Search Results (115)

Background/Objectives: Safe anesthesia and effective pain management in conflict-affected regions are limited by violence, damaged infrastructure, disrupted supply chains, medication and equipment shortages, and loss of trained personnel. This narrative review examines major barriers to perioperative care and practical strategies that may improve access and safety. Methods: A structured literature search evaluated peer-reviewed studies, global health reports, and humanitarian publications, primarily from January 2015 through September 2025, with older foundational clinical sources included when directly relevant to specific anesthesia techniques. Results: Major barriers included shortages of essential anesthetic medications and trained providers, damaged healthcare infrastructure, limited monitoring and oxygen availability, and disrupted supply chains. Reported strategies included ketamine-based anesthesia, regional anesthesia, portable oxygen and anesthesia technologies, telemedicine, and task-sharing models supported by training and local health-system capacity. Obstetric, neonatal, and pediatric patients may face additional risks when appropriately sized equipment, blood products, monitoring, and specialist support are limited. Conclusions: Improving anesthesia and pain management in conflict settings requires adaptable clinical strategies, workforce training, reliable access to essential medications and equipment, and partnerships that strengthen local capacity. Evidence remains heterogeneous, and more conflict-specific outcome data are needed. Full article

Background/Objectives: Endoscopic and interventional procedures in pediatric gastroenterology are increasing in number and complexity, and most require sedation or, in selected cases, general anesthesia (GA); children face a higher risk of serious sedation-related adverse events than adults. Written jointly by pediatric gastroenterologists and anesthesiologists, this review provides a practical, evidence-referenced framework for procedural sedation across pediatric gastrointestinal procedures. Methods: We performed a narrative review of PubMed/MEDLINE (inception to 20 June 2026, the date of the final search), prioritizing society guidelines, systematic reviews, randomized controlled trials, and large registries on pediatric procedural sedation, sedative agents, capnography, and high-flow nasal oxygen (HFNO). Results: Sedation should be matched to the procedure and to a structured risk tier, targeting the lightest depth that allows safe completion. Propofol-, ketamine-, and dexmedetomidine-based regimens dominate; remimazolam and esketamine are emerging, but pediatric data are limited. Capnography detects hypoventilation before desaturation, and HFNO reduces hypoxemia in adults, whereas pediatric-specific evidence remains limited and the pediatric subgroup analysis did not reach statistical significance. Higher-risk groups require tailored planning, monitoring, and rescue readiness; most evidence is observational or extrapolated from adults. Conclusions: Safe pediatric gastrointestinal sedation combines structured risk assessment, rational drug combinations, capnography-supported monitoring, and consistent complication reporting. Who administers deep sedation, and whether general anesthesia is preferred, should depend on patient and procedural risk together with local regulations, institutional policy, training and credentialing, and rescue capability, within a shared gastroenterology-anesthesiology framework. Adequately powered pediatric trials of HFNO and of remimazolam/esketamine, and long-term neurodevelopmental follow-up, are priorities. Full article

S-ketamine is increasingly used in anesthesia and neurocritical care and has been associated with anticonvulsant and potentially neuroprotective effects. Such neuroprotective effects have been observed particularly in states of severe hyperexcitability, including status epilepticus and spreading depolarizations, in which neuronal energy demand rises sharply and mitochondrial function may become compromised. However, the direct effects of S-ketamine on neuronal oxidative metabolism across different activity states remain incompletely understood. In acute hippocampal slices from 6–12-week-old male and female C57BL/6 mice, cerebral metabolic rate of oxygen (CMRO₂) was quantified using depth-resolved tissue oxygen measurements under baseline conditions, during electrical stimulation, kainate-induced gamma oscillations, and Mg²⁺-free-induced epileptiform activity. Extracellular potassium dynamics and flavin adenine dinucleotide autofluorescence were recorded to assess neuronal excitability and mitochondrial redox state. S-ketamine was tested at concentrations of 100–1000 µM, and findings were integrated with computational modeling. At 100 µM, S-ketamine did not alter basal or stimulus-evoked CMRO₂ or extracellular potassium handling. During gamma oscillations, S-ketamine modestly reduced CMRO₂ and decreased oscillation frequency. Under Mg²⁺-free conditions, S-ketamine abolished seizure-like events and normalized CMRO₂ to pre-Mg²⁺-free levels. Higher concentrations suppressed stimulus-evoked metabolism and attenuated mitochondrial redox responses, consistent with reduced neuronal activity rather than acute energy failure. These findings demonstrate an activity-dependent neurometabolic profile of S-ketamine characterized by preservation of oxidative metabolism under physiological conditions and reduced metabolic stress during pathological hyperexcitability. Full article

