Journal of Anesthesiology and Clinical Research
Journal of Anesthesiology and Clinical Research/JACR is a scientific journal, includes original research, review article, case report, and correspondence, that focuses on anesthesiology; pain management; intensive care; emergency medicine; disaster management; pharmacology; physiology; clinical practice research; health research and palliative medicine. This journal is a peer-reviewed journal established to improve the understanding of factors involved in anesthesiology and emergency medicine. JACR is published by CMHC (Research & Sains Center) and HM Publisher. The journal is intended for scientists, clinicians, and professionals in anesthesiology, emergency, and related sciences. We welcome contributions from specialists in academia, industry, clinical practice, public health, and pharmacy, as well as from specialists in economics, social sciences, and other disciplines. JACR has Electronic ISSN (eISSN): 2745-9497. JACR also has International ISSN (ROAD) 2745-9497.
Multimodal Neuroanesthesia with an Ultrasound-Guided Dexamethasone-Adjuvanted Scalp Block for Endoscopic Transsphenoidal Resection of a Giant Sellar-Suprasellar Rathke Cleft Cyst: A Case Report
Introduction: Sellar and suprasellar masses commonly present with visual failure and endocrinopathy, and the endoscopic endonasal transsphenoidal route is now the standard corridor for their resection. The procedure imposes intense but intermittent nociceptive surges upon a narrow, blood-intolerant surgical field, so the neuroanesthetic plan must reconcile profound analgesia, brain relaxation, hemodynamic stability, and rapid neurological emergence. We describe the perioperative management of a giant Rathke cleft cyst using a multimodal regimen anchored by a regional scalp block. Case Presentation: A 45-year-old woman (body mass index 31.1 kg/m²) presented with one year of progressive bitemporal visual field narrowing. Magnetic resonance imaging showed a cystic sellar-suprasellar mass with a mural nodule compressing the optic chiasm, favoring a giant Rathke cleft cyst over a sellar abscess. She was American Society of Anesthesiologists physical status III with stage 1 hypertension. Under total intravenous anesthesia titrated to a bispectral index of 40 to 60, a bilateral scalp block using 0.375% ropivacaine with 10 mg dexamethasone in 20 mL was performed after induction to blunt the sympathetic response. Mean arterial pressure was held at 65 to 80 mmHg across the five-hour endoscopic transnasal resection with sphenoidectomy and nasoseptal flap reconstruction. Emergence was smooth without bucking. In intensive care the patient was Glasgow Coma Scale 15 with no deficit; urine output reached 2.35 mL/kg/hr and sodium fell mildly to 132 mEq/L, and both were managed conservatively without desmopressin. Conclusion: Integrating a fully endoscopic transsphenoidal approach with a dexamethasone-adjuvanted scalp block and target-controlled total intravenous anesthesia delivered a bloodless field, immaculate hemodynamic control, and prompt neurological recovery. Structured intensive care surveillance for diabetes insipidus and dysnatremia secured a safe trajectory, offering a transferable framework for complex sellar tumor anesthesia.
Spinal Anesthesia for Emergency Cesarean Section in a Parturient with Coexisting Myasthenia Gravis, Ankylosing Spondylitis, and Multiple Sclerosis: A Rare Case Report and Structured Anesthetic Approach
Introduction: The simultaneous occurrence of myasthenia gravis, ankylosing spondylitis, and multiple sclerosis in a pregnant woman requiring emergency cesarean section is exceptionally rare and, to our knowledge, has not previously been documented. These autoimmune disorders impose overlapping neuromuscular, demyelinating, and axial-skeletal constraints that interact to make peripartum anesthetic decision-making uniquely hazardous. Case Presentation: A 34-year-old multiparous woman with a five-year history of myasthenia gravis, ankylosing spondylitis, and multiple sclerosis presented at 30 weeks' gestation with premature rupture of membranes, irregular contractions, and reduced fetal movement, alongside ptosis, diplopia, dysphagia, dysarthria, dysphonia, dyspnea, and limb weakness. She was maintained on pyridostigmine, methylprednisolone, and adalimumab with pregnancy-adjusted dosing. After multidisciplinary evaluation, emergency cesarean section was performed under single-shot spinal anesthesia using 0.5% bupivacaine 10 mg with fentanyl 25 mcg at L4-L5 via a 27-gauge Quincke needle in a single, uncomplicated pass, with a difficult-airway cart and rocuronium-sugammadex prepared as contingency. Hemodynamics remained stable apart from a transient rise in respiratory rate that resolved with oxygen. A preterm female infant weighing 1,415 g was delivered with Apgar scores of 5, 7, and 8. Mother and infant were monitored in intensive care; the mother reached the ward on postoperative day one without myasthenic crisis. Conclusion: Pregnancy with three coexisting autoimmune diseases generates synergistic, not merely additive, anesthetic risk. Carefully conducted spinal anesthesia, supported by multidisciplinary planning, disease-tailored drug selection, and a staged airway-rescue plan, achieved a safe outcome and offers a transferable framework for comparable emergencies.
Corticosteroid Responsiveness in Acute Respiratory Distress Syndrome of Different Aetiologies: A Two-Patient Case Series
Introduction: Acute respiratory distress syndrome (ARDS) is a life-threatening, biologically heterogeneous form of acute hypoxaemic respiratory failure arising from a broad spectrum of direct and indirect pulmonary insults. Although lung-protective ventilation and supportive care remain the foundation of management, the role of corticosteroids is still debated, with benefit concentrated in carefully selected patients and specific inflammatory phenotypes. We describe two patients whose ARDS arose from distinct aetiologies yet responded favourably to low-dose corticosteroid therapy. Case Presentation: The first patient was a 14-year-old girl with Marfan syndrome who developed abrupt severe hypoxaemia with bilateral infiltrates within six hours of massive intraoperative transfusion during scoliosis correction, consistent with post-transfusion (transfusion-related) acute lung injury. The second was a 39-year-old man with severe ARDS from bilateral pulmonary contusion after blunt chest trauma, complicated by Acinetobacter baumannii and Enterobacteriaceae hospital-acquired pneumonia. Both received lung-protective mechanical ventilation with individualised positive end-expiratory pressure and intravenous methylprednisolone 62.5 mg/day. Oxygenation and radiographic appearance improved progressively, with the ratio of arterial oxygen tension to inspired oxygen fraction rising from 72 to 343 by day 5 in the first patient and from 72 to 357 by day 11 in the second, permitting successful liberation from the ventilator. Conclusion: In these two aetiologically distinct patients, early low-dose methylprednisolone added to lung-protective ventilation was associated with rapid clinical and radiographic recovery. The series supports an individualised, aetiology- and phenotype-aware approach to adjunctive corticosteroid therapy in ARDS rather than uniform application or avoidance.
