Search Results (537)

For perioperative analgesia in thoracic surgery, epidural anesthesia has long been considered the gold standard. However, as surgical techniques have become less invasive, interest in less invasive analgesic strategies has increased. According to the procedure-specific postoperative pain management (PROSPECT) guidelines published by the European Society of Regional Anesthesia in 2021, epidural anesthesia is no longer recommended as the method of choice for regional anesthesia in video-assisted thoracic surgery (VATS), and thoracic paravertebral block (TPVB) and erector spinae plane block (ESPB) are now recommended. Understanding the effectiveness and limitations of each regional technique is essential to facilitating appropriate anesthetic planning for individual cases. This narrative review summarizes current evidence regarding thoracic epidural anesthesia, TPVB, ESPB, serratus anterior plane block, and emerging intertransverse process block techniques for thoracic surgery. Full article

Shoulder surgery often requires effective regional analgesia, but interscalene brachial plexus block, the current reference technique, is frequently associated with hemidiaphragmatic paresis and upper-extremity motor blockade. These limitations have driven interest in diaphragm-sparing approaches that preserve respiratory and functional recovery. The sub-omohyoid fascial plane block (SOFPB) is an emerging ultrasound-guided interfascial concept that targets the fascial compartment deep to the omohyoid muscle near the superior trunk–suprascapular nerve complex. In this narrative review, SOFPB is considered as an operational umbrella term for closely related sub-omohyoid approaches rather than as a fully standardized single technique. This review summarizes the anatomical rationale, sonoanatomy, proposed mechanisms, technical considerations, and available clinical evidence for SOFPB and related sub-omohyoid approaches in shoulder surgery. Current evidence suggests that sub-omohyoid approaches may provide clinically meaningful analgesia through suprascapular nerve involvement, partial superior trunk coverage, and variable interfascial spread while potentially reducing phrenic nerve exposure compared with conventional interscalene block. However, direct evidence remains limited and heterogeneous, with inconsistent nomenclature, variable injectate volumes, and insufficient standardized assessment of diaphragmatic function, motor preservation, and patient-centered outcomes. Cadaveric dye studies provide anatomical plausibility but should be interpreted as indirect and hypothesis-generating evidence rather than proof of clinical efficacy or respiratory safety. Therefore, SOFPB should currently be regarded as a promising but unvalidated addition to the spectrum of diaphragm-sparing shoulder blocks rather than a replacement for established techniques. Future anatomical imaging studies, dose-finding trials, and head-to-head randomized comparisons are needed to define its optimal role in contemporary shoulder regional anesthesia. Full article

Background/Objectives: Older adults undergoing surgery for intracranial hemorrhagic lesions after head trauma are clinically heterogeneous, and burr-hole drainage for trauma-related chronic or localized subdural hematoma differs substantially from craniotomy for acute lesions. We evaluated whether a protected-airway local/regional analgesia-dominant strategy (LA), in which airway protection was maintained but continuous maintenance-dose general anesthesia was not planned, was associated with shorter intensive care unit (ICU) stay than conventional general anesthesia (GA). Materials and Methods: In this single-center propensity score-matched retrospective cohort study, 330 patients aged ≥65 years with admission Glasgow Coma Scale (GCS) ≤ 8 who underwent surgery between 2015 and 2024 were analyzed. The LA approach was a pragmatic, jointly selected anesthesiologist–neurosurgeon strategy for carefully selected short burr-hole or localized subdural hematoma procedures; it was not an awake technique and not a protocol of leaving an intubated patient without drugs for airway-device tolerance. A protected airway could include a tracheal tube, supraglottic airway, or preexisting endotracheal tube according to clinical context, and titrated analgesic, sedative, or rescue anesthetic medications were permitted when clinically required. Propensity scores were estimated using age, sex, admission GCS, American Society of Anesthesiologists class, and Charlson Comorbidity Index; lesion category, procedure type, antithrombotic therapy, and intraoperative hypotension were examined as major sources of residual confounding. Results: After matching, the LA group had shorter ICU stay (4 [IQR 2–6] vs. 6 [4–10] days; p < 0.001). Negative binomial regression showed a 28% lower expected ICU stay with LA (incidence rate ratio 0.72, 95% CI 0.58–0.89; p = 0.003), and competing-risk analysis showed faster alive ICU discharge (subdistribution hazard ratio 1.41, 95% CI 1.08–1.84; p = 0.012). Conclusions: In this heterogeneous retrospective cohort, the LA strategy was associated with shorter ICU stay, particularly within selected burr-hole-dominant cases. These findings are hypothesis-generating and should not be interpreted as proof of superiority across acute traumatic brain injury, all lesion types, or all neurosurgical procedures. Full article