Background: The use of pediatric non-operating room anesthesia (NORA) has increased substantially, yet information regarding current practices in Saudi Arabia remains limited. This study assessed pediatric NORA practices, resources, and reported complications among anesthesiologists in Saudi Arabia. Methods: A cross-sectional online survey was conducted among anesthesiologists practicing in Saudi Arabia. The questionnaire collected information on participant characteristics, indications for pediatric NORA, patient selection criteria, staffing patterns, infrastructure and equipment availability, anesthetic and monitoring practices, recovery arrangements, and post-procedural complications. Results: A total of 234 anesthesiologists participated. Magnetic resonance imaging (97.9%) and computed tomography (85.5%) were the most common indications. Most participants accepted patients with American Society of Anesthesiologists physical status I–III (65.8%) and reported no age restrictions (62.8%). Hospital infrastructure was considered appropriate by 85.0% of respondents. Pulse oximetry (99.6%), electrocardiography (93.2%), capnography (91.5%), and noninvasive blood pressure monitoring (89.7%) were widely used. General anesthesia (80.8%) and deep sedation (70.1%) were the most frequently used techniques. Propofol (88.9%), midazolam (82.5%), and ketamine (73.9%) were the most used sedative agents. Recovery most frequently occurred in dedicated recovery rooms (88.9%). The complications most frequently reported by respondents were delayed recovery (35.5%), agitation or delirium (27.4%), cough (21.8%), and nausea or vomiting (17.5%). Conclusions: Pediatric NORA in Saudi Arabia is commonly performed for imaging procedures and is generally supported by appropriate infrastructure and monitoring practices. Nevertheless, variations in resource availability highlight opportunities for further standardization and quality improvement. Full article

Background/Objectives: Drug-induced sleep endoscopy (DISE) enables dynamic, real-time visualization of the level, severity, and configuration of upper airway collapse during pharmacologically induced sleep, providing anatomical information that polysomnography cannot. It is increasingly used to guide individualized surgical planning in obstructive sleep apnea (OSA), particularly in children with persistent OSA after adenotonsillectomy or at elevated risk of surgical failure. However, the absence of a universally accepted pediatric-specific classification system and standardized protocol continues to limit comparability across studies and the development of evidence-based treatment algorithms. This review evaluates the role of DISE in pediatric OSA, focusing on airway assessment, classification systems, anesthesia protocols, and its impact on surgical decision-making. Methods: A PubMed literature review (2013–2025) identified 42 pediatric-specific studies, including cohort studies, systematic reviews, and meta-analyses. Data were extracted regarding indications, classification scales, anesthetic techniques, safety, and surgical outcomes. Results: DISE provides dynamic visualization of multilevel obstructions often missed during awake examinations. While adult-derived systems such as VOTE are used, pediatric-specific tools (e.g., Chan–Parikh, NAVOTEL, PedDISE-8, IPSES) offer more age-appropriate assessments. Anesthetic choice is a key factor; dexmedetomidine, alone or with ketamine, best approximates non-rapid eye movement (NREM) sleep while maintaining airway tone and stability. DISE findings altered surgical plans in 30–60% of patients, facilitating targeted procedures such as supraglottoplasty, lingual tonsillectomy, and epiglottopexy. Conclusions: DISE is a valuable diagnostic and decision-support tool for complex pediatric OSA. Clinical utility depends on standardized assessment and anesthesia. Further multicenter studies are required to validate classification systems and determine long-term impacts on quality of life. Full article

