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

Background: With advancements in medical technology, surgery has become a primary therapeutic option for numerous diseases. A successful surgical procedure requires proper anesthesia and accurate monitoring of vital signs, particularly blood pressure and arterial oxygen saturation. In the lateral decubitus position (LDP), hydrostatic forces may cause differences in blood pressure between the dependent and non-dependent limbs. This study aims to investigate non-invasive blood pressure (NiBP) and arterial oxygen saturation positional differences between dependent and non-dependent limbs.
Methods: 17 males and 22 females undergoing nephrectomy with convenience sampling, aged 18–70 years, with ASA physical status I or II were selected. Patients with peripheral vascular disease, cardiac disorders (e.g., atrial fibrillation, coarctation), inability to measure BP in one arm, significant preoperative BP asymmetry, uncontrolled hypertension, and refusal to participate were excluded. Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), and Arterial Oxygen Saturation (SpO₂) were pre-specified and were consistently measured using non-invasive monitors.
Results: A significant difference was observed in systolic, diastolic, and mean arterial pressures between the two arms following the lateral positioning (p < 0.001). However, oxygen saturation levels did not differ before and after positioning.
Conclusion: The findings indicate a significant variation in blood pressure between dependent and non-dependent limbs in LDP, but no change in oxygen saturation. This emphasizes the importance of choosing the correct arm for accurate blood pressure measurement and hemodynamic management.

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

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

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

Background: Burn patients present unique anesthetic challenges: massive fluid shifts, airway edema, and hypermetabolism that demand rapid, evidence-based management. Although web-based learning can deliver standardized, on-demand education, anesthesia technologists rarely have access to rigorously developed burn-specific resources. To design, implement, and evaluate the usability and short-term educational impact of a web-based burn-anesthesia program for practicing anesthesia technologists.
Methods: We conducted a four-phase mixed-methods study (September 2023 – April 2025). Phase 1 mapped required content through a scoping review (2014–2024) and a two-round Delphi survey of 15 experts. Phase 2 converted the validated content into a conceptual model and low-fidelity prototype, iteratively refined by two focus groups. Phase 3 produced the final application using a Python/Django back-end, a React front-end, and a PostgreSQL database. Phase 4 assessed real-world use over four weeks by 45 technologists at two Iranian teaching hospitals. Outcomes included the 27-item Questionnaire for User Interaction Satisfaction (QUIS; 0–9) and 20-item pre/post knowledge tests, analyzed with paired t-tests (α = 0.05).
Results: Forty-eight learning objects spanning eight modules (airway, fluid therapy, analgesia, pharmacology, burn pathophysiology, monitoring, nutrition, and postoperative care) met Delphi validity thresholds. The mean overall QUIS was 7.12 ± 0.78 (“good”), with subdomain means of 7.25 (overall reaction), 7.09 (screen design), 7.07 (terminology), 7.18 (learnability), and 7.00 (system capabilities). Knowledge increased from 63.4 ± 9.2 to 83.1 ± 7.6 (Δ = 19.7 ± 8.5 points; t = 14.2; p < 0.001; Cohen’s d = 2.29). No serious technical issues arose; the median weekly log-ins per user was four.
Conclusion: A systematically developed, user-centered web curriculum produced high usability scores and substantial knowledge gains among anesthesia technologists. The model offers a scalable solution for closing critical educational gaps in burn anesthesia, particularly where formal training is limited. Future research should examine long-term retention, effects on clinical performance, and patient outcomes.

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

Background: Intradialytic hypotension (IDH) is a common and serious complication of intermittent hemodialysis (IHD) in critically ill patients with acute kidney injury (AKI). Accurate pre-dialysis risk stratification remains a challenge, particularly in the ICU. This study aims to determine whether ultrasound-based cardiopulmonary profiles could predict IDH in this high-risk population.
Methods: This prospective cohort study included 100 critically ill adults undergoing IHD for AKI. All patients underwent pre-dialysis echocardiography and lung/inferior vena cava (IVC) ultrasound to assess stroke volume, cardiac output, B-lines, and IVC collapsibility index (IVC-CI). Patients were divided into two groups based on the presence or absence of IDH.
Results: IDH occurred in 35% of patients. Significant predictors of IDH included lower systolic blood pressure (124.86 ±16.02 vs. 139.92 ±22.8 mmHg, P < 0.001), higher IVC-CI [51% (13–58) vs. 27.38% (13–60), P < 0.001], sepsis (88.6% vs. 70.8%, P = 0.044), and elevated potassium (5.17 ±1.34 vs. 4.62 ±0.87 mmol/L, P = 0.015). Multivariate analysis identified IVC-CI (OR = 1.097, P < 0.001) and SBP (OR = 0.942, P = 0.001) as independent predictors. IVC-CI >49.5% predicted IDH with 68.6% sensitivity and 87.7% specificity (AUC = 0.757, 95% CI: 0.652–0.862).
Conclusion: Ultrasound-derived IVC-CI is a valuable, noninvasive tool for predicting IDH in critically ill patients receiving IHD. Incorporating sonographic profiles into routine pre-dialysis evaluation may enhance risk stratification and improve dialysis safety.

