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Background: This study aimed to investigate the effects of general intravenous anesthesia and combined inhalation anesthesia on regional saturation of oxygen (rSO 2 ) and cerebral hemodynamics during carotid endarterectomy (CEA). Optimizing intraoperative brain protection strategies has become a key focus in CEA research., Methods: Fifty-four patients (43 males, 11 females, aged 44-80) undergoing unilateral CEA were randomly assigned to Group IVA (intravenous anesthesia) or Group CIA (combined inhalation anesthesia), with 27 patients each. Group IVA was maintained with propofol and remifentanil, while Group CIA used sevoflurane, propofol, and remifentanil, with sevoflurane stopped after carotid exposure. Hemodynamics were controlled at various stages: ±10% before clamping, + 20% during clamping (metaraminol), and 0 to -10% after exposure. HR, MAP, and rSO₂ were recorded at T0 (pre-induction), T1 (pre-clamping), T2 (post-clamping), T3 (5 min post-clamping), T4 (10 min post-clamping), T5 (15 min post-clamping), and T6 (15 min post-reperfusion). Blood samples were taken at T1, T6, and T7 (24 h post-surgery) for blood gas and S100-β analysis., Results: No significant differences in rSO₂ were observed at T0 and T6 (P > 0.05). However, Group CIA had significantly higher rScO₂ at T1, T2, T3, T4, and T5 (P < 0.05). From T2 to T5, rSO₂ increased in both groups (P < 0.05). MAP and HR showed no significant differences (P > 0.05). ΔrSO₂ increased more in Group CIA (P < 0.05). At T6, S100-β protein was higher in Group IVA (P = 0.016), and pH differed significantly at T1 (P = 0.009). No other significant differences were observed., Conclusion: Both intravenous and combined inhalation anesthesia may reduce rSO₂ decline during temporary clamping in CEA. Combined inhalation anesthesia showed a trend toward higher rSO₂ levels, potentially leading to better outcomes, but further studies are needed to confirm these findings., Retrospectively Registered Clinical Trial Number: ISRCTN17014575; Registration Date: 2024/6/10., Competing Interests: Declarations. Ethics approval and consent to participate: The study was approved by the Ethics Committee of the First Affiliated Hospital of Xinjiang Medical University, and informed consent was obtained from all subjects(Clinical Trial Number: ISRCTN17014575; Registration Date: 2024/6/10, https://www.isrctn.com/ISRCTN17014575?q=ISRCTN17014575&filters=&sort=&offset=1&totalResults=1&page=1&pageSize=10 ). The final version of the experimental protocol, informed consent form, researcher manual, and Clinical Trial Observation Form (CRF) were developed and revised in accordance with the guidelines of the Ethics Committee. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: To compare the effects of inhalational anesthetics and intravenous anesthetics on the neurological function of patients with moyamoya disease (MMD) after vascular bypass surgery., Methods: The clinical anesthesia data of patients were retrospectively collected. Patients who underwent bypass grafts with general anesthesia from January 1st, 2019, to December 31st, 2020, in Huashan Hospital affiliated with Fudan University, were selected. The primary endpoint was stroke incidence within seven days after anesthesia, and the secondary endpoints included transient neurological deficits (TNDs) and incidence of postoperative Epilepsy., Results: We compared the data of MMD patients who received inhalational anesthetics (Sevoflurane anesthetics, n = 197, group S) and intravenous anesthetics (Propofol anesthetics, n = 219, group P). The stroke incidence in the two groups (group S vs. group P) was 6.6% vs. 5.9% (OR = 0.893; 95% CI, 0.404-1.976; p = 0.780), and the group S vs. group P of TNDs incidence was 32.5% vs. 31.1% (OR = 0.936; 95% CI, 0.619-0.1.415, p = 0.753). At discharge, anesthetics didn't affect the neurological endpoint. Intravenous anesthetics provided patients with better hemodynamics compared with inhalational anesthetics during MMD vascular bypass surgery (group S vs. group P, ARV SBP : 6.4 vs. 5.2, p < 0.001, ARV DBP : 3.9 vs. 3.3, p = 0.002, ARV MBP : 4.5 vs. 3.8, p = 0.001,). There were statistical no differences in the NHISS score (S group vs. P group = 2:1, p = 0.082) at 7 days after surgery, but mRS score (S group vs. P group = 2:1, p < 0.001) at 7 days after surgery, as well as the mRS score at 6 months of follow-up (S group vs. P group = 0:0, p < 0.001), although the difference in scores was small., Conclusion: Our data indicated that both inhalational and intravenous anesthetics had protective effects on patients who underwent MMD bypass grafts. MMD patients who received inhalational anesthetics and intravenous anesthetics had similar odds of neurological deficits. When comparing long-term clinical data, most patients experience good neurological recovery after receiving inhalation or intravenous anesthesia, when compared p 75 mRS score(S group vs. P group = 3:1)in 6 month indicate that intravenous anesthetics might be more suitable for patients undergoing MMD bypass grafts. During the operation hemodynamic stability in the propofol group is greater than that in the sevoflurane anesthesia group., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the ethics committee of the Huashan Hospital affiliated with Fudan University (Ethics number KY2024-795). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Perioperative neurocognitive disorders (PND) are a prevalent complication in elderly patients undergoing surgery with general anesthesia. Sevoflurane, a commonly used anesthetic, has been associated with cognitive impairment and neurotoxicity. In this study, we aim to explore the mechanisms through which sevoflurane impairs cognitive function in aged mice and hence identify potential therapeutic strategies. Female C57BL/6 J mice were treated with 2-h-daily Environmental enrichment (EE) for 4 weeks before being exposed to single 3% sevoflurane plus 60% oxygen inhalation for 2 h. WHI-P180, a TTBK1 inhibitor, was administered 5 min prior to anesthesia. Cognitive function, TTBK1, Tau p-Ser422, AT8 (Tau p-Ser202/p-Thr205), TNF-ɑ, IL-6, and IL-1β were measured. The results indicated that sevoflurane inhalation induced cognitive dysfunction, elevated TTBK1 expression and phosphorylated Tau levels, and increased inflammatory factors in the hippocampus of aged mice. However, EE treatment reduced elevated TTBK1, phosphorylated Tau, and inflammatory factor levels in the hippocampus. Additionally, EE alleviated cognitive impairment caused by sevoflurane in aged mice. Furthermore, WHI-P180 mitigated cognitive dysfunction by decreasing Tau phosphorylation and inflammatory cytokine levels in the hippocampus of aged mice. In conclusion, TTBK1 plays a crucial role in cognitive impairment induced by sevoflurane in aged mice, and EE mitigates sevoflurane-induced cognitive dysfunction by inhibiting TTBK1 and Tau protein phosphorylation in the hippocampus of old mice. These findings suggest that EE could be a potential therapeutic strategy for preventing or treating PND in elderly patients undergoing general surgery with sevoflurane anesthesia., Competing Interests: Declarations. Conflict of interests: The authors declare that they have no conflict of interest. Ethical approval and consent to participate: The experimental protocol was approved by the Animal Ethics Committee of Tianjin Medical University General Hospital (Approval No. IRB2021-DWFL-292). Consent for publication: Not applicable., (© 2025. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The available data on the effect of dexmedetomidine premedication on anesthesia depth in children during general anesthesia are limited. This study was designed to determine the effect of preoperative dexmedetomidine administration on the bispectral index (BIS) and sevoflurane requirements in children during sevoflurane anesthesia., Methods: 120 children aged 5 to 12 years undergoing concealed penis repair or hypospadias plastic surgery were randomized to receive preoperative administration of 0.25 µg kg - 1 dexmedetomidine, 0.5 µg kg - 1 dexmedetomidine, 0.75 µg kg - 1 dexmedetomidine, or the same volume of placebo. The primary outcome was the change in the BIS value from before dexmedetomidine administration to 60 min after surgical incision. The secondary outcomes included the end-tidal sevoflurane concentration (ETsevo), hemodynamic data, anesthesia recovery data and intraoperative awareness., Results: Compared with those in Group C, the BIS values of children in Group D2 and Group D3 were significantly lower during sevoflurane induction and early maintenance (P < 0.017). Moreover, children in Group D2 and Group D3 had a lower ETsevo (P < 0.001) during sevoflurane maintenance than did those in Group C (P < 0.017). There were statistically significant differences in heart rate(P < 0.0001) and mean arterial pressure(P < 0.001) between the groups, but the incidence of bradycardia or hypotension was similar between the groups (p = 0.779 and p = 0.901)., Conclusions: Children who received 0.5 µg kg - 1 or 0.75 µg kg - 1 dexmedetomidine preoperatively were more likely to achieve the target depth of anesthesia (BIS less than 60) during anesthesia induction and had lower BIS values during the early stage of anesthesia maintenance., Trail Registration: The trial is registered with the China Clinical Trials Registry Registration Number: ChiCTR1900026872. Date of registration: 10/24/2019., Competing Interests: Declarations. Ethics approval and consent to participate: The research protocol for this project has been meticulously designed, incorporating a detailed and comprehensive informed consent form that thoroughly safeguards the rights and well-being of the participants, adhering to the principles outlined in the Helsinki Declaration. After careful review by the ethics committee, the project has received approval to proceed. The reviewing ethics committee is based at the Affiliated Children’s Hospital of Xiangya School of Medicine, Central South University (also known as the Hunan Children’s Hospital); the ethical approval number assigned is HCHLL-2019-10. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. CONSORT statement: Our study conformed to the CONSORT guidelines., (© 2025. The Author(s).)

Respiratory rate monitoring is essential especially for anesthetized animals in veterinary and biomedical research. Current methods often rely on invasive or wearable devices, which can stress animals, especially smaller ones like rodents. Here we present a non-invasive, environmentally integrated device that detects subtle breathing movements through waveform analyzed data via a triaxial accelerometer under a flexible fabric sheet in a trampoline-like box. The accuracy of the system was tested on anesthetized mice under varying isoflurane concentrations (1 to 3%) by comparison with a laser displacement sensor. The accelerometer data closely correlated with that from a laser displacement sensor, particularly under deeper anesthesia, with minimal deviations in respiratory rate detection. This method may provide a promising alternative for animal respiratory monitoring.

Accumulation of the results of basic and clinical research has advanced the safety and quality of management in cardiovascular anesthesia. To address recent developments in this field, a symposium was held during the 71th Japanese Society of Anesthesiologists annual meetings in 2024, focusing on new advancements in both clinical and basic research in cardiovascular anesthesia. During this symposium, four experts reviewed recent findings in their respective areas of study, covering the following topics: clinical reliability and concerns regarding volatile anesthetics during cardiopulmonary bypass; novel basic and clinical findings regarding the cardioprotective effects of dexmedetomidine; advancements in optimizing blood and hemostasis management during cardiovascular surgery; and innovative strategies for managing postoperative cognitive disorders following cardiovascular and thoracic surgery. Each expert summarized recent novel findings, clinical reliability and concerns, as well as future directions in their respective topics. We believe that this special article provides valuable insights into both clinical practice and basic research in cardiovascular anesthesia while also inspiring anesthesiologists to pursue further research in this field., Competing Interests: Declarations. Conflict of interest: The authors have no financial interests in products related to this Special Article., (© 2024. The Author(s) under exclusive licence to Japanese Society of Anesthesiologists.)

