Background: An incidence of difficult intubation in elective surgery is 1.5%–8%. Multiple attempts during tracheal intubation can cause airway injuries bleeding, brain hypoxia, and even cardiac arrest. Unanticipated failure and inability to secure difficult airway can lead to “cannot ventilate, cannot intubate” condition. Preoperative assessment and bedside tests play a vital role in predicting and stratifying risk of difficult intubation. This study was done to determine the incidence of difficult intubation and diagnostic accuracy of different bedside tests for predicting intubation difficulty in patients without airway pathology scheduled for elective surgery under general anesthesia. Materials and Methods: Two hundred patients, aged 20–50 years, American Society of Anaesthesiologists I and II, without airway pathology undergoing elective surgery were evaluated preoperatively using simple bedside tests such as Mallampati grading (MPG), interincisor gap (IIG), thyromental distance (TMD), sternomental distance, upper lip bite test, neck circumference, and atlantooccipital extension to predict difficult intubation. Statistical confirmation was done using Pearson’s chi-square test and univariate and multivariate logistic regression. Results: In our study, the incidence of difficult intubation was observed as 6%. High sensitivity for predicting difficult intubation was seen with IIG > TMD > MPG, and high specificity among the relevant bedside tests was seen with TMD > MPG > IIG. Tests with high positive predictive value were TMD > MPG, whereas high negative predictive value was seen with IIG > TMD >MPG. Conclusion: IIG, TMD, and MPG can be used to predict difficult intubation in patients without airway pathology.

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Background: SARS-CoV-2 was discovered in December 2019 and later become global pandemic. Preliminary studies stated that broad vaccine coverage will suppress mortality and incidence of COVID-19. Therefore, we conduct a cross-sectional study to assess the efficacy of COVID-19 vaccination. Materials and Methods: We collected secondary data from electronic medical records of 343 COVID-19 positive patients confirmed via reverse transcription polymerase chain reaction from July 2021 to December 2021. We analyzed epidemiologic data, vaccination history, baseline symptoms, comorbidity, baseline vital signs, and outcome using hypothesis testing χ² and logistic regression. Results: Sex had an χ² of 9.34 (P < 0.001) while type of vaccine had an χ² of 1.49 (P = 0.22) to clinical severity. Age, pulse rate, respiration rate, body temperature, and Glasgow coma scale were found to be significant risk factors to clinical severity. Number of vaccines previously received was found to be a protective factor to clinical severity (odds ratio (OR) = 0.49, 95% CI = 0.32–0.74, P < 0.001). We also found that sex (χ² = 10.42, P < 0.001) was a predictor to discharge condition. Moreover, age was also found to be a significant predictor (OR = 1.03, 95% CI = 1.03–1.05, P < 0.001), as well as number of symptoms (OR = 0.66, P < 0.001), comorbidities (OR = 1.64, P < 0.001), pulse rate (OR = 1.04, P < 0.001), respiration rate (OR = 1.17, P < 0.001), and Glasgow coma scale (OR = 0.72, P = 0.03). Conclusion: Age, sex, number of vaccines received, number of symptoms, number of comorbidities, pulse rate, and respiration rate were significant predictors of clinical severity and outcome in COVID-19 patients. In addition, body temperature was also a predictor for clinical severity, while Glasgow coma scale was a predictor for outcome.

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Introduction: Pressure-controlled volume-guaranteed (PCV-VG) mode has the advantage of both volume-controlled (VCV) and pressure-controlled ventilation (PCV). Our objective is to compare gaseous exchange and lung dynamic compliance (C_dyn) after pneumoperitoneum and just before desufflation in VCV, PCV, and PCV-VG mode in laparoscopic cholecystectomy (LC). Materials and Methods: A total of 105 patients undergoing LC under general anesthesia were randomly distributed to group V (received VCV), group P (PCV), and group PV (PCV-VG) as mode of ventilation. Two arterial blood samples were taken for blood gas analysis: after the pneumoperitoneum (T1) and right before abdominal desufflation (T2). Arterial partial oxygen pressure (PaO₂) and carbon dioxide (PaCO₂) levels, oxygen saturation (SpO₂) and end-tidal carbon dioxide were compared at these two points of time between the groups. Results: C_dyn was higher in group P (43.21 ± 4.4 mL/cmH₂O) compared with group V (39.18 ± 3.2 mL/cmH₂O) and PV (40.37 ± 2.45 mL/cmH₂O) at T2 (P < 0.001). PaO₂ was significantly higher (P < 0.001) in group P (197.50 ± 17.29 mm Hg) at T2 compared with group V (178.90 ± 23.7 mm Hg) and PV (183.47 ± 22.99 mm Hg). Furthermore, PaCO₂ was also significantly higher in Group P (40.19 ± 2.92 mm Hg) compared with group V (32.57 ± 2.09 mm Hg) and group PV (34.14 ± 3.27 mm Hg). Conclusion: PaO₂ and dynamic compliance are higher in pressure-controlled mode but, high PaCO₂ in pressure-controlled mode indicates inadequate ventilation. Therefore, pressure controlled volume guaranteed mode can be considered as a favorable ventilation strategy during LC because dynamic compliance and PaO₂ are higher than volume controlled ventilation and PaCO₂ is significantly less than pressure controlled mode.