Admission Glucose-to-Potassium Ratio as a Predictor of Mortality Risk in Severe Traumatic Brain Injury Undergoing Craniotomy: A Retrospective Cohort Study
Introduction: Traumatic brain injury (TBI) is a leading cause of death and disability, and case fatality after emergency neurosurgery remains high, creating an urgent need for inexpensive, rapidly available prognostic tools. The admission glucose-to-potassium ratio (GKR) integrates the concurrent hyperglycaemia and hypokalaemia of the neuroendocrine stress response and may outperform either parameter alone; this study analysed its correlation with mortality risk in severe-TBI patients undergoing craniotomy. Methods: A retrospective cohort of 95 adults (18–60 years) with severe TBI (Glasgow Coma Scale ≤8) managed surgically at Dr. Moewardi Regional General Hospital, Surakarta (March–August 2024) was studied by consecutive sampling. GKR was calculated from admission blood glucose (mg/dL) divided by serum potassium (mmol/L); mortality risk was quantified with the MOST score (low 0–30, moderate 31–60, high 61–100). Analyses included Spearman correlation with 95% confidence intervals, Kruskal–Wallis testing with ε², ROC analysis, and multivariable logistic regression. Results: Median GKR was 35.14 (range 23.18–64.14) and rose monotonically across strata (26.94, 35.21, 55.67). GKR correlated with mortality risk (ρ = 0.376, 95% CI 0.19–0.54, p < 0.001), more strongly than glucose (ρ = 0.329, p = 0.001) or potassium (ρ = −0.243, p = 0.018). GKR discriminated high mortality risk with an area under the curve of 0.91 (95% CI 0.82–0.99) at a cut-off of 47.0, and each unit raised the adjusted odds of high risk 1.35-fold (95% CI 1.09–1.66, p = 0.006). Conclusion: Admission GKR is a simple, robust bedside marker for early mortality-risk stratification in severe-TBI craniotomy patients.
Epidural Anesthesia and Staged Inodilator–Vasopressor Support for Emergency Cesarean Section in a Parturient with Severe Tricuspid Regurgitation, Pulmonary Hypertension, and Systemic Lupus Erythematosus: A Case Report
Introduction: Pregnancy imposes a progressive haemodynamic burden that can be lethal in women with fixed cardiac output states. The coexistence of severe tricuspid regurgitation, pulmonary hypertension and systemic lupus erythematosus (SLE) in a parturient is rare and carries a high risk of right ventricular decompensation, especially when an intracardiac right-to-left shunt is present. Case Presentation: We describe a 30-year-old gravida 3 para 2 woman at 37+1 weeks of gestation who presented with antepartum vaginal bleeding and known SLE, severe tricuspid regurgitation (effective regurgitant orifice area 0.4 cm², vena contracta 0.7 cm), high-probability pulmonary hypertension (estimated systolic pulmonary artery pressure 74.7 mmHg) and a patent foramen ovale with right-to-left shunt. Emergency caesarean section was performed under graded epidural anaesthesia with 0.5% levobupivacaine. Intraoperative haemodynamics were supported with titrated infusions of norepinephrine, milrinone, dobutamine and furosemide under deliberate fluid restriction. A 2.56 kg male neonate was delivered with Apgar scores of 7, 8 and 9. Transient maternal hypotension and tachycardia responded to vasoactive titration; pharmacological support was staged down and discontinued by postoperative day 2, and the patient was transferred to the ward on day 3 with an improved tricuspid regurgitant velocity. Conclusion: Graded epidural anaesthesia combined with a pathophysiology-driven, staged inodilator–vasopressor strategy and deliberate fluid restriction enabled a favourable maternal and neonatal outcome in a parturient with the tricuspid–pulmonary hypertension–lupus triad. Multidisciplinary planning and meticulous, lesion-specific haemodynamic monitoring were decisive.
Anesthetic Management of a Child with Fraser Syndrome and an Atrial Septal Defect Undergoing Laparoscopic Orchidopexy: A Case Report
Introduction: Fraser syndrome is a rare autosomal recessive disorder with multisystem manifestations, including craniofacial, ocular, urogenital, and musculoskeletal anomalies, and it may create anesthetic challenges related to difficult airway management. The risk is magnified when congenital heart disease and laparoscopic surgery coexist, because each adds an independent physiologic burden to a child with limited reserve. Case presentation: A 10-year-old boy weighing 8.3 kg and measuring 80 cm, with Fraser syndrome, bilateral anophthalmia, intellectual disability, a history of congenital cytomegalovirus infection, and marasmic malnutrition, underwent laparoscopic exploration of the right testis and orchidopexy of the left testis. Echocardiography demonstrated an atrial septal defect with right atrial and right ventricular dilatation; the patient was classified as American Society of Anesthesiologists physical status III. After midazolam 1 mg premedication, anesthesia was induced with fentanyl 3 mcg/kg, sevoflurane 1-2 vol%, atracurium 5 mg, and dexamethasone 4 mg, and the trachea was intubated with a 4.5-mm cuffed tube. Anesthesia was maintained with sevoflurane 1.5-2 vol% and 50% oxygen. Over the 2-hour procedure, hemodynamics were stable (blood pressure 100-130/60-68 mmHg, heart rate 82-95 beats/min) with a net positive fluid balance of 10 mL. The patient was extubated and remained stable through 24 hours. Conclusion: Safe anesthesia in this setting rested on a layered airway plan, an understanding of shunt physiology, close hemodynamic monitoring, and measured ventilation and fluid strategies rather than on any single drug regimen. The report also highlights data elements that should be documented prospectively to strengthen comparability across similar cases.
Anesthetic Management of a Child with Severe Hydrocephalus, Predicted Difficult Airway, Obstructive Ileus, and Sepsis Undergoing Exploratory Laparotomy: A Case Report
Introduction: Severe hydrocephalus with macrocephaly creates a predicted difficult airway and raised intracranial pressure (ICP), a challenge magnified when it coexists with obstructive ileus and sepsis. The simultaneous demand to protect the brain, secure a distorted airway, prevent aspiration, and preserve perfusion in a septic, malnourished child makes anesthetic planning exceptionally complex. Case presentation: A 5-year-old boy with cerebral palsy and untreated severe communicating hydrocephalus (head circumference 81 cm) presented with vomiting, abdominal distension, and obstipation. He was septic, severely dehydrated, and marasmic, with imaging confirming severe hydrocephalus, agenesis of the corpus callosum, and low small-bowel obstruction. Exploratory laparotomy was prioritized over ventriculoperitoneal shunting. Anesthesia used a modified rapid sequence induction with a ketamine-based regimen and ramp positioning to align the head-body axis for intubation. Surgery lasted 2.5 hours with stable hemodynamics. The child was transferred intubated to the pediatric intensive care unit for controlled ventilation and neurological monitoring. Conclusion: Integrated, individualized planning allowed safe anesthesia in a child with colliding neurological, surgical, infectious, and nutritional emergencies. A ketamine-based modified rapid sequence induction with ramp positioning, neuroprotective maintenance, surgical sequencing, and planned postoperative ventilation balanced ICP control against septic hemodynamic stability.