Moyamoya disease is a progressive steno-occlusive cerebrovascular disorder in which cerebral perfusion may become highly dependent on systemic arterial pressure, arterial carbon dioxide tension, and collateral flow. Encephaloduroarteriosynangiosis (EDAS) is an indirect revascularization procedure that promotes neovascularization over weeks to months but does not immediately augment cerebral blood flow intraoperatively. Anesthetic management therefore requires preservation of cerebral oxygen delivery during a period of persistent physiologic vulnerability. This narrative review presents a practical perioperative framework for EDAS anesthesia, emphasizing maintenance of mean arterial pressure near baseline or modestly above baseline, avoidance of hypotension and hypovolemia, normoxia, normothermia, and careful regulation of carbon dioxide. Hyperventilation should be avoided because hypocapnia can reduce cerebral blood flow through vasoconstriction, while excessive hypercapnia may contribute to regional maldistribution or steal physiology. Raw electroencephalography may provide cortical ischemia surveillance where available, whereas somatosensory evoked potentials, motor evoked potentials, near-infrared spectroscopy, and transcranial Doppler should be considered adjunctive and institution-dependent. A structured algorithm that integrates hemodynamics, ventilation, oxygen delivery, anesthetic depth, neuromonitoring, and surgical communication may support the timely recognition and correction of intraoperative hypoperfusion. Full article

Background and Clinical Significance: Hyaluronic acid fillers are currently the most widely used materials in aesthetic medicine and represent one of the most frequently performed minimally invasive procedures worldwide. Vascular occlusion is the most severe complication associated with this type if filler injections due to the risk of tissue necrosis and permanent sequelae. Early recognition and precise identification of the affected vascular territory are essential to prevent irreversible damage. Case Presentation: his report describes a case of infraorbital artery occlusion with retrograde extension to the anterior superior alveolar artery and associated gingival ischemia, highlighting the role of high-frequency ultrasound in diagnosis and management. A 60-year-old woman developed vascular occlusion following supraperiosteal HA injection in the medial cheek. Clinical findings included livedo reticularis in the infraorbital and nasal regions, along with ipsilateral gingival anesthesia and mucosal ischemia. High-frequency ultrasound was used to assess the extent and mechanism of vascular involvement. A targeted treatment approach was implemented using low-dose hyaluronidase (100 IU/mL), with 200 IU administered in the infraorbital region and an additional 100 IU delivered under ultrasound guidance to the affected alveolar branch. Ultrasound examination revealed extrinsic compression of the infraorbital artery and secondary occlusion of the anterior superior alveolar artery consistent with retrograde embolization. Following image-guided administration of hyaluronidase, complete reperfusion was achieved, with resolution of both cutaneous and gingival ischemia and no functional or aesthetic sequelae. Conclusions: High-frequency ultrasound provides critical diagnostic information in vascular complications after HA filler injection, allowing for accurate identification of the mechanism and extent of vascular involvement. Ultrasound-guided low-dose hyaluronidase may represent an effective and safe strategy to restore perfusion while minimizing unnecessary enzyme exposure and associated adverse effects. Full article

