Background: Maintenance of stable blood pressure (BP) during cerebrovascular bypass surgery is crucial to prevent cerebral ischemia. We compared the effect of remimazolam anesthesia with that of propofol-induced and desflurane-maintained anesthesia on intraoperative hemodynamic stability and the need for vasoactive agents in patients undergoing cerebrovascular bypass surgery. Methods: Sixty-five patients were randomized into remimazolam (n = 31, remimazolam-based intravenous anesthesia) and control groups (n = 34, propofol-induced and desflurane-maintained anesthesia). The primary outcome was the occurrence of intraoperative hypotension. The secondary outcomes included hypotension duration, lowest mean BP (MBP), generalized average real variability (ARV) of MBP, and consumption of phenylephrine, norepinephrine, or remifentanil. Results: Occurrence rate and duration of hypotension were significantly lower in the remimazolam group (38.7% vs. 73.5%, P = 0.005; 0 [0, 10] vs. 7.5 [1.25, 25] min, P = 0.008). Remimazolam also showed better outcomes for lowest MBP (78 [73, 84] vs. 69.5 [66.25, 75.8] mmHg, P < 0.001) and generalized ARV of MBP (1.42 ± 0.49 vs. 1.66 ± 0.52 mmHg/min, P = 0.036). The remimazolam group required less phenylephrine (20 [0, 65] vs. 100 [60, 130] μg, P < 0.001), less norepinephrine (162 [0, 365.5] vs. 1335 [998.5, 1637.5] μg, P < 0.001), and more remifentanil (1750 [1454.5, 2184.5] vs. 531 [431, 746.5] μg, P < 0.001) than the control group. Conclusions Remimazolam anesthesia may provide better hemodynamic stability during cerebrovascular bypass surgery than propofol-induced and desflurane-maintained anesthesia.

Background: Laparoscopic sleeve gastrectomy (LSG) causes significant postoperative pain, necessitating effective multimodal analgesia strategies. This study evaluated the efficacy of the external oblique intercostal block (EOIB) in this context. Methods: This prospective, randomized, controlled, single-blind study conducted between April and December 2023 included 60 patients who underwent LSG. Patients were divided into the EOIB (30 ml 0.25% bupivacaine/side) and control (no block) groups. The primary outcome was the cumulative intravenous morphine milligram equivalent (MME) consumption in the first 24 h postoperatively. Secondary outcomes included 12-h MME consumption, pain scores, intraoperative remifentanil use, rescue analgesia requirements, time to first analgesic request, nausea/vomiting scores, antiemetic use, and American Pain Society Patient Outcome Questionnaire-Revised Turkish Version (APS-POQ-R-TR) scores. Results: The control group had significantly higher median opioid consumption than the EOIB group at 12 (14.4 vs. 5.8 mg; P < 0.001) and 24 h (25.9 vs. 10.6 mg; P < 0.001) postoperatively. The need for rescue analgesics did not differ significantly (43.3 vs. 23.3%; P = 0.1). The EOIB group exhibited significantly higher patient satisfaction (APS-POQ-R-TR score 2.91 vs. 4.42; P < 0.001) and consistently lower pain scores across all time points (P < 0.001). The EOIB group had lower nausea/vomiting scores (P < 0.001), fewer patients requiring antiemetics (16.7% vs. 40%; P = 0.045), longer time to first morphine request (57.5 vs. 25 min; P < 0.001), and lower remifentanil use (850 vs. 1050 μg; P < 0.001). Conclusions The preoperative EOIB, as a part of multimodal analgesia, provides effective analgesia for acute pain in patients undergoing LSG.

Background: Regional anesthesia techniques that provide analgesia to the entire lateral abdomen are limited. We present a modified external oblique intercostal block for complete lateral abdominal analgesia with a single injection. Case: We performed a modified version of the external oblique intercostal block unilaterally at the tenth rib along the mid-axillary line in three patients undergoing robot-assisted partial nephrectomy (two single injections, one catheter placement) and tested the technique on a cadaver with 20 ml of dye bilaterally. All patients reported good postoperative pain relief without complications and had consistent sensory coverage of the T8–T12 dermatomes from the anterior-to-posterior axillary line. Anatomical assessment confirmed consistent bilateral staining of the lateral cutaneous branches T8–T12. Conclusions The initial clinical success and anatomical findings of the modified approach to the external oblique intercostal block suggest that this technique may be an effective option for lateral abdominal analgesia.