Pericapsular Nerve Group (PENG) Block as Opioid-Sparing Postoperative Analgesia in a Geriatric Patient Undergoing Cemented Hip Hemiarthroplasty with Traumatic Intracerebral Hemorrhage and Right Bundle Branch Block: A Case Report
Introduction: Postoperative pain control in geriatric hip-fracture patients is challenging, and the challenge is magnified when neurological and cardiovascular comorbidities restrict the safe use of systemic opioids. Opioids, the analgesic standard, carry risks of respiratory depression, sedation, and hemodynamic instability that are particularly hazardous after intracranial hemorrhage and in cardiac conduction disease. The pericapsular nerve group (PENG) block is a sensory-selective, motor-sparing regional technique that may reconcile effective analgesia with these constraints. Case presentation: A 64-year-old man presented after a 2-meter fall with a displaced closed right intertrochanteric femoral fracture (Boyd-Griffin II), minimal traumatic intracerebral hemorrhage (right frontal lobe, ICH score 0), and electrocardiographic right bundle branch block (RBBB). He was classified ASA III and underwent cemented hip hemiarthroplasty under general endotracheal anesthesia. A multimodal, opioid-minimizing strategy centered on an ultrasound-guided PENG block combined with intravenous paracetamol was implemented. Analgesia was effective, systemic opioid requirements were minimized, the Glasgow Coma Scale remained E4V5M6, and hemodynamic and neurological parameters stayed stable throughout the high-care postoperative period. Conclusion: In a high-risk geriatric patient in whom opioids threatened both neuromonitoring and cardiac stability, a PENG block-centered multimodal regimen delivered reliable analgesia while preserving neurological assessability and hemodynamic stability. The PENG block is a safe, practical regional option for complex hip-fracture surgery and merits prospective study in comparably comorbid populations.
Anesthetic Management of Emergency Esophagoscopy for Denture Foreign Body Extraction in an Adult with Uncorrected Pulmonary Atresia–Ventricular Septal Defect, Major Aortopulmonary Collateral Arteries, and Bacterial Pneumonia: A Case Report
Introduction: Esophageal foreign body impaction is a common emergency, but its management becomes uniquely complex when superimposed on uncorrected cyanotic congenital heart disease and acute pulmonary infection. Adults with pulmonary atresia–ventricular septal defect (PA-VSD), major aortopulmonary collateral arteries (MAPCA) and patent ductus arteriosus represent a fragile physiology in which any deterioration in cardiac output, oxygenation or systemic vascular resistance may precipitate refractory hypoxemia. Case presentation: A 51-year-old man presented with sudden throat pain after accidentally swallowing a denture. Cervical radiography revealed an irregular opacity at C4–C5. He had longstanding uncorrected PA-VSD with MAPCA, patent ductus arteriosus and moderate aortic regurgitation; echocardiography showed cardiac output 2.9 L/min and cardiac index 1.86 L/min/m². He was concurrently diagnosed with Klebsiella pneumoniae bacterial pneumonia (chest radiograph: cardiothoracic ratio 75% with pulmonary edema; SpO₂ 94% on room air). Following multidisciplinary preoperative optimization—nebulized ipratropium-salbutamol, furosemide, digoxin, lansoprazole, warfarin, bisoprolol and spironolactone—he underwent emergency rigid esophagoscopy under general anesthesia with endotracheal intubation. Hemodynamic-protective induction preserved systemic vascular resistance and avoided hypoxic-hypercapnic shifts. The denture was extracted intact and the patient was transferred to the intensive care unit with blood products on standby. Conclusion: Successful management required prompt diagnosis, multidisciplinary preoperative optimization and a hemodynamic-protective anesthetic plan tailored to balanced systemic-pulmonary circulation. Awareness of the specific physiology of unrepaired PA-VSD with MAPCA and concurrent pneumonia is essential to safe perioperative care.
Ultrasound-Guided Axillary Brachial Plexus Block as a Definitive Anesthetic Strategy in a Patient with Anticipated Difficult Airway Following Post-Burn Cervical Flap Reconstruction: A Case Report
Introduction: Airway management in patients with post-burn cervical flap reconstruction is challenging because hypertrophic scars, restricted neck mobility and limited mouth opening compromise both ventilation and laryngoscopy. Ultrasound-guided regional anesthesia is increasingly proposed as an alternative that preserves spontaneous ventilation and avoids airway instrumentation entirely. Case presentation: A 47-year-old woman scheduled for bilateral hand contracture release presented with extensive post-burn cervical flap reconstruction performed 15 years earlier, persistent neck contractures, facial scarring, Mallampati class III, limited inter-incisor distance and markedly reduced cervical extension. Routine laboratory and chest radiographic findings were within normal limits. An ultrasound-guided axillary brachial plexus block was selected as the sole anesthetic technique, using 20 mL of 2% lidocaine delivered in-plane around the median, ulnar, radial and musculocutaneous nerves. A complete sensorimotor block was achieved within 15 minutes. The procedure proceeded uneventfully without conversion to general anesthesia, and the patient remained hemodynamically stable with effective postoperative analgesia and no neurological deficit. Conclusion: Ultrasound-guided axillary brachial plexus block can serve as a safe and effective definitive anesthetic strategy for distal upper-limb surgery in post-burn cervical flap patients with anticipated difficult airway, supporting the principle that distance from the airway is itself a deliberate anesthetic plan.
Emergency General Anesthesia with Rapid Sequence Intubation for Cesarean Delivery in Severe Eclampsia Complicated by Pulmonary Edema and Premature Rupture of Membranes: A Multidisciplinary Critical Care Case Report
Introduction: Eclampsia complicated by acute pulmonary edema is a life-threatening obstetric emergency that demands rapid, coordinated multidisciplinary intervention. Premature rupture of membranes (PROM) coexisting with refractory eclamptic seizures and respiratory failure further heightens maternal-fetal risk and complicates anesthetic decision-making. Optimal management requires individualized airway strategy, aggressive seizure control, and meticulous fluid balance under intensive care. Case presentation: A 28-year-old primigravida at term was referred from the emergency department after two generalized tonic-clonic seizures (5 minutes each), with severe hypertension (168/95 mmHg), tachypnea (RR 30/min), Glasgow Coma Scale 12 (sopor), bilateral basal rales, and oxygen desaturation to 92% on room air. Laboratory studies showed proteinuria +2, elevated transaminases (SGOT 62 U/L), and a PaO₂/FiO₂ ratio of 423 mmHg consistent with non-cardiogenic pulmonary edema. Emergency cesarean delivery was performed under general anesthesia with rapid sequence intubation (lidocaine-dexamethasone pretreatment, ketamine-propofol induction, rocuronium paralysis). A live male neonate (3420 g, APGAR 7-8-9) was delivered; surgery duration was 45 minutes. In the ICU, lung-protective mechanical ventilation, continuous furosemide infusion (5 mg/h, negative fluid balance strategy), and escalating multimodal anticonvulsant therapy (magnesium sulfate, midazolam, phenytoin) for refractory seizures were employed. The patient was extubated after 16 seizure-free hours, transferred to the ward on day 3, and discharged with her infant on day 4. Conclusion: Early recognition of eclampsia with pulmonary edema, individualized rapid sequence intubation general anesthesia, multimodal seizure control, and aggressive negative fluid balance under multidisciplinary critical care can yield favorable maternal-neonatal outcomes even in resource-constrained settings.