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Background: Pain has a wide spectrum of effects on the body and inadequate management of postoperative pain outcomes in multiple physiological and psychological consequences; and increases morbidity. The use of opioid-based analgesia in high doses can have multiple adverse effects including respiratory depression, nausea, and vomiting. Objectives: Our aim was to evaluate the efficacy of analgesic and safety of both techniques (transversus abdominis plane block [TAPB] and erector spinae plane block [ESPB]) in cases having lower abdominal surgery through laparotomy. Materials and Methods: This randomized trial was performed on 62 cases who underwent laparotomy for lower abdominal surgery under general anesthesia were recruited. Subjects were equally distributed into either TAPB or ESPB. The primary outcome was total morphine intake postoperatively for 24 h. Other variables were intraoperative fentanyl consumption, delay to first morphine demand, and intraoperative morphine consumption, the number of patients who needed rescue analgesia by morphine, perioperative heart rate and mean blood pressure, numerical rating score (NRS), postoperative nausea and vomiting, and block-related complications. Results: ESPB patients consumed less total postoperative morphine than the TAPB group (5.35 ± 2.65 vs. 8.52 ± 3.35 mg; P < 0.001). Patients who received ESPB showed less postoperative pain scores and, thus, needed rescue medication after a longer period than the TAPB group (12.50 ± 7.31 h vs. 7.72 ± 5.69 h; P = 0.008). In addition, ESPB patients needed less intraoperative fentanyl doses than TAPB (138.71 ± 35.85 vs. 203.23 ± 34.00 mcg; P < 0.001). ESPB group demonstrated statistically significant lower scores of NRS at rest and at movement. Conclusions: Ultrasound (US)-guided ESPB provides more safe and effective analgesia in lower abdominal surgeries compared with US-guided TAPB.

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Background: Gynecomastia is a benign proliferative condition affecting the glandular tissue of the male breast. This study compared the efficacy of ultrasound-guided thoracic interfacial plane block (TIPB) with ultrasound-guided thoracic paravertebral block (TPVB) in providing anesthesia for gynecomastia surgery. Materials and Methods: This prospective randomized open label clinical trial included 90 patients scheduled for elective surgery for idiopathic gynecomastia. Patients were randomly allocated into three equal groups: group C (control group) received bilateral tumescent local anesthesia, group TPVB received bilateral ultrasound guided TPVB, and group TIPB received bilateral ultrasound guided TIPB. We evaluated postoperative analgesic requirements, pain score, and patient’s satisfaction. Results: Intraoperative fentanyl requirement and total diclofenac in the first 24 hours postoperative were significantly lower in both TPVB and TIPB groups compared to control group (P = 0.002 and P < 0.001, respectively). Patient satisfaction was significantly better (P = 0.004) in both TPVB and TIPB groups when compared to control group. In postoperative evaluation, we found both TPVB and TIPB produced significantly lower pain score compared to control group in 2-hours (P < 0.001) and 4-hours (P = 0.001) after the surgery. Mean arterial blood pressure, heart rate, and peripheral oxygen saturation were comparable in all groups, as well as the occurrence of complications. Conclusion: Either TIPB and TPVB may provide effective analgesic property for anesthesia in gynecomastia surgery. This is shown by lower intraoperative analgesic requirements, lower postoperative pain score, and better patient’s satisfaction.

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Background: Majority of invasive candidiasis in critically ill patients was developed after admission to intensive care unit. The aim of this study was to identify risk factors for development of invasive candidiasis among patients admitted to intensive care unit, especially considering the timing of laboratory, microscopic, and culture examinations. Materials and Methods: This was a prospective observational study in which critically ill patients were assessed on the first, fifth, and ninth day since admission to intensive care unit. Potential risk factors were demographic and clinical characteristic, clinical managements profile proportions, laboratory profile (leukocyte, platelet, erythrocyte sedimentation rate, C-reactive protein and procalcitonin), morphological change (from yeast to hypae or pseudohyphae in microscopic examination) and colonization increase (from serial culture examination). Results: A total of 115 subjects enrolled in this study. Multivariate analysis identified older age (HR 2.8, 95% CI 0.8–8.9), parenteral nutrition (HR 3.1, 95% CI 0.77–12.3), central venous catheter (HR 1.7, 95% CI 0.43–6.67), corticosteroid (HR 2.8, 95% CI 0.53–14.8), procalcitonin day-5 (HR 3.1, 95% CI 0.89–10.8), morphology change in the axilla and rectal swab (HR 5.1, 95% CI 1.6–18.51), and morphology change and colonization increase in rectal swab day-9 (HR 4.3, 95% CI 1.0–18.02) as independent risk factors of invasive candidiasis. Conclusion: In addition to several typical risk factors, procalcitonin test on day-5 as well as serial microscopic and culture examinations were associated with the development of invasive candidiasis, therefore potentially help in the diagnosis and treatment of critically ill patients in intensive care unit.