Background and Objectives: With the rising number of geriatric surgical patients, postoperative cognitive dysfunction (POCD) has become a major concern, linked to impairments in memory, attention, and executive function. POCD increases morbidity, prolongs hospitalization, and diminishes quality of life. This review examines the mechanisms underlying POCD, with emphasis on neuroinflammation, blood–brain barrier (BBB) disruption, and oxidative stress, and evaluates the impact of anesthetic techniques on cognitive outcomes in the elderly. Materials and Methods: This narrative review used a targeted literature search to identify relevant clinical, translational, and mechanistic evidence on POCD in older surgical patients. The evidence was synthesized qualitatively, with attention to heterogeneity in study populations, anesthetic techniques, cognitive assessment methods, and follow-up duration. Results: Neuroinflammation, BBB compromise, oxidative stress, perioperative stress responses, and patient vulnerability appear to contribute to POCD. Evidence comparing anesthetic techniques remains heterogeneous. Some studies suggest associations between general anesthesia, volatile agents, and early postoperative cognitive changes, whereas other comparative and randomized studies do not demonstrate consistent long-term cognitive differences between general, regional, neuraxial, volatile, and intravenous anesthetic approaches. Regional and neuraxial techniques may reduce anesthetic or opioid exposure in selected patients, but they should not be interpreted as definitively superior for POCD prevention. Adjunctive and multimodal strategies, including dexmedetomidine and non-opioid analgesics, show potential benefits, although evidence remains variable. Conclusions: Individualized anesthetic planning, early risk stratification, avoidance of excessive anesthetic depth, hemodynamic optimization, multimodal analgesia, and postoperative recovery strategies may help reduce modifiable contributors to POCD. Current evidence does not support a definitive hierarchy of anesthetic techniques for preventing POCD, and further high-quality studies are needed. Full article

Background: Penetrating keratoplasty (PK) is a technically demanding corneal transplant procedure frequently performed in elderly patients with substantial systemic comorbidities. In this population, an anesthetic strategy that ensures hemodynamic stability, cooperative sedation, adequate analgesia, and preserved spontaneous ventilation is highly desirable. Dexmedetomidine, a highly selective alpha2-adrenergic agonist, provides “cooperative” sedation with minimal risk of respiratory depression and additional sympatholytic benefits. Methods: This single-center retrospective observational case series included 50 consecutive patients (American Society of Anesthesiologists [ASA] II–III, age 50–90 years) undergoing PK under sub-Tenon block combined with continuous dexmedetomidine infusion. Dexmedetomidine was administered without a loading bolus at 0.7 mcg/kg/h for 10–15 min, then reduced to 0.5 mcg/kg/h, targeting a Ramsay Sedation Scale (RSS) score of 2–3. The sub-Tenon block was performed using a mixture of levobupivacaine 0.5% and lidocaine 2% (3–5 mL). Heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO₂) and RSS were recorded in nine predefined perioperative phases. Data were analyzed descriptively. Results: The mean age was 72 ± 9 years; 52% of patients were ASA III. Hypertension was present in all patients; 30% had cardiovascular disease, 28% diabetes mellitus type II, and 30% chronic obstructive pulmonary disease. Progressive, controlled bradycardia was observed (mean HR decreased from 76 to 57 beats/min during graft transplantation), while MAP gradually decreased from hypertensive baseline values (150–160 mmHg) to an optimal intraoperative range of 115–130 mmHg, without episodes of clinically significant hypotension. SpO₂ remained stable at 98–99% throughout all phases, with no episodes of desaturation or need for airway intervention or supplemental oxygen. Target sedation (RSS 2–3) was achieved in all patients (median RSS 3), with preserved spontaneous breathing and cooperation. Sub-Tenon block-related bulging occurred in 6% of cases. No episodes of clinically significant bradycardia, malignant arrhythmia, respiratory compromise, or need to discontinue dexmedetomidine were recorded. No opioids or non-steroidal analgesics were required intraoperatively or in the early postoperative period. Conclusions: The combination of sub-Tenon block and continuous dexmedetomidine sedation without a loading bolus represents a hemodynamically stable and respiratory-safe anesthetic strategy for PK in elderly, high-risk patients. These preliminary, hypothesis-generating findings suggest that the protocol provides stable surgical conditions and a favorable safety profile, justifying future prospective randomized controlled trials to establish its comparative efficacy against general anesthesia or standard sedative regimens. Full article