Copyright (c) 2026 Muhammad Ibrahim, Propan Hanggada Satyamakti Mubarak
Opioid-Sparing Anesthetic Strategy with Ultrasound-Guided Superficial Cervical Plexus Block in Pediatric Recurrent Lymphangioma Surgery: A Case Report
Introduction: Pediatric cervical mass surgery presents unique perioperative challenges, including airway proximity, hemodynamic lability, and the need for effective opioid-sparing analgesia. The superficial cervical plexus block (SCPB) targets the cutaneous branches of C2-C4 emerging at the posterior border of the sternocleidomastoid muscle, but its use in pediatric oncologic neck surgery is infrequently reported. Case presentation: A 9-year-old girl (24 kg) presented for excision of a progressively enlarging recurrent right cervical mass clinically and radiologically suggestive of a multiloculated lymphatic malformation. After balanced general anesthesia with endotracheal intubation, an ultrasound-guided right SCPB was performed using 8 mL of ropivacaine 0.2% with dexamethasone 5 mg as an adjuvant. The 2-hour excision proceeded with stable hemodynamics, no additional intraoperative opioid requirement after a single induction-phase fentanyl dose, and a positive fluid balance of +40 mL. The patient was extubated uneventfully, recovered in the post-anesthesia care unit (PACU) without rescue analgesic demand, and was transferred to the ward on postoperative day 1 with excellent analgesia and no neurologic, respiratory, or wound complications. Conclusion: Ultrasound-guided SCPB combining low-concentration ropivacaine with perineural dexamethasone provided effective opioid-sparing analgesia for pediatric cervical lymphangioma excision while preserving respiratory reserve and hemodynamic stability. Compared with previously published pediatric SCPB cases — predominantly in vocal cord, otologic, and tympanomastoid surgery — the present report extends documented experience to recurrent oncologic cervical mass excision, contributing to the developing pediatric regional anesthesia literature in the Indonesian and broader Asian setting.
Vasovagal Syncope Following Pulsed Radiofrequency of Cervical Dorsal Root Ganglia and Occipital Nerves in a Patient with Chronic Cervical Radiculopathy and Occipital Neuralgia: A Case Report
Introduction: Pulsed radiofrequency is a minimally invasive, non-destructive neuromodulation technique used to manage chronic cervical radicular pain and occipital neuralgia. It is generally considered safe, with common adverse events limited to mild transient dysaesthesia or local discomfort. Vasovagal syncope following pulsed radiofrequency of the cervical dorsal root ganglia and occipital nerves has not been well documented in the anaesthesia and pain medicine literature. Case presentation: A 41-year-old woman with chronic cervical radiculopathy attributable to C5–C6 herniated disc disease, tension-type headache with pericranial tenderness, a history of cluster headache, chronic spontaneous vertigo, and newly diagnosed hypertension underwent bilateral pulsed radiofrequency of the lesser and greater occipital nerves and of the C3 and C4 dorsal root ganglia under fluoroscopic guidance. The procedure was performed under light sedation with intravenous propofol and midazolam and completed without immediate complication. Approximately 20 hours later, the patient developed an acute decrease in consciousness with a nadir Glasgow Coma Scale of 12 and a heart-rate profile consistent with a reflex vasovagal event. Gradual spontaneous recovery of consciousness was documented over seven hours, reaching a Glasgow Coma Scale of 15 without any neurological deficit. Pre- and post-procedural symptom comparison showed clear improvement in cervical paraesthesia, vertigo, tinnitus, and cluster-type headache, while tension-type headache persisted at a similar intensity. Conclusion: Vasovagal syncope is a rare but clinically relevant adverse event after pulsed radiofrequency of the cervical dorsal root ganglia and occipital nerves. The likely pathophysiology involves afferent stimulation of the trigeminocervical complex and activation of the Bezold–Jarisch reflex in a susceptible patient. Multimodal monitoring, adequate hydration, careful sedation titration, and structured post-procedural observation are recommended to anticipate and manage this complication.
Daily Sedation Interruption Versus Continuous Sedation for Reducing Mechanical Ventilation Duration in the Intensive Care Unit: A Meta-Analysis
Introduction: Mechanical ventilation is a critical intervention in intensive care units, yet prolonged ventilation increases complications including ventilator-associated pneumonia, delirium, and mortality. Daily sedation interruption (DSI) has been proposed as a strategy to reduce ventilation duration, but evidence remains inconsistent. Methods: A systematic review and meta-analysis was conducted searching PubMed, Embase, Cochrane Library, and Web of Science from inception to March 2024. Randomised controlled trials (RCTs) and observational studies comparing DSI with continuous sedation were included. The primary outcome was duration of mechanical ventilation. Pooled standardised mean difference (SMD) and 95% confidence intervals (CI) were calculated using Hedges’ g with a random-effects model. Heterogeneity was assessed using I² statistics, and subgroup analyses stratified by intensive care unit type and study design. Results: Ten studies comprising 2,011 participants were included. Pooled SMD for ventilation duration was −0.3655 (95% CI −0.7611 to 0.0301; p = 0.0662), indicating a non-significant trend favouring DSI, with very high heterogeneity (I² = 91.54%). Subgroup analysis in general intensive care units (three studies, n = 426) demonstrated significant reduction in ventilation duration (SMD = −0.6763, 95% CI −0.1265 to −0.2262; p = 0.0231; I² = 20.38%), whereas medical (three studies) and medical-surgical (three studies) units showed non-significant effects. Sensitivity analysis indicated robustness of findings when studies by Nassar Jr and Mehta (2016) were sequentially excluded. Conclusion: Daily sedation interruption showed a non-significant trend towards reducing mechanical ventilation duration in pooled analysis, with significant benefit demonstrated specifically in general intensive care units. High heterogeneity suggests practice variation in DSI protocols and patient populations influences outcomes. Future standardised DSI protocols and trials in homogeneous populations are warranted.
Anesthetic Management of a Teenage Primigravida with Impending Eclampsia Undergoing Emergency Cesarean Section: A Comprehensive Case Report
Introduction: Impending eclampsia represents a medical emergency requiring immediate maternal delivery to prevent progression to seizures and maternal-fetal compromise. The selection of an appropriate anesthetic technique for emergency cesarean section in severely preeclamptic patients remains clinically challenging, balancing the risks and benefits of regional versus general anesthesia. Case presentation: A 19-year-old primigravida at 35 weeks and 6 days of gestation presented with frontal headache, blurred vision, and nausea. Clinical evaluation revealed new-onset hypertension (131/81 mmHg), proteinuria (+2), and mild hypokalemia (3.4 mmol/L), consistent with impending eclampsia. Emergency cesarean section was performed under subarachnoid block utilizing heavy bupivacaine 15 mg with fentanyl 25 micrograms intrathecally. Hemodynamics remained stable throughout the operative period without vasopressor requirement. A male neonate was delivered with Apgar scores of 7-8-9 and a birth weight of 1825 grams. Both mother and infant had favorable postoperative outcomes with resolution of hypertensive crisis and normal neonatal transition. Conclusion: This case demonstrates the efficacy and safety of regional anesthesia in eclamptic parturients undergoing emergency cesarean delivery. Careful patient selection, appropriate drug dosing, and vigilant hemodynamic monitoring enable successful outcomes even in this high-risk scenario.