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

Background: This study aimed to compare the combination of intravenous ibuprofen and intravenous paracetamol versus combined diclofenac suppository and intravenous paracetamol for pain control after tonsillectomy or adenotonsillectomy in children.
Methods: This is a randomized controlled study involving 90 children aged between 1 and 7 years, classified as ASA I or II, scheduled to undergo tonsillectomy or adenotonsillectomy between February 2023 and February 2024 at Cairo University Hospitals.
Results: There was a statistically significant difference regarding FLACC score between the two groups (p=0.006) at 10 min after arrival to PACU, while it was not significantly different between the two groups on arrival or discharge from PACU (p=0.054 and 0.208, respectively). There was no statistically significant difference in PPPM between the two groups at 4, 12, and 24 hours postoperative (p=0.718, 0.470, and 0.738, respectively). Regarding the number of patients who received rescue analgesia (pethidine), they were fewer in group A (p=0.031), and the mean dose of pethidine received/kg as rescue analgesia was also significantly lower in group A (p=0.0316). The incidence of postoperative adverse events, i.e., nausea, vomiting, hypotension (low SBP = <70 + 2 (age in years)), bradycardia (less than 60 beats/min), drug allergic reaction, and postoperative bleeding requiring return to the operative room, was zero in the two groups.
Conclusion: The combination of intravenous ibuprofen and intravenous paracetamol was a more effective analgesic regimen than the combined rectal diclofenac and intravenous paracetamol in pediatric patients undergoing tonsillectomy or adenotonsillectomy without increased complications.

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: Optimal sizing of endotracheal tubes (ETTs) in pediatric patients may lead to repeated laryngoscopies, intubations, and ETT exchanges. The subglottis is functionally the narrowest part of the pediatric airway and is prone to edema, tracheal lumen narrowing, and post-extubation stridor due to repeated airway manipulations. Objectives: To compare the proportion of infants up to 3 months of age who require ETT exchanges and who develop postoperative respiratory adverse events (PRAEs) following intubation with Microcuff versus uncuffed ETTs.
Methods: This prospective randomized study included 100 patients up to 3 months of age. They were randomized into two groups of 50 each: Gp M: intubated with microcuff ETT. Gp U: intubated with uncuffed ETT. A leak test was done after intubation. In Gp U, excessive leak at 10 cm of water pressure required a 0.5-size bigger ETT. A minimal leak at 10-20 cm of water was acceptable. No leak at 20 cm of water required downsizing ETT by 0.5. In Gp M, the cuff was inflated until minimal leak at 10-20 cm of water. No leak with the deflated cuff at 20 cm of water warranted exchange with an uncuffed ETT of size 3.0.
Results: In Gp U, 12/50 (24%) patients underwent tube exchanges, and 6/50 (12%) had post-extubation stridor. In group M, 4/50 (8%) patients required tube exchange to size 3.0 uncuffed ETT, and one patient (2%) had post-extubation stridor.
Conclusion: Microcuff ETTs have a lesser incidence of tube exchange and post-extubation stridor as compared to uncuffed ETTs in infants up to three months of age.

