms may include optimized drug titration, improved hemodynamic control, and reduced neuroinflammation.
Conclusion: BIS monitoring may represent an effective approach to mitigate POCD, especially in high-risk patients. Further large-scale trials are needed to confirm these findings and refine guidelines.

Background: The presence of a difficult airway (DA) remains a major concern in anesthesia, contributing significantly to patient complications and adverse outcomes. Traditional clinical assessments often fall short in accurately predicting difficult intubation. With the advancement of artificial intelligence, machine learning (ML) has emerged as a promising approach for enhancing airway risk prediction. This systematic review aimed to evaluate current studies that utilize machine learning models for predicting difficult laryngoscopy and intubation and to assess the features, algorithms, and predictive performance of these models.
Methods: Following PRISMA guidelines, a comprehensive search was conducted in seven databases (PubMed, Scopus, Web of Science, Science Direct, Wiley, SID, and Google Scholar) to identify relevant original articles published between 2000 and July 2025. Studies using ML models to predict difficult intubation based on clinical, morphological, or acoustic features were included. A total of nine eligible studies were reviewed.
Results: Various ML algorithms, including KNN, SVM, Random Forest, XGBoost, and decision trees (J48), were applied across studies. Feature inputs ranged from traditional clinical parameters (e.g., Mallampati score, neck circumference) to advanced modalities such as voice analysis and facial image processing. Reported model performance (AUC) ranged from 0.71 to 0.924, indicating generally high predictive accuracy. Models incorporating non-traditional data (e.g., acoustic or imaging features) tended to perform better.
Conclusion: ML-based models show strong potential in improving the prediction of difficult airways and can serve as supportive tools in preoperative assessment. However, standardization of input features, external validation, and enhanced model interpretability are essential for successful clinical implementation.

Trauma to the brain or spinal cord is a type of injury that triggers a cascade of secondary pathophysiological events after the primary mechanical trauma. Neuroinflammation is indeed of foremost importance, acting both as a mediator for tissue repair and an instigator for progressive neurodegeneration. Activated microglia and astrocytes, peripherally derived immune cells infiltrating that site, mediate a complex interaction involving cytokines, oxidative stress, mitochondrial dysfunction, and neurovascular disruption. This early inflammatory signaling helps remove debris and support neuronal regeneration in traumatic brain injury (TBI) and spinal cord injury (SCI). However, when this particular inflammation becomes chronic, it leads to glial damage with aberrant synaptic connections and irreversible harm to neural network circuitry. Mediators, including IL-1β, TNF-α, and the NLRP3 inflammasome, have been identified as promising therapeutic targets; cutting-edge therapies, ranging from small-molecule inhibitors to mitochondrial stabilizers to cell-based interventions, have shown efficacy in preclinical models. Nonetheless, the translation to the clinic has been hindered through shortcomings in classical animal models, failure to integrate biomarker application, and an inability to account for the heterogeneity of human central nervous system (CNS) injury. To bridge this gap, temporally targeted immunomodulation, precision diagnostics, and systems-level approaches will need to align with the molecular pathology involved in disease intervention. Understanding this dual property within post-traumatic inflammation presents an important frontier to develop truly efficacious neuroprotective therapies.

This case report outlines a rare occurrence of accidental intrathecal injection of atracurium during spinal anesthesia for knee arthroscopy in a 22-year-old male patient. The solution intended to be bupivacaine mixed with fentanyl raised concerns after the ampule was discarded before verification. Fortunately, the patient showed no signs of paralysis or analgesia post-injection. The anesthesia team promptly administered high-dose methylprednisolone to reduce potential neurotoxic effects and monitored the patient closely in the Post-Anesthesia Care Unit. After six hours of stability and no neurological deficits, follow-up evaluations confirmed no lasting damage, allowing for safe discharge after 24 hours. This incident underscores the critical need for rigorous drug verification and safety protocols in anesthesia to prevent medication errors.

A 37-year-old male with no significant medical history presented to the hospital following a fall into a pit containing animal feces, resulting in aspiration pneumonia. He was intubated and treated with antibiotics, and after 15 days of hospitalization, he was discharged in stable condition. Four days later, he returned with scrotal pain and swelling, diagnosed as epididymitis, and successfully treated with ceftriaxone. On September 1st, he re-presented with headache, dizziness, and malaise, and imaging revealed a brain abscess. Despite undergoing stereotactic surgery, the patient experienced persistent neurological symptoms, including fluctuating consciousness, nausea, and vomiting. He subsequently developed hydrocephalus, necessitating the placement of an external ventricular drain and transfer to the ICU. The patient was treated with antifungal and antibiotic therapies, but his clinical condition deteriorated. Despite intensive care, he succumbed to his illness after 19 days in the ICU.

