Search Results (115)

Background/Objectives: Pterygoid implants are increasingly used to provide distal support in full-arch maxillary rehabilitation, improving biomechanical stability and reducing posterior cantilevers. Despite high reported survival rates, their placement is technically demanding because of the complex anatomy of the pterygomaxillary region and the proximity of critical neurovascular structures. Implant displacement into adjacent deep anatomical spaces is a rare but potentially serious complication. The aim of this report is to describe the management of sequential intraoperative complications involving pterygoid implants—initial migration into the maxillary sinus followed by displacement into the pterygopalatine fossa—and to analyse the technical factors that contributed to them. Case Description: A 68-year-old woman underwent full-arch maxillary rehabilitation with eight implants, including bilateral pterygoid implants. Both pterygoid implants showed progressively decreasing primary stability and migrated into the maxillary sinus. During a salvage attempt, a newly inserted pterygoid implant deviated and was displaced beyond the pyramidal process into the pterygopalatine fossa together with the insertion driver. Cone-beam computed tomography (CBCT) localized the implant—lying medial to the lateral pterygoid plate, anterior to the pterygoid process—and guided a targeted retrieval based on careful blunt dissection, performed in an outpatient setting without general anesthesia or endoscopic assistance. A correctly positioned pterygoid implant was then placed. The anterior implants (insertion torque > 60 N·cm) were immediately loaded; at four months the right pterygoid implant was uncovered, and the left implant retained in the sinus was retrieved and replaced using a trans-sinus technique with elevation of the Schneiderian membrane. Conclusions: This case highlights the importance of accurate, consistent anatomical localization, complete osteotomy preparation, appropriate implant selection, and controlled, torque-monitored insertion during pterygoid implant placement. It also demonstrates that rare displacement of an implant into a deep anatomical space can be safely managed in an outpatient dental setting by experienced clinicians using a structured, image-guided approach. 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

Background and Objectives: The Hypotension Prediction Index (HPI) is a predictive algorithm that enables proactive management of intraoperative hypotension (IOH) and has been integrated into finger cuff devices for practical use in obstetric settings. This study aims to evaluate the effectiveness of HPI in reducing IOH during elective cesarean sections (CS). Materials and Methods: This randomized controlled trial enrolled parturients undergoing elective CS under spinal anesthesia. The parturients were randomized to either the HPI or the control group using non-invasive blood pressure (NIBP) monitoring. The primary outcome was the time-weighted average mean arterial pressure below 65 mmHg (TWA-MAP < 65 mmHg). Secondary outcomes included maternal nausea and vomiting, intraoperative fluid and vasopressor requirements, incidences of hypertension and bradycardia, estimated blood loss, duration of high-dependency unit admission, fetal Apgar scores, umbilical cord pH, and length of neonatal intensive care unit (NICU) stay. Results: A total of 100 parturients were enrolled in the study, with 96 included in the analysis. Baseline demographic characteristics were similar between the groups. The TWA-MAP < 65 mmHg was significantly lower in the HPI group (0.24 [0, 0.70] vs. 1.67 [0.71, 2.57] mmHg; p < 0.001). The incidence of intraoperative and postoperative nausea and vomiting were significantly reduced in the HPI group (p < 0.01). Incidence of intraoperative hypertension and bradycardia, fetal Apgar scores, umbilical cord pH, and length of NICU stay did not differ between the two groups (p > 0.05). Conclusions: HPI-guided management was associated with a reduction in hypotension burden and perioperative nausea and vomiting. Full article

Background: Pharmacokinetic/pharmacodynamic (PK/PD)-guided intravenous anesthesia and target-controlled infusion (TCI) have progressively transformed modern anesthetic practice from empirical drug administration toward individualized, model-informed precision anesthesia. Recent advances in neuromonitoring, closed-loop systems, and artificial intelligence (AI) are further expanding this paradigm. Methods: This Perspective article provides a conceptual and educational synthesis of the historical foundations, mathematical principles, clinical applications, and AI-based perspectives of PK/PD-guided intravenous anesthesia and TCI. Results: The concentration–effect relationship derived from Hill’s equation represents the conceptual basis of modern anesthetic pharmacology. Contemporary TCI systems integrate PK/PD models, effect-site targeting, synergistic drug interactions, and multimodal monitoring to improve anesthetic precision and safety. Recent evidence supports the advantages of total intravenous anesthesia (TIVA) in postoperative recovery outcomes, including reduced postoperative nausea and vomiting, emergence delirium, and improved quality of recovery. Emerging developments include increasingly generalizable PK “supermodels,” adaptive closed-loop control systems, multimodal AI integration, and patient-specific digital twins that may eventually support simulation of physiological responses and optimization of drug administration. However, biological variability, monitoring limitations, signal artifacts, model uncertainty, and the need for prospective validation, regulatory oversight, and continuous clinician supervision remain major challenges to the routine implementation of AI-assisted individualized anesthesia. Conclusions: PK/PD-guided anesthesia and TCI increasingly represent a clinically relevant framework for precision anesthesia, integrating pharmacology, monitoring, adaptive control, and AI-assisted systems. Future developments may progressively reduce the discrepancy between predicted and observed clinical effects, moving anesthetic practice toward continuously adaptive, feedback-driven, and individualized anesthesia care. Full article