Background: Stewart's method of acid-base analysis involves analyzing the strong ion difference in the blood. The anion gap (AG), strong ion difference (SID), and strong ion gap (SIG) not only assist in diagnosing underlying acid-base disturbances but also serve as prognostic markers. This study aimed to analyze Stewart's approach in patients with cirrhosis.
Methods: Acid-base parameters of forty-eight cirrhosis patients requiring intensive care were prospectively studied. The primary objective of this study was to evaluate the prognostic value of SIG. The secondary objective was to examine the correlation between acid-base parameters, such as lactate, base excess of arterial blood gas analysis (ABG-BE), base excess of unmeasured anions [BE (UA)], AG, SID, and SIG.
Results: The median SIG was 4.1 (IQR: 2.5 - 5.6). The median albumin-corrected AG (acAG) level was 15 (IQR, 14–20). The median BE (UA) was -4.2 (IQR: -7.1, 1.7). Apparent SID and BE (UA) demonstrated a strong correlation (r = 0.92; p < 0.001). Effective SID was strongly correlated with ABG-BE (r = 0.83, p < 0.001). SIG and acAG showed a strong correlation with an r value of 0.94 (p < 0.001). An ICU stay of more than 8 days was considered prolonged (75th percentile). ABG-BE, SIG, and acAG on admission day effectively predicted prolonged ICU stay, with AUCs of 0.73, 0.75, and 0.78, respectively.
Conclusion: SIG effectively predicts prolonged ICU stay with good predictive ability. However, the anion gap, when corrected for albumin, is better than SIG in terms of predictive accuracy, requiring fewer variables and offering greater ease of use.

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

Background: The 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: Cataract surgery requires proper sedation level and immobilization of the patient. This research sought to evaluate the impact of sublingual fentanyl versus sub-dissociative dose ketamine in achieving optimal conditions in cataract surgery.
Methods: 90 participants were randomly assigned to two cohorts: sublingual fentanyl (SLF) or intravenous sub-dissociative dosage ketamine (SDK). In the SLF cohorts, fentanyl was administered sublingually at a dosage of 1.5 μg/kg and in the second cohort (SDK), ketamine was given intravenously with a dosage of 0.3 mg/kg. In both study cohorts, propofol was administered intravenously at a dosage of 0.4 mg/kg, followed by intermittent boluses of 0.1 mg/kg at 30-second intervals until desired level 4 sedation, according to the Ramsey Sedation Scale (RSS). The quality of sedation, hemodynamic parameters, patient and surgeon satisfaction, and complications were determined and compared between cohorts.
Results: No notable disparency was found among the SLF and SDK cohorts regarding the quality of sedation during the operation and recovery (p > 0.05). The SDK cohort demonstrated superior pain control in comparison to the SLF cohort (p = 0.009) and required significantly less propofol (p = 0.047). Hemodynamic stability, including systolic (p<0.05) and diastolic (p<0.05) blood pressure, mean arterial pressure (p<0.05), and heart rate (p=0.02), was significantly better in the SDK cohort. However, no notable disparency were observed in SpO2 levels among the two cohorts (p>0.05). In the SDK cohort, both patient and surgeon satisfaction were found to be greater. (p=0.009 and p=0.048, respectively). Four participants in the SLF cohort and two in the SDK cohort experienced adverse events during surgery. However, during recovery, ten participants in the SDK cohort had complications, while none of the participants in the SLF cohort exhibited adverse reactions.
Conclusion: The findings of this research suggest that SDK is a superior option for attaining optimal sedation, analgesia, and overall satisfaction for both patients and surgeons in the context of cataract surgery, particularly in comparison to SLF.

Background: Effective postoperative pain management after cesarean section enhances maternal recovery, facilitates early newborn care, and reduces postoperative complications. Due to the limitations and adverse effects of neuraxial opioids, non-opioid adjuvants have become an attractive alternative. This study compared the analgesic efficacy of dexmedetomidine and low-dose neostigmine as adjuvants to bupivacaine in spinal anesthesia for cesarean delivery.
Methods: In this double-blind randomized clinical trial, 110 women undergoing elective cesarean were randomly allocated to receive either dexmedetomidine plus bupivacaine (Group D) or neostigmine plus bupivacaine (Group N). Demographic and intraoperative data were recorded. Sensory and motor block characteristics, postoperative pain intensity (VAS scores at 2, 4, 8, and 12 hours), time to first analgesic request, total 24-hour analgesic consumption, sedation levels, muscle relaxation quality, Apgar scores, and side effects (nausea, vomiting, shivering, pruritus) were assessed.
Results: Baseline characteristics, sedation scores, muscle relaxation quality, and neonatal outcomes were comparable between groups. The onset of sensory and motor block was significantly faster in the neostigmine group, whereas their regression was markedly prolonged in the dexmedetomidine group (P<0.001). Pain scores were consistently lower, the first analgesic request was delayed, and total analgesic use was reduced in Group D (P<0.001). Nausea and vomiting occurred more frequently in Group N (P=0.007).
Conclusion: Dexmedetomidine as an intrathecal adjuvant to bupivacaine provides superior and longer-lasting analgesia with fewer gastrointestinal side effects than neostigmine in cesarean sections under spinal anesthesia.