Purpose: The influence of anesthetic interactions on motor-evoked potentials in infants has rarely been reported. In infants, adding a small dose of sevoflurane to propofol-based total intravenous anesthesia is reasonable for reducing propofol administration. We collected preliminary data regarding the effect of low-dose sevoflurane in propofol-based total intravenous anesthesia on motor-evoked potentials in infants., Methods: This pilot interventional study included 10 consecutive infants requiring motor-evoked potentials between January 2023 and March 2024. The motor-evoked potential amplitudes in the upper and lower extremities were recorded twice when general anesthesia was maintained using (1) propofol-based total intravenous anesthesia and (2) 0.1-0.15 age-adjusted minimum alveolar concentration sevoflurane + propofol-based total intravenous anesthesia., Results: The motor-evoked potential amplitude in the right upper extremity was not significantly different after the addition of a small dose of sevoflurane [192 (75.3-398) μV, 121 (57.7-304) μV, P = 0.19]. All the motor-evoked potential amplitudes in the right lower extremity (quadriceps femoris, anterior tibialis, and gastrocnemius muscles) were significantly attenuated by adding a small dose of sevoflurane (median [interquartile range]: 47.9 [35.4-200] μV, 25.2 [12.4-55.3] μV, P = 0.014; 74.2 [51.9-232] μV, 31.2 [2.7-64] μV, P = 0.0039; 29.8 [20-194] μV, 9.9 [3.8-92.4] μV, P = 0.0039, respectively). Similar results were observed in the left lower extremities., Conclusion: Adding even 0.1-0.15 age-adjusted minimum alveolar concentration sevoflurane to propofol-based total intravenous anesthesia attenuated the motor-evoked potential amplitudes in the lower extremities. A further prospective interventional study with an appropriate sample size is required to investigate the study hypothesis., Competing Interests: Declarations. Conflict of interest: The authors report no competing interests. Prior presentation: Parts of these findings were reported during an invited presentation at the 71st Annual Meeting of the Japanese Society of Anesthesiologists in Kobe, Japan on June 6, 2024., (© 2024. The Author(s).)

Purpose: Perioperative respiratory adverse events continue to pose significant challenges in pediatric anesthesia. Research has hinted at a lower incidence of these complications in children anesthetized with propofol than sevoflurane. This study aimed to assess and compare respiratory complications in children undergoing general anesthesia with either sevoflurane or propofol during surgery., Design: Systematic review and meta-analysis., Methods: We conducted comprehensive searches of the PubMed, Embase, and Cochrane Library databases and manual searches to identify pertinent randomized controlled trials (RCTs) published up to August 19, 2023. The Cochrane risk assessment tool was employed to evaluate the risk of bias in the selected studies. The pooled analysis of relevant data compared respiratory complications, vomiting, agitation, anesthesia duration, extubation time, and recovery time in pediatric patients undergoing anesthesia with sevoflurane and propofol., Findings: A total of 17 RCTs, containing 1,758 pediatric participants, were included and analyzed. Respiratory adverse events were examined, encompassing laryngospasm, apnea, cough, and SpO2. In comparison to sevoflurane, children subjected to propofol anesthesia demonstrated a significant reduction in the risk of laryngospasm (P = .001), vomiting (P < .001), and agitation (P = .029). Especially in patients receiving laryngeal mask airway, propofol anesthesia significantly reduced the incidence of laryngospasm (P = .003) and agitation (P < .001). At the same time, they exhibited an increased risk of apnea (P = .039). Notably, no statistically significant disparities were observed between sevoflurane and propofol concerning cough, SpO2 < 95%, anesthesia time, extubation time, and recovery time. Administration of propofol following sevoflurane anesthesia did not significantly impact the occurrence of vomiting or the recovery time., Conclusions: While propofol presents an elevated risk of apnea, it concurrently yields a significant reduction in laryngospasm, vomiting, and agitation. Consequently, propofol emerges as a favorable anesthetic option for pediatric patients., Competing Interests: Declaration of Competing Interest None to report., (Copyright © 2025 The American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Remimazolam is a novel short-acting benzodiazepine that has recently been used for general anesthesia. This study compared the safety and efficacy of remimazolam-based total intravenous anesthesia (TIVA) and volatile agent-based anesthesia in adults undergoing general anesthesia., Methods: We searched electronic databases including PubMed, Embase, CENTRAL, and Scopus for relevant studies. The primary outcome was the proportion of patients who experienced hypotension during surgery. Secondary outcomes included incidence of bradycardia, extubation time, duration in the post-anesthesia care unit hospital stay, and incidence of postoperative nausea and/or vomiting (PONV). We estimated the relative risk (RR) and mean difference with 95% CIs using a random-effects model., Results: A total of 969 patients from 12 randomized controlled trials were included. The incidence of hypotension was 14% and 34% in the remimazolam and volatile agent groups, respectively. Remimazolam significantly lowered the incidence of hypotension (RR: 0.43, 95% CI [0.29-0.63], P = 0.0000, I2 = 26%). The remimazolam group had a PONV incidence of 13%, compared to 28% in the volatile agent group, indicating a significant difference (RR: 0.51, 95% CI [0.37-0.72], P = 0.0001, I2 = 15%). No significant differences were observed in the other outcomes., Conclusions: Remimazolam-based TIVA demonstrated favorable hemodynamic effects, with a lower incidence of hypotension and similar bradycardia rates, compared to volatile agent-based anesthesia. Furthermore, the reduction in PONV supports the use of remimazolam-based TIVA as a valuable method for general anesthesia.

Purpose: Living kidney transplantation is a common treatment for end-stage renal disease. The impact of anaesthetics on postoperative biomarkers of renal injury in living kidney transplant donors is not well understood., Patients and Methods: 70 transplant donors who underwent kidney extraction were randomly assigned to following two groups: sevoflurane (S group) and propofol (P group). Urine and blood were collected before induction and 1, 2, 6 days after operation. Kidney injury marker-1 (KIM-1), interleukin-18 (IL-18) and tissue inhibitor of metalloproteinase-2 (TIMP-2) were measured by enzyme-linked immunosorbent assay. Record the cystatin C, glomerular filtration rate, urine output during perioperative period., Results: There were both increases in biomarkers of kidney injury before and 1, 2 and 6 days after the anaesthetic surgery in donors, However, no statistical differences in KIM-1 (P (0.42 pg/mL (95% CI 0.21 to 0.63 pg/mL)) vs S (0.26 pg/mL (95% CI 0.02 to 0.49 pg/mL)), -0.16 pg/mL (95% CI -0.48 to 0.16 pg/mL)), IL-18 (P (178.54 pg/mL (95% CI 110.15 to 24693 pg/mL)) vs S (175.86 pg/mL (95% CI 100.35 to 251.38 pg/mL)), -2.68 pg/mL (95% CI -105.61 to 100.25 pg/mL)), and TIMP-2 (P (12.88 ng/mL (95% CI 8.69 to 17.07 ng/mL)) vs S (14.85 ng/mL (95% CI 10.23 to 19.46 ng/mL)), 1.97 ng/mL (95% CI -4.30 to 8.23 ng/mL)) concentration changes between the two types of anaesthesia., Conclusion: There was no difference between sevoflurane and propofol anaesthesia on postoperative changes in biomarkers of renal injury in living kidney transplant donors., Competing Interests: The authors declare no conflicts of interest in this work., (© 2025 Cai et al.)

Anesthetic gases contribute to global warming. We described a two-year performance improvement project to examine the association of individualized provider dashboard feedback of anesthetic gas carbon dioxide equivalent (CDE 20 ) production and median perioperative fresh gas flows (FGF) during general anesthetics during perioperative management. Using a custom structured query language (SQL) query, hourly CDE 20 for each anesthetic gas and median FGF were determined. During the first year, practitioners were not given any feedback on their use of anesthetic gases. During the second year of the study protocol, a commercially available business intelligence platform was used to deliver individualized monthly dashboard of these parameters to each practitioner. Continuous values are expressed as median [first quartile, third quartile]. During the study period, 53,294 patients managed by 79 anesthesiologists were available for analysis. Bivariate analysis revealed an overall decrease in median FGF from 2.0 [1.9, 3.0] liters/minute (l/min) to 1.9 [1.7, 2.0] l/min (p < 0.001). There was a significant decrease in the overall total CDE 20 from 5.10 [0,12.3] to 3.59 [0,8.78] kg/hr (p < 0.001). Multivariate analysis demonstrated an initial decrease in monthly practitioner total CDE 20 production with the intervention (odds ratio (OR) 0.875 95% confidence interval (CI) 0.809-0.996, p < 0.001) and a faster decrease rate in monthly total CDE 20 (OR 0.986, 95% CI 0.976-0,996, p < 0.001). Dashboard distribution initially decreased isoflurane (intervention OR 0.97 95% CI 0.96-0.99, p = 0.001) and N 2 O (OR 0.82 95% CI 0.73-0.94, p = 0.003) CDE 20 production and was associated with a steeper declining rate of isoflurane (OR 0.87, CI 0.79-0.94, p < 0.001) and desflurane (OR 0.9, 0.84-0.97, p = 0.005) CDE 20 production. The intervention did not have a significant effect on the monthly rate of decline of sevoflurane or N 2 O CDE 20 . The average practitioner FGF decreased by 0.3 l/m (95% confidence interval (CI): -0,011, -0.5, p = 0.002) with dashboard distributions. Dashboard distribution may be an effective tool to decrease FGF as well as components of anesthetic greenhouse gas emissions., Competing Interests: Declarations. Competing Interests: The authors declare no competing interests., (© 2025. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

There is a paucity of literature regarding the effect of anesthetic techniques on antitumor immunity, especially in gall bladder malignancies. We designed a study to compare the effect of propofol-based total intravenous anesthesia and sevoflurane-based general anesthesia-on antitumor immunity, including tumor growth factor-β (TGF-β), T-helper cell profile, and inflammatory markers. A pilot prospective randomized trial was conducted in 64 patients undergoing surgery for gall bladder malignancy under general anesthesia in a tertiary specialty cancer hospital. Adult cancer patients of ASA physical status I-III fulfilling the inclusion criteria were randomized to either group S (sevoflurane-based general anesthesia) or group T (propofol-based total intravenous anesthesia). Preoperative (morning of surgery) and postoperative (24 h and 1 month after surgery) blood samples were obtained. Demographic profile and preoperative parameters were comparable between both groups. There was a statistically significant difference in the postoperative value of TGF-β (higher in group T). There was a statistically significant difference in postoperative interleukin-17A value (indicative of TH17 cells), and it was found to be higher in group S. Propofol-based TIVA increases serum TGF-β levels. At the same time, Sevoflurane modulates T-helper cells-based immunity to increase TH17 cells in patients with gall bladder cancer. Multiple larger studies will be required to validate the results and provide useful recommendations., (© 2024 UICC.)