Lymphatic malformations (LMs) are rare congenital low-flow vascular anomalies that frequently involve the head and neck and may be managed with surgery, laser therapy, sclerotherapy, or multimodal approaches depending on lesion type, size, depth, and relationship with adjacent structures. Ultrasound-guided sclerotherapy with doxycycline is an established treatment option for macrocystic lesions, whereas the practical role of high-frequency superficial ultrasound as a technical adjunct has been less specifically discussed. We report the case of a 32-year-old man presenting with a painless left submandibular swelling of approximately two years’ duration. Magnetic resonance imaging showed a well-encapsulated cystic lesion measuring 56 × 35 mm in the left submandibular region, extending into the internal paralaryngeal space and causing mild compression of the laryngeal wall. Previous fine-needle aspiration cytology had not conclusively established the lymphatic nature of the lesion; therefore, an incisional biopsy was performed and confirmed a macrocystic LM. The patient underwent day-surgery intralesional doxycycline sclerotherapy under real-time high-frequency ultrasound guidance using an 18 MHz hockey-stick transducer. After aspiration of the main cystic compartment through a 25-gauge needle, 100 mg of doxycycline diluted to 10 mg/mL in normal saline was slowly injected under continuous visualization. The procedure was well tolerated under topical local anesthesia, without pain, complications, or adverse effects. A partial clinical reduction was observed after the first session; the treatment was repeated after three months, resulting in apparent complete clinical resolution at one-year follow-up; no post-treatment imaging was available to confirm radiological resolution. This case highlights the potential technical value of high-frequency superficial ultrasonography, particularly for needle positioning, improved delineation of superficial locules, and real-time monitoring of sclerosant distribution. Full article

Objectives: This randomized, single-blind study aimed to compare the effects of ultrasound-guided erector spinae plane block (ESPB), thoracic paravertebral block (TPVB) and intravenous (IV) analgesia on postoperative pain, opioid consumption and quality of recovery in patients undergoing laparoscopic cholecystectomy (LC). Methods: A total of 120 adult patients (ASA I-III) scheduled for elective LC were randomized into three groups: ESPB (GI), TPVB (GII) and IV analgesia (GIII). Bilateral ESPB or TPVB was performed preoperatively; then all patients received standardized general anesthesia and postoperative analgesia including paracetamol, tenoxicam and IV tramadol via patient-controlled analgesia. The primary outcome was 24 h tramadol consumption. Secondary outcomes included pain scores, rescue analgesia requirement, patient satisfaction, postoperative nausea and vomiting, time to first ambulation, length of hospital stay and Quality of Recovery-15 (QoR-15) scores. Results: Twenty-four-hour tramadol consumption was significantly higher in GIII (135.78 ± 22.73 mg) compared with GI (101.05 ± 26.99 mg) and GII (95.67 ± 31.49 mg) (p < 0.001), with no difference between GI and GII. Both static and dynamic pain scores were lower in GI and GII compared with GIII at most time points. Rescue analgesia requirement and patient dissatisfaction were significantly higher in GIII. QoR-15 scores were significantly improved in GI and GII compared with GIII (p < 0.001), while no difference was observed between the regional techniques. Block performance time was shorter with ESPB than TPVB (p < 0.001). No complications were reported. Conclusions: ESPB and TPVB provided effective analgesia and improved recovery after LC compared with IV analgesia alone. Both regional techniques may be considered as components of multimodal analgesia after LC. Full article