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: Tracheostomy is a critical procedure for airway management in mechanically ventilated patients, yet its biological impact on systemic inflammation remains unclear. Procalcitonin (PCT), a biomarker of bacterial infection and inflammatory activity, provides valuable insight into infection dynamics in critically ill patients. This study sought to examine fluctuations in serum PCT levels before and after tracheostomy in ICU patients to evaluate inflammatory responses and potential advantages in infection management.
Methods: Between January and July 2025, a prospective cohort study was done in three tertiary ICUs in Makassar, Indonesia. Twenty adult patients need extended mechanical ventilation received tracheostomy. We checked serum PCT levels four times: one day before the tracheostomy (H−1) and on days 3, 5, and 7 after the surgery. We used the Friedman and Least Significant Difference (LSD) tests to look at the data. The cutoff for significance was p < 0.05.
Results: The average PCT levels dropped dramatically from 13.52 ± 22.86 ng/mL (H−1) to 6.64 ± 14.13 ng/mL (H+3; p = 0.048). They then progressively went back up on days 5 and 7. Younger patients (under 50 years old) and those who were intubated for a shorter duration (7 days or fewer) showed better PCT patterns, which implies that there was less inflammation after early tracheostomy.
Conclusion: Tracheostomy was associated with a transient reduction in systemic inflammation, seen by decreased PCT levels by the third day post-procedure. The later rise in PCT suggests possible secondary infection or inflammatory rebound. Early tracheostomy and serial PCT monitoring are recommended to enhance infection control and optimize ICU outcomes.

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: Shivering is a common and distressing complication of spinal anesthesia for cesarean section. While intrathecal meperidine is an effective prophylactic agent, its side effect profile prompts the search for alternatives. Intravenous acetaminophen has been proposed as a potential option due to its central antipyretic effect, but its efficacy compared to meperidine remains unclear. This study aimed to compare the efficacy and safety of prophylactic intrathecal meperidine versus intravenous acetaminophen for preventing shivering during cesarean section under spinal anesthesia.
Methods: In this triple-blind randomized controlled trial, 151 parturient (ASA II) scheduled for elective cesarean section under spinal anesthesia were allocated to three groups: 1) PARA group (n=49): received 1 g IV acetaminophen; 2) MEP-IT group (n=49): received 0.1 mg/kg intrathecal meperidine; 3) Control group (n=51): received placebo. The primary outcome was the incidence of clinically significant shivering (Grade ≥2). Secondary outcomes included shivering onset time, hemodynamic parameters, and adverse effects.
Results: The incidence of shivering was significantly lower in the MEP-IT group (24.5%) compared to both the PARA and control groups (49% each; P<0.0001). Shivering onset occurred significantly earlier in the PARA group (median: 5 minutes) than in the MEP-IT and control groups (median: 45 minutes; P<0.001). The PARA group exhibited a pronounced and sustained reduction in mean arterial pressure (MAP) and required vasopressor support more frequently (43%) than the control group (19%).
Conclusion: Intrathecal meperidine is highly effective for shivering prophylaxis. Our study showed that although intrathecal meperidine is more effective than intravenous pracetamol in preventing shivering after spinal anesthesia, paracetamol not only has no preventive effect compared to the control group, but also has higher hypotension and calls for additional studies.

Background: Post spinal anesthesia shivering (PSAS) remains a common and distressing complication during cesarean delivery, with potential metabolic and cardiovascular consequences for parturients. Although several pharmacological strategies have been proposed for its prevention, the optimal prophylactic regimen with minimal adverse effects is still under investigation.