Physiological responses to inhaled anesthetics vary among species. Therefore, a precise anesthetic technique is important for each individual species. In this study, we focused on the degu (Octodon degus), a small herbivorous rodent. Degus have recently begun to be used as laboratory models for brain research because of certain human-like characteristics, such as spontaneous development of Alzheimer's disease. In this study, we evaluated appropriate induction and maintenance anesthesia conditions for isoflurane and sevoflurane in degus by a stimulation test, electroencephalography (EEG), minimum alveolar concentration (MAC), and vital signs. During induction, more rapid time to loss of the righting reflex and deeper anesthesia in degus were observed in isoflurane. The MAC value for degus were 1.75 ± 0.0% in isoflurane and 2.25 ± 0.27% in sevoflurane. Whereas some degus were awake during maintenance anesthesia using both anesthetics at concentrations of ≤2%, no rats were awake when using sevoflurane at a concentration of 2%. The duration of the total flat EEG, a measure of the depth of maintenance anesthesia, was longer for isoflurane than for sevoflurane. Furthermore, higher concentrations of both anesthetics suppressed the respiratory rate in degus. These new findings regarding inhalation anesthesia in degus will contribute to future developments in the fields of laboratory animals and veterinary medicine.

Background: Inhalational anesthetic agents are a major source of potent greenhouse gases in the medical sector, and reducing their emissions is a readily addressable goal. Nitrous oxide (N 2 O) has a long environmental half-life relative to carbon dioxide combined with a low clinical potency, leading to relatively large amounts of N 2 O being stored in cryogenic tanks and H cylinders for use, increasing the chance of pollution through leaks. Building on previous findings, Stanford Health Care's (SHC's) N 2 O emissions were analyzed at 2 campuses and targeted for waste reduction as a precursor to system-wide reductions., Objective: We aimed to determine the extent of N 2 O pollution at SHC and subsequently whether using E-cylinders for N 2 O storage and delivery at the point of care in SHC's ambulatory surgery centers could reduce system-wide emissions., Methods: In phase 1, total SHC (Palo Alto, California) N 2 O purchase data for calendar year 2022 were collected and compared (volume and cost) to total Palo Alto clinical delivery data using Epic electronic health records. In phase 2, a pilot study was conducted in the 8 operating rooms of SHC campus A (Redwood City). The central N 2 O pipelines were disconnected, and E-cylinders were used in each operating room. E-cylinders were weighed before and after use on a weekly basis for comparison to Epic N 2 O delivery data over a 5-week period. In phase 3, after successful implementation, the same methodology was applied to campus B, one of 3 facilities in Palo Alto., Results: In phase 1, total N 2 O purchased in 2022 was 8,217,449 L (33,201.8 lbs) at a total cost of US $63,298. Of this, only 780,882.2 L (9.5%) of N 2 O was delivered to patients, with 7,436,566.8 L (90.5%) or US $57,285 worth lost or wasted. In phase 2, the total mass of N 2 O use from E-cylinders was 7.4 lbs (1 lb N 2 O=247.5 L) or 1831.5 L at campus A. Epic data showed that the total N 2 O volume delivered was 1839.3 L (7.4 lbs). In phase 3, the total mass of N 2 O use from E-cylinders was 10.4 lbs or 2574 L at campus B (confirming reliability within error propagation margins). Epic data showed that the total N 2 O volume delivered was 2840.3 L (11.5 lbs). Over phases 2 and 3, total use for campuses A and B was less than the volume of 3 E-cylinders (1 E-cylinder=1590 L)., Conclusions: Converting N 2 O delivery from centralized storage to point-of-care E-cylinders dramatically reduced waste and expense with no detriment to patient care. Our results provide strong evidence for analyzing N 2 O storage in health care systems that rely on centralized storage, and consideration of E-cylinder implementation to reduce emissions. The reduction in N 2 O waste will help meet SHC's goal of reducing scope 1 and 2 emissions by 50% before 2030., (©Eric P Kraybill, David Chen, Saadat Khan, Praveen Kalra. Originally published in JMIR Perioperative Medicine (http://periop.jmir.org), 09.01.2025.)

Objective: To investigate the haemodynamic effects of gamma-hydroxybutyric acid (GHB) in isoflurane-anaesthetized pigs., Study Design: Experimental, randomized, nonblinded, crossover study., Animals: A group of six stress-resistant Landrace pigs (approximately 3 months old; three male, three female; bodyweight 39.2 ± 4 kg, mean ± standard deviation)., Methods: After premedication (midazolam 0.5 mg kg -1 and ketamine 10 mg kg -1 intramuscularly) and induction [propofol 0.25-0.5 mg kg -1 intravenously (IV)], anaesthesia was maintained with isoflurane in oxygen, and either GHB 250 mg kg -1 IV or an equal volume of saline was administered (minimum washout period 1 week). Systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures, heart rate and rhythm and respiratory rate were recorded every 5 minutes for 2 hours. Arterial samples were collected for blood gas and pharmacokinetic analyses. Relative changes from baseline were calculated and compared between treatments using a mixed model with time, period and treatment as variables (α < 0.05)., Results: Changes from baseline differed significantly between treatments (p < 0.001) for SAP (GHB -1.6 ± 10.7; saline -5.9 ± 14.8 mmHg), DAP (GHB +2.9 ± 9.6; saline -6.5 ± 10.7 mmHg) and MAP (GHB +2.2 ± 10.5; saline -5.7 ± 9.6 mmHg). Statistical analysis of secondary outcomes suggested effects on PaO 2 [GHB -45.2 ± 29.8 mmHg (-6.03 ± 3.97 kPa); saline +24.5 ± 32.4 mmHg (+3.27 ± 4.32 kPa); p < 0.001] and PaCO 2 [GHB -2 ± 10 mmHg (-0.27 ± 1.33 kPa); saline -9 ± 8 mmHg (-1.20 ± 1.07 kPa); p < 0.001]. Mean maximum blood concentration of GHB was 1171.1 ± 229.3 μg mL -1 , with volume of distribution 335.3 ± 68.5 mL kg -1 , clearance 77.2 ± 19.12 mL kg -1 hour -1 and elimination half-life 3.10 ± 0.80 hours., Conclusions and Clinical Relevance: GHB did not cause severe physiological side effects and may reduce cardiovascular depression., (Copyright © 2024 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Objective: To characterize the effect of buprenorphine on the minimum alveolar concentration of isoflurane (MACiso) in cats., Study Design: Randomized, crossover, experimental study., Animals: A group of six healthy male neutered cats, aged 2-8 years with body mass 5.0 ± 0.3 kg., Methods: The MACiso had been determined in each cat in a previous study. Cats were anesthetized with isoflurane in oxygen. Catheters were placed in a medial saphenous vein for drug and fluid administration and in a jugular vein for blood sampling. Buprenorphine was administered intravenously using a target-controlled infusion system to reach and maintain plasma concentrations of 0.5, 1, 2, 4, 8, 16, 32 and 64 ng mL -1 , and MACiso was determined in duplicate at each concentration using the tail clamp technique. Four target plasma buprenorphine concentrations were administered on each study day, with at least 2 weeks between experiments. Blood was sampled after the second MAC determination at each target for determination of plasma buprenorphine concentration., Results: A significant effect of buprenorphine on MAC was found; however, pairwise comparisons to MACiso without buprenorphine did not reach statistical significance. Maximum reduction in MACiso in individual cats ranged from 2% to 34% at plasma buprenorphine concentrations ranging from 0.25 to 8.15 ng mL -1 ., Conclusions and Clinical Relevance: Although buprenorphine significantly affected MACiso in cats, the magnitude of the effect and the plasma concentration at which the largest effect occurred was highly variable among cats, limiting the clinical usefulness of buprenorphine as an agent to reduce MAC in cats., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: The effects of anesthetics on electroencephalograms and cerebral perfusion remain understudied in children with congenital heart disease. With regard to this, we compared inhalational anesthesia induction and intravenous anesthesia induction., Design: A randomized controlled trial., Setting: Operating room in 2 tertiary hospitals., Participants: A cohort of 116 pediatrics patients undergoing cardiac surgery., Measurements and Main Results: The patients were randomly assigned to either the intravenous group (n = 58) or the inhalational group (n = 58). The inhalational group received anesthesia induction with 4% to 6% sevoflurane and a bolus of pipecuronium 0.2 mg/kg, whereas the intravenous group received anesthesia induction with intravenous midazolam 0.2 mg/kg, pipecuronium 0.2 mg/kg, and sufentanil 1 μg/kg. Ten minutes after tracheal intubation, the following parameters were measured: spectral edge frequency, burst suppression event, patient state index, middle cerebral artery blood flow velocity, cerebral oxygen saturation, and hemodynamic parameters. In comparison with the intravenous group, the inhalational group exhibited significant increases in 95% spectral edge frequency, ratio of burst suppression event, blood flow velocity in the middle cerebral artery, and cerebral oxygen saturation (p < 0.05 for all), as well as decreases in systolic pressure, diastolic pressure, cardiac index, and the maximal slope of systolic upstroke (p < 0.05 for all)., Conclusions: The administration of sevoflurane for anesthesia induction results in more burst suppression, while also demonstrating superior cerebral perfusion when compared with the use of intravenous medications for anesthesia induction., Trial Registration: Chinese Clinical Trial Registry (ChiCTR1800015946)., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To explore the influence of acepromazine on the cardiovascular effects of dobutamine in isoflurane-anaesthetised horses premedicated with romifidine., Study Design: Prospective randomised clinical trial., Animals: A total of 18 horses undergoing elective arthroscopy were enrolled, of which 12 horses requiring dobutamine were included., Methods: Horses were randomised to receive acepromazine 0.02 mg kg -1 (Group A+) intravenously (IV) or none (Group A-), 35 minutes before anaesthesia. Horses received xylazine 0.2 mg kg -1 concurrently to facilitate IV access. Horses were premedicated with romifidine 0.08 mg kg -1 , induced with ketamine 2.2 mg kg -1 and diazepam 0.08 mg kg -1 IV, and maintained with isoflurane in oxygen. Dobutamine infusion was commenced when mean arterial pressure (MAP) was < 60 mmHg. Cardiovascular data were collected prior to dobutamine, and at a target MAP of ≥ 70 mmHg. Dobutamine start time from induction, duration and dose to reach target MAP were compared using Mann-Whitney U test. Cardiovascular variables were compared using repeated measures ANOVA and post-hoc Fisher's least significant difference test., Results: Cardiac index (CI) and its percentage change from baseline were significantly higher at target MAP in group A+ [62.0 (49.9-74.2) mL minute -1 kg -1 ; 42.8 (17.0-68.7) %] than in A- [49.5 (39.6-59.5) mL minute -1 kg -1 ; -4.05 (-21.2-13.0) %] (p = 0.049; p = 0.003). Group A+ required significantly earlier dobutamine [20 (18-25) minutes] than group A- [36 (27-60) minutes] (p = 0.02). Group A+ required significantly higher dobutamine dose [1.5 (1-2.5) μg kg -1 minute -1 ] to reach target MAP than group A- [0.5 (0.5-1) μg kg -1 minute -1 ] (p = 0.009)., Conclusion and Clinical Relevance: Dobutamine significantly increased MAP and CI following pre-anaesthetic acepromazine sedation, in isoflurane-anaesthetised horses premedicated with romifidine. Without acepromazine, dobutamine increased MAP but not CI. Interactions between acepromazine, romifidine and dobutamine on the cardiovascular system should be considered., Competing Interests: Conflict of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Objective: To evaluate the dose of alfaxalone needed for induction of anesthesia following sedation with medetomidine-vatinoxan plus hydromorphone (MVH), dexmedetomidine plus hydromorphone (DH), or hydromorphone (H) alone. A secondary objective included evaluating selected cardiopulmonary variables before, during, and after sedation and general anesthesia with sevoflurane in healthy dogs., Study Design: Prospective, randomized, masked, crossover., Animals: Eight healthy Beagle dogs, 3-4 years old., Methods: All dogs received three intramuscular (IM) treatments: H (0.1 mg kg -1 ), DH (0.005 mg kg -1  + 0.1 mg kg -1 , respectively), or MVH (0.01 mg kg -1  + 0.2 mg kg -1  + 0.1 mg kg -1 , respectively) at least 6 days apart. General anesthesia was induced with alfaxalone 20 minutes after treatment administration and maintained for 60 minutes with 2.8% sevoflurane (expired). Sedation scores, selected cardiopulmonary variables, and recovery scores were measured before, during, and after anesthesia at selected timepoints. Mixed-effects ANOVA and ANOVA on ranks were used to evaluate differences between treatments, time, and their interaction, and Tukey-Kramer method was used for post hoc analysis (p < 0.05). Data are presented as mean ± SD or median (range)., Results: Dogs given MVH required a lower dose of alfaxalone for induction of anesthesia (0.77 ± 0.4 mg kg -1 ) compared to DH and H (1.16 ± 0.34 mg kg -1 ; p = 0.02, 1.13 ± 0.18 mg kg -1 ; p = 0.02), and had a higher incidence (50%; p = 0.038) and longer duration [median; 10 (0-35) minutes] of hypotension during sevoflurane anesthesia compared to H [0%; 0 (0-0) minutes; p = 0.040] but not DH (p = 0.272)., Conclusions and Clinical Relevance: Premedication with MVH provided the greatest alfaxalone-sparing effect. However, this treatment was associated with lower arterial pressures and clinically relevant hypotension. Off-label use of medetomidine-vatinoxan before sevoflurane-based anesthesia should be used with caution due to a high incidence of hypotension., (Copyright © 2024 Association of Veterinary Anaesthetists and American College of Veterinary Anesthesia and Analgesia. Published by Elsevier Ltd. All rights reserved.)

