A Comparison of Perioperative Complications and Outcomes in Patients Undergoing Cerebral Aneurysm Clipping Performed Ultra-Early (≤ 24 hours) versus Late (> 24 hours): A 7-Year Retrospective Study of 302 Patients.

Objectives The intracerebral aneurysm with subarachnoid hemorrhage (SAH) has a high morbidity and mortality rate. This study aimed to compare the incidences of perioperative complications in ultra-early surgery (within 24 hours) with those in late surgery (> 24 hours). Methods Retrospective data were reviewed for 302 patients who underwent craniotomies with aneurysm clipping between January 2014 and December 2020. Perioperative data were obtained from the medical records and reviewed by the investigators. The complications were compared between ultra-early and late operations. We were interested in major complications such as delayed ischemic neurologic deficit (DIND), intraoperative aneurysm rupture (IAR), and anesthesia-related complications. The short-term (in hospital) and long-term (1 year) outcomes in patients with or without DIND and IAR were compared. The collected data was statistically analyzed. Results Three hundred and two patients were analyzed, and 264 patients had completed follow-up. The ultra-early cases (150 patients) had a higher American Society of Anesthesiologists physical status, a lower Glasgow Coma Scale, and higher Hunt and Hess scales. The surgeons operated on more cases of the anterior cerebral artery as ultra-early operations. The incidence rates of DIND, IAR, severe hemodynamic instability, and cardiac arrest were 5.6, 8.3, 6.3, and 0.3%, respectively, which were not different between groups. However, the reintubation rate was higher in the ultra-early surgery cases (0 vs. 3.3%, p = 0.023). The DIND and IAR patients had poorer short-term (in hospital) outcomes. Conclusions There were no differences in major complications between ultra-early and late craniotomy with aneurysm clipping. However, the reintubation rate was strikingly higher in the ultra-early group. Patients with major complications had early, unfavorable outcomes.

Early Hip Fracture Surgery Within 24 hours did not Reduce the Mortality Rate but Resulted in Less Postoperative Opioid use and a Shorter Length of Stay: A Retrospective Study of 276 Patients From a Tertiary Private Hospital in Thailand.

Introduction: The comparative results of early hip fracture surgery including mortality and postoperative complications in Thailand were not reported. Therefore, we conducted this study to compare the outcomes between patients who received hip surgery within and after 24 hours. Methods: A retrospective study was conducted at a single center, a tertiary private hospital in Thailand. The medical records of patients who were admitted from 2018 to 2020 were reviewed. Patients aged <50 years, high-energy fracture, pathological fractures, or multiple traumas were excluded. The patients were categorized into two groups for comparison: surgery within and surgery after 24 hours groups. The outcome measures were in-hospital, 30-day, and 1-year mortality rates, length of stay, and the incidences and severities of postoperative complications. Results: A total of 276 hip fracture patients were analyzed, with the majority (77.9%) undergoing surgery within 24 hours. Patients who underwent earlier surgery had a significantly shorter hospital stay [6 (4, 9) vs 8 (7, 13) days, P < .001]. The cumulative mortality rates at in-hospital, 30 days, and 1 year were 0%, 1.1%, and 2.5%, respectively. The most common postoperative complications observed were anemia (43.1%) and acute kidney injury (32.6%). However, there were no statistically significant differences in mortality rates (P > .05) or postoperative complications (P = .410) between the two groups. Conclusion: While surgery within 24 hours showed some benefits, such as a shorter hospital stay and reduced pain rescue, it did not reduce mortality or major complications in hip fracture patients.

Incidence, Outcomes, and Risk Factors of Intraoperative Cardiac Arrest During Orthotopic Liver Transplantation.