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Rothmund-Thomson Syndrome (RTS) is a rare, multisystem disease accompanied by many anomalies that require careful attention from preoperative evaluation to discharge regarding anesthesia preparation and management. Due to craniofacial deformities accompanying facial abnormalities, maintaining the airway becomes a complete struggle with a race against time for survival. This case report presents the preoperative preparation and perioperative management, the risks that may be encountered, and the detailed preparation for a 7-year-old patient diagnosed with RTS and multiple system involvement. General anesthesia was administered to this patient, who had intrauterine growth retardation, nail streaking, redness of the bullae and legs, and a history of somatotropin treatment and antinuclear antibody (ANA) positivity under optimum conditions. Thanks to successful and detailed preoperative preparation and perioperative management, the patient was followed up and discharged without any complications. Although RTS is rare, the need for general anesthesia often arises due to juvenile cataracts, dental anomalies, syndactyly and other extremity anomalies in these patients whose airway management is complex. Furthermore, this increases the current risk in the population of these patients. Managing these patients with a multidisciplinary approach will reduce complications, morbidity, mortality, and length of stay.

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Brain tumors and intracranial bleeding are rare cases in pregnancy. Anesthesia management for a C-section with comorbidity remains challenging. We presented a 33-year-old woman (34–36 weeks pregnant) with the complaint of weakness in her right extremities, blurred vision, and ptosis of her left eye from a month before hospitalization. The brain computed tomography (CT) revealed a mass at the left parasellar region with a bleeding component and cerebral edema accompanied by subfalcine herniation. We conducted general anesthesia for cesarean delivery in a patient with a brain-protective technique. Brain CT revealed a decrease in the mass size and neither intracranial bleeding nor cerebral edema. In conclusion, general anesthesia management provided a good outcome in a parturient with a brain tumor and intracranial bleeding that underwent C-section. The mechanism of clinical improvement and tumor regression is unclear and requires further research, but it is believed that it is related to pregnancy hormones.

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It is important for clinicians to perform a continuous comprehensive assessment of the depth of sedation, including the use of processed electroencephalographic monitors and the review of clinical signs. Ketamine is a safe anesthetic and sedative traditionally used in the clinical practice. It possesses analgesic, anti-inflammatory, and antidepressant activities and is used as a therapeutic agent in intractable pain. In this case series, we present a comparison between patient state index (PSI) and bispectral index (BIS) in a sample of eight patients with complex regional pain syndrome undergoing ketamine infusion therapy. Blood pressure, heart rate, respiratory rate, end-tidal carbon dioxide, and oxygen saturation were all noted, as well as the PSI and BIS values. The PSI and BIS readings were not recorded when the artifact was larger than 50%. Four patients (50%) received intravenous midazolam 5 mg when their agitation or movement could not be managed by the clinicians’ verbal instructions. In five patients (62%), 20 min after the ketamine infusion began, deep drowsiness was attained. There are fewer research studies on PSI than there are on BIS. We found that PSI values did not match BIS values. This case series could help clinicians select an appropriate course of action for ketamine sedation in individual patients.

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Epidural anesthesia (EA) can be applied in the perioperative period (PP) in addition to general anesthesia (GA) or as a stand-alone anesthesia technique. EA provides better hemodynamic stability in high-risk patients, reduced neurohormonal surgical stress response, and preserved airway reflexes with spontaneous breathing. In addition, EA prevents pulmonary dysfunction through decreasing multifactorial mediators, improves pulmonary functions by reducing the decrease in functional residual capacity, and protects spontaneous respiratory and airway reflexes. Herein, we wanted to emphasize the importance of the perioperative approach, the choice of anesthesia technique, and the effects of this choice on the postoperative period in a high-risk patient with incidental stage four lung adenocarcinoma, right parietal brain, lumbar vertebral, liver, and adrenal metastasis, as well as hydropneumothorax. With a successful epidural catheterization and anesthesia, the patient was follow-up without any problems. As in our patient, we should adopt a multimodal approach in the perioperative period, perform a detailed examination before the operation, and evaluate all risks and benefits comparatively when choosing the most appropriate anesthesia technique. Thus, it should be kept in mind that the chosen technique will significantly affect perioperative complications, morbidity and mortality, drug use, length of hospital stay, and cost.

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