Introduction: Domestic rabbits have higher perioperative mortality rates (1.39%-4.8%) compared with dogs and cats (0.1%-0.2%), with cardiovascular and respiratory complications reported most. Understanding anaesthetic risk factors is essential to minimise mortality risks., Objective: To determine the perioperative mortality risks and risk factors in rabbits undergoing general anaesthesia., Methods: This retrospective cohort study evaluated 1757 records of rabbits that underwent general anaesthesia with inhaled isoflurane, categorised by the American Society of Anesthesiologists (ASA) physical status classification system (January 2019-April 2023). Data were collected on physical characteristics, anaesthetic protocol, airway management and patient outcomes. Potential risk factors were analysed using multivariable logistic regression modelling guided by directed acyclic graphs., Results: The perioperative mortality risk was 2.05% (95% CI: 1.39, 2.71). Increased mortality was most associated with poorer health status (ASA score) and non-routine procedures. Following induction of anaesthesia, rabbits with a body mass of less than 1 kg (RR: 7.57, 95% CI: 1.18, 61.2) and Netherland Dwarf rabbits (RR: 23.4, 95% CI: 2.75, 200) were at higher risk. The use of a supraglottic airway device was protective against mortality during anaesthesia compared with endotracheal tubes (RR: 0.27, 95% CI 0, 3.78) and anaesthetic masks (RR: 0.42, 95% CI: 0, 3.71). Increased mortality was observed with a fentanyl-based protocol compared with a medetomidine-based protocol (RR: 4.62, 95% CI: 0.477, 44.7)., Discussion: Perioperative mortality was multifactorial, with health status, surgical complexity and physical characteristics representing primary risk factors. Clinicians should choose a suitable anaesthetic protocol, implement effective airway control and follow precautions for brachycephalic rabbit breeds., (© 2024 Australian Veterinary Association.)

Background: Sevoflurane causes emergence agitation (EA) in up to 80% of pediatric patients., Objectives: Using midazolam, dexmedetomidine (DEX), and gabapentin, this work aimed to assess the prophylactic effect of oral premedication on EA incidence experienced by pediatric patients during recovery from sevoflurane anesthesia., Study Design: Randomized controlled trial., Setting: Kafrelsheikh University, Kafrelsheikh, Egypt., Methods: This study was performed on 240 men and women aged 3 to 10 years who were scheduled for adenotonsillectomy. Patients were randomized into 4 equal-sized groups. Thirty minutes before general anesthesia, oral premedication was applied in the form an apple-flavored sugary fluid plus 0.5 mg/kg of midazolam in Group M, 4 µg/kg of DEX in Group D, 10 mg/kg of gabapentin in Group G, or no drugs whatsoever in Group P (placebo)., Results: The incidence of EA was reduced more greatly in the M, D, and G groups than in the P group, and the D group's incidence of EA was lower than that of the M or G groups. The severity of EA exhibited a more significant reduction in the M, D, and G groups than in Group P. Similarly, the time until extubation was more prolonged in the M, D, and G groups than it was in the P group. Hemodynamics measurements were significantly lower in Groups M, D, and G than in Group P, and the D group had a lower hemodynamics measurement than did the M or G groups. Sedation scores were greater in the D and G groups than in the P group, and the D group had a higher sedation score than did Group M., Limitations: This study used a small sample, took place at a single center, and had a short follow-up period., Conclusion: Premedication using oral midazolam, DEX, or gabapentin reduced the incidence of EA, and DEX provided the best sedation and hemodynamics of all.

Studies have suggested volatile anaesthetics may alleviate depression and anxiety symptoms in patients. However, there is a paucity of research in this area. We wanted to determine the association between volatile anaesthetics and depression/anxiety symptoms in elderly patients within 7 days after surgery. This study retrospectively analysed data from a prospective database of patients aged 65 and above who underwent non-cardiac, non-neurosurgical elective surgery in 19 tertiary hospitals across 10 provinces in China. The study period spanned from April 1, 2020 to April 30, 2022. Patients receiving volatile anaesthetics received at least one volatile anaesthetic (sevoflurane, isoflurane, desflurane), and those who received non-volatile anaesthetics did not receive any volatile anaesthetic. Binary logistic regression analyses were conducted, and propensity score-matching (PSM) and subgroup analyses were also applied. A total of 7165 patients were included in the analysis. Among them, 4957 (69.18%) cases received volatile anaesthetics. The administration of volatile anaesthetics was associated with a lower rate of postoperative depression [22.76% vs. 27.26%, odds ratio (OR): 0.75, P < 0.001], and reduced the incidence of postoperative anxiety (19.59% vs. 24.68%, OR: 0.78, P < 0.001). The risk of postoperative depression (24.78% vs.27.93%, OR: 0.85, P = 0.035), and anxiety (21.45% vs. 25.92%, OR: 0.81, P = 0.006) were both significantly decreased in the volatile anaesthetics group in the PSM cohort. The results suggest that using volatile anaesthetics maybe associated with a reduction in the incidence of depression and anxiety in elderly patients during the early postoperative period., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: There is currently insufficient evidence on potential predictors of a child's behaviour with nitrous oxide (N 2 O) sedation., Aim: To examine the association between a child's temperament and behavioural outcomes during dental treatment with N 2 O sedation, and the child's perception to N 2 O sedation., Design: At the first visit (dental treatment visit), temperament was assessed using the Child Behaviour Questionnaire-Short Form and behaviour was assessed by an independent rater using the Venham Behaviour Rating Scale. At the second visit, the child's experience with N 2 O sedation was elicited., Results: Seventy-two healthy children aged between 36 and 95 months were recruited. Planned dental treatment was completed in 84.7% of the subjects. Venham behaviour success <3 and Venham behaviour success <1 were achieved in 73.6% and 33.3%, respectively. The temperament domain of effortful control was associated with Venham behaviour score (ρ = -0.266, p = .024) and Venham behaviour success <1 (OR = 3.506, 95% CI = 1.328-9.259, p = .011). Baseline Frankl behaviour score was significantly associated with all behavioural outcomes. Venham behaviour success <3 was significantly associated with a child reporting to have enjoyed the dental treatment visit (p = .026)., Conclusion: Effortful control and baseline behaviour were associated with behavioural outcomes of N 2 O sedation and can be used to predict a child's behaviour., (© 2024 BSPD, IAPD and John Wiley & Sons Ltd.)