BACKGROUND: Intraoperative cardiac arrest (ICA) during liver transplantation (LT) is a rare surgical complication that results in devastating outcomes. Moreover, previous worldwide studies have found inconsistencies in the risk factors associated with ICA in LT. METHODS: This was a retrospective cohort study of adult patients who underwent LT between January and October 2021 at Siriraj Hospital, a tertiary care hospital. The incidence of ICA and outcomes of patients who experienced ICA were examined. Risk factors associated with ICA were investigated as a secondary objective. RESULTS: Among 342 patients, the incidence of ICA was 3.5% (95% CI 1.8%-6.1%). Of these, 33.3% died intraoperatively. Among patients with ICA, 41.7% died within 30 days, compared with only 7.6% in those without ICA (P = .002). Moreover, the in-hospital mortality rate of those with ICA was 58.3%, which was significantly higher than that of those without ICA (9.7%, P < .001). However, 41.7% of patients with ICA were discharged alive with long-term survival. Because ICA is a rare event, we found only 2 independent factors significantly associated with ICA. These factors include intraoperative temperature below 35°C, with an odds ratio (OR) of 6.07 (95% CI:1.32-27.88, P = .02) and elevated intraoperative serum potassium, with an OR of 4.57 (95% CI:2.15-9.67, P < .001). CONCLUSIONS: ICA is associated with high perioperative and in-hospital mortality. However, our findings suggest that with effective management of ICA, more than 40% of these patients could be discharged with excellent long-term outcomes. Hypothermia and hyperkalemia were independent risk factors significantly associated with ICA.

Incidence, risk factors and outcomes of early post-operative stroke in a university-based, tertiary care hospital: A 7-year retrospective case-control study.

Most post-operative stroke cases occur within 24 hours. This retrospective case-control study aimed to investigate the incidence, risk factors, and outcomes of early post-operative stroke that occurred within 24 hours after surgery in a university-based tertiary care hospital. Medical records were collected and reviewed between 2015 and 2021. Early post-operative stroke cases were compared with age-matched controls in a 1:3 ratio, and data regarding patient characteristics, intra-operative events, and post-operative outcomes were analyzed. Multiple logistic regression was performed to identify the risk factors for post-operative stroke. The incidence of early (≤24 hours) post-operative stroke was 0.015% (43 out of 284,105 cases). The multivariable analysis revealed that American Society of Anesthesiologists (ASA) physical status ≥3 (adjusted odds ratio [OR]: 3.12; 95% confidence interval [CI]: 1.22-7.99, P = .017), operation time >120 minutes (adjusted OR: 10.69; 95% CI: 3.95-28.94, P < .001), and intra-operative hypotension and inotrope/vasopressor use (adjusted OR: 2.80; 95% CI: 1.08-7.24, P = .034) were risk factors for early post-operative stroke. Compared to the controls, stroke patients had higher rates of planned and unplanned intensive care unit (ICU) admission, length of stay, ventilator use, and death. Despite its low incidence (0.015%), stroke is associated with poor clinical outcomes and increased mortality. Stratification of potential risks and establishment of risk optimization may help reduce stroke incidence.

Postoperative analgesia of intraoperative nefopam in patients undergoing anterior cervical spine surgery: A prospective randomized controlled trial.

BACKGROUND: Nefopam is a non-opioid, non-nonsteroidal anti-imflammatory drug, analgesic drug that inhibits the reuptake of serotonin, norepinephrine, and dopamine. It is widely used as an adjuvant for pain. This study investigated whether the intraoperative, intravenous infusion of nefopam (20 mg) reduces postoperative morphine consumption, pain scores, and alleviates neuropathic pain in patients undergoing cervical spine surgery. METHODS: A prospective, paralleled design, randomized study was conducted on 50 patients (aged 18-75 years) in a university-based hospital. The patients were assigned to an intervention or a control group (25 patients in each). The intervention group received a 1-hour infusion of nefopam (20 mg) before the end of surgery. The control group received normal saline (NSS). The outcome measures were morphine consumption during the first 24 postoperative hours, numerical rating scale (NRS) pain scores, and scores for the Thai version of the Neuropathic Pain Symptom Inventory (NPSI-T) in patients with neuropathic pain and adverse drug reactions. The NPSI-T scores were assessed on the preoperative day, postoperative day 1, 3, 15, and 30. The outcome assessors were blinded to group allocation. RESULTS: Fifty patients were analyzed. During the first 24 postoperative hours, morphine consumption was 8 mg (nefopam) and 12 mg (NSS; P = .130). The intervention and control groups demonstrated no significant differences in the median NRS scores or total NPSI-T scores or adverse drug reactions. CONCLUSIONS: A single, intraoperative infusion of 20 mg of nefopam did not significantly reduce postoperative (24 hours) morphine consumption in patients undergoing anterior cervical spine surgery.