Two client-owned Lionhead rabbits underwent median sternotomy for mediastinal mass excision. Premedication included methadone, dexmedetomidine, and midazolam, with ketamine added for one rabbit. Anesthesia was maintained with isoflurane in oxygen and a ketamine infusion. Bilateral ultrasound-guided TTP blocks were performed at the level of the second and fifth intercostal spaces using a linear transducer and a spinal needle advanced in-plane in a lateromedial direction. Bupivacaine 0.5% was injected at a total dose of 2 mg/kg per rabbit, divided equally among four injection sites (total volumes of 0.9 mL and 1.0 mL for the first and second rabbits, respectively). Only one rabbit exhibited a brief intraoperative nociceptive response. The second rabbit developed severe postoperative respiratory compromise related to inadequate thoracic drain function and died 4 h after surgery. These cases indicate that the TTP block is technically feasible in rabbits and can contribute to intraoperative analgesia during thoracic surgery. Further studies are needed to evaluate the optimal injectate volume and its distribution, as well as the safety and efficacy of the anesthetic dose. Full article

The reversible effects of general anesthesia can be used to examine how brain activity changes during transitions into and out of altered conscious states. Such changes are commonly tracked using behavioral responses, electroencephalographic recordings, and measures of functional connectivity. These measures, however, reflect processes occurring at lower levels of organization, including the activity of pyramidal neurons, dendritic integration, interneuron function, thalamocortical signaling, and glial regulation of the extracellular environment. Anesthesia does not affect all neural processes equally. Propofol and volatile agents interfere with synaptic transmission and apical dendritic integration, as well as cortical feedback and thalamocortical signaling. The resulting activity is not necessarily absent or uniformly weaker. It is often more stereotyped, temporally restricted, and poorly coordinated between regions. Ketamine produces a different organization. Substantial neural activity and complex cortical responses may persist after behavioral responsiveness has been lost, although deeper anesthesia also produces slower and less complex activity. Responsiveness, environmental connectedness, memory, reportability, and conscious content may therefore become partly uncoupled. Ketamine produces a dissociative state that cannot be interpreted simply as another form of the predominantly restrictive state produced by propofol or volatile anesthetics. This narrative review synthesizes evidence identified through a structured PubMed search to examine how anesthesia reshapes conscious processing and why unresponsiveness or absent recall may not indicate absent experience. Full article

Ketamine produces clinical states ranging from subanesthetic analgesia and dissociation to anesthetic-dose behavioral unresponsiveness. Its electroencephalographic (EEG) effects differ from the slow-delta and frontal-alpha patterns commonly observed with GABAergic-dominant anesthetics and vary with exposure, administration kinetics, and co-administered agents. After anesthetic bolus dosing, ketamine may produce alternating slow-delta and gamma activity; at lower exposures, spectral and connectivity findings are more heterogeneous. When ketamine is added to propofol or volatile anesthesia, bispectral index and spectral-entropy values may remain elevated or increase, limiting their interpretation as stand-alone measures of hypnotic state. Prior syntheses have largely addressed molecular, cellular, and cortical-circuit mechanisms of dissociation; this narrative review instead synthesizes human EEG, connectivity, imaging, and selected mechanistic evidence using a dose–state framework. We distinguish behavioral responsiveness, environmental connectedness, and conscious experience; assess which network measures are technically derivable from clinical scalp recordings; and consider implications for operating-room and critical-care monitoring. Available evidence supports a cautious interpretation of processed indices and greater attention to the raw EEG, spectrogram, background hypnotic, administration pattern, and clinical context. Validated ketamine-specific EEG biomarkers and prospective monitoring algorithms are not yet available. Potential links between acute EEG effects and antidepressant mechanisms are discussed as shared upstream pathways rather than a single electrophysiological state. Full article