A 14-year-old intact female mongrel dog presented for periodontal disease underwent anesthesia for dental procedures. During surgery, the dog developed cardiopulmonary arrest (CPA) characterized by a sudden drop in end-tidal carbon dioxide and pulseless electrical activity. Cardiopulmonary resuscitation was initiated and return of spontaneous circulation was achieved after 20 min. Post-resuscitation imaging revealed moderate pneumoperitoneum, hepatic portal venous gas, and gas within the caudal vena cava without evidence of gastrointestinal rupture or peritonitis. Conservative management including intensive monitoring and supportive care resulted in progressive resolution of these gas accumulations and complete clinical recovery. This is the first veterinary report to describe pneumoperitoneum following CPR during dental surgery. The case broadens current understanding of nonsurgical etiologies of pneumoperitoneum in small animals and demonstrates that conservative management may be a viable option in selected post-resuscitation patients. Full article

Background/Objectives: To evaluate whether gabapentin pretreatment modulates neuronal excitability and attenuates second-eye hyperalgesia in patients undergoing sequential bilateral cataract surgery under monitored anesthesia care with retrobulbar block. Methods: We conducted a prospective, parallel-group, randomized controlled trial with blinded outcome assessors at a tertiary university hospital. Patients aged > 60 years undergoing elective sequential bilateral cataract surgeries with a 1-week interval were enrolled. Participants were randomized 1:1 to receive gabapentin (100 mg three times daily for 1 week between surgeries) or no pretreatment. The primary outcome was the incidence of hyperalgesia, defined as greater intraoperative pain during the second-eye surgery compared to the first. Secondary outcomes included preoperative anxiety level, intraoperative and postoperative pain score, opioid rescue requirements, and surgeon/patient satisfaction for first- and second-eye surgeries. Results: Sixty-four patients (128 eyes) were included and analyzed (31 per group). Hyperalgesia was lower in the gabapentin pretreatment group than in the control group (4 [12.9%] vs. 17 [54.8%], risk ratio 0.24, 95% confidence interval 0.09–0.63, p = 0.001). Maximum intraoperative pain significantly decreased from the first to the second surgery in the gabapentin pretreatment group, whereas it increased in the control group (mean difference [standard deviation], −1.48 [2.14] vs. 0.97 [1.96], p < 0.001). Preoperative anxiety improved similarly in both groups before the second surgery. Conclusions: Gabapentin pretreatment may represent a promising strategy for reducing second-eye hyperalgesia and improving perioperative pain-related outcomes in older patients undergoing sequential bilateral cataract surgery under monitored anesthesia care with retrobulbar block. Full article

Mucopolysaccharidosis (MPS) are a group of inherited lysosomal storage genetic disorders that affect the body’s ability to break down glycosaminoglycans (GAGs) due to the deficiency of required enzymes. This leads to depositions of these GAGs in various tissues and organs resulting in multi-systemic manifestations including pulmonary and sleep related issues. In recent years, there have been significant advancements in therapeutic options and supportive management which have led to the overall improvement in respiratory care, culminating in improved quality of life for MPS patients. Management of pulmonary and sleep disorders in mucopolysaccharidosis requires a multidisciplinary approach due to the multi-systemic affectation of the genetic disorders. Therapeutic options such as enzyme replacement therapy (ERT) and hematopoietic stem cell transplantation (HSCT) have yielded varying success in mitigating respiratory complications. Emerging treatments such as gene therapies have shown exciting and promising results thus far. Supportive therapies such as airway clearance, regular vaccination and use of positive airway pressure devices are also essential. Pre-operative airway and anesthesia planning is critical to mitigate peri-operative and post-operative complications. Early diagnosis, close monitoring and a patient focused individualized approach are essential for respiratory optimization and overall improvement in clinical outcomes. This review article aims to discuss these advancements in a comprehensive format, making it accessible to medical providers who care for this subset of patients. Full article