Posterior mediastinal masses pose challenges for anesthesiologists due to their compressive nature. The most frequently used surgical approach is thoracotomy and anesthesia involves awareness of potential complications and airway management strategies. Among different types of foreign bodies (FBs), the esophageal FBs are one of the most common pediatric emergencies among infants and young children and the proximal part is the most common site. Presentation can range from being asymptomatic to symptoms such as vomiting, dysphagia, and drooling, or respiratory issues like coughing, wheezing, choking, or stridor. In this report, we present a case of a posterior mediastinal mass in a child with a history of respiratory disorders and multiple treatment courses.

Lobectomy with one-lung ventilation presents significant anesthetic challenges, particularly in elderly patients with multiple comorbidities. This case report describes the successful anesthetic management of an elderly patient with adenocarcinoma lung undergoing right lower lobe lobectomy. An elderly male with adenocarcinoma of the right upper lobe presented for lobectomy. His complex medical history included chronic kidney disease requiring regular hemodialysis, post-stroke right-sided hemiparesis, hypertension, hypothyroidism, and diabetes mellitus. The anesthetic management involved careful preoperative optimization, use of a left-sided double-lumen tube for one-lung ventilation, and meticulous hemodynamic monitoring. Challenges encountered included a brief episode of hypoxemia during one-lung ventilation and hypertension, which were successfully managed with ventilator adjustments and dexmedetomidine infusion, respectively. The six-hour surgery was completed successfully with minimal blood loss. The patient was extubated postoperatively and maintained stable oxygenation on supplemental oxygen. Pain management was achieved through multimodal analgesia, including a fentanyl patch. This case illustrates that complex thoracic surgery can be safely conducted in high-risk patients through comprehensive preoperative evaluation, careful intraoperative management, and adherence to enhanced recovery protocols. The successful outcome emphasizes the importance of a multidisciplinary approach in managing such challenging cases.

Pan facial trauma, involving multiple fractures of the facial bones, presents significant challenges in anaesthetic management. These injuries often result from high-impact accidents and can lead to airway compromise, making intubation and ventilation difficult. The anaesthesiologist must navigate potential obstacles such as facial distortion, bleeding, and limited mouth opening, all while maintaining cervical spine precautions. The management of these cases requires a thorough preoperative assessment, careful planning, and often necessitates advanced airway techniques. This case report describes the anaesthetic management of a 50-year-old male patient with pan facial trauma scheduled for reconstructive surgery. It highlights the use of CMAC video laryngoscopy intubation as a safe and effective technique in securing the airway in a patient with anticipated difficult intubation. The report also discusses the rationale behind the anaesthetic choices made and the perioperative challenges encountered. By sharing this experience, we aim to contribute to the existing body of knowledge on managing complex airway scenarios in trauma patients and emphasize the importance of individualized anaesthetic planning in such cases.

Cerebral salt wasting syndrome (CSWS) is a cause of hyponatremia in patients with brain injury, but it often improves in a short time. In this article, a patient with prolonged CSWS after craniotomy for subdural hematoma (SDH) and intracranial hemorrhage (ICH) is presented. A 73-year-old woman was transferred to the ICU due to a decreased level of consciousness (GCS= 9) with a diagnosis of SDH and ICH. The patient had a history of atrial fibrillation. The pupils were mid-sized and reactive. BP= 130/90 mm/Hg, HR=80/min, T=37.3, and initial tests were HB=12.7 gr/dl, Bun=12, Cr=0.7, Na=138 Meq/lit, K=4meq/lit, Ptt=25 Sec, INR=1.1, ESR=10. The patient was intubated 48 hours later due to a decreased level of consciousness and underwent craniotomy and hematoma drainage. From the 4th day after the operation, the patient developed hyponatremia and polyuria, but despite the administration of hypertonic sodium and normal saline, the hyponatremia persisted. On the 8th day after the operation, fludrocortisone was started, one tablet twice a day, and the patient showed a partial response to the treatment after one week, but the hyponatremia was corrected after 2 weeks. CSWS is more common and prolonged in severe and multiple brain injuries, and in these cases, the administration of fludrocortisone in addition to normal sodium and hypertonic sodium is helpful.

Diabetic ketoacidosis (DKA) may become life-threatening when accompanied by acute pancreatitis, sepsis, and acute respiratory distress syndrome (ARDS), resulting in a cascade of inflammation and multi-organ dysfunction. We describe a 70-year-old male with severe DKA complicated by septic shock, ARDS, and multi-organ failure, who required individualized, precision-based fluid therapy. Aggressive but closely titrated resuscitation, guided by dynamic clinical markers, together with early initiation of Continuous Renal Replacement Therapy (CRRT), achieved stabilization. This case highlights the value of adaptive fluid management and timely CRRT in critically ill patients with complex DKA.