Goal-Directed Fluid Therapy Based on Pulse-Pressure Variation Compared with Standard Fluid Therapy in Patients Undergoing Complex Spine Surgery: A Randomized Controlled Trial.

STUDY DESIGN: Prospective, randomized, controlled study. PURPOSE: To determine whether the use of goal-directed fluid therapy (GDT) guided by pulse-pressure variation (PPV) and fluid management protocol can reduce intraoperative hypotension, blood transfusion requirements, and postoperative complications in adults undergoing complex spine surgery. OVERVIEW OF LITERATURE: Complex spine surgeries involve a significant risk of blood loss and intraoperative hypotension. Previous studies showed that GDT reduces intraoperative hypotension and postoperative complications in these surgery types; however, limited information exists about GDT guided by PPV. METHODS: Sixty adults (18-70 years) patients undergoing complex spine surgeries at Siriraj Hospital, Mahidol University, Thailand were enrolled. Patients were allocated to two groups (30 patients in each) using computer-generated randomization. Intraoperative fluid and vasopressor were administrated via either GDT or standard care. The GDT algorithm used PPV and fluid protocol as the primary tool to guide hemodynamic management. The incidences and episodes of perioperative hypotension were measured as the outcomes. RESULTS: Fifty-seven patients were analyzed (three patients in the GDT group were excluded). The baseline characteristics and surgical procedures of the two groups did not differ significantly. The prevalence of intraoperative hypotension was 80.0% for the control group and 66.7% for the GDT group (p=0.25). Two episodes (1-3) of intraoperative hypotension occurred in the control group, and one episode (0-3) occurred in the GDT group; the difference was not significantly different (p=0.57). The intraoperative blood transfusion requirements and postoperative complications were similar in both the groups. In the subgroup analysis, patients with intraoperative hypotension exhibited a higher incidence of postoperative bowel dysfunction. CONCLUSIONS: PPV-guided GDT and fluid protocol, as compared with standard practice, did not show significant advantages with respect to intraoperative hypotension, blood transfusion, or postoperative complications in patients undergoing complex spine surgery in the prone position.

Factors Related to Delayed Extubation in Cervical Spine Surgery in an Academic Hospital: A Retrospective Study of 506 Patients

Objective: The incidence of airway obstruction has been reported to be 1.2­6.1% after cervical spine surgery and up to 27% in posterior occipito-cervical spinal fusion. Communication between the anesthesiologist, surgeon, and staff responsible for postoperative care, and the identifi cation of patients at risk of airway complications are important. We aimed to determine the incidences of delayed extubation and reintubation, and the factors related to delayed extubation after cervical spine surgery. Methods: A review was conducted of the medical records of patients who underwent cervical spine surgery in the orthopedic and neurosurgery units, Siriraj Hospital, between January 2012 and May 2017. The data included demographics, perioperative airway management, postoperative airway complications (delayed extubation and reintubation), and outcomes. Results: Of the 506 patients analyzed, delayed extubation occurred in 116 (22.9%), and 15 (3.0%) were reintubated. The independent related factors for delayed extubation were blood loss ≥ 300 mL (odds ratio [OR], 2.71; 95% confi dence interval [CI], 1.33­5.49); intraoperative fl uid administration ≥ 2,000 mL (OR, 2.17; 95% CI, 1.08­4.36); anesthetic time of ≥ 300 min (OR, 3.74; 95% CI, 1.83­7.63); and case fi nished after service hours (OR, 3.18; 95% CI, 1.73­5.88). Conclusion: The incidence of delayed extubation in cervical spine surgery patients was high, and reintubation was common. Anesthesiologists should be cognizant of the related risk factors before deciding between immediate or delayed extubation.