The application of extended reality (XR) technology is rapidly expanding in the medical field, including anesthesia. This review aims to introduce the current literature on XR utilization to help anesthesiologists adopt this technology in education and clinical practice. XR is useful for both knowledge acquisition and skill training in a wide range of settings, from students to medical professionals. One of its major benefits is harm reduction through simulation scenarios that allow for immersion in clinical situations and opportunities to practice procedures and tasks. These scenarios often involve both technical and non-technical skills, enabling clinicians to enhance their capabilities without risking patient safety. In clinical settings, XR can also be used with patients to increase familiarity with medical procedures, provide education, and reduce anxiety. XR can also serve as a distraction technique, diverting the patient’s attention from medical procedures and enhancing comfort, which may contribute to reduced opioid use. Although the potential benefits of XR in anesthesia have been reported in various educational and clinical contexts, challenges, such as limited financial reimbursement and restricted technical accessibility, remain. With further research and technological advancements, XR technology has the potential for widespread adoption in anesthesia practice.

Background: Remimazolam is a novel ultra-short-acting benzodiazepine known for its hemodynamic stability over propofol. However, its hemodynamic effects compared to those of etomidate are not well established. This study aimed to determine whether the use of remimazolam is non-inferior to etomidate with regard to the occurrence of post-induction hypotension in patients undergoing coronary artery bypass grafting. Methods: Patients were randomly assigned to either the remimazolam group (6 mg/kg/h) or the etomidate group (0.3 mg/kg) for induction of anesthesia. Anesthetic depth was adjusted based on the bispectral index. Primary outcome was the incidence of post-induction hypotension, defined as a mean arterial pressure less than 65 mmHg within 15 min after endotracheal intubation, with a non-inferiority margin of 12%. Results: A total of 144 patients were finally analyzed. Incidence of post-induction hypotension was 36/71 (50.7%) in the remimazolam group and 25/73 (34.2%) in the etomidate group, with a rate difference of 16.5% (95% CI [3.0–32.6]) between the two groups that was beyond the prespecified non-inferiority margin of 12.0%. The number of patients who needed vasopressors was similar in the two groups. Conclusions In this non-inferiority trial, remimazolam failed to show non-inferiority to etomidate in terms of post-induction hypotension when used as an induction drug for general anesthesia in patients undergoing coronary artery bypass grafting. However, different doses or infusion techniques of remimazolam should be compared with etomidate in various patient groups to fully assess its hemodynamic non-inferiority during induction of anesthesia.

Background: Remimazolam is a novel short-acting benzodiazepine. This study compared the effects of remimazolam and propofol on cognitive function in adult patients after surgery or other procedures. Methods: We searched electronic databases, including PubMed, Embase, CENTRAL, Web of Science, and Scopus, for relevant studies. The primary outcome was the proportion of participants who experienced delirium or impaired cognitive function postoperatively. Secondary outcomes included the incidence of hypotension, bradycardia, and postoperative nausea and vomiting. We estimated the odds ratios (OR) and mean differences (MD) with 95% CIs using a random-effects model. Results: In total, 1295 patients from 11 randomized controlled trials were included. The incidence of postoperative delirium was 8.0% in the remimazolam group and 10.4% in the propofol group that was not significantly different (OR: 0.74, 95% CI [0.39–1.42], P = 0.369, I2 = 32%). More favorable cognitive function, as assessed using the Mini-Mental State Examination, was observed in the remimazolam group compared to the propofol group (MD: 1.06, 95% CI [0.32–1.80], P = 0.005, I2 = 89%). Remimazolam lowered the incidence of hypotension (OR: 0.28, 95% CI [0.21–0.37], P = 0.000, I2 = 0%) compared to propofol. Conclusions Remimazolam did not increase the risk of postoperative delirium and maintained cognitive function well, providing hemodynamic stability during surgery compared to propofol.

Background: Delirium in the post-anesthesia care unit (PACU) may be associated with worse outcomes in children with moyamoya disease (MMD). This retrospective study aimed to describe the prevalence of PACU delirium in children with MMD and investigate its risk factors. Methods: Patients with MMD aged < 15 years who underwent indirect revascularization between January 2014 and October 2023 were included in this study. Delirium was assessed using the Pediatric Anesthesia Emergence Delirium Scale. Potential risk factors for PACU delirium were evaluated using multivariate logistic regression. Results: PACU delirium occurred in 245 (33%) of the 750 hemispheric procedures performed in 522 patients. Delirium was associated with a higher incidence in patients undergoing the first revascularization (37%) than in those undergoing the second (25%; P = 0.002). Cerebral infarction as the initial presentation (odds ratio [OR]: 4.64, first revascularization), high pediatric moyamoya magnetic resonance imaging (MRI) score (OR: 2.75, first revascularization; OR: 3.50, second revascularization), and high intraoperative mean arterial pressure variability (mmHg/min) (OR: 9.17, first revascularization; OR: 8.82, second revascularization) were associated with PACU delirium. Conversely, total intravenous anesthesia (TIVA) was associated with a lower incidence of PACU delirium (OR: 0.46, first revascularization; OR: 0.25, second revascularization). Conclusions A significant proportion of patients with MMD developed delirium in the PACU. High intraoperative blood pressure variability and preoperative MRI lesions are independent risk factors for PACU delirium in children with MMD. TIVA may exert a protective effect against PACU delirium. Further studies are required to clarify the causality of these associations.