Glucose homeostasis disturbance is a common complication among patients in intensive care units (ICUs), frequently resulting in stress-induced dysglycemia. Individuals with diabetes mellitus (DM) are particularly susceptible to hyperglycemia and face a higher risk of severe hypoglycemia due to overtreatment. Particularly for patients on insulin or glucose-lowering drugs, it is crucial to maintain regular meal patterns in terms of timing, food type, and quantity. The 63-year-old female patient in this case study was referred from the neurology department after experiencing diminished awareness and going two days without eating. She had experienced multiple seizures lasting more than five minutes and presented with a nasogastric tube (NGT) insertion showing 150 mL of greenish gastric residual. The patient reported reduced intake over the past week due to nausea and headaches, occasional vomiting, intermittent fever, and a weight loss of 2.2 kg (4.8%) within one week. Medical nutrition therapy (MNT) was initiated to ensure adequate nutrient intake through enteral and parenteral routes, followed by a gradual transition to oral feeding. This approach aimed to improve the patient’s nutritional and metabolic status through personalized and adequate nutritional care. The patient's clinical condition was managed concurrently, with continuous monitoring of intake, anthropometry, and laboratory parameters to evaluate the intervention’s effectiveness. This case highlights that proper medical nutrition therapy for critically ill patients with metabolic encephalopathy, diabetes mellitus, cerebral infarction, and status epilepticus complicated by severe protein-energy malnutrition can lead to significant improvements in clinical outcomes.

Bilateral adrenalectomy, in the event of elective surgery, poses problems for an anesthetic manager due to hemodynamic instability, glucocorticoid replacement dependency, adrenal insufficiency, or a whole series of their associated endocrine disorders, one of which is hypothyroidism. This case report deals primarily with the perioperative considerations and management of the patient with Cushing's syndrome, who was planned for elective rhinoplasty following bilateral adrenalectomy. A 33-year-old woman who underwent bilateral adrenalectomy in childhood due to Cushing's syndrome came for elective rhinoplasty to correct post-traumatic nasal septal deviation. The preoperative workup revealed severe hair loss, dry skin, symptoms of orthostatic hypotension, and a systolic blood pressure reading consistently below 80 mmHg. Laboratory investigations gave evidence of elevated TSH (18.9 mIU/L), suggestive of hypothyroidism. Therefore, she was referred to an endocrinologist, and treatment with levothyroxine and fludrocortisone was initiated. An improvement in thyroid function was established a month later (TSH: 1.9 mIU/L), and hypotension was controlled. Surgery was scheduled after getting approval from the anesthesiology team and a detailed risk discussion with an informed patient consenting to proceed. During surgery, constant monitoring of the patient's vitals was carried out. Everything went on very well, and the patient was discharged, stable. Among challenging patients such as those with adrenal insufficiency, careful preoperative evaluation, hormone imbalance correction, and proper steroid supplementation play a vital role in avoiding adrenal crisis states during or after surgery. Effective teamwork is achieved between anesthesiologists, endocrinologists, and surgeons in endeavoring to make a surgical outcome safe and successful.

In certain patients, particularly those receiving mechanical aortic valve replacement, warfarin is the sole permitted anticoagulant. Some individuals exhibit resistance to warfarin for a variety of reasons, necessitating extremely high and occasionally fatal doses of the medication for their survival. This report details a patient who demonstrates warfarin resistance and investigates the fundamental causes of this phenomenon. The case report emphasizes the possible role of genetic polymorphism in elucidating the mechanisms behind warfarin resistance.

Acute ST-segment elevation myocardial infarction (STEMI) complicated by cardiac arrest presents a major clinical challenge, especially in resource-limited settings without immediate access to percutaneous coronary intervention (PCI). We report a 37-year-old man with anterior STEMI who suffered prolonged ventricular fibrillation cardiac arrest. After 20 minutes of high-quality CPR and failed thrombolysis at a rural hospital, he was urgently transferred 250 km to a PCI-capable center. Emergent coronary angiography revealed complete proximal left anterior descending artery occlusion, treated successfully with thrombus aspiration and stenting. Comprehensive intensive care, including early antibiotics for aspiration pneumonia, meticulous hemodynamic management, and multidisciplinary rehabilitation, resulted in full neurological recovery. The patient was discharged hemodynamically stable with improving left ventricular function and remained asymptomatic at two-week follow-up. This case underscores the importance of organized regional care networks, adherence to advanced cardiac life support protocols, timely recognition of thrombolysis failure, and prompt transfer for PCI in achieving favorable outcomes in STEMI patients with cardiac arrest. Systems enabling rapid interhospital coordination can significantly improve survival and neurological outcomes, even in geographically isolated settings.

This case report describes the anesthetic management of a 27-year-old man with hypermobile Ehlers-Danlos syndrome (hEDS) who underwent scleral buckling surgery for retinal detachment. The patient who had joint hypermobility and mild mitral valve prolapse required careful anesthetic management. The surgery, which was performed under general anesthesia with a laryngeal mask airway and EDS-tailored monitoring, was uneventfully accomplished in 85 minutes. The patient was discharged the next day, recovering well, emphasizing the importance of careful preoperative evaluation, correct positioning, and multidisciplinary care for patients with hEDS undergoing complex ophthalmic surgery.

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.

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.