James Watt (1736-1819) is remembered as a steam engine innovator and industrial magnate. A polymath, he was also a hands-on contributor to the Medical Pneumatic Institution of Thomas Beddoes. Watt recruited Humphry Davy, who there discovered analgesic action of inhaled nitrous oxide in 1799. Watt also built pneumatic equipment, and he introduced a gas mixture, dubbed hydro-carbonate, as a medical tonic. The bioactive component was carbon monoxide, a readily-lethal inhibitor of the transport and utilization of respiratory oxygen. Despite appreciable toxicity, carbon monoxide is an endogenous product of heme catabolism, and low doses of the gas are under laboratory investigation for therapeutic purposes. However, Watt's hydro-carbonate constituted a setback in the development of pharmacologically useful gases., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Objectives: To explore the effect of mild cognitive impairment (MCI) and MCI with sleep disorders on the potency of sevoflurane anesthesia in the elderly., Design: Prospective study methods. Dixon up-and-down methods., Setting: Comprehensive public tertiary hospital, Cangzhou City, Hebei Province, China., Participants: 70 elderly patients scheduled for elective unilateral breast cancer surgery and finally analyzed 58 patients, including 30 patients with MCI (group M) and 28 patients with MCI with sleep disorders (group MS)., Outcome Measures: The required minimum alveolar concentration (MAC) value of sevoflurane in the two groups was determined using the Dixon up-and-down method. The MAC value of sevoflurane and its 95% confidence interval (CI) were calculated using the logistic regression method. Serum melanin-concentrating hormone concentrations were determined by Elisa kits., Results: The MAC value of sevoflurane in group M was 1.43 (95% CI 1.05-1.61%), and the MAC value of sevoflurane in group MS was 1.93 (95% CI 1.78-2.08%), There were notable differences between the two groups (P < 0.0001). The level of melanin-concentrating hormone (MCH) in the MS group was significantly lower than that in the M group (21.52 ± 3.82 vs. 37.17 ± 3.66 pg/ml, P < 0.0001). There was a significant negative correlation between MCH levels and the probability of body movement during skin incision (OR = 0.844, 95% CI: 0.715-0.996, P = 0.045)., Conclusions: Patients with MCI with sleep disorders required higher doses of sevoflurane than those with MCI alone. Changes in anesthetic requirements may be related to changes in MCH levels., Competing Interests: Declarations. Ethical approval and consent to participate: This study involves human participants and the Institutional Review Board of Cangzhou Central Hospital (2021-206-02 (z)). This study was conducted in accordance with the principles set out in the Declaration of Helsinki for medical research involving human subjects. Informed consent was obtained from all participants and their legal guardians. The study adheres to CONSORT guidelines. Consent for publication: Not Applicable. Trial registration number: ChiCTR2400082114 (21/03/2024). The ethical approval of this study was approved by the Ethics Committee of Cangzhou Central Hospital on December 15, 2021. Patient and public involvement: Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: Pain therapy is an important first-response measure in the pre-clinical care of trauma patients. Injured individuals on ski slopes are usually given first aid by members of the ski patrol. The early implementation of adequate pain therapy by these paramedical rescuers can increase patient satisfaction and have a positive effect on the entire treatment process. In this context, we analysed the administration of methoxyflurane by ski patrol members on Swiss ski slopes., Methods: In this retrospective observational study, we evaluated 172 datasets, of which 149 concerned patients who were administered methoxyflurane. These datasets were taken from a quality-control survey related to the administration of methoxyflurane by members of the ski patrol in seven ski resorts in the Swiss Alps. The data was collected in the winter months of 2022/23. The ski patrol members had been previously trained by medical professionals and employed methoxyflurane following a defined algorithm, according to which patients with an initial numeric pain score of ≥ 4 qualified for the use of methoxyflurane. After each treatment, data on effectiveness and feasibility were collected by means of a standardised questionnaire. The primary outcome was defined as achieving effective pain therapy, which was designated as a reduction on the numerical rating scale of two or more points and a pain score of seven or less after administration. We then performed a linear regression analysis with the relative pain reduction as the outcome and sex, age, ski resort and injury class as covariates., Results: Methoxyflurane led to effective pain reduction in around two-thirds of patients on the ski slopes and was easy to use for trained ski patrol members. Median pain reduction was 2 points (interquartile range: 1 to 3) on the NRS scale. The regression model showed lower reduction in pain in lower extremity injuries. Sex, age and initial pain score were not associated with the extent of pain reduction. No serious side effects were observed., Conclusion: The administration of methoxyflurane by trained ski patrol members is a safe and effective option for early pain management in ski slope injuries. Methoxyflurane could thus represent a useful bridging measure, enabling the ski patrol to relieve moderate to severe pain until professional rescue services arrive. However, it does not seem ideal for lower leg injuries., Competing Interests: Declarations. Ethics approval and consent to participate: The local ethical committee evaluated the study and waived written informed consent (KEK 2024 − 00611). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Sevoflurane is extensively employed as an inhalation anesthetic in medical practices, due to its promising pharmacokinetics. Conversely, the data regarding effects of prolonged exposure to trace amounts of sevoflurane on the female reproductive system is obscure. Therefore, this study aimed to investigate the reproductive toxicity and underlying mechanism of long-term sevoflurane inhalation in female rats. A total 60 SPF grade SD female rats were randomly alienated into four equal groups as control group (A), 50 ppm sevoflurane group (B), 150 ppm sevoflurane group (C), and 300 ppm sevoflurane groups (D). Ovaries and uterine organs were collected for gross as well as histopathological analysis, western blotting, and immuno-histochemistry evaluation. Results revealed that pregnancy rate, number of fetuses (fetal mice) and general body weight of group B, C, and D were substantially lower (P < 0.05), while were compared with control. On the contrary, estrous period in groups B, C, D was shortened noticeably (P < 0.05), and estrus interval and cycle were significantly longer (P < 0.05). In fact, the ovarian and uterine coefficients of group B, C and D were significantly reduced as compared with control. However, ovarian and uterine histomorphology remained normal in control group, while obvious pathological alterations were detected in groups B, C, and D. Although, the expression of SOD protein in the ovarian and uterine tissues of groups B, C, and D was significantly reduced (P < 0.05), in contrast to group A. However, the MDA protein expression increased significantly (P < 0.05) as compared with group A. While expression of apoptosis-related genes (Bcl2 and Bax) and humoral immunity related genes (IL-6, IL-10 and TNF-α) showed highest elevation in groups exposure with sevoflurane (p < 0.001) in comparison to control. Conclusively, long-term inhalation of trace amounts of sevoflurane is toxic to female reproductive system and can severely affect reproductive organs and fertility by induction of oxidative stress and apoptosis., Competing Interests: Declarations. Competing interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Malignant hyperthermia (MH) is a potentially fatal disorder triggered by volatile anesthetics or succinylcholine, inducing a hypermetabolic crisis in susceptible patients. The caffeine-halothane contracture test (CHCT) remains a gold standard for MH detection. The authors describe a pregnant patient with a history of exertional rhabdomyolysis, who required urgent MH screening for administration of MH-triggering anesthetics. This anesthetic plan allowed for an in utero myelomeningocele repair for a 24-week-old fetus. A multi-institutional team coordinated the urgent CHCT and repair with a favorable outcome., Competing Interests: The authors declare no Conflicts of Interest., (Copyright © 2024 International Anesthesia Research Society.)

Background: It remains unclear whether opioid-free anesthesia (OFA), when compared to opioid-sparing anesthesia (OSA), reduces postoperative opioid consumption while still providing adequate pain control. We thus tested the hypothesis that patients having an OFA strategy during laparoscopic colectomy would require less postoperative opioids when compared to an OSA strategy., Methods: This single-center, prospective randomized controlled superiority trial, randomly allocated consecutive patients undergoing laparoscopic colectomy to receive either sevoflurane-dexmedetomidine anesthesia with a continuous infusion of lidocaine and ketamine (OFA group) or sevoflurane-sufentanil boluses anesthesia with a continuous infusion of lidocaine (OSA group). Both groups received multimodal antinociception with boluses of dexamethasone, lidocaine, and ketamine during anesthesia induction, as well as acetaminophen, ketoprofen, and nefopam before the end of the surgery. OFA patients also received a dose of magnesium sulfate during induction. The primary outcome was cumulative opioid consumption at 48 h after surgery, expressed in oral morphine equivalents (OME). Secondary exploratory outcomes were pain scores, opioid-related adverse events, and patient quality of life (WHODAS score)., Results: Of the 160 randomized patients, 155 were included in a modified intention-to-treat analysis. Median [Q1-Q3] OME consumption at 48 h after surgery did not differ between groups (9 [0-30] mg for OFA vs. 14 [0-30] mg for OSA; p = 0.861). Key secondary outcomes were not different between groups except a three time higher incidence of bradycardia in the OFA group., Conclusions: In patients undergoing laparoscopic colectomy with a multimodal antinociception protocol, OFA, when compared to OSA, did not decrease postoperative opioid consumption., Clinical Trial Registry and Number: NCT05031234., Competing Interests: Declaration of competing interest Alexandre Joosten is consultant for Edwards Lifesciences, Irvine, CA, USA. Sean Coekelenbergh has received honoraria for presentations from Medtronic, Medasense, and Med—Storm. The other authors have no conflicts of interest to declare., (Copyright © 2024 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Study Objective: Evaluate the impact of deep neuromuscular blockade on intraoperative nociception Deep neuromuscular blockade has been shown to improve surgical conditions and postoperative outcomes compared to moderate neuromuscular blockade in laparoscopic surgery. Still, its impact on intraoperative nociception and opioid requirement has never been assessed., Design: Monocentric randomised controlled trial., Setting: Operating room., Patients: We included 100 ASA I to III patients who underwent colorectal laparoscopic surgery with desflurane-remifentanil anesthesia., Interventions: Patients were randomised into two groups to achieve either moderate (1-3 train of four response) or deep (1-2 post-tetanic count) neuromuscular block (NMB) with repeated boluses of rocuronium. The Nociception Level (NOL) index guided intraoperative remifentanil administration in both groups., Measurements: The primary endpoint was total intraoperative remifentanil administration per hour of surgery. Secondary endpoints included, Leiden Surgical Rating Scale (L-SRS), intra-abdominal pressure, postoperative pain scores and opioids' consumption., Main Results: Ninety-three patients were analysed. Forty-five in the deep group and 48 patients in moderate group. Intraoperative administration of remifentanil was 348 (228-472) μg.h -1 in the deep NMB group compared to 494 (392-618) μg.h -1 in the moderate NMB group (P < 0.001). Lowest L-SRS was 5 (4-5) in the deep NMB group versus 3 (2-5) (P < 0.001) in the moderate NMB group. Mean intra-abdominal pressure was 11.9 (1.3) in the deep NMB group versus 13 (1.3) (P < 0.001) in the moderate NMB group. Secondary postoperative outcomes including pain scores and analgesics administration were not significantly different., Conclusions: This study shows that deep neuromuscular blockade reduces intraoperative NOL-guided administration of remifentanil in colorectal laparoscopic surgeries. It also improves surgical conditions., Trial Registration: The study was registered at ClinicalTrials.gov under NCT03910998., Competing Interests: Declaration of competing interest Philippe Richebé received honorariums as a consultant and to give lectures from the following companies: Medasense, Abbvie, Medtronic-Covidien, Biosyent, and Merck. The other authors declare no conflict of interest., (Copyright © 2024. Published by Elsevier Inc.)