Optimizing Patient Blood Management: Successful Intraoperative Cell Salvage During Cesarean Hysterectomy for Placenta Accreta Spectrum - A Case Report
Introduction: Placenta accreta spectrum disorders represent a critical maternal health concern with a high risk of massive obstetric hemorrhage, which conventionally necessitates substantial allogeneic blood transfusion. Intraoperative cell salvage serves as a highly efficient autotransfusion alternative within modern patient blood management frameworks. Case presentation: A 37-year-old female (Gravida 4, Para 1) at 37-38 weeks of gestation presented with total placenta previa and a Placenta Accreta Index score of 6, correlating to a 69% probability of placenta accreta. A transperitoneal profunda cesarean section with subsequent hysterectomy was planned. A combined spinal-epidural anesthesia technique was utilized, justified by favorable airway metrics and supported by a proactive massive transfusion protocol. Surgical estimated blood loss was 3,500 mL. An intraoperative cell salvage device processed 2,438 mL of shed fluid, which included 1,000 mL of surgical irrigation. This yielded 451 mL of washed packed red blood cells that were successfully reinfused. The patient’s hemodynamics were stabilized using a continuous norepinephrine infusion. The patient received zero allogeneic blood products throughout her admission. Hemoglobin levels were maintained from 10.1 g/dL preoperatively to 9.2 g/dL at discharge. Postoperative coagulation profiles remained stable. The patient was discharged on postoperative day 5 without complications. Conclusion: The application of intraoperative cell salvage in major obstetric surgery is demonstrably safe and clinically beneficial. This technology provides a resource-optimized alternative to allogeneic transfusion.
A Rare Complication of Vasovagal Syncope Induced by Pulsed Radiofrequency in a Patient with Cervical Spondylosis and Occipital Neuralgia: A Case Report
Introduction: Pulsed radiofrequency is widely utilized as a minimally invasive neuromodulation technique for managing chronic neuropathic pain, including cervical radicular pain and occipital neuralgia. While pulsed radiofrequency is generally celebrated for its robust safety profile and absence of thermal tissue destruction, unexpected autonomic complications remain poorly characterized in the literature. Case presentation: A 41-year-old female with a six-month history of chronic cervical root syndrome (C3-C6) and refractory occipital neuralgia presented for interventional pain management. Following a comprehensive clinical and radiological evaluation, the patient underwent fluoroscopy-guided pulsed radiofrequency of the bilateral C3 and C4 dorsal root ganglia and the greater and lesser occipital nerves. The procedure was technically successful and uneventful. However, approximately 24 hours post-procedure, the patient experienced a sudden, profound episode of vasovagal syncope, characterized by acute hypotension, bradycardia, and a precipitous drop in consciousness (Glasgow Coma Scale: E3V3M6). Immediate resuscitation, including intravenous fluid boluses and continuous hemodynamic monitoring, led to a full neurological recovery. At follow-up, the patient reported significant attenuation of both radicular and occipital pain scores. Conclusion: This report documents a rare and severe episode of delayed vasovagal syncope following upper cervical and occipital pulsed radiofrequency neuromodulation. The temporal association suggests a complex neuro-autonomic reflex, potentially mediated by the trigeminocervical complex and sudden withdrawal of chronic sympathetic tone. Clinicians performing cervical pulsed radiofrequency must remain vigilant regarding delayed autonomic dysregulation, necessitating extended postoperative observation protocols in susceptible individuals.
Neuroprotective Anesthetic Management Using Thiopental in a 17-Year-Old with Multifocal Epidural Hematoma and Impending Brain Herniation: A Case Report
Introduction: Epidural hematoma resulting from severe traumatic brain injury demands immediate neuroanesthetic intervention. Multifocal lesions accompanied by pneumocephalus and impending brain herniation present profound perioperative challenges requiring targeted cerebral perfusion management. Case presentation: A 17-year-old male weighing 50 kg sustained severe polytrauma, presenting with a Glasgow Coma Scale of 12 and active auditory canal bleeding. Imaging revealed multifocal epidural hematomas in the right frontotemporal (66 cc) and right parietal (43 cc) regions, alongside pneumocephalus, a 1.5 cm subfalcine herniation, and downward transtentorial herniation. The patient, classified as ASA physical status 4E, required an emergent decompressive craniotomy and concurrent facial reconstruction. A neuroprotective anesthetic strategy was deployed utilizing thiopental, fentanyl, and atracurium to minimize the cerebral metabolic rate and control intracranial pressure. Anesthesia was maintained with sevoflurane. Hemodynamics were strictly titrated to ensure optimal cerebral perfusion pressure. Following successful surgical hematoma evacuation, the patient was admitted to the intensive care unit and demonstrated an excellent neurological recovery after a five-day admission. Conclusion: Thiopental serves as a highly effective neuroprotective induction agent for severe traumatic brain injury with intracranial hypertension. Meticulous hemodynamic control and targeted reduction of cerebral metabolism are critical in preventing secondary ischemic cascades and improving functional outcomes in polytrauma patients.
Precision Anesthetic Management of the Triple-Pathology Parturient: Graded Epidural Technique for Emergency Cesarean Section in Severe Tricuspid Regurgitation, Pulmonary Hypertension, and Systemic Neurofibromatosis
Introduction: Maternal cardiac disease, specifically right-sided valvular lesions exacerbated by pulmonary hypertension, remains a primary driver of maternal mortality. The physiological demands of pregnancy act as a cardiovascular stress test, often leading to decompensation in patients with underlying pathology. This case describes the management of a triple-pathology parturient. Case presentation: A 37-year-old female (G2P1A0) at 34 weeks’ gestation presented with NYHA Class IV symptoms, including progressive dyspnea and orthopnea. Echocardiography revealed severe tricuspid regurgitation (regurgitant volume 112 mL), right ventricular dilatation, and a high probability of pulmonary hypertension with a mean pulmonary arterial pressure of 50.39 mmHg and a systolic pulmonary arterial pressure of 79.32 mmHg. Systemic neurofibromatosis added concerns regarding neuraxial anatomy and airway management. An emergency Cesarean Section was performed under a graded epidural technique using 0.375 percent Levobupivacaine and 50 mcg Fentanyl, administered in 3 mL increments every 5 minutes. Hemodynamic stability was maintained through strict fluid restriction of 300 mL and titrated vasopressors. Conclusion: A carefully titrated graded epidural provides superior stability in the hostile hemodynamics of right heart failure by allowing a slow, compensatory sympathetic blockade. Early multidisciplinary coordination is essential for success in complex cardio-obstetric cases.
Preserving Spontaneous Ventilation in ASA III Patients: Transtracheal Block as a Primary Anesthetic Strategy for Complex Bronchoscopy
Introduction: Fiberoptic bronchoscopy (FOB) in patients with American Society of Anesthesiologists (ASA) physical status III presents a significant anesthetic challenge. General anesthesia carries risks of hemodynamic instability and respiratory compromise, while conventional topical anesthesia is often insufficient for cough suppression. This study evaluates the efficacy of transtracheal block (TTB) combined with dexmedetomidine as a primary anesthetic strategy to preserve spontaneous ventilation in high-risk patients. Case presentation: We present a serial case report of four adult males (aged 43-66 years) with severe pulmonary comorbidities, including advanced lung malignancies, atelectasis, and massive pleural effusion. All patients were classified as ASA III. The anesthetic protocol utilized a multimodal approach: intravenous dexmedetomidine sedation (loading dose 1 mcg/kg, maintenance 0.2-0.7 mcg/kg/hr) combined with a TTB using 20 mg of 2% lidocaine. All procedures were successfully completed without conversion to general anesthesia. Hemodynamic monitoring revealed that mean arterial pressure (MAP) and heart rate variability remained within 15% of baseline. No episodes of desaturation (SpO2 < 90%) or significant periprocedural respiratory distress were observed. Patients demonstrated rapid recovery with minimal coughing (Visual Analog Scale for Cough < 2/10) and were discharged from the ICU within 24 hours. Conclusion: Transtracheal block combined with dexmedetomidine provides profound airway anesthesia while maintaining spontaneous ventilation and hemodynamic stability. This technique represents a superior safety profile compared to general anesthesia for complex bronchoscopy in patients with compromised respiratory reserve.
Efficacy of Particulate versus Non-Particulate Corticosteroids as Adjuvants for Popliteal Sciatic Nerve Block: A Randomized Controlled Superiority Trial
Introduction: Single-shot ultrasound-guided popliteal sciatic nerve blocks are the gold standard for distal lower limb analgesia but are limited by a finite duration, often necessitating adjuvants. While dexamethasone (non-particulate) is the standard of care, methylprednisolone (particulate) theoretically offers a depot effect for sustained release. This study aimed to determine if perineural methylprednisolone provides superior analgesic duration compared to dexamethasone. Methods: In this prospective, double-blind, randomized controlled trial, 36 ASA I-III patients undergoing distal lower limb surgery were randomized (1:1) to receive 20 mL of 0.5% Ropivacaine with either Dexamethasone 8 mg (Group D) or Methylprednisolone 40 mg (Group M). To ensure blinding, solutions were prepared by an independent pharmacist and administered via opaque syringes. The primary outcome was the duration of analgesia (time to Numeric Rating Scale [NRS] greater than 3), analyzed using Kaplan-Meier survival curves and Log-Rank tests. Secondary outcomes included cumulative opioid consumption, rebound pain severity, and block onset time. The study was powered for superiority with a clinically significant difference of 4 hours. Results: Thirty-six patients completed the study. Demographic and surgical characteristics were comparable. The median duration of analgesia was 18.4 (SD 3.2) hours in Group D and 19.1 (SD 3.5) hours in Group M (p = 0.58; Log-Rank p = 0.61). Pain scores at 12, 24, and 48 hours showed no significant difference, with both groups demonstrating a floor effect due to multimodal analgesia (Median NRS less than 2). No adverse events, including neurotoxicity or infection, were observed. Conclusion: Perineural methylprednisolone failed to demonstrate superior analgesic duration compared to dexamethasone in this cohort. The theoretical depot advantage did not translate to clinical superiority, likely due to vascular clearance in the popliteal fossa. Given the comparable efficacy but superior safety profile of non-particulate agents, dexamethasone remains the preferred adjuvant. Methylprednisolone serves as a viable alternative only when non-particulate options are unavailable.
Hemodynamic Attenuation During Tracheal Intubation: A Randomized Comparative Analysis of Video vs. Direct Laryngoscopy in Adult Elective Surgery
Introduction: Laryngoscopy and tracheal intubation inevitably trigger a sympathoadrenal response, manifesting as tachycardia and hypertension. While video laryngoscopy (VL) offers improved glottic visualization compared to direct laryngoscopy (DL), its efficacy in specifically attenuating this hemodynamic stress remains a subject of debate. This study investigates whether VL provides superior hemodynamic stability during the critical post-intubation period by analyzing the rate pressure product (RPP) and temporal hemodynamic interactions. Methods: In this prospective, single-blind, randomized controlled trial, 40 adult patients (ASA I-II) undergoing elective surgery were allocated to either Group VL (GlideScope, n=20) or Group DL (Macintosh, n=20). Anesthesia was strictly standardized with Fentanyl 2 mcg/kg, Propofol 2 mg/kg, and Atracurium 0.5 mg/kg. Hemodynamic parameters, including systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR), were recorded at baseline (T0) and at 1 (T1), 2 (T2), and 5 (T5) minutes post-intubation. The primary analysis utilized a general linear model (Repeated Measures ANOVA) to assess Time-Group interactions, corrected for sphericity. Results: Demographics were homogeneous between groups. A significant Time-Group interaction was observed for MAP (p less than 0.001), indicating a blunted pressor response curve in the VL group. Heart Rate at 1-minute post-intubation was significantly lower in Group VL (75.45 plus or minus 11.23 bpm) compared to Group DL (90.15 plus or minus 15.22 bpm; p equals 0.001). Analysis of the rate pressure product revealed that Group DL approached ischemic thresholds, whereas Group VL maintained significantly lower myocardial workload at minutes 1 and 2 (p less than 0.01). Conclusion: Video laryngoscopy significantly attenuates the reflex tachycardia and arterial pressure surge associated with tracheal intubation compared to direct laryngoscopy. VL is recommended to minimize cardiovascular stress in susceptible surgical populations.
Comparative Efficacy of Low-Dose Ketamine versus Midazolam Co-induction on Hemodynamic Stability and Early Neurocognitive Recovery in Geriatric Anesthesia: A Randomized Double-Blind Pilot Trial
Introduction: Geriatric patients undergoing general anesthesia are susceptible to hemodynamic instability and delayed neurocognitive recovery. The choice of co-induction agent significantly influences these outcomes. This study compares the effects of low-dose Ketamine versus Midazolam co-induction on intraoperative hemodynamic stability and immediate post-operative cognitive trajectory. Methods: A prospective, double-blind, randomized controlled pilot trial was conducted on 32 geriatric patients aged 65 years or older classified as American Society of Anesthesiologists (ASA) physical status II or III undergoing elective surgery. Patients were randomized to receive either intravenous Ketamine (0.3 mg/kg, n=16) or Midazolam (0.075 mg/kg, n=16) prior to Propofol induction. The primary outcome was the magnitude of early cognitive change measured by the Mini-Mental State Examination (MMSE) at 1-hour post-operation relative to baseline. Secondary outcomes included intraoperative mean arterial pressure (MAP), incidence of hypotension, total Propofol consumption, and time to extubation. Data were analyzed using Analysis of Covariance (ANCOVA) and independent t-tests; effect sizes were calculated using Cohen’s d. Results: Baseline characteristics were comparable between groups. The Ketamine group exhibited significantly superior early cognitive preservation with a mean decline of -0.50 ± 0.63 compared to the Midazolam group, which showed a decline of -1.25 ± 0.93 (p = 0.012; Cohen’s d = 0.93). Hemodynamically, the Ketamine group maintained significantly higher Mean Arterial Pressure post-induction (p = 0.003) with a lower risk of hypotension (Relative Risk 0.29, 95% Confidence Interval 0.07–1.18). Additionally, the Ketamine group required significantly less induction of Propofol (p < 0.001) and achieved faster extubation times (p < 0.001). Conclusion: Co-induction with sub-anesthetic Ketamine provides superior hemodynamic stability and facilitates faster early neurocognitive recovery compared to Midazolam in geriatric patients. These findings suggest Ketamine is a preferable adjuvant for optimizing emergence profiles and maintaining perfusion pressure in the aging population.