This study aimed to evaluate the effectiveness of dexamethasone, alone or in combination with meperidine, in preventing post spinal anesthesia shivering in patients undergoing cesarean section.
Methods: In this randomized double-blind trial, 144 parturients undergoing cesarean section under spinal anesthesia were assigned to receive intravenous dexamethasone 4 mg (n=50), dexamethasone 6 mg (n=43), or saline placebo (n=51). Shivering was graded on a validated four-point scale. The primary outcome was shivering intensity, while shivering incidence, hemodynamic parameters, adverse events, pethidine requirements, and patient satisfaction were considered secondary outcomes. Sample size was calculated based on a prior effect size with a power of 80% and a significance level of 0.05.
Results: Shivering incidence was 70% in the dexamethasone 4 mg group, 53.5% in the 6 mg group, and 49% in controls (DEXA-4 vs control: OR=2.41, 95% CI: 1.10–5.31; DEXA-6 vs control: OR=1.20, 95% CI: 0.55–2.63) (p=0.083). Shivering intensity was significantly lower in both dexamethasone groups compared with the control (p=0.001). Time to shivering onset and need for pethidine were also reduced in the dexamethasone groups (p=0.010 and p=0.017, respectively). Hemodynamic profiles and adverse event rates did not differ significantly among groups.
Conclusion: The findings suggest that dexamethasone, particularly when used as an adjunct to low dose meperidine, may provide effective prophylaxis against PSAS while potentially reducing opioid related side effects. This approach represents a practical and well tolerated strategy for shivering prevention during cesarean delivery under spinal anesthesia.

Background: Intraoperative handovers, the transfer of patient care between anesthesia providers, are common in the operating room and represent a critical juncture for communication failures. Ineffective handovers are associated with the loss of essential clinical information and an increased risk of adverse postoperative outcomes. This systematic review aimed to synthesize the existing evidence regarding the impact of structured intraoperative handovers on patient safety, communication quality, and continuity of care.
Methods: This systematic review was conducted according to the PRISMA guidelines. The study evaluated 17 published research studies (2000–2025) investigating structured intraoperative anesthesia handovers, including the utilization of checklists, SBAR (Situation-Background-Assessment-Recommendation), I-PASS, and cognitive aids. Data extraction focused on patient safety outcomes, communication quality, and the continuity of care.
Results: The findings demonstrate that non-standardized handovers commonly result in information loss and variability in clinical practice, thereby potentially compromising patient safety. In contrast, the use of standardized handover tools reliably promotes information transmission, bolsters team collaboration, and minimizes variability in patient-transfer procedures. Moreover, available data suggest that implementing structured intraoperative handovers is associated with reductions in postoperative morbidity, although study findings are heterogeneous.
Conclusion: Structured intraoperative handovers are a viable and economical technique to improve communication and patient safety under anesthesia. Standardization and targeted education may further optimize the outcomes. Future research should identify the optimal handover components, evaluate their long-term clinical impact, and guide the development of international implementation strategies.

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.

Mucopolysaccharidoses (MPS) refer to a group of disorders classified as congenital metabolic defects, characterized by airway management challenges because of facial deformities, macroglossia, short neck, hypertrophic tonsils and adenoids, kyphoscoliosis, an immobile jaw, narrowed nasal passages, and atlantoaxial instability. In this report, we present a case of successful management of a difficult airway in a pediatric patient with MPS.

Military personnel face a heightened risk of suicide due to firearm accessibility. Bullet impacts can cause significant tissue damage and bleeding, which varies depending on the affected area. This report details a case of a 20-year-old Iranian Baluch soldier who was admitted to the emergency room with hemorrhagic shock after suicide with a firearm. The bullet damaged his mandible, tongue, and maxilla, exited from his forehead, and damaged his nose. In hemorrhagic shock, prioritize blood products over isotonic fluids; consider norepinephrine if hemodynamics remain unstable.

Spontaneous intracerebral hemorrhage (ICH) with intraventricular extension (IVH) is a life-threatening condition associated with high rates of morbidity and mortality. Current management is primarily supportive, with few pharmacologic options available to optimize cerebral perfusion. Milrinone, a phosphodiesterase-3 (PDE-3) inhibitor commonly used in cardiology to boost cardiac output and stabilize hemodynamics, has rarely been explored in neurocritical care. We describe a 70-year-old man with hypertension who experienced a sudden collapse and left-sided paralysis. Imaging revealed a large hemorrhage affecting the right thalamus and basal ganglia with extension into the ventricles. Despite standard interventions, his neurological condition deteriorated. Intravenous milrinone was initiated as a salvage therapy to support mean arterial pressure (MAP) and preserve cerebral perfusion pressure (CPP). Following treatment, his hemodynamics stabilized, intracranial pressure remained controlled, and neurological function improved. At discharge, he had a Glasgow Coma Scale (GCS) of 14, and follow-up imaging confirmed complete resolution of the clot. This case highlights the potential of milrinone to support both systemic and cerebral hemodynamics in patients with ICH/IVH, demonstrating its combined cardiac and neuroprotective effects. To our knowledge, this is among the first documented uses of intravenous milrinone in spontaneous hemorrhagic stroke, suggesting a promising new application for PDE-3 inhibition in critical care beyond traditional cardiology.