Background/Objectives: Postoperative nausea and vomiting (PONV) remain frequent after breast surgery despite prophylaxis. This single-center, parallel-group randomized controlled trial evaluated whether intraoperative opioid-sparing anesthesia using dexmedetomidine and lidocaine reduced 48 h PONV compared with opioid-based anesthesia. Methods: Adult women undergoing elective breast surgery were randomized 1:1 to opioid-sparing anesthesia with dexmedetomidine and lidocaine or conventional opioid-based anesthesia with remifentanil. Participants and postoperative outcome assessors were blinded to group allocation; attending anesthesiologists were not blinded. All patients received standardized sevoflurane anesthesia, dexamethasone, ramosetron, quantitative neuromuscular monitoring, and postoperative fentanyl patient-controlled analgesia. The primary outcome was PONV within 48 h after surgery. Results: Among 68 randomized patients, 67 were analyzed (opioid-sparing group, n = 33; control group, n = 34). PONV within 48 h occurred in 8 patients (24.2%) in the opioid-sparing group and 28 patients (82.4%) in the control group (risk ratio, 0.29; 95% confidence interval, 0.16–0.55; p < 0.001; absolute risk reduction, 58.1%; number needed to treat, 1.7). Rescue antiemetic use was lower in the opioid-sparing group in the postanesthesia care unit and at 1 h postoperatively. Pain scores and cumulative opioid consumption were comparable. No Clavien–Dindo grade III or higher complications occurred. Conclusions: Intraoperative opioid-sparing anesthesia was associated with lower 48 h PONV after breast surgery without apparent compromise in analgesia. These single-center findings, from a trial registered after enrollment of one participant, require confirmation in larger prospectively registered multicenter trials. Trial Registration: Clinical Research Information Service (CRIS), KCT0009829. Registered on 10 October 2024. Full article

During deep anesthesia, the EEG becomes discontinuous. Burst-suppression is often an intended target during deep sedation or medically induced coma. Within this state, anesthetic depth is commonly monitored by the suppression ratio (SR), which expresses the fraction of time spent in suppression. However, accumulating evidence suggests that SR remains reactive to external stimulation. We tested whether ambient music commonly played in operating theaters alters the SR in male Wistar rats under sevoflurane, chloral hydrate, or isoflurane anesthesia. To this end, the first 60 s of the Stayin’ Alive audio track by the Bee Gees were played to examine auditory-induced burst-suppression reactivity in an experimental model previously established for intermittent photic stimulation. SR and the burst-suppression reactivity index (BSRi, derived as the decrease in SR during stimulation normalized to pre-stimulation SR) were measured in repeated trials. Auditory stimulation transiently decreased SR under all three anesthetics. This was associated with an increase in the rate of burst occurrence without increased burst duration. The BSRi changes depended on the anesthetic type, comparable to photic stimulation. Our experimental data suggest that the suppression ratio used to monitor targeted burst-suppression reflects both anesthetic depth and the level of ambient stimulation. Ambient sound in the operating theater or intensive care settings could influence EEG-based measures used for anesthesia monitoring. Full article

Postoperative nausea and vomiting (PONV) remain a leading preventable perioperative complication despite advances in anesthetic and surgical care, significantly affecting recovery within Enhanced Recovery After Surgery (ERAS) pathways. ERAS protocols provide a structured, multidisciplinary framework for perioperative optimization; however, variability in the implementation of PONV prevention strategies persists. This narrative review synthesizes current evidence on perioperative strategies for PONV prevention within ERAS pathways, focusing on patient risk stratification, multimodal pharmacologic prophylaxis, anesthetic techniques, and adjunctive non-pharmacologic interventions. We evaluate validated risk prediction tools, including the Apfel score, and highlight the importance of individualized prophylactic strategies based on patient, surgical, and anesthetic risk factors. Multimodal antiemetic regimens, opioid-sparing anesthesia, total intravenous anesthesia (TIVA), and regional techniques are discussed as key components of perioperative management. In addition, non-pharmacologic interventions such as optimized fluid therapy, early mobilization, and supportive perioperative care are reviewed as integral elements of ERAS-based recovery pathways. Complementing existing consensus guidelines, this review provides a practical, workflow-based framework spanning preoperative risk assessment, intraoperative decision-making, and postoperative monitoring for direct application within ERAS protocols. Full article