Although extensively studied in humans, data on the middle cranial fossa foramina remain limited in dogs, despite their different skull morphology and high relevance to veterinary neurology, surgery and oncology. In this retrospective anatomic study, we aimed to fill this gap by presenting the morphometric data of these foramina in domestic dogs of different breeds, ages, body weights, and skull sizes. The study used CBCT images of 40 dogs. Dogs were divided into three groups (small, medium, and large), regardless of sex, body weight, and breed, using neurocranium length. Then, morphological and morphometric analyses of the foramina were performed. The neurocranium length of each group differed significantly from the others (p < 0.001). In each group, the orbital fissure and round and oval foramina were bilaterally located rostrally to caudally and were of similar size (p > 0.05). While the orbital fissure was a canal in 80% of dogs, in dogs with medium and large skull sizes (17.5%), the spinous foramen showed variation, becoming both a foramen and a canal. The opening sizes increased along with the skull size (p < 0.001); the widest opening was the orbital fissure, and the narrowest opening (except for the spinous foramen) was the oval foramen. The findings may guide skull base surgeries, regional anesthesia, and the diagnosis of cranial nerve dysfunctions. Furthermore, a classification based on neurocranial length is anticipated to provide more objective craniometric measurements in animals with diverse head types and body weights. Full article

Background: The Keystone Island Perforator Flap (KIPF) is a well-established reconstructive option for defect closures but poses challenges in regions with limited skin laxity, such as the pretibial region. This often leads to impaired wound healing and subpar cosmetic results. We examine a modified approach incorporating the fascial release technique to observe both functional and aesthetic outcomes. Methods: A retrospective review was conducted of 20 adult patients who underwent pretibial reconstruction with the modified KIPF at a single institution. All procedures were performed in an office setting under local anesthesia. Data on demographics, comorbidities, flap size, and postoperative outcomes was collected. Results: Patients ranged from 46 to 91 years of age (mean 69). The majority (60%) were female and nonsmokers (90%). Common comorbidities included hypertension (45%), hyperlipidemia (25%), and diabetes (10%). Most procedures (90%) were performed following oncologic excisions. Defect sizes ranged from 1.95 to 17.5 cm². No intraoperative flap failures were seen. Two patients developed minor wound dehiscence, both managed conservatively. Complete wound healing was often seen within one month. Conclusion: The modified KIPF provides a safe, reliable method of pretibial reconstruction. Its low complication rate and feasibility under local anesthesia support its expanded use in anatomically constrained regions. Full article

Background: Total knee arthroplasty is associated with significant postoperative pain. The erector spinae plane block (ESPB) is increasingly used as part of multimodal analgesia, but its duration may be limited. Adjuvants such as dexamethasone and dexmedetomidine may enhance analgesic efficacy; however, direct comparisons between these agents in ESPB remain limited. Methods: In this prospective, randomized, double-blind trial, 90 patients undergoing total knee arthroplasty were allocated to receive ESPB with ropivacaine alone (control), with ropivacaine plus dexamethasone (DEX), or with ropivacaine plus dexmedetomidine (DEM) (n = 30 per group). The primary outcome was time-to-first opioid requirement within 48 h. Secondary outcomes included total opioid consumption, postoperative pain intensity (NRS), and adverse events. Time-to-event analysis was performed using Kaplan–Meier and Cox regression. Results: Time-to-first opioid requirement was significantly prolonged in both DEX and DEM groups compared with control (log-rank p < 0.0001). Median time was 7.85 h (95% CI 7.40–8.50) in control, 13.70 h (12.80–14.50) in DEX, and 12.40 h (11.20–14.30) in DEM. Both DEX (HR 0.036, 95% CI 0.017–0.079) and DEM (HR 0.058, 95% CI 0.028–0.121) significantly reduced the hazard of opioid requirement (p < 0.0001). Total opioid consumption was significantly lower in the DEX group compared with both control and DEM (p < 0.0001), while no difference was observed between DEM and control. Pain scores were lower in the DEX group in the early postoperative period. No statistically significant differences in adverse events were observed between groups. Conclusions: Both dexamethasone and dexmedetomidine prolong ESPB analgesia in total knee arthroplasty. However, dexamethasone provides superior analgesic efficacy without increasing adverse events. Full article