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.

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

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.

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.

Epidural steroid injection is an effective method for controlling spinal radicular pain. However, in elderly patients with a history of lumbar fusion surgery, anatomical changes can lead to complications such as headache, nausea, and vomiting after the injection. In this report, two patients, 70 and 75 years old, with a history of multilevel lumbar fusion surgery who developed these complications after epidural injection are presented. Conservative treatment, including furosemide and 3% hypertonic saline, was associated with complete improvement of symptoms.

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.

Kearns-Sayre Syndrome (KSS) is a rare mitochondrial cytopathy caused by large deletions in mitochondrial DNA, leading to impaired energy production in cells. It has an estimated incidence of 1 to 3 cases per 100,000 population. KSS has no racial or sex predilection. The significant concerns for an anesthesiologist associated with this syndrome are multi-system involvement, including cardiac conduction defects, endocrinopathies, sensorineural deafness, and neurological dysfunction. These manifestations make it challenging for the anesthesiologist. These concerns significantly influence the choice of anesthesia given to the patient, particularly regarding the selection of neuromuscular blockers and their effects on patients with this syndrome compared to those in the general population. Anesthetic management of Kearns-Sayre syndrome patients requires careful preoperative assessment of cardiac, neurological, and metabolic status due to risks of heart block, malignant hyperthermia, respiratory muscle weakness, and lactic acidosis. Also, intraoperative and postoperative vigilance is necessary to prevent any adverse events. We report a 48-year-old female, a known case of Kearns-Sayre Syndrome, scheduled for hysteroscopic polypectomy. This case highlights the importance of detailed preoperative evaluation and tailoring the anesthetic technique to minimize mitochondrial stress.

Double aortic arch (DAA) is a rare congenital vascular anomaly that forms a complete vascular ring encircling the trachea and esophagus, potentially leading to respiratory and feeding difficulties. We present a case of a 15-month-old male with an incomplete cleft palate who had an incidental finding of codominant double arch of aorta on preoperative imaging. The child underwent successful cleft palate surgery under general anesthesia with appropriate airway precautions and multidisciplinary planning. This report highlights the anesthetic implications of vascular rings and the need for thorough preoperative assessment in children presenting with non-specific symptoms like recurrent upper respiratory tract infections (URTI) and feeding intolerance.

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

Myasthenia gravis (MG) is an autoimmune disorder affecting the neuromuscular junction. This condition is often associated with respiratory and bulbar muscles and increases the risk of aspiration and respiratory failure. Studies have shown that respiratory issues, such as pneumonia, may lead to higher morbidity and mortality. A 54-year-old woman was admitted to an intensive care unit (ICU) due to myasthenic crisis triggered by pneumonia. Her condition was complicated by progressive dyspnea, dysphagia, recurrent choking, and cough. After admission, she exhibited respiratory issues (a PF ratio = 265) while receiving high-flow nasal cannula (HFNC) support, and elevated procalcitonin levels. Because the ROX index keeps declining, she decided to undergo elective intubation and received mechanical ventilation. The treatment was initially administered using pressure-controlled settings, followed by an adaptive support mode. Sputum culture identified Acinetobacter baumannii and Streptococcus pneumoniae, which were sensitive to cefoperazone–sulbactam. After 14 days of the regimen, there was a gradual clinical improvement and a decrease in procalcitonin levels. The patient also received pyridostigmine dosing, intravenous methylprednisolone, plasma exchange, and enteral nutrition. Due to prolonged ventilator dependence, a percutaneous dilatational tracheostomy was performed, facilitating successful weaning and transfer to a lower-care unit. This case highlights the importance of early recognition of HFNC failure, timely transition to invasive ventilation, and integrated multidisciplinary management (immunologic, antimicrobial, ventilatory, and nutritional strategies) in patients with myasthenic crisis complicated by pneumonia.

Occipital meningoencephalocele is a rare neural tube defect presenting challenging anesthetic management due to a difficult airway and risk of sac rupture. This report presents two neonates with different lesion sizes managed using contrasting intubation techniques: lateral positioning with manual finger guidance in a 15-day-old with a massive lesion and microcephaly, and supine positioning with doughnut-shaped cushion support in a 2-day-old with a moderate lesion. Both cases achieved successful first-pass intubation with no intraoperative complications. This comparison demonstrates the importance of individualized airway management strategies based on lesion size and anatomy.