Background: The Nociception Level Index has shown benefits in estimating the nociception/antinociception balance in adults, but there is limited evidence in the pediatric population. Evaluating the index performance in children might provide valuable insights to guide opioid administration., Aims: To evaluate the Nociception Level Index ability to identify a standardized nociceptive stimulus and the analgesic effect of a fentanyl bolus. Additionally, to characterize the pharmacokinetic/pharmacodynamic relationship of fentanyl with the Nociception Level Index response during sevoflurane anesthesia., Methods: Nineteen children, 5.3 (4.1-6.7) years, scheduled for lower abdominal or urological surgery, were studied. After sevoflurane anesthesia and caudal block, a tetanic stimulus (50 Hz, 60 mA, 5 s) was performed in the forearm. Following the administration of fentanyl 2 μg/kg intravenous bolus, three similar consecutive tetanic stimuli were performed at 5-, 15-, and 30-min post-fentanyl administration. Changes in the Nociception Level Index, heart rate, mean arterial pressure, and bispectral index were compared in response to the tetanic stimuli. Fentanyl plasma concentrations and the Nociception Level Index data were used to elaborate a pharmacokinetic/pharmacodynamic model using a sequential modeling approach in NONMEM®., Results: After the first tetanic stimulus, both the Nociception Level Index and the heart rate increased compared to baseline (8 ± 7 vs. 19 ± 10; mean difference (CI95) -12(-18--6) and 100 ± 10 vs. 102 ± 10; -2(-4--0.1)) and decrease following fentanyl administration (19 ± 10 vs. 8 ± 8; 12 (5-18) and 102 ± 10 vs. 91 ± 11; 11 (7-16)). In subsequent tetanic stimuli, heart rate remained unchanged, while the Nociception Level Index progressively increased within 15 min to values similar to those before fentanyl. An allometric weight-scaled, 3-compartment model best characterized the pharmacokinetic profile of fentanyl. The pharmacokinetic/pharmacodynamic modeling analysis revealed hysteresis between fentanyl plasma concentrations and the Nociception Level Index response, characterized by plasma effect-site equilibration half-time of 1.69 (0.4-2.9) min. The estimated fentanyl C50 was 1.93 (0.73-4.2) ng/mL., Conclusion: The Nociception Level Index showed superior capability compared to traditional hemodynamic variables in discriminating different nociception-antinociception levels during varying fentanyl concentrations in children under sevoflurane anesthesia., (© 2024 John Wiley & Sons Ltd.)

Objective: To compare the incidence of hypotension between remimazolam and sevoflurane under general anesthesia for cardiac catheterization in patients with congenital heart disease., Design: Retrospective observational study., Setting: A single university hospital with 300 pediatric cardiac catheterizations by general anesthesia performed annually., Participants: Patients younger than 15 years who underwent cardiac catheterization under general anesthesia between March 1, 2021, and December 31, 2022. Exclusion criteria were general anesthesia maintained with other than remimazolam or sevoflurane, receipt of remifentanil, American Society of Anesthesiologists score 4 or 5, emergency procedures, and no direct arterial pressure measurement., Interventions: General anesthesia was maintained with remimazolam or sevoflurane., Measurements and Main Results: A total of 309 patients were analyzed, including 28 in the remimazolam group and 281 in the sevoflurane group. Propensity score matching adjusted for confounding factors resulted in 28 patients in each arm, with no apparent differences in background factors. Hypotension was defined as a time-averaged area > 1, in which systolic arterial pressure fell below 80% of the baseline from the start of anesthesia to the end of procedure. The significance level was set at P < .05. The incidence of hypotension was 39.3% in the remimazolam arm and 46.4% in the sevoflurane arm, with no significant difference (P = .79), although the ratio of the median systolic arterial pressure to the baseline value was significantly higher in the remimazolam arm (91.4 ± 15.2% vs 83.2 ± 11.4% in the sevoflurane arm; P = .03)., Conclusions: Remimazolam was not associated with a lower incidence of hypotension compared to sevoflurane during pediatric cardiac catheterization for congenital heart disease while maintaining significantly higher blood pressure overall., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

General anesthetics exposure, particularly prolonged or repeated exposure, is a crucial cause of neurological injuries. Notably, isoflurane (ISO), used in pediatric anesthesia practice, is toxic to the developing brain. The relatively weak antioxidant system at early ages needs antioxidant support to protect the brain against anesthesia. Cerium oxide nanoparticles (CeO 2 -NPs, nanoceria) are nano-antioxidants and stand out due to their unique surface chemistry, high stability, and biocompatibility. Although CeO 2 -NPs have been shown to exhibit neuroprotective and cognitive function-facilitating effects, there are no reports on their protective effects against anesthesia-induced neurotoxicity and cognitive impairments. Herein, Wistar albino rat pups were exposed to ISO (1.5 %, 3-h) at postnatal day (P)7+P9+P11, and the protective properties of CeO 2 -NP pretreatment (0.5 mg/kg, intraperitoneal route) were investigated for the first time. The control group at P7+9+11 received 50 % O 2 (3-h) instead of ISO. Exposure to nanoceria one-hour before ISO protected hippocampal neurons of the developing rat brain against apoptosis [determined by hematoxylin-eosin (HE) staining, immunohistochemistry (IHC) analysis with caspase-3, and immunoblotting with Bax/Bcl2, cleaved caspase-3 and PARP1] oxidative stress, and inflammation [determined by immunoblotting with 4-hydroxynonenal (4HNE), nuclear factor kappa-B (NF-κB), and tumor necrosis factor-alpha (TNF-α)]. CeO 2 -NP pretreatment also reduced ISO-induced learning (at P28-32) and memory (at P33) deficits evaluated by Morris Water Maze. However, memory deficits and thigmotactic behaviors were detected in the agent-control group; elimination of these harmful effects will be possible with dose studies, thus providing evidence supporting safer use. Overall, our findings support pretreatment with nanoceria application as a simple strategy that might be used for pediatric anesthesia practice to protect infants and children from ISO-induced cell death and learning and memory deficits., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The author is an Editorial Board Member/Editor-in-Chief/Associate Editor/Guest Editor for [Journal name] and was not involved in the editorial review or the decision to publish this article., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Study Objective: This study aimed to analyze the effects of two volatile anesthetic agents, desflurane and sevoflurane, on graft outcomes in patients undergoing deceased donor liver transplantation (DDLT) for cirrhosis, with a specific focus on fatty grafts., Design: A retrospective observational study., Setting: A tertiary hospital (Severance Hospital, Korea)., Patients: This study included 151 patients with liver cirrhosis who underwent DDLT for cirrhosis between January 2006 and December 2022., Interventions: Patients were grouped according to maintenance anesthesia received (desflurane or sevoflurane), the model for end-stage liver disease (MELD) score, and macrovesicular steatosis (MVS) of the liver graft., Measurements: Survival curves were constructed from the date of surgery to graft failure or death. After propensity score matching (PSM), Cox regression analysis was used to compare hazards ratios (HR) for 5-year graft and overall survival. Subgroup analyses were performed for the MELD score and MVS of the liver graft. Incidences of 1-month acute rejection and early allograft dysfunction (EAD) were also compared between the two groups., Main Results: Among 151 eligible patients, 49 patients remained in each group after PSM, with 14 (28.6 %) graft failures and deaths occurring in each group. In matched analysis, sevoflurane showed poorer 5-year graft and overall survival compared to desflurane in recipients of graft with ≥10 % MVS, and this trend was significant in patients with MELD score of ≥35. In Cox regression model, compared to desflurane sevoflurane showed a propensity score-matched HR of 5.8 (95 % CI, 1.13-30.50 for both 5-year graft and overall survival. Additionally, sevoflurane showed an increased risk of 1-month acute rejection; however, no difference was observed for EAD., Conclusions: Sevoflurane as a maintenance agent during DDLT in recipients with high MELD scores and fatty grafts may be associated with poorer outcomes compared to desflurane., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Interest in passive flow filter systems to remove sevoflurane from anaesthetic machine exhaust have increased recently to mitigate the environmental impact of volatile anaesthetics. These filter systems consist of chemically activated carbon, with limited evidence on their performance characteristics. We hypothesised that their efficiency depends on filter material., Methods: Binding capacity was tested for three carbon filter materials (CONTRAfluran®, FlurAbsorb®, and Anaesthetic Agent Filter AAF633). Adsorption efficiency and resistive pressure were determined during simulated ventilation at different stages of filter saturation and fresh gas flow. In addition, sevoflurane concentration in filtered gas was measured at randomly selected anaesthesia workstations., Results: Sevoflurane concentration in filtered gas exceeded 10 ppm when saturated with 184 ml sevoflurane each for CONTRAfluran and FlurAbsorb and 276 ml for AAF633. During simulated ventilation, sevoflurane concentration >10 ppm passed through CONTRAfluran and AAF633 at fresh gas flow 10 L min -1 only at maximum saturation, but through FlurAbsorb at all stages of saturation. The resistance pressure of all filters was negligible during simulated ventilation, but increased up to 5.2 (0.2) cm H 2 O during simulated coughing. At two of seven anaesthesia workstations, sevoflurane concentration in filtered exhaust gas was >10 ppm., Conclusions: Depending on the filter material and saturation, the likelihood of sevoflurane passing through passive flow carbon filters depends on the filter material and fresh gas flow. Combining the filter systems with anaesthetic gas scavenging systems could protect from pollution of ambient air with sevoflurane., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction : Postoperative agitation is a common complication of sevoflurane anesthesia in children and might lead to self-harm and recovery disruption. This study aimed to compare the prophylactic effect of dexmedetomidine and remifentanil on postoperative agitation after anesthesia with sevoflurane. Methods : In this clinical trial, 60 children aged 2 to 7 years with ASA class І, II, candidates for elective strabismus surgery, were randomly assigned to three groups using block randomization. Patients in the first group D received 0.5 µgr/kg dexmedetomidine, the second group R received 0.1 µgr/kg remifentanil, and another group C received normal saline at the end of anesthesia. Children's agitation degree was measured by the Pediatric Anesthesia Emergence Delirium (PAED) scales and the 4-point agitation scale at the time of extubation, entering the recovery room, 10, 20, and 30 minutes after entrance. Data analysis was performed using descriptive and inferential statistical tests. Results : The postoperative agitation and pain were significantly lower among children who received dexmedetomidine compared with those in remifentanil and the control group ( p  < .001). It was observed that the administration of dexmedetomidine at the end of anesthesia significantly decreased the incidence of postoperative agitation ( p  < .001). None of the patients in group D had a PAED score of over 12. Conclusion : Based on PAED and the 4-point scales, none of the cases in group D had experienced postoperative agitation; this made a significant statistical difference compared with groups C and R ( p -value <. 001). Although both dexmedetomidine and remifentanil can prevent and attenuate postoperative agitation, dexmedetomidine administration seems significantly more effective.