A study into perioperative anaesthetic adverse events in Thailand (PAAd THAI): An analysis of suspected emergence delirium.

The purpose of this study is to demonstrate the characteristics, contributing factors and recommended policy changes associated with emergence delirium. Relevant data were extracted from the PAAd Thai database of 2,006 incident reports which were conducted from 1 January to 31 December 2015. Details pertinent to the patient, surgery, anaesthetic and systematic factors were reviewed independently. Seventeen incidents of emergence delirium were recorded. Emergence delirium was common in the following categories: male (70.6%), over 65 years of age (53%), elective surgery (76%) and orthopedic surgery (35%). Physical restraint was required in 53% (9 of 17) of cases and 14 patients (82%) required medical treatment. One patient developed postoperative delirium and required medical treatment. The study led to the following recommendations: Development of a classification of practice guidelines and a screening tool, and training for restraint use.

The Efficacy of Two Oxygen Therapy Devices (Nasal Cannula vs. Simple Mask) for Preventing Hypoxemia after General Anesthesia: A Randomized Controlled Non-Inferiority Trial of 500 Patients.

OBJECTIVE: To compare the efficacy of two oxygen devices (nasal cannula and mask) and two flows for preventing hypoxemia in post anesthesia care unit (PACU). MATERIAL AND METHOD: Five hundred (18-70 year old) patients were enrolled into a randomized, controlled non-inferiority trial at Sirirai Hospital, Mahidol University from May 2013 to December 2014. They received oxygen therapy after general anesthesia according to their groups by computer-generated randomization. Group I received oxygen nasal cannula 4 liters per minute and group II received oxygen mask 5 liters per minute. Both methods gave comparable FiO2 (FiO2 = 0.35). Inclusion criteria were elective surgery, American Society of Anesthesiologist (ASA) physical status 1-3. Exclusion criteria were unstable pulmonary disease, BMI > 35 kg/m², baseline SpO2 < 94%, myopathy, alteration of consciousness, and nasal problems. The high-risk operations for post operative hypoxemia were excluded The efficacy of two oxygen devices and flows were compared in term of preventing hypoxemia in PACU. RESULTS: Five hundred patients were analyzed (249 patients in the cannula group and 251 patients in the mask group). They were comparable in demographics and operations. At PACU, none of 500 patients had SpO2 < 94% (non-inferiority trial, 95% CI-0.0152, 0.0152). They were mildly sedated or fully awake and had no respiratory complications. CONCLUSION: In low risk patients undergoing low risk operations, both nasal cannula or simple mask with FiO2 = 0.35 are equally effective for preventing hypoxemia in PACU.

Severe Venous Air Embolism Related to Positioning in Posterior Cranial Fossa Surgery in Siriraj Hospital.

BACKGROUND: Posterior cranial fossa surgery is commonly performed under sitting and horizontal position in our institution. Venous air embolism is a potentially serious complication of neurosurgery especially in the sitting position. OBJECTIVE: We aim to compare the incidence of severe venous air embolism and other complications of both positions. MATERIAL AND METHOD: A retrospective analysis of medical record was performed in 192 patients undergoing posterior cranial fossa craniotomy from January 2010 to December 2013. Data collected from the records included demographic profile, patient position, hemodynamic changes, venous air embolism (VAE), blood loss/transfusion, duration of surgery, postoperative complications, duration of ICU stay, and postoperative discharge status. The definition of severe air embolism was identified as suspected VAE with decreased systolic blood pressure greater than 20%. RESULTS: There were 92 patients in sitting position (SP) group and 100 patients in horizontal position (HP) group. The incidence of severe venous air embolism was signficantly higher in SP group compared with HP group (41.3% vs. 11.0%, p<0. 001). SP group had more complications than HP group in both central nervous system (71% vs. 34.0%, p = 0.001), and cardiovascular system (17% vs. 6%, p = 0.001). Although postoperative ventilator time in SP group was less than HP group (1.24 vs. 1.60 days, p = 0.029), ICU and hospital stay were not different in either group. CONCLUSION: The incidence of severe venous air embolism detected by end tidal CO2 was significantly higher in SP group. However, 11% of HP group were suspected of severe air embolism.

