Rajesh Prabhakar Bhavsar

Background and Aims: Videolaryngoscopy (VL) improves glottic visualisation, yet successful endotracheal intubation may remain challenging. Although this discrepancy is well recognised, the underlying patterns of tube-delivery difficulty (TDD) remain poorly described. Using recorded VL intubations, we aimed to describe patterns of TDD and assess whether these patterns could be reproducibly identified during VL-assisted intubation using a structured classification system. Materials and Methods: In this retrospective observational study, 176 VL recordings obtained during routine clinical practice were reviewed. Videos with adequate visualisation of the glottic inlet and complete recording of the tube-delivery phase were included. TDD was defined as any deviation from smooth tube advancement despite an adequate glottic view. Tube-delivery events were categorised into predefined phenotypes based on trajectory and site of obstruction. Two independent reviewers assessed TDD and phenotype classification. Interrater reliability was evaluated using Cohen’s kappa. Results: Of 176 screened recordings, 150 were included. TDD was identified in 67 (44.7%) cases. The most frequent pattern was excessive posterior trajectory towards the oesophageal inlet (29.9%), followed by subglottic advancement failure after passage through the vocal cords (22.4%), posterior impingement at the arytenoid level (17.9%) and lateral misplacement into the pyriform fossa (14.9%). Interrater agreement was substantial for identification of TDD (observed agreement 88.7%; κ = 0.74) and video-quality grading (86.1%; κ = 0.68) and moderate for phenotype classification (78.0%; κ = 0.61). Conclusion: VL recordings identified distinct, reproducible patterns of TDD. Recognition of these patterns may improve understanding of tube-delivery dynamics and may assist in documentation and future research in difficult airway management.

Background and Objectives: Hemodynamic instability during anesthesia induction and endotracheal intubation remains a clinically important concern. Low-dose ketamine and intravenous lