Journal of Anesthesiology and Clinical Research

Admission GCS, Age, and Pupillary Response as a Multivariable Triad for Predicting Outcomes Following Emergent Surgery for Traumatic Brain Injury

Ramadhan Saputro — 2025-11-18

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.

Risk-Adapted Anesthesia and Sympathetic Attenuation in Geriatric Cardiometabolic Multimorbidity: Navigating the Limited Physiologic Reserve

Luh Ayu Mahetri — 2025-11-25

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.

Comparative Efficacy of Prophylactic Bolus Phenylephrine versus Ephedrine on Maternal Hemodynamics and Neonatal APGAR Scores in Elective Cesarean Section: A Randomized Controlled Trial

Pande Made Praskita Putra Soma — 2025-12-30

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.

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

Aditya Guna Wicaksono Panatagama — 2026-01-14

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.

Hemodynamic Attenuation During Tracheal Intubation: A Randomized Comparative Analysis of Video vs. Direct Laryngoscopy in Adult Elective Surgery

Imam Safi'i — 2026-01-15

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.

Efficacy of Particulate versus Non-Particulate Corticosteroids as Adjuvants for Popliteal Sciatic Nerve Block: A Randomized Controlled Superiority Trial

Erma Rosita — 2026-01-19

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.

Preserving Spontaneous Ventilation in ASA III Patients: Transtracheal Block as a Primary Anesthetic Strategy for Complex Bronchoscopy

Yoga Indrawan Pratama — 2026-01-19

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.

Precision Anesthetic Management of the Triple-Pathology Parturient: Graded Epidural Technique for Emergency Cesarean Section in Severe Tricuspid Regurgitation, Pulmonary Hypertension, and Systemic Neurofibromatosis

Purwoko — 2026-02-10

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.

Neuroprotective Anesthetic Management Using Thiopental in a 17-Year-Old with Multifocal Epidural Hematoma and Impending Brain Herniation: A Case Report

Sutan Malik Maulana Syah — 2026-02-26

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.

A Rare Complication of Vasovagal Syncope Induced by Pulsed Radiofrequency in a Patient with Cervical Spondylosis and Occipital Neuralgia: A Case Report

Fajar Ristranda — 2026-03-27

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.

Optimizing Patient Blood Management: Successful Intraoperative Cell Salvage During Cesarean Hysterectomy for Placenta Accreta Spectrum - A Case Report

Fathimah Azzahra — 2026-03-30

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.

Anesthetic Management of a Teenage Primigravida with Impending Eclampsia Undergoing Emergency Cesarean Section: A Comprehensive Case Report

Paramita Putri Hapsari — 2026-04-21

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.

Daily Sedation Interruption Versus Continuous Sedation for Reducing Mechanical Ventilation Duration in the Intensive Care Unit: A Meta-Analysis

Indah Ika Suryaningsih H — 2026-04-28

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.

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

Kurnia Hendra Wijaya — 2026-05-04

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.

Opioid-Sparing Anesthetic Strategy with Ultrasound-Guided Superficial Cervical Plexus Block in Pediatric Recurrent Lymphangioma Surgery: A Case Report

Rofiudin Ali — 2026-05-07

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.