The Changes in Cortisol Levels during Cardiac Surgery: A Randomized Double-Blinded Study between Two Induction Agents Etomidate and Thiopentone.

OBJECTIVE: To study the changes in cortisol levels during and after cardiac surgery after an inductive dose of either etomidate or thiopentone and their consequences. MATERIAL AND METHOD: A prospective, randomized, double-blinded study was conducted in 26 patients undergoing elective cardiac surgery. They received either etomidate or thiopentone for induction. Serum cortisol levels were measured preoperatively, and then at 2-, 4-, 8-, and 24-hour All of the patients received standard anesthesia and surgery. The data also included patients perioperative management and outcome. RESULTS: There is no difference in patients' characteristics. The baseline plasma morning cortisols in the two groups were comparable (11.7 ± 7.5 mcg/dL in etomidate group vs. 12.0 ± 8.2 mcg/dL in thiopentone group). In both groups, during surgery, the cortisol levels rose to higher levels and reached peak levels at four to eight hours and related to surgical stress. At all times, the etomidate group had lower cortisol levels but only at 8-hour the etomidate group had significantly lower cortisol level (39.9 ± 14.2 vs. 65.9 ± 20.0 mcg/dL). At 24 hours, in both groups, cortisol levels were lower than at 8-hour but did not return to normal baseline levels. There were no differences in the dose of inotropic use and ICU stay. However surprisingly the etomidate group had shorter hospital stay. CONCLUSION: A single dose of etomidate usedfor induction in elective cardiac patients can partially and reversibly inhibit of the cortisol synthesis for, at least, 24 hours, but its association with any hemodynamic consequences cannot be concluded. REGISTRATION: ClinicalTrials.gov as NCT01495949.

Two Doses of Tranexamic Acid Reduce Blood Transfusion in Complex Spine Surgery: A Prospective Randomized Study.

STUDY DESIGN: Prospective, double-blinded, randomized controlled study. OBJECTIVE: To determine whether the use of 2 doses of tranexamic acid (TXA) can reduce perioperative blood loss and blood transfusions in low-risk adult patients undergoing complex laminectomy. SUMMARY OF BACKGROUND DATA: Complex laminectomy (multilevel laminectomy or laminectomy and instrumentation) is a procedure with a medium risk of blood loss, which may require allogeneic blood transfusion. Previous studies of TXA showed its inconsistent effectiveness in reducing blood loss during spine surgery. The negative results may stem from ineffective use of a single dose of TXA during long and complex operations. METHODS: 80 adult (18-65 yr old) patients in Siriraj Hospital, Mahidol University, Thailand were enrolled and allocated into 2 groups (40 patients in each group) by computer-generated randomization. Patients with history of thromboembolic diseases were excluded. Anesthesiologists in charge and patients were blinded. Group I received 0.9% NaCl (NSS) or placebo and group II received 2 doses (15 mg/kg) of TXA. The first dose was administered before anesthesia induction and the second dose, after 3 hours. The assessed outcomes were the amount of perioperative blood loss and the incidence of blood transfusions. RESULTS: 78 patients were analyzed (1 patient in each group was excluded) with 39 patients randomized to each group. There were no differences in patient demographics and pre and postoperative hematocrit levels. The total blood loss in the control group (NSS) was higher [900 (160, 4150) mL] than in the TXA group [600 (200, 4750) mL]. Patients in the control group received more crystalloid, colloid, and packed red blood cell transfusions. Within 24 hours, we observed a 64.6% reduction of blood transfusions (43.5% vs.15.4%, P = 0.006). No serious thromboembolic complications occurred. CONCLUSION: 2 effective doses (15 mg/kg) of TXA can reduce blood loss and transfusions in low-risk adults undergoing complex spine surgery. LEVEL OF EVIDENCE: 1.

Oral rehydration with 10% carbohydrate drink for preventing postoperative nausea and vomiting (PONV) after low dose of spinal morphine.