Background: Intensive care units (ICUs) provide management of critically ill patients requiring continuous monitoring and complex therapeutic interventions. The aim of this study was to analyze the clinical and biological characteristics associated with mortality in patients admitted to the intensive care unit. Methods: This retrospective observational study included 108 adult patients admitted to the Anesthesia and Intensive Care Unit of the “Sf. Apostol Andrei” Emergency County Clinical Hospital in Galați, who were in a coma at the time of admission. Demographic data, comorbidities, clinical parameters and biological biomarkers determined at admission were analyzed. Statistical analysis was performed using the SPSS program and included non-parametric tests (Mann–Whitney U), Spearman correlation analysis, multivariate logistic regression and ROC curve analysis to evaluate the predictive performance of biomarkers. Results: Hypertension (60.2%) and diabetes mellitus (35.2%) were the most common comorbidities. Comparative analysis revealed significant differences between deceased and surviving patients for several biological parameters, including leukocytes, C-reactive protein, LDH, D-dimers, INR and APTT. In multivariate analysis, LDH (OR = 0.998; p < 0.001) and APTT (OR = 0.951; p = 0.033) remained independently associated with mortality. ROC analysis revealed good discrimination capacity for LDH (AUC ≈ 0.805) and moderate performance for APTT. Conclusions: Determination of LDH and APTT at the time of admission to the ICU may provide useful information for assessing the prognosis of critically ill patients and for early stratification of mortality risk. 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

Background/Objectives: Wolfram syndrome type 1 (WS1) is a rare, progressive, multisystem neurodegenerative disorder characterized by diabetes mellitus, optic atrophy, diabetes insipidus, and sensorineural hearing loss. As survival has improved, an increasing number of affected women are reaching reproductive age. However, evidence on pregnancy and peripartum management in WS1 remains scarce, and practical guidance is limited. This case report describes the multidisciplinary management of pregnancy and delivery in a woman with genetically confirmed WS1 and highlights key considerations for peripartum care. Case Presentation: A woman with genetically confirmed WS1 and long-standing multisystem involvement, including diabetes mellitus, diabetes insipidus, neurogenic bladder requiring frequent self-catheterization, progressive neurologic manifestations, and severe sensory impairment, achieved pregnancy through assisted reproduction with oocyte donation and was closely monitored by a multidisciplinary team. Due to persistent breech presentation, a planned external cephalic version was performed at 37 + 5 weeks’ gestation with immediate availability for cesarean delivery. After unsuccessful attempts, cesarean delivery was performed under combined spinal–epidural anesthesia. Peripartum management focused on strict glycemic control, careful monitoring of fluid balance and urine output, neuraxial anesthesia with proactive hemodynamic management, precautions related to the cochlear implant, and tailored communication strategies. Postpartum recovery was favorable, although anemia on postoperative day 1 required transfusion of one unit of packed red blood cells and intravenous iron therapy. Discussion and Conclusions: Pregnancy in WS1 represents a high-risk clinical scenario because of the coexistence of endocrine, urologic, and neurologic comorbidities, while published evidence on peripartum management remains limited. This case supports an individualized, multidisciplinary approach to obstetric and anesthetic planning and the use of a practical framework to optimize peripartum management and enhance maternal–fetal safety in this rare condition. 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

The main distinction between open and laparoscopic ovariectomy (OVE) is pneumoperitoneum (PNP) and anesthesia management. The objective of this study was to evaluate the effect of laparoscopic and open OVE on plasma cortisol, oxidative stress (OS), and cardiorespiratory parameters in dogs under the same anesthesia protocol. Twenty healthy female dogs were assigned to laparotomy OVE (LPTOVE, n = 10) and laparoscopic OVE (LAPOVE, n = 10) groups. OS was assessed using the total oxidant status (TOS), total antioxidant status (TAS), and oxidative stress index (OSI). Blood samples were collected prior to sedation (T0); prior to surgical incision (T1); prior to surgical closure in the LPTOVE group; and prior to the deflation of CO₂ in the LAPOVE group (T2), 2 h after the surgery (T3). The monitored cardiorespiratory parameters were heart rate, respiratory rate, and end-tidal CO₂ (EtCO₂). Cortisol levels at T3 were markedly elevated in the LPTOVE group compared to the LAPOVE group. No substantial changes in TOS, TAS, or OSI between groups were detected. In the LAPOVE group, TOS diminished at T2, but TAS declined and OSI escalated at T3. EtCO₂ levels were elevated in the LAPOVE group at the end of the procedure. These findings support laparoscopic OVE as a less traumatic alternative to open surgery, with careful management of PNP and anesthesia recommended to minimize postoperative stress. Full article