Comparative Efficacy of Prophylactic Bolus Phenylephrine versus Ephedrine on Maternal Hemodynamics and Neonatal APGAR Scores in Elective Cesarean Section: A Randomized Controlled Trial
Introduction: Spinal anesthesia-induced hypotension is a pervasive physiological challenge during cesarean delivery, precipitating maternal hemodynamic instability and compromising uteroplacental perfusion. While phenylephrine and ephedrine are the mainstay vasopressors for prophylaxis, their comparative impact on immediate neonatal vitality in the context of bolus administration remains a critical subject of investigation, particularly in resource-limited settings where infusion pumps are not universally available. This study aimed to rigorously compare the efficacy of prophylactic intravenous bolus phenylephrine versus ephedrine regarding maternal blood pressure control and neonatal APGAR scores. Methods: We conducted a prospective, randomized, double-blind experimental study at Dr. Saiful Anwar Regional General Hospital, Malang. Forty-two parturients classified as ASA I or II undergoing elective cesarean section were randomized into two groups. Immediately following subarachnoid block, Group P received a bolus of Phenylephrine (125 µg), and Group E received Ephedrine (10 mg). Hemodynamic parameters were recorded at baseline and at 1, 3, 6, 9, 12, 15, and 18 minutes post-anesthesia. The primary outcome was the neonatal APGAR score at the first minute. Results: Both vasopressor regimens successfully mitigated severe spinal-induced hypotension. There were no statistically significant differences in the magnitude of systolic or diastolic blood pressure reduction between the Phenylephrine and Ephedrine groups at any observed time point (p>0.05). However, a significant divergence was observed in neonatal outcomes. The mean first-minute APGAR score in the Phenylephrine group was significantly higher (7.62 ± 0.97) compared to the Ephedrine group (7.05 ± 0.74) with a p-value of 0.038. Conclusion: Phenylephrine and ephedrine demonstrated equipotent efficacy in maintaining maternal hemodynamic stability when administered as prophylactic boluses. However, phenylephrine prophylaxis resulted in superior immediate neonatal vitality as evidenced by significantly higher first-minute APGAR scores. Phenylephrine should be prioritized as the vasopressor of choice to optimize neonatal safety during cesarean delivery.
Risk-Adapted Anesthesia and Sympathetic Attenuation in Geriatric Cardiometabolic Multimorbidity: Navigating the Limited Physiologic Reserve
Introduction: The aging surgical population is defined by homeostenosis, a critical reduction in physiologic reserve that leaves patients vulnerable to perioperative stressors. This vulnerability is exponentially increased by the cardiometabolic triad of hypertension, coronary artery disease, and type II diabetes mellitus. This report illustrates the management of these competing physiological demands during high-stress open abdominal surgery. Case presentation: A 71-year-old male, ASA III, body mass index 27 kg/m², with stage II hypertension, insulin-dependent type II diabetes, and ischemic heart disease, presented for open cholecystectomy. Preoperative functional capacity was less than 4 METs. Baseline ward blood pressure was 138/84 mmHg. Intraoperatively, surgical traction on the gallbladder mesentery precipitated a sympathetic surge, with systolic blood pressure spiking to 171/95 mmHg, representing a 24% increase from baseline mean arterial pressure, without compensatory tachycardia (heart rate stable at 83 bpm), indicative of autonomic neuropathy. Utilizing a risk-adapted protocol, anesthesia was deepened with Sevoflurane to 3.5% and a targeted Fentanyl bolus of 50 mcg was administered. This intervention successfully attenuated the surge, reducing systolic blood pressure to less than 150 mmHg within 4 minutes. A restrictive fluid strategy of 500 mL total input was employed. Postoperative renal function remained stable with a Creatinine of 1.05 mg/dL, and the patient was discharged with a pain score of 2 out of 10. Conclusion: Successful management of the geriatric vascular stiffness phenotype requires anticipating the dissociation between heart rate and blood pressure. Vigilant, physiologically-guided titration of volatile agents and opioids, rather than invasive technology alone, can mitigate myocardial ischemia in low-resource settings.
Admission GCS, Age, and Pupillary Response as a Multivariable Triad for Predicting Outcomes Following Emergent Surgery for Traumatic Brain Injury
Introduction: Early prognostication for patients with moderate-to-severe traumatic brain injury (TBI) requiring emergent surgery and intensive care is critical but complex. While the Glasgow Coma Scale (GCS) is foundational, its standalone predictive power, especially when unadjusted for known confounders, can be misleading. This study aimed to determine the independent predictive value of admission GCS within a multivariable model including other key clinical predictors. Methods: We conducted a retrospective, descriptive-analytic study at a tertiary referral center in Indonesia, analyzing a specific cohort of 150 patients with moderate-to-severe TBI (GCS 3–12) who all underwent the emergent ED-OR-ICU pathway between July and December 2024. Data on admission GCS, patient age, pupillary reactivity, and CT findings (Marshall score) were extracted. We built multivariable logistic regression models to predict two primary outcomes: (1) In-Hospital Mortality and (2) Unfavorable Functional Outcome (a composite of mortality or discharge to a skilled nursing/palliative care facility). Results: A univariate analysis identifying a GCS cut-off of 9.5 produced a statistically unstable odds ratio (OR) for mortality of 104.87, consistent with quasi-complete separation. However, in the multivariable model, this effect was resolved. After adjusting for confounders, GCS remained a significant independent predictor of mortality (Adjusted OR 2.78 per point decrease) and unfavorable outcome (aOR 3.11 per point decrease). Crucially, non-reactive pupils (aOR 5.12 for mortality) and patient age (aOR 1.07 per year for unfavorable outcome) were found to be equally, if not more, powerful independent predictors. Conclusion: Admission GCS is a robust and independent predictor of outcome in high-risk surgical TBI patients, but its true value is only revealed when used as part of a multivariable assessment. The statistical power of univariate GCS is easily inflated by confounding. We conclude that prognostication in this cohort must be a multivariable exercise, incorporating GCS, pupillary response, and age as an essential prognostic triad.