Introduction: Neuromonitoring during general anesthesia (GA) is recommended to reduce the incidence of postoperative delirium and intraoperative awareness, particularly during total intravenous anesthesia. Guidelines emphasize that anesthesiologists should not rely solely on processed depth-of-anesthesia indices such as the Bispectral Index or Patient State Index but should also interpret the raw electroencephalographic (EEG) waveform and the density spectral array (DSA). Although EEG patterns associated with individual anesthetic agents or combinations of hypnotics and opioids have been described, limited evidence exists regarding EEG activity during multimodal anesthetic regimens. This systematic review aimed to evaluate DSA patterns as pharmacodynamic markers of the cortical effects of GABAergic anesthetics, opioids, and ketamine. Methods: PubMed, Embase, and the Cochrane Library were searched without date restrictions up to September 2025. Eligible studies included adult patients undergoing general anesthesia and reporting raw EEG data or specific DSA patterns associated with the investigated drugs. Risk of bias was assessed using RoB 2 and ROBINS-I according to study design. Owing to the limited number of eligible studies, findings were synthesized narratively. Results: Out of 273 papers screened, 3 studies met the inclusion criteria, comprising 72 patients. The studies achieved an appropriate and stable effect-site concentration of propofol–remifentanil GA, demonstrated by a baseline DSA recorded before ketamine administration. Ketamine administration produced a shift from the baseline alpha–delta pattern to a beta–delta DSA pattern. Conclusions: Ketamine administration during stable propofol–remifentanil anesthesia produces a characteristic shift towards a beta–delta DSA pattern, which may increase processed EEG indices, leading to misinterpretation of anesthetic depth. Further studies are needed to characterize DSA signatures associated with multimodal anesthesia and to identify patterns indicative of adequate anesthetic depth when multiple agents are administered. Full article

Background and Objectives: Hemodynamic instability during anesthesia induction and endotracheal intubation remains a clinically important concern. Low-dose ketamine and intravenous lidocaine may provide complementary effects that improve cardiovascular stability and peripheral perfusion. This pilot study evaluated effects of adding ketamine and lidocaine to a propofol-based induction regimen using mean arterial pressure (MAP) and perfusion index (PI) as monitoring parameters. Materials and Methods: In this prospective observational pilot study, 30 adult patients undergoing elective surgery requiring general anesthesia and endotracheal intubation were allocated to either a standard induction regimen (Group 1: propofol 2 mg/kg and fentanyl 2 μg/kg) or an adjunctive regimen (Group 2: propofol 2 mg/kg, ketamine 0.4 mg/kg, lidocaine 1 mg/kg, and fentanyl 1 μg/kg). Hemodynamic variables and PI were recorded at baseline, after induction, and after intubation. Postoperative sore throat and cough-reflex responses were also assessed. Results: No significant differences between-groups were observed in heart rate, systolic blood pressure, diastolic blood pressure, MAP, or oxygen saturation at any time point. However, MAP decreased significantly within Group 1 after induction (94.9 ± 10.1 vs. 76.9 ± 13.8 mmHg, p < 0.001) and remained lower after intubation (p = 0.001), whereas no significant MAP changes occurred within Group 2. PI increased in both groups but was significantly higher in Group 2 after induction (5.35 ± 2.34 vs. 3.46 ± 2.90, p = 0.043) and after intubation (7.02 ± 2.89 vs. 4.71 ± 2.22, p = 0.020). Postoperative sore throat scores were lower in Group 2 (0.53 ± 0.91 vs. 1.67 ± 1.76, p = 0.035), and cough-reflex scores were also reduced (p = 0.024). Conclusions: The addition of low-dose ketamine and intravenous lidocaine to propofol-based induction was associated with higher perfusion index values and reduced airway-related adverse effects. No statistically significant between-group difference in mean arterial pressure (MAP) was detected. These findings are hypothesis-generating and warrant confirmation in larger randomized trials. Full article