BACKGROUND: Preoperative oral carbohydrate (CHO) drink may improve patients' comfort. However, whether it prevents or reduces postoperative nausea and vomiting (PONV) is questionable. OBJECTIVE: Evaluate the effect of oral rehydration with 10% CHO drink before anesthesia on incidence and severity of postoperative nausea and vomiting (PONV) after spinal morphine injection. MATERIAL AND METHOD: One hundred patients scheduled for unilateral total knee replacement (TKR) were randomly divided into two equal groups (n = 50 each). Group I patients received 400 ml 10% CHO drink the preoperative night and 2-hour before anesthesia, whereas Group II patients served as control. Spinal anesthesia for all patients contained 0.5% bupivacaine 2.0 to 3.5 ml plus morphine 0.2 mg. Pain therapy was standardized with femoral nerve block, local infiltration, intravenous parecoxib, and oral paracetamol. Incidence and severity of PONV within 24 hours were recorded In addition, preoperative intensity of thirst and hunger, dry lips and throat, and anxiety was also recorded RESULTS: Incidence and severity of PONV (81.2% vs. 72.0%, p = 0.536) as well as preoperative thirst, hunger dry lips, and throat were not different between the groups. CONCLUSION: Preoperative oral rehydration with carbohydrate drinks had no positive effect on PONV nor patients' comfort.

Patients with osteoporotic hip fractures: factors affecting length of hospital stay (LOS) and outcome.

OBJECTIVE: Identify risk factors associated with prolonged hospital stay (LOS more than 14 days) in patients with osteoporotic hip fracture. MATERIAL AND METHOD: One hundred and fifty out of 356 patients with fractured femur were selected between April 2008 and August 2009. Analysis of patient's LOS (group I equal or less than 14 days, group II more than 14 days) is performed by backward binary multiple logistic regression. RESULTS: LOS in group I (n=46) was 12.5 (+/- 4) days compared to 21 (+/- 11) days in group II (n=104). Patients were mainly female (74%) and about 50% were aged over 80 years. The 30-days mortality in group I and II was zero and two patients respectively. Time-to-surgery was three days (+/- 2) in group I and seven (+/- 5) days in group II. Significant predicting risk factors were waiting for investigation (odds ratio (OR) 3.77, confidence interval (CI) 1.12-12.69) and receiving systemic opioids (OR 3.44; CI 1.54-7.66). CONCLUSION: Unnecessary surgery delay after hip fracture should be avoided. Higher need for opioids in those patients might be the result of prolonged waiting for surgical treatment.

Three-day unrecognized cefazolin anaphylaxis in a case undergoing coronary bypass graft surgery.

Cephalosporin anaphylaxis is rare but the diagnosis is usually not delayed when the catastrophic reaction occurs shortly after cephalosporin injection. The authors wish to report a patient who had never had a history of beta-lactam hypersensitivity and developed the first episode of cefazolin anaphylaxis during coronary artery bypass surgery. Hypotension developed during the operation but it was immediately corrected by volume infusion and inotrope administration. Shaking chills, drenching sweats, and tingling sensation on the head developed when she regained consciousness from general anesthesia. The adverse reaction disappeared soon and was thought to be the side effects of anesthetic drugs, morphine administrations, and/or blood transfusion. Similar reactions, together with hypotension and oxygen desaturation, recurred each time cefazolin was infused but it took three days and doses of 12 grams of cefazolin administration before a correct diagnosis was reached. The present case report would remind surgeons and anesthesiologists of cefazolin as a potential cause of anaphylaxis during peri- and post-operative periods.

Periarticular infiltration of 0.25% bupivacaine on top of femoral nerve block and intrathecal morphine improves quality of pain control after total knee arthroplasty: a randomized double-blind placebo controlled clinical trial.