Purpose of the Review: Penthrox® (inhaled methoxyflurane, IMF) is an inhaled analgesic used for the treatment of moderate-to-severe acute pain. It has various advantages including the capacity for being self-administered in the presence of healthcare providers (HCPs), rapid onset and offset, and having documented evidence for minimal adverse events post-use. In a variety of non-oncological settings such as pre-hospital transport and minor outpatient procedures, amongst others, IMF has significantly reduced acute pain. As IMF has the capacity to provide appreciable pain relief but is not as widely used as other acute analgesics (i.e., opioids), this review of past and current literature hopes to explore the impact of inhaled IMF on patient outcomes, procedures where it could be used, and to inform readers about this compound., Recent Findings: In general, patients who used IMF had decreased pain, improved psychosocial factors (i.e., reduced anxiety, improved satisfaction), and minimal adverse events thereby being concluded as safe for use., Summary: Future use in remote medical interventions such as military contexts, in emergency room settings, and administration under the supervision of first responders such as non-paramedic and non-HCPs further broadens the scope of settings where IMF can meaningfully be implemented., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The aim of the proof-of-concept study is to investigate the level of concordance between the heart rate variability (HRV), the EEG-based Narcotrend Index as a surrogate marker for the depth of hypnosis, and the minimal alveolar concentration (MAC) of the inhalation anesthetic sevoflurane across the entire course of a surgical procedure. This non-blinded cross-sectional study recorded intraoperative HRV, Narcotrend Index, and MAC in 31 male patients during radical prostatectomy using the Da-Vinci robotic-assisted surgical system at Mannheim University Medical Center. The degree of concordance was calculated using repeated measures correlation with the R package (rmcorr) and presented using the rmcorr coefficient (rrm). The Narcotrend Index correlates significantly across all measures with the time-dependent parameter of HRV, the standard deviation of the means of RR intervals (SDNN) (rrm = 0.2; p < 0.001), the frequency-dependent parameters low frequency (LF) (rrm = 0.09; p = 0.04) and the low frequency/high frequency ratio (LF/HF ratio) (rrm = 0.11; p = 0.002). MAC correlated significantly negatively with the time-dependent parameter of heart rate variability, SDNN (rrm = -0.28; p < 0.001), the frequency-dependent parameter LF (rrm = -0.06; p < 0.001) and the LF/HF ratio (rrm = -0.18; p < 0.001) and the Narcotrend Index (rrm = -0.49; p < 0.001) across all measures. HRV mirrors the trend of the Narcotrend Index used to monitor depth of hypnosis and the inhibitory influence of the anesthetic sevoflurane on the autonomic nervous system. Therefore, HRV can provide essential information about the homeostasis of the autonomic nervous system during general anesthesia. DRKS00024696, March 9th, 2021., Competing Interests: Declarations. Ethical approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee II of the University of Heidelberg, Germany (2020–550 N, June 16th, 2020). Consent to participate and Consent to publish: Written informed consent was obtained from all individual participants included in the study. The authors affirm that manuscript does not contain any identifying information in any form (including any individual details, images or videos). Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: The Trial Remifentanil DEXmedetomidine (TREX) trial aimed to determine whether, in children less than 2 yr old, low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia is superior to standard-dose sevoflurane anesthesia in terms of global cognitive function at 3 yr of age. The aim of the current secondary analyses was to compare incidence of intraoperative hypotension and bradycardia, postoperative pain, time to recovery, need for treatment of intraoperative hypotension and bradycardia, incidence of light anesthesia and need for treatment, need for postoperative pain medications, and morbidity and mortality outcomes at 5 days between the two arms., Methods: This phase III randomized active controlled, parallel group, assessor blinded, multicenter, superiority trial was performed in 20 centers in Australia, Italy, and the United States. A total of 455 infants less than 2 yr of age expected to undergo general anesthesia for at least 2 h were enrolled. They were randomized between low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia and standard-dose sevoflurane. The short-term perioperative outcomes noted above were compared between these two groups., Results: There was less hypotension (risk difference, -11.6%; 95% CI, -18.9 to -4.3%) and more bradycardia (risk difference, 18.2%; 95% CI, 8.8 to 27.7%) in the low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia compared to the standard-dose sevoflurane arm. There were more patients with episodes of light anesthesia (89 vs. 4), and protocol abandonments (1 vs. 0) in the low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia arm. Time from eye opening to postanesthesia care unit discharge was similar in both arms, as were morbidity and mortality. One patient in each arm suffered a life-threatening event, but neither suffered long-term sequelae., Conclusions: These early postoperative results suggest that in children less than 2 yr of age receiving greater than 2 h of general anesthesia, the low-dose sevoflurane/dexmedetomidine/remifentanil anesthesia technique and the standard sevoflurane anesthesia technique are broadly clinically similar, with no clear evidence to support choosing one technique over the other., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc., on behalf of the American Society of Anesthesiologists.)

The aim of this pragmatic approach to retrospective observational study was to identify the end-tidal concentration of sevoflurane which was associated with optimal surgical conditions (i.e., absence of any movement, coughing and straining) in 127 pregnant sheep. Optimal surgical conditions were observed in 90% of the ewes with an end-tidal concentration of sevoflurane of 2.4 Vol-% [95% CI: 2.2; 2.8] during minimal-mild nociceptive stimuli (placement of arterial catheter, bladder catheter, shaving), with 4.4 Vol-% [95% CI: 4.0; 5.2] during maternal laparotomy and hysterotomy and with 4.4 Vol-% [95% CI: 3.9; 5.8] during subsequent manipulation of the uterus and fetal surgery.

Sevoflurane has been widely used in clinical anesthesia as an inhalation anesthetic. With the development of medicine, there have been several new applications in recent years, such as daytime surgery, labor analgesia, and combined nerve block for some surgeries. Moreover, as research progresses, it has been found that it not only has potential organ protection effects but can also be used to treat severe asthma and relieve the tracheal spasm state. In addition, local administration can effectively treat vascular ulcers. We briefly review the organ protective effect of sevoflurane, its application in dental treatment, asthma treatment, vascular ulcer treatment and some new progress in clinical application., (Copyright © 2024 Copyright: © 2024 Medical Gas Research.)

Xenon gas has significant advantages over conventional general anesthetic agents but its use has been limited by the cost associated with its production. Xenon also has significant potential for medical use in the treatment of acquired brain injuries and for mental health disorders. As the demand for xenon gas from other industries increases, the costs associated with its medical use are only likely to increase. One solution to mitigate the significant cost of xenon use in research or medical care is the conservation of xenon gas. During delivery of xenon anesthesia, this can be achieved either by separating xenon from the other gases within the anesthetic circuit, conserving xenon and allowing other gases to be excluded from the circuit, or by selectively recapturing xenon utilized during the anesthetic episode at the conclusion of the case. Several technologies, including the pressurization and cooling of gas mixtures, the utilization of gas selective membranes and the utilization of gas selective adsorbents have been described in the literature for this purpose. These techniques are described in this narrative review along with important clinical context that informs how these technologies might be best applied. Whilst these technologies are discussed in the context of xenon general anesthesia, they could be applied in the delivery of xenon gas inhalation for other therapeutic purposes., (Copyright © 2024 Copyright: © 2024 Medical Gas Research.)

Animal studies have shown that exposure of newborns to general anesthesia drugs can lead to neurodegenerative diseases and subsequent decline in learning and memory abilities. The neurotoxicity of general anesthesia drugs can also occur in the fetus. Therefore, in order to investigate the effect of the Long non-coding RNA(LncRNA)-LIN-microRNA(miRNA)-9-Dopamine receptor D2(DRD2) regulatory network on the development of the neuronal system after the inhalation of the anesthetic sevoflurane, RT-qPCR was used to detect the mRNA levels of LncRNA-LIN, miRNA-9, and DRD2. A dual-luciferase reporter system was used to detect the relationship between LncRNA-LIN and miRNA-9, and miRNA-9 and DRD2. Western blotting and immunofluorescence staining was employed to detect the protein levels of DRD2 and cleaved caspase-3. Flow cytometry was carried out to detect the number of apoptotic cells. The escape latency, swimming distance, and platform crossing times were analyzed using the Morris water maze. The results showed that, after treatment with sevoflurane, the mRNA levels of LncRNA-LIN and DRD2, the expression levels of the DRD2 protein, and the number of neuronal levels of DRD2 were significantly decreased, whereas the expression levels of miRNA-9 and the cleaved caspase-3 protein and neuronal apoptosis were significantly increased. miR-9 knockdown revealed that miRNA-9 regulated DRD2 expression and affected the function of mouse neuronal cells. In turn, LncRNA-LIN overexpression indicated that LncRNA-LIN regulated miR-9 and affected the function of mouse neuronal cells. The present results demonstrated that the LncRNA-LIN-miRNA-9-DRD2 regulatory network is involved in the effects of the inhalation anesthetic sevoflurane on neuronal system development., Competing Interests: Declarations. Ethic approval and consent participate: Not applicable. Animal ethics: The study was performed in accordance with the ethical standards as laid down in the Animal ethics committee and approved by the ethics committee of the First Hospital of Nanchang city. Conflict of interest: The authors declare that they have no competing interest., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Liver cancer, one of the most common malignant tumors, has seriously threatened people's physical and mental health. The paper was conducted to investigate the functions of two different anesthesia methods on Tumor necrosis factor-α (TNF-α), C-reactive protein (CRP) and T lymphocyte subsets in patients undergoing liver cancer resection, and to explore the liver function impact of patients undergoing liver cancer surgery. 80 liver cancer patients were split into propofol intravenous anesthesia group and sevoflurane inhalation anesthesia group. The patient's operation-related indicators and changes in TNF-α, CRP and T lymphocyte subsets before anesthesia, after anesthesia, 1 day after anesthesia, and 3 days after anesthesia were calculated. The levels of TNF-α and CRP in the two groups after operation were clearly higher than those before anesthesia, but there was no obvious difference between the two groups. After operation, the TNF-α of the propofol intravenous anesthesia group was lower than the sevoflurane inhalation anesthesia group. The CD3+, CD4+ and CD4+/CD8+ levels in both groups recovered to the pre-anaesthesia level 3 days after the operation. The levels of ALT, AST, ALB and TBIL returned to normal at d4 in both propofol intravenous anesthesia and sevoflurane inhalation anesthesia groups. Compared with evoflurane inhalation anesthesia for patients with liver cancer, intravenous anesthesia with propofol can reduce the body's inflammatory response to a certain extent, has weak inhibitory effect on T lymphocyte immune function, and a smaller effect on liver function.