Transient myocardial thickening (TMT) is considered a reversible feline cardiac disease that initially mimics hypertrophic cardiomyopathy. The exact etiopathogenesis remains unknown and is likely multifactorial. General anesthesia and surgery may contribute to the development of TMT in predisposed patients due to systemic inflammation, perioperative stress, surgery itself, anesthetic management, and individual susceptibility. Additionally, inadequate analgesia could result in pain, which triggers a stress response. This stress response could stimulate endogenous catecholamine release and facilitate the development of TMT. In this retrospective study, anesthetic and analgesic protocols were compared between cats with and without TMT following gonadectomy. The study group consisted of 15 cats that presented with congestive heart failure after recent anesthesia and were later suspected of or diagnosed with TMT. The control group consisted of 300 cats without TMT after gonadectomy. All cats were considered healthy prior to gonadectomy based on physical examination; no echocardiography was performed prior to anesthesia. All cats in the TMT group were anesthetized with ketamine and an alpha-2 agonist, which was medetomidine in 14/15 (93.3%) and dexmedetomidine in 1/15 (6.7%) of the cats. In the control group, all cats were anesthetized with ketamine and dexmedetomidine. The ketamine dose was significantly higher (p < 0.001) in the TMT group compared to the control group, with a median dose of 6.78 mg/kg (4.52–10.34) and 4.29 mg/kg (2.08–6.45), respectively. The doses of the alpha-2 agonist and atipamezole were not significantly different. The most commonly administered non-steroidal anti-inflammatory drug was meloxicam in 83.3% of the study group cats and 98.7% of the control group cats. The dose of meloxicam was significantly lower (p < 0.001) in the study group compared to the control group, with median doses of 0.2 mg/kg (0–0.3) and 0.29 mg/kg (0–0.38), respectively. In the control group, 93.0% of the cats received buprenorphine, and 75.0% of males received intratesticular lidocaine. None of the cats in the study group received buprenorphine or intratesticular lidocaine during the procedure. Additionally, oxygen supplementation was significantly different (p < 0.017), and lack of oxygen was associated with the development of TMT. Anesthetic protocols between the two groups were significantly different. However, it is important to note that not all observed complications can solely be attributed to anesthetic or analgesic differences; effects might also be due to different perioperative circumstances. Full article

Background/Objectives: Opioid-free anesthesia (OFA) has emerged as a potential alternative to opioid-based anesthesia (OBA) to reduce opioid-related adverse effects. This meta-analysis compares OFA and OBA with respect to postoperative pain and opioid consumption. Methods: PubMed, Cochrane, and Embase libraries were searched for OFA studies published through 12 June 2025. Randomized controlled trials (RCTs) conducted on adult humans were selected; observational studies, studies including neuraxial anesthesia, and RCTs currently awaiting approval were excluded. A forest plot was used to summarize findings of a random-effects meta-analysis to compare OFA (treatment) and OBA (control). Results: Of 1446 citations found, twenty-nine articles met our inclusion criteria. Twenty-six studies reported pain scores with a 0–10 scale. OFA was associated with lower postoperative pain scores (Hedges’ g = –0.34; 95% CI –0.55 to –0.13; p < 0.001; I² = 84%) but with high heterogeneity, limiting clinical significance or strong interpretation of results. Eleven trials were analyzed for opioid use, showing a small reduction with OFA (Hedges’ g = –0.55; 95% CI –1.10 to –0.005; p = 0.048; I² = 96.22%). Subgroup outcomes favored OFA, with an overall reduction in pain found specifically in endoscopic abdominal surgeries. Some secondary outcomes also indicated potential improved recovery profiles through OFA for certain surgeries. Conclusions: OFA was associated with statistically significant lower postoperative pain scores, along with opioid consumption, but with a small effect size and high heterogeneity when compared to OBA. This is potentially comparable in pain control and opioid consumption with limited clinical significance. Overall, outcomes support the continued controlled study of OFA as an alternative to conventional analgesia. Full article