The ultrasound-guided erector spinae plane (ESP) block is a locoregional anesthesia technique primarily aimed at providing analgesia to structures innervated by the dorsal branches of the spinal nerves (DBSN). While this block has been widely studied in dogs, evidence in cats is limited, and only a few cadaveric studies have addressed the lumbar region. The aim of this study was to compare the injectate distribution and staining of the DBSN following ultrasound-guided lumbar ESP blocks performed using either a longitudinal or transverse approach in feline cadavers. A total of 15 feline cadavers were included, with 3 used for anatomical dissection and 12 for ultrasound-guided injections (24 sides). Injections were performed at the level of the third lumbar vertebra (L3) using a mixture of methylene blue, lidocaine, and iopromide (0.4 mL kg⁻¹ per side). Needle placement and injectate spread were guided and confirmed by ultrasonography, followed by computed tomography (CT) and anatomical dissection to evaluate contrast and dye distribution. CT images revealed longitudinal spread of the contrast in all injections, with the transverse approach producing exclusively longitudinal distribution and the longitudinal approach showing occasional ventral spread beneath the transverse processes (25% of sides). Dissections demonstrated staining of a median of 2 DBSN per side for both approaches, predominantly L2–L3, with rare partial staining of ventral branches (VBSN) observed only with the longitudinal approach. The sympathetic trunk was not stained in any injection. No statistically significant differences were observed between approaches, except for L1 DBSN staining, which was identified significantly more frequently with the transverse approach (p = 0.033). These findings indicate that ultrasound-guided lumbar ESP block is anatomically feasible in feline cadavers and that both longitudinal and transverse approaches can result in injectate distribution to the DBSN. Full article

Background and Objectives: This prospective, randomized study aimed to evaluate the effects of different local anesthetic (LA) volume–dose combinations administered during supraclavicular brachial plexus block (SCBPB), a widely used technique in upper extremity surgery. These effects were assessed by analyzing changes in the ratios of optic nerve sheath diameter (ONSD) to eyeball transverse diameter (ETD), obtained by ultrasound (US) and considered indirect measures of intracranial pressure (ICP). Materials and Methods: Sixty four ASA I–II patients aged 18–50 years undergoing upper extremity surgery were randomized into four groups receiving 15 mL (Group A), 20 mL (Group B), 25 mL (Group C), or 30 mL (Group D) of LA (equal volumes of 0.5% bupivacaine and 2% prilocaine). ONSD/ETD ratios were measured bilaterally at baseline, 20, and 60 min. Perfusion index (PI), end-tidal carbon dioxide (EtCO₂), block onset times and block duration were also assessed. Results: Groups C and D showed significant bilateral increases in both ONSDint/ETD and ONSDext/ETD ratios at 20 and 60 min compared with baseline (p < 0.05). Group B demonstrated a significant increase only in the ONSDext/ETD ratio on the block side, whereas Group A showed no significant change. PI increased earlier and more markedly with increasing LA volume–dose. No significant intergroup differences were observed in EtCO₂. In pairwise comparisons, sensory block onset was significantly longer in Group A than in Groups B, C, and D (p < 0.001). Motor block onset was significantly longer in Group A than in Groups C and D, and in Group B than in Group D (p < 0.001). Analgesia duration was significantly shorter in Group A than in Groups B, C, and D, and in Group B than in Groups C and D (p < 0.001). Conclusions: Increasing the LA volume–dose in US-guided SCBPB accelerates sensory and motor block onset and significantly prolongs block duration. A volume-dependent increase in ONSD/ETD ratios was observed on both the blocked and contralateral sides. PI showed an early and marked increase, particularly in high-volume–dose administrations, reflecting block success. Non-invasive EtCO₂ monitoring did not detect significant changes. Full article