Successful Use of Low-Dose Combined Spinal-Epidural Anesthesia for Cesarean Section in a Parturient with Eisenmenger Syndrome: A Case Report
Introduction: Eisenmenger syndrome (ES) in pregnancy is a catastrophic condition associated with maternal mortality rates of 30-50%. The profound physiological changes of pregnancy, particularly the decrease in systemic vascular resistance (SVR), exacerbate right-to-left (R-L) shunting, leading to severe hypoxemia and right ventricular failure. Anesthetic management is perilous, as both general and neuraxial anesthesia can precipitate hemodynamic collapse. Case presentation: We present the case of a 25-year-old G2P101Ab000 parturient at 32-34 weeks of gestation with ES secondary to a large secundum atrial septal defect and severe pulmonary hypertension. She presented for an urgent Cesarean section due to labor. A meticulous anesthetic plan was executed, centered on a low-dose Combined Spinal-Epidural (CSE) technique. This involved an intrathecal injection of 7.5 mg hyperbaric bupivacaine with 50 mcg fentanyl, followed by incremental epidural titration of 0.2% ropivacaine. Hemodynamic stability was proactively managed with inline infusions of phenylephrine and milrinone. The procedure was successful, maintaining stable maternal hemodynamics, SVR, and oxygen saturation. A healthy infant was delivered with APGAR scores of 7 and 8. The patient had an uncomplicated postoperative recovery. Conclusion: This case demonstrates that a carefully titrated, low-dose CSE technique, combined with invasive monitoring and proactive pharmacological support, can be a safe and effective strategy for Cesarean section in ES patients. This approach successfully navigates the hemodynamic dilemma by providing excellent analgesia while preventing a clinically significant drop in SVR.
Pharmacodynamic Mismatch in Adductor Canal Blockade: Dexamethasone Phosphate (Rapid-Salt) Outperforms Methylprednisolone Acetate (Depot-Suspension) for Early Mobilization
Introduction: The motor-sparing adductor canal block (ACB) is central to enhanced recovery after surgery (ERAS) protocols for knee surgery. Corticosteroid adjuvants are used to prolong analgesia, but a direct comparison of perineural Dexamethasone and Methylprednisolone is lacking. This study aimed to observe real-world associations between these adjuvants, postoperative pain, and functional recovery. Methods: This analytical, prospective, observational cohort study was conducted at a tertiary hospital from November 2024 to April 2025. Fifty-three patients undergoing knee surgery under subarachnoid anesthesia were enrolled. Following surgery, patients received an ultrasound-guided ACB with 20 mL of Ropivacaine 0.5% combined with either Dexamethasone 10 mg (n=24) or Methylprednisolone 60 mg (n=29), based on the attending anesthesiologist's preference. The primary functional outcome was time to mobilization. Secondary outcomes included Numerical Rating Scale (NRS) pain scores at 12, 24, and 48 hours. Results: A significant association was observed for the primary functional outcome: 87.5% of the Dexamethasone cohort mobilized within 24 hours, versus 62.1% of the Methylprednisolone cohort (p = 0.037). This functional advantage was congruent with a superior early analgesic profile; the Dexamethasone group reported significantly lower mean NRS scores at 12 hours (2.71 ± 0.81 vs. 3.86 ± 1.13; p < 0.001) and 24 hours (2.17 ± 0.56 vs. 3.24 ± 0.69; p < 0.001). A significant baseline difference in age distribution (p = 0.009) was identified as a key variable. Conclusion: This study provides the first clinical comparison of a rapid-acting salt (Dexamethasone Phosphate) versus a depot-suspension (Methylprednisolone Acetate) as perineural adjuvants in ACB. The observed superior functional and analgesic profile of Dexamethasone aligns with its pharmacokinetic properties, suggesting a pharmacodynamic mismatch between slow-release formulations and the pathophysiology of acute 24-hour postoperative pain.
A Neuroprotective Anesthetic Strategy: Ultrasound-Guided Dual Plexus Blockade for Clavicle Fixation Following Decompressive Craniectomy
Introduction: Anesthetic management for non-neurosurgical procedures in patients with recent severe traumatic brain injury (TBI) presents a formidable challenge. General anesthesia carries inherent risks of hemodynamic instability and increased intracranial pressure (ICP), which can precipitate devastating secondary brain injury. Regional anesthesia offers a neuroprotective alternative, though its application in this specific high-risk population is not extensively documented. Case presentation: A 24-year-old male, ASA status III-E, required open reduction and internal fixation of a clavicle fracture six days after an emergency decompressive craniectomy for an acute epidural hematoma. To mitigate neurological risk, a definitive anesthetic plan consisting of an ultrasound-guided dual plexus blockade was implemented. This involved a combination of an interscalene brachial plexus block (15 mL of 0.375% levobupivacaine) and a superficial cervical plexus block (10 mL of 0.375% levobupivacaine), supplemented with light, non-opioid sedation using dexmedetomidine. The 150-minute surgery was completed with exceptional hemodynamic stability, no requirement for airway manipulation, and no anesthetic or surgical complications. The patient remained comfortable and neurologically intact throughout. Conclusion: This case demonstrates that an ultrasound-guided dual plexus blockade is a safe, effective, and neurologically protective primary anesthetic technique for clavicle surgery in the post-craniotomy patient. By providing dense surgical anesthesia while preserving stable cerebral perfusion pressure, this approach represents a superior alternative to general anesthesia in this fragile patient population. We advocate for its consideration in similar clinical scenarios.
Determinants of Postoperative ICU Admission in the Elderly: A Prospective Multicenter Study of Elective Surgeries in Indonesia
Introduction: The increasing global geriatric population presents significant challenges for surgical care, particularly regarding the allocation of Intensive Care Unit (ICU) resources. This study aimed to identify determinants of postoperative ICU admission among elderly patients in Indonesia, a setting with a rapidly aging demographic. Methods: We conducted a prospective, multicenter cohort study across 15 Indonesian hospitals from February to April 2021. Patients aged ≥60 years undergoing elective surgery were enrolled via consecutive sampling. Data on patient demographics, American Society of Anesthesiologists (ASA) physical status, Charlson Comorbidity Index (CCI), and type of anesthesia (general vs. regional) were collected. The primary outcome was postoperative ICU admission. Multivariate logistic regression was used to identify independent predictors. Results: Of 893 patients enrolled, 18.8% required postoperative ICU admission. The final multivariate model revealed that a higher ASA physical status was the strongest predictor of ICU admission (Odds Ratio [OR] 4.13; 95% CI 2.88-5.92; p < 0.001). The administration of general anesthesia was also independently associated with a significantly increased likelihood of ICU admission compared to regional anesthesia (OR 2.77; 95% CI 1.83-4.19; p < 0.001). While the CCI was a significant factor in unadjusted analyses, its effect was attenuated after inclusion of the ASA score. Conclusion: ASA physical status and the choice of general anesthesia are powerful, independent determinants of postoperative ICU admission in the Indonesian geriatric surgical population. These findings highlight the critical role of preoperative physiological assessment and suggest that the choice of anesthetic technique has significant implications for postoperative resource needs.