Utami NP, Rachmadhianto R, Wiyono MR
… +2 more, Nugraha SA, Santoso AB
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 41181244
·
Full text
BACKGROUND AND AIMS: The mechanism of paradoxical reaction is still a big question for the medical world, but several theoretical approaches have arisen. Midazolam, a high-potency benzodiazepine, carries a higher risk of...BACKGROUND AND AIMS: The mechanism of paradoxical reaction is still a big question for the medical world, but several theoretical approaches have arisen. Midazolam, a high-potency benzodiazepine, carries a higher risk of paradoxical reaction. Paradoxical reactions associated with midazolam are often misunderstood and mismanaged, with clinicians frequently attributing them to factors like inadequate dosing or low sedation levels. This leads to the common practice of escalating midazolam dosage or exploring alternative sedatives, despite flumazenil offering a safer solution theoretically. Flumazenil emerges as a viable antidote as it swiftly and effectively reverses paradoxical reactions, proving to be a safer alternative to dose escalation strategies. MATERIAL AND METHODS: In this systematic review, we conducted a search regarding the use of flumazenil in midazolam-induced paradoxical reactions over a quarter-century period (1998-2023) in three databases. We include 10 case reports presenting a total of 14 cases, which adhered to the specified inclusion criteria. RESULT: We selected 10 case reports published from 1998 to 2023 with a total of 14 cases. Study characteristics, patient demographics, midazolam dose and administration route, incident of paradoxical effect, flumazenil dose and administration route, and outcome of flumazenil administration. CONCLUSIONS: All the cases showed the prosperous effectiveness of flumazenil in reducing paradoxical reaction symptoms with no adverse effect on hemodynamics. Ongoing research and study in this field are essential to refine protocols and enhance patient outcomes.
Biswal M, Reddy A, Sarna R
… +4 more, Singh N, Chauhan R, Meena SC, Luthra A
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 41181242
·
Full text
BACKGROUND AND AIMS: Pain on propofol injection (POPI) leads to intense patient discomfort during the induction of anesthesia. This study aimed to compare the efficacy of intravenous dexmedetomidine and topical cold ther...BACKGROUND AND AIMS: Pain on propofol injection (POPI) leads to intense patient discomfort during the induction of anesthesia. This study aimed to compare the efficacy of intravenous dexmedetomidine and topical cold thermotherapy in the relief of POPI. MATERIAL AND METHODS: This randomized controlled trial was conducted on 274 adults undergoing elective surgery under general anesthesia. Patients received dexmedetomidine (0.25 µg/kg) following the application of a tourniquet proximal to the intravenous cannulation site for 30 s (Group D, n = 137), or an ice pack gel (260 mm × 125 mm) was applied proximal to the site of the cannula for 1 min (Group T, n = 137). The primary objective was to assess and compare the incidence and severity of POPI using the McCrirrick and Hunter Scale. The secondary objectives included the comparison of the induction dose of propofol and the hemodynamics (heart rate, blood pressure) at induction, along with the assessment of the presence of discomfort following ice gel pack application. RESULTS: The incidence of pain was greater in Group D as compared to Group T (54.74% v/s 29.17%, < 0.001). The severity of pain was also greater in Group D as compared to Group T, (pain scores ≥2, Group D v/s T,33 (24%) v/s 5 (3.6%), < 0.001). The incidence of pain scores 1 and 2 was also higher in Group D as compared to Group T [pain score 1: 42 (30.7%) v/s 35 (25.5%), = 0.348; pain score 2: 27 (19.7%) v/s 4 (2.9%), < 0.001]. There was no significant difference in the induction dose of propofol and hemodynamic variables between the groups. CONCLUSION: The application of ice gel pack thermotherapy is associated with a significant reduction in POPI as compared to pre-treatment with dexmedetomidine (0.25 µg/kg), with no significant adverse effects.
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 41181241
·
Full text
Lung transplantation is considered the curative treatment of end-stage lung disease. Severe chronic obstructive pulmonary disease (COPD), interstitial lung disease, cystic fibrosis, idiopathic and secondary pulmonary art...Lung transplantation is considered the curative treatment of end-stage lung disease. Severe chronic obstructive pulmonary disease (COPD), interstitial lung disease, cystic fibrosis, idiopathic and secondary pulmonary artery hypertension are the main indications for lung transplantation. It can either be a single lung transplant as in COPD or pulmonary fibrosis or a bilateral sequential lung transplant as in suppurative lung disease (bronchiectasis, cystic fibrosis) and severe pulmonary hypertension. If cardiac decompensation is associated with the end-stage lung disease, combined heart-lung transplantation can be considered. Anesthesiologists have a significant role to play in the multidisciplinary assessment of the recipient before fitness for listing, pretransplantation bridging by extracorporeal life support (ECLS), anesthetic management during organ retrieval and implantation, implementation of the complex perioperative protocols, and management of one-lung anesthesia. Titration of intraoperative anticoagulation, hemodynamic management, close liaison with the perfusionist during cardiopulmonary bypass or extracorporeal membrane oxygenation, and performing transesophageal echocardiography also fall under the shared responsibility of the anesthesiologist. As part of the core team, anesthesiologists also actively take part in the postoperative care protocols, ventilatory and hemodynamic management, maintaining ECLS, immunosuppressant administration, pain management, and proactive management of complications. After half a century since its inception, lung transplantation is still considered a very high-risk procedure with significant perioperative morbidity and mortality. Because of its complexity, not too many centers are doing it worldwide. Till now, in our center, we have conducted 15 bilateral sequential lung transplants. Although we did not list any recipient from pulmonary hypertension point of view, most of our patients showed very high pulmonary pressures when measured by the pulmonary artery (PA) catheter intraoperatively, some even showing >100 mmHg. The article is a culmination of our experience and knowledge gained so far on this challenging procedure. We hope that in the near future, many centers will start their lung transplantation program and our article will be helpful in formulating protocols as per the available resources in our country.
Singh S, Chaturvedi A, Bindra A
… +2 more, Dube SK, Devarajan Sebastian LJ
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 41181240
·
Full text
BACKGROUND AND AIMS: Hypovolemia and hypotension are the main risk factors for the development of vasospasm or delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to compare the...BACKGROUND AND AIMS: Hypovolemia and hypotension are the main risk factors for the development of vasospasm or delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to compare the duration of hypovolemia and hypotension between goal-directed fluid therapy (GDFT) and standard fluid therapy (SFT) in patients undergoing endovascular therapeutic procedures for aSAH. MATERIAL AND METHODS: Twenty patients were enrolled in this single-center, prospective, randomized controlled, and double-blind study. Patients were randomized into the GDFT group ( = 10) and SFT group ( = 10). A cardiac output monitoring device was used in both groups to calculate the duration of hypovolemia and hypotension. Appropriate statistical tests were used, and a value < 0.05 was considered statistically significant. RESULTS: The demographic profile was comparable between both the groups. Fifty percent of the study population was hypovolemic before the procedure. The total duration of hypovolemia and hypotension [median (minimum-maximum)] was 3.66 min (0-10.66) and 4 (0-30) min ( = 0.82) and 4.33 (3-6.66) min and 4.66 (3.33-7.33) min ( = 0.09) in GDFT and SFT groups, respectively. Patients in the GDFT groups received significantly lower volumes of intraprocedural crystalloids. However, the total volume of fluids used was comparable between the groups. CONCLUSIONS: Preprocedural hypovolemia is prevalent among patients scheduled for endovascular therapeutic procedures for aSAH. Duration of intraprocedural hypovolemia and duration of hypotension is comparable between GDFT and SFT groups in patients undergoing endovascular therapeutic procedures for aSAH. Hence, GDFT offers no distinctive advantage over SFT and should be individualized to specific patient needs (and not generalized to all the patients) undergoing endovascular therapeutic procedures for aSAH.
Malhotra N, Bansal S, Kumar A
… +3 more, Goyal S, Mohanty A, Sinha N
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 41181239
·
Full text
BACKGROUND AND AIM: Genicular nerve block has recently become a promising treatment option along with radiofrequency ablation in the management of osteoarthritis of the knee. MATERIAL AND METHODS: Sixty patients of age a...BACKGROUND AND AIM: Genicular nerve block has recently become a promising treatment option along with radiofrequency ablation in the management of osteoarthritis of the knee. MATERIAL AND METHODS: Sixty patients of age above 50 years with a pain pattern consistent with osteoarthritis of the knee, with their X-ray knee joint findings corresponding to their clinical symptoms, and with a failure to respond to conservative treatment were included in this study. The patients were divided into two groups of 30 each as follows: group I: patients were administered fluoroscope-guided radiofrequency ablation of genicular nerve using RF electrode set to a temperature of 60℃ for 120 sec and group II: patients were administered fluoroscope-guided genicular nerve block using 9 ml drug solution comprising 8 ml of 0.25% bupivacaine plus 1 ml (40 mg) of methylprednisolone. RESULTS: Both techniques of knee injection were effective and provided good pain relief to the patients with symptomatic osteoarthritis of the knee. Pain scores were clinically less in group I compared to group II at all time intervals of the study period. However, they were statistically significant between the two groups at 2, 3, 6, and 12 months ( < 0.05) with lesser Numerical Rating Scale in group I compared to group II. Western Ontario and McMaster Universities osteoarthritis index was clinically better in group I at all time intervals of the study period, but was statistically significant at 2 weeks, 1 month, and 12 months after the procedure ( < 0.05). CONCLUSIONS: Fluoroscope-guided radiofrequency ablation of genicular nerve is better than fluoroscope-guided genicular nerve block in terms of improvement in pain score, physical status, and patient satisfaction.
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 40635843
·
Full text
BACKGROUND AND AIMS: Caudal block is a part of multimodal analgesic regimen to alleviate pain in pediatric patients undergoing variety of surgeries. This study compares the effectiveness of caudal versus intravenous dexm...BACKGROUND AND AIMS: Caudal block is a part of multimodal analgesic regimen to alleviate pain in pediatric patients undergoing variety of surgeries. This study compares the effectiveness of caudal versus intravenous dexmedetomidine as an additive to caudal bupivacaine for prolonging analgesia in children posted for elective lower abdominal surgeries. The level of sedation and hemodynamic effects through both routes were also compared. MATERIAL AND METHODS: Ninety-six children (aged 1-8 years) of either gender scheduled for elective lower abdominal and pelvic surgeries were prospectively enrolled and randomized into two groups of 48 each: Group A (caudal bupivacaine + caudal dexmedetomidine) and Group B (caudal bupivacaine + intravenous dexmedetomidine). The postoperative pain was monitored using the Face, Legs, Activity, Cry, Consolability (FLACC) scale, and sedation was assessed using the Ramsay sedation scale (RSS). RESULTS: The degree of analgesia was comparable in both groups in the initial hours after surgery. Significantly higher FLACC scores were seen in Group B at 8 h (- 0.016), 12 h ( < 0.001), and 16 h ( < 0.001), with 89.58% patients needing two rescue analgesic doses. RSS was higher in Gr=oup A till 12 h postsurgery. CONCLUSION: Caudal dexmedetomidine with bupivacaine provides improved analgesia after 8 h of surgery in comparison to caudal bupivacaine with intravenous dexmedetomidine in children undergoing lower abdominal surgeries.
Malviya AK, Gupta A, Kumar V
… +3 more, Gupta J, Deepika, Khanna P
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 40635842
·
Full text
Pregnancy is a period marked by significant hormonal fluctuations, which can influence pain perception. There are only a limited number of analgesic options that are considered safe for newborns and mothers. Understandin...Pregnancy is a period marked by significant hormonal fluctuations, which can influence pain perception. There are only a limited number of analgesic options that are considered safe for newborns and mothers. Understanding the impact of pregnancy hormones on pain sensitivity can be crucial for effective pain management during childbirth and the postpartum period. The literature shows encouraging evidence of the role of pregnancy hormones on pain modulation, with some studies suggesting a potential reduction in pain sensitivity. Studies have shown progesterone to be associated with reduced post-cesarean pain scores and anesthesia requirements, while oxytocin levels inversely correlated with post-cesarean pain severity in some studies. However, the overall evidence remains inconclusive, indicating a need for further research to elucidate the complex mechanisms underlying hormonal modulation of pain perception during pregnancy and postpartum accurately. This narrative review summarizes the available literature to provide insights into the mechanisms and role of pregnancy hormones including progesterone, estrogen, and oxytocin in pain modulation during pregnancy, delivery, and the peripartum period. Future research should focus on clarifying the mechanisms through which pregnancy hormones influence pain perception and identifying individual factors that may contribute to variability in pain sensitivity among pregnant individuals. Well-designed randomized controlled trials should be planned to evaluate the effect of hormonal therapy on pain modulation in the peripartum period. This knowledge would help to generate evidence and design pain management protocols for obstetric patients.
Chowdhury SR, Bindra A, Singh GP
… +2 more, Mahajan C, Khan MA
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 40635839
·
Full text
BACKGROUND AND AIMS: Traumatic cervical spine injury (tCSI) is associated with an increased risk of postoperative pulmonary complications (POPC) after surgical fixation. Sugammadex provides superior neuromuscular recover...BACKGROUND AND AIMS: Traumatic cervical spine injury (tCSI) is associated with an increased risk of postoperative pulmonary complications (POPC) after surgical fixation. Sugammadex provides superior neuromuscular recovery; however, its effectiveness in reducing POPC in tCSI remains unclear. The primary outcome of this study was the ultrasonographic lung aeration score (LAS) at 24 hours after surgery. Secondary outcomes included extubation success in the operation theatre, POPC, length of intensive care unit stay, duration of mechanical ventilation, need for tracheostomy, hospital stay after surgery, and in-hospital mortality. MATERIAL AND METHODS: In this prospective, double-blinded, randomised control trial, 75 patients undergoing elective fixation of tCSI were randomly allocated to either the neostigmine (N) group ( = 37) or sugammadex (S) group (n = 38) for neuromuscular blockade (NMB) reversal. A value less than 0.05 was considered statistically significant. RESULTS: There was no significant difference in LAS at 24 hours between groups [median (range) LAS: 2 (0-18) in the N group, 2 (0-19) in the S group] ( = 0.632) or in any other secondary outcomes. The incidence of POPC was 27.03% in the N group and 26.32% in the S group ( = 0.944) Exploratory analysis did not find any difference in outcomes based on the level [high (C1-C4) vs. low (C5-C7)] or severity [American Spinal Injury Association (ASIA) impairment scale: A, B vs. C, D, E] of spinal injury ( > 0.05). A LAS of 4 at 24 h predicted the development of POPC within 7 days with 80% sensitivity and 87.27% specificity (area under the receiver operator characteristics curve: 0.9032). CONCLUSION: In tCSI, NMB reversal using either sugammadex or neostigmine resulted in comparable LAS at 24 h postoperatively following cervical spine fixation. Additionally, a LAS of 4 was found to be a strong predictor of POPC within a 7-day follow-up period.
Jagadish A, Babu S, Sukesan S
… +3 more, Dash PK, Gadhinglajkar SV, Radhakrishnan BK
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 40635837
·
Full text
BACKGROUND AND AIMS: The main aim of this study was to evaluate the efficacy of real-time intraoperative transesophageal echocardiography (TEE) in guiding the central venous catheter (CVC) tip placement at the superior v...BACKGROUND AND AIMS: The main aim of this study was to evaluate the efficacy of real-time intraoperative transesophageal echocardiography (TEE) in guiding the central venous catheter (CVC) tip placement at the superior vena cava (SVC)-right pulmonary artery (RPA) junction. MATERIALS AND METHODS: One hundred patients aged between 18 and 65 years undergoing elective cardiac surgery were enrolled in the study. In the operation room, under ultrasound guidance, right internal jugular vein was punctured and CVC was inserted. The primary outcome was to determine the accuracy of placing the CVC tip under TEE guidance at the SVC-RPA junction by intraoperative surgical palpation and to correlate between the preoperative chest radiograph-predicted CVC depth and the TEE-guided placement of CVC depth. The secondary outcomes were to evaluate the position of CVC tip in relation to the carina in postoperative chest radiograph and the incidence of complications. RESULTS: A total of 98 patients were included in the analysis. The CVC tip was palpable by the surgeon intraoperatively at the SVC-RPA junction in 76 patients (77.6%). A significant direct correlation was observed between the predicted preoperative CVC depth and TEE-guided placement of CVC depth ( = 0.7441, < 0.0001). In the postoperative chest radiograph, 78 (79.5%) patients had the CVC tip positioned above the carina. Twenty-nine patients had atrial ectopics and six patients had ventricular ectopics during CVC insertion. CONCLUSIONS: TEE-guided SVC-RPA junction is an accurate landmark for the intraoperative positioning of CVC tip in the extra-pericardial portion of SVC to prevent life-threatening cardiac complications.
J Anaesthesiol Clin Pharmacol
· 2025 · PMID 40635835
·
Full text
Supraglottic airway devices (SADs) have a great application as an alternative to tracheal intubation, prompting a paradigm shift in routine anesthetic practice. However, its usage in neuroanesthesia is limited and debata...Supraglottic airway devices (SADs) have a great application as an alternative to tracheal intubation, prompting a paradigm shift in routine anesthetic practice. However, its usage in neuroanesthesia is limited and debatable, considering the clinical challenges and complexity of neurosurgical procedures. Even though literature evidence exits regarding successful airway management with SADs in neurosurgery, there is no clear-cut evidence or consensus among anesthesiologists. Articles were searched in PubMed and Google Scholar by using the keywords "Supraglottic airway" AND "Laryngeal Mask" OR "LMA" AND "Craniotomy" over the past 30 years. In addition, a manual search was performed (with additional keywords "neurosurgery," spine surgery," "I-gel," "ILMA," "awake craniotomy," "radiology," "electroconvulsive therapy," and "magnetic resonance imaging") to retrieve additional articles. The primary goal of this narrative review is to determine the applicability of SADs in various neurosurgical settings. According to the review, SADs play an important role as a rescue device during intraoperative emergencies such as accidental tracheal extubation (supine, lateral, and prone positions with head fixed on cranial pins), sudden airway loss due to seizure during awake craniotomy, postoperative airway loss following trans-nasal pituitary surgeries, and macroglossia. SADs can be used successfully for short-duration minimally invasive elective procedures such as cranioplasty, burr hole evacuation of subdural collection, battery implantation for deep brain stimulation, vario-guided biopsies, and minimally invasive spine surgeries. Furthermore, SADs serve a significant function in blunting extubation responses, thereby preventing cerebral edema and tumor bed hemorrhage. Only a few studies have supported the use of SADs in long-duration major intracranial tumour surgeries, making its use controversial in major surgeries where intracranial pressure control is the key. The SADs also have clinical utility in various non-operating room neuroanesthesia procedures.