Objective: Penthrox® (methoxyflurane) is a convenient, portable, self-administered disposable single-use handheld inhaler licenced as an emergency, rapid-onset, short-acting, analgesic in adult trauma patients. Outpatient hysteroscopy is one of the commonest procedures in contemporary gynecology but it can be associated with significant pain leading to poor patient experience and failed procedures. We evaluated the feasibility and acceptability of Penthrox® in women undergoing outpatient hysteroscopic procedures and its potential efficacy to reduce pain and improve patient experience., Study Design: We conducted a prospective observational cohort study on women undergoing hysteroscopy or other intrauterine procedures, such as coil fitting, endometrial biopsy, polypectomy, endometrial ablation and manual vacuum aspiration in an outpatient setting. Women were offered Penthrox® inhalers for pain control, instructed how to use it and asked to record the intra-procedural pain they expected and actually experienced using a 10 cm Visual Analogue Scale. The acceptability, side effects and ease of use of the Penthrox® device were also recorded., Results: 122/146 (83.6 %) women chose to use Penthrox®. 116 out of the 122 (95.1 %) underwent an intrauterine procedure, including 59 hysteroscopic polypectomies and 34 global endometrial ablations. The average pain expected during the procedure was 6.0 (SD = 2.8) and the pain experienced during the procedure was 5.1 (SD = 2.8). The intended procedure was completed in 117 (96 %) women. Penthrox® was considered easy to use by 118 (97 %) women and 111 (91 %) would use it again, although 22 (18 %) women would prefer general anaesthesia in the future. No adverse events occurred but 88 (72 %) women reported mild, self-limiting side effects., Conclusion: Penthrox® appears safe, feasible and acceptable as a pain relief option during outpatient hysteroscopy and other intrauterine procedures. The effectiveness of Penthrox® should be evaluated against conventional pain control in an adequately powered multicentre randomised controlled trial., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Study Objective: Nitrous oxide affects memory and recall. We aimed to determine if using nitrous oxide during labor affected patients' ability to learn and recall the risks and benefits of neuraxial analgesia., Design: Single-center, prospective cohort study., Setting: Labor and delivery unit in a large academic medical center., Patients: Nulliparous patients with spontaneous or planned induction of labor., Interventions: Parturients chose whether to use nitrous oxide during labor. At the discussion for epidural consent, 4 risks were described: headache, infection, nerve damage, bleeding., Measurements: Labor pain score, time from nitrous oxide discontinuation, and cervical dilation were documented at the discussion of epidural risks. Patients were assessed for unprompted recall and prompted recall of epidural risks on postpartum day 1 and unprompted recall at postpartum week 6. The number and proportion of patients who indicated each true risk (unprompted and prompted recall) or distractor (prompted recall only) were summarized by treatment group and results compared using Pearson χ 2 tests., Main Results: Of the 403 enrolled patients, 294 (73%) did not use nitrous oxide, and 109 (27%) did. The 2 groups were similar except women who used nitrous oxide were more likely to be cared for by midwives and had higher pain scores at their epidural request. Scores for unprompted or prompted recall of epidural risks were not different between women who received or did not receive nitrous oxide. All 4 risks were recalled unprompted by only 3% in the nitrous oxide group and by 6% in the group not receiving nitrous oxide (P = .18)., Conclusions: The use of nitrous oxide for labor analgesia does not adversely influence a parturient's ability to recall the risks of epidural placement. Patients who receive nitrous oxide for labor analgesia should be considered eligible to provide consent for subsequent procedures., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To investigate if fentanyl induces immobility through activation of the serotonergic 5HT 1A receptor, by using the 5HT 1A -antagonist robalzotan., Study Design: A prospective, blinded, randomized, two-group study., Animals: A group of 12 mixed-breed pigs aged 71-79 days., Methods: The motor response to clamping a claw was assessed in isoflurane-anaesthetized pigs at baseline, then fentanyl was infused intravenously (IV) for 40 minutes and clamping was repeated. The infusion started at 20 μg kg -1 hour -1 and was increased by 60% until fentanyl produced immobility, defined as no motor response for 60 seconds. Subsequently, either robalzotan (1 mg kg -1 ) or the same volume of saline was injected IV and clamping was repeated. The change in response was compared with Fisher's exact test. Mean arterial blood pressure (MAP) and heart rate (HR) were extracted for 2 minutes before and after 60 seconds of clamping, and the differences compared with a Wilcoxon signed-rank test. Dynamic respiratory compliance was calculated at baseline and after fentanyl; p < 0.05., Results: Baseline clamping produced a motor response within 5 seconds. This was abolished by fentanyl. Robalzotan or saline did not alter this (p = 0.45). As a response to clamping, MAP and HR changed with median (range) -0.5 (-4.4 to 22.2) mmHg and -1 (-7 to 1.5), respectively, where HR changed significantly (p = 0.039). The 95% confidence interval for the effect size of fentanyl upon dynamic compliance was -3.25 to -1.65 mL cmH 2 O -1 ., Conclusions and Clinical Relevance: No indication was found for the 5HT 1A receptor to be involved in fentanyl-induced reduction of the motor response to claw clamping. The decreased compliance after fentanyl could suggest onset of chest wall rigidity., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Cannabis use is associated with higher intravenous anesthetic administration. Similar data regarding inhalational anesthetics are limited. With rising cannabis use prevalence, understanding any potential relationship with inhalational anesthetic dosing is crucial. Average intraoperative isoflurane or sevoflurane minimum alveolar concentration equivalents between older adults with and without cannabis use were compared., Methods: The electronic health records of 22,476 surgical patients 65 yr or older at the University of Florida Health System between 2018 and 2020 were reviewed. The primary exposure was cannabis use within 60 days of surgery, determined via (1) a previously published natural language processing algorithm applied to unstructured notes and (2) structured data, including International Classification of Diseases codes for cannabis use disorders and poisoning by cannabis, laboratory cannabinoids screening results, and RxNorm codes. The primary outcome was the intraoperative time-weighted average of isoflurane or sevoflurane minimum alveolar concentration equivalents at 1-min resolution. No a priori minimally clinically important difference was established. Patients demonstrating cannabis use were matched 4:1 to non-cannabis use controls using a propensity score., Results: Among 5,118 meeting inclusion criteria, 1,340 patients (268 cannabis users and 1,072 nonusers) remained after propensity score matching. The median and interquartile range age was 69 (67 to 73) yr; 872 (65.0%) were male, and 1,143 (85.3%) were non-Hispanic White. The median (interquartile range) anesthesia duration was 175 (118 to 268) min. After matching, all baseline characteristics were well-balanced by exposure. Cannabis users had statistically significantly higher average minimum alveolar concentrations than nonusers (mean ± SD, 0.58 ± 0.23 vs. 0.54 ± 0.22, respectively; mean difference, 0.04; 95% confidence limits, 0.01 to 0.06; P = 0.020)., Conclusion: Cannabis use was associated with administering statistically significantly higher inhalational anesthetic minimum alveolar concentration equivalents in older adults, but the clinical significance of this difference is unclear. These data do not support the hypothesis that cannabis users require clinically meaningfully higher inhalational anesthetics doses., (Copyright © 2024 American Society of Anesthesiologists. All Rights Reserved.)

Intensive care unit (ICU) patients receive highly complex care and often require sedation as part of their management. ICU sedation has traditionally been delivered using intravenous (IV) agents due to the impractical use of anaesthetic machines in this setting, which are used to deliver volatile sedation. Sedaconda anaesthetic conserving device (ACD)-S (previously known as AnaConDa-S) is a device which allows for the delivery of volatile sedation via the majority of mechanical ventilators by being inserted in the breathing circuit where the heat and moisture exchanger is normally placed. The National Institute of Health and Care Excellence (NICE), as part of the Medical Technologies Evaluation Programme, considered the potential benefits of using Sedaconda ACD-S compared to standard IV sedation in ICU patients. Here we describe the evidence evaluation undertaken by NICE on this technology, supported by CEDAR. CEDAR considered the evidence present in 21 publications that compared the clinical outcomes of patients receiving Sedaconda ACD-S-delivered sedation and IV sedation, and critiqued the economic model provided by the manufacturer. Clinical expert input during the evaluation process was used extensively to ensure that the relevant clinical evidence was captured and that the economic model was suitable for the UK setting. Due to the uncertainty of the evidence, sensitivity analysis was carried out on the key economic inputs to ensure the reliability of the results. Economic modelling has shown that Sedaconda ACD-S-delivered isoflurane sedation is cost saving on a 30-day horizon compared to IV sedation by £3833.76 per adult patient and by £2837.41 per paediatric patient. Clinical evidence indicated that Sedaconda ACD-S-delivered isoflurane sedation is associated with faster patient wake-up times than standard of care. Consequently, NICE recommended Sedaconda ACD-S as an option for delivering sedation in the ICU setting, but noted that further research should inform whether Sedaconda ACD-S-delivered sedation is of benefit to any particular subgroup of patients., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Patient age is assumed to be an important risk factor for the occurrence of burst suppression, yet this has still to be confirmed by large datasets., Methods: In this single-center retrospective analysis at a university hospital, the electronic patient records of 38,628 patients (≥18 years) receiving general anesthesia between January 2016 and December 2018 were analyzed. Risk factors for burst suppression were evaluated using univariate and multivariable analysis. We measured the incidence of burst suppression as indicated by the burst suppression ratio (BSR) of the Entropy Module, the maximum and mean BSR values, relative burst suppression duration, mean volatile anesthetic concentrations, and mean age-adjusted minimum alveolar concentrations (aaMAC) at burst suppression, and cases of potentially misclassified burst suppression episodes. Analyses were done separately for the total anesthesia period, as well as for the Induction and Maintenance phase. The association with age was evaluated using linear and polynomial fits and by calculating correlation coefficients., Results: Of the 54,266 patients analyzed, 38,628 were included, and 19,079 patients exhibited episodes with BSR >0. Patients with BSR >0 were significantly older, and age had the highest predictive power for BSR >0 (area under the receiving operating characteristic [AUROC] = 0.646 [0.638-0.654]) compared to other patient or procedural factors. The probability of BSR >0 increased linearly with patient age (ρ = 0.96-0.99) between 1.9% and 9.8% per year. While maximal and mean BSR showed a nonlinear relationship with age, relative burst suppression duration also increased linearly during maintenance (ρ = 0.83). Further, episodes potentially indicating burst suppression that were not detected by the Entropy BSR algorithm also became more frequent with age. Volatile anesthetic concentrations sufficient to induce BSR >0 were negatively correlated with age (sevoflurane: ρ = -0.71), but remained close to an aaMAC of 1.0., Conclusions: The probability of burst suppression during general anesthesia increases linearly with age in adult patients, while lower anesthetic concentrations induce burst suppression with increasing patient age. Simultaneously, algorithm-based burst suppression detection appears to perform worse in older patients. These findings highlight the necessity to further enhance EEG application and surveillance strategies in anesthesia., Competing Interests: Conflicts of Interest, Funding: Please see DISCLOSURES at the end of this article., (Copyright © 2024 International Anesthesia Research Society.)