OBJECTIVE: Find out if the addition of periarticular local anesthetic infiltration enhances the quality of postoperative pain control in patients with knee arthroplasty (TKA) in spinal anesthesia and intrathecal morphine plus single shot femoral nerve block (FNB). MATERIAL AND METHOD. Ninety-nine patients scheduled for TKA under spinal anesthesia were enrolled after written informed consent, and randomized into two groups with either periarticular injection of 20 ml 0.25% bupivacaine (B-gr n = 50) or isotonic saline solution (S-gr n = 49). All patients had intrathecal morphine 0.2 mg and single shot FNB with 20 ml bupivacaine 0.25% and were adjusted postoperative analgesic requirement via patient controlled analgesia with morphine. Effect of postoperative pain control and requirement of additional analgesics were recorded. RESULTS: Randomization created comparable groups. Periarticular infiltration of bupivacaine in addition to femoral nerve block and intrathecal morphine was efficient and superior to saline regarding pain control, morphine consumption, and patient's satisfaction. More patients in B-gr did not require any supplement morphine in the first 24 hours (26% compared to 12.2%, p < or = 0.01). In patients who required morphine, B-gr had longer pain free period (25 hours compared to 14.8 hours, p < 0.001) and needed lower dose of morphine (5.16 mg compared to 8. 67mg, p = 0.005). No significant side effects were recorded. CONCLUSION: Adding periarticular infiltration to femoral block and intrathecal morphine significantly enhances the quality of postoperative pain therapy in TKA patients. However combining three methods for analgesic therapy may be too much effort. Modifying infiltration techniques including continuous application needs further research.

Femoral nerve block versus fentanyl: Analgesia for positioning patients with fractured femur.

PURPOSE: Fracture of femur is a painful bone injury, worsened by any movement. This prospective study was performed to compare the analgesic effects of femoral nerve block (FNB) with intravenous (IV) fentanyl prior to positioning patients with fractured femur for spinal block. PATIENTS AND METHODS: Sixty-four ASA I-III patients aged 18-80 years undergoing surgery for femur fracture were randomized into two groups. Fifteen minutes before spinal block, the FNB group received nerve stimulator-assisted FNB with a mixture of 20 mL bupivacaine 0.5% and 10 mL normal saline 0.9%, and the fentanyl group received two doses of IV fentanyl 0.5 µg/kg with a five-minute interval between doses. Numeric rating pain scores were compared. During positioning, fentanyl in 0.5 µg/kg increments was given every five minutes until pain scores were ≤4. RESULTS: There were no statistically significant differences between the groups according to pain scores, need for additional fentanyl, and satisfaction with positioning before spinal block. CONCLUSION: We were unable to demonstrate a benefit of FNB over IV fentanyl for patient positioning before spinal block. However, FNB can provide postoperative pain relief, whereas side effects of fentanyl must be considered, and analgesic dosing should be titrated based on pain scores. A multimodal approach (FNB + IV fentanyl) may be a possible option.

Unrecognised aspiration pneumonitis during enteroscopy: two cases report.

Two patients (one underwent balloon enteroscopy and the other had endoscopic retrograde cholangiopancreatoscopy, ERCP) developed desaturation in the post anesthetic care unit (PACU) despite high oxygen supplement. Aspiration pneumonitis was suspected The chest x-rays taken in PACU showed lung infiltration in both cases and arterial blood gases revealed hypoxemia. During anesthesia, there were brief episodes of choking, regurgitation, and desaturation, which were improved by giving high FiO2 and positive pressure ventilation. The diagnosis and management of aspiration pneumonitis was discussed

Acute epiglottitis: a report of the two different methods of airway management in adults.

The authors present two cases of acute epiglottitis with upper airway obstruction that urgently needed artificial airways. In case 1, a 55-year-old woman with DM presented with severe upper airway obstruction and sepsis. The tracheostomy was chosen for airway management, antibiotic was given, and fluid and inotropic drug (dopamine) were used for cardiovascular support. She received continuing care in the intensive care unit for several days. In case 2, a 40-year-old man presented with acute airway obstruction when he breathed forcefully. The prophylaxis tracheal intubation was done by using sevoflurane inhalation. The life-threatening situations of both patients were managed successfully by the team approach of ENT surgeons, anesthesiologists, and intensivists.