Background and Objectives: Controlled hypotension during functional endoscopic sinus surgery (FESS) improves surgical field visibility but may pose a risk of subclinical cerebral hypoperfusion. Serum S100Β and neuron-specific enolase (NSE) are established biomarkers of glial and neuronal injury and may reflect perioperative neuroprotection associated with different anesthetic regimens. This study evaluated the effect of four anesthetic protocols on perioperative brain biomarker release during FESS. Materials and Methods: In this single-center, randomized, controlled trial, 88 adult patients (ASA I–III) undergoing FESS under moderately controlled hypotension (mean arterial pressure < 55 mmHg) were allocated to one of four groups: propofol–remifentanil, propofol–remifentanil with ketamine–magnesium, sevoflurane–remifentanil, or sevoflurane–remifentanil with ketamine–magnesium. Serum S100Β and NSE concentrations were measured at three timepoints: early intraoperatively, during hypotension, and at the end of surgery. Biomarker data were analyzed using nested ANOVA and linear mixed-effects models adjusted for relevant covariates. Secondary outcomes included recovery characteristics, surgical field quality, bleeding scores, and perioperative hemodynamics. Results: Baseline demographic and perioperative characteristics were comparable across groups. The group receiving sevoflurane–remifentanil combined with ketamine–magnesium showed the lowest S100B levels (p = 0.01 compared to the propofol–remifentanil group; p = 0.04 compared to the sevoflurane–remifentanil group). Additionally, NSE concentrations were markedly lower in both sevoflurane groups (sevoflurane–remifentanil and sevoflurane–remifentanil plus ketamine–magnesium) compared to the propofol–remifentanil group (p = 0.003 and p = 0.007, respectively). No intergroup differences were observed at baseline and surgical field quality, bleeding, and hemodynamic parameters did not differ significantly among groups. Recovery and extubation times were shortest with propofol–remifentanil, whereas ketamine–magnesium prolonged emergence. Conclusions: Anesthetic technique significantly influences perioperative brain biomarker release during FESS. Sevoflurane-based regimens, with or without ketamine–magnesium, demonstrate more favorable neurobiological profiles under controlled hypotension, although propofol-based anesthesia offers faster recovery. Full article

Although radiotherapy is a cornerstone in the management of several pediatric malignancies, its administration in children poses unique anesthetic challenges. Unlike adults, pediatric patients, particularly younger children, often require repeated sedation or general anesthesia to ensure immobility and reduce psychological distress during daily treatment sessions that may extend over several weeks. This narrative review summarizes current evidence on anesthetic strategies for children undergoing radiotherapy, focusing on clinical indications, pharmacological approaches, safety considerations, and organizational aspects. We discuss the main sedation and anesthesia techniques used in non-operating room anesthesia (NORA) settings, including deep sedation with midazolam, propofol, ketamine, and dexmedetomidine, as well as general anesthesia with laryngeal mask airway management. Particular attention is given to the cumulative effects of repeated anesthetic exposure, airway management challenges in remote radiation environments, and the risk of respiratory and hemodynamic complications. The review also highlights the importance of individualized, protocol-driven management, rapid recovery strategies, and continuous remote monitoring systems. Non-pharmacological interventions and audiovisual-assisted techniques are also discussed as potential strategies to reduce anesthesia requirements in selected patients. A multidisciplinary approach involving anesthesiologists, radiation oncologists, nurses, psychologists, and technical staff is essential to optimize safety, treatment adherence, and overall quality of care. Tailored anesthetic management, supported by standardized protocols and specialized pediatric expertise, remains crucial to balancing procedural efficacy with short- and long-term safety in this vulnerable population. Full article

This case report describes the potential adverse effects of the combination of alpha 2-adrenergic agonists and dissociative anesthetics and discusses its prevention. The cases of 2 dogs and 3 cats, including 4 juvenile (<7 months old) animals and 1 adult cat (2 years old), that presented with dyspnea immediately after induction at local veterinary clinics and were referred to the Seoul National University Veterinary Medicine Teaching Hospital are described. Four animals were premedicated with atropine, and all were anesthetized intravenously using a combination of an alpha 2-adrenergic agonist (medetomidine or xylazine) and a dissociative anesthetic (ketamine or Zoletil^®). Both dogs developed immediate epistaxis, dyspnea, and radiographic evidence of diffuse alveolar infiltration. One dog was euthanized after experiencing seizures. All 3 cats developed anorexia followed by dyspnea within 24 to 48 h post-anesthesia, resulting in death in 2 cats, while 1 cat recovered with symptomatic treatment. The sympathomimetic effects of dissociative anesthetics and vasoconstrictive alpha 2-adrenergic agonists can cause transient hypertension, which can precipitate pulmonary edema and hemorrhage, leading to dyspnea. Either juvenile or atropine-premedicated patients may be at an increased risk, warranting dose adjustment, route selection, and careful monitoring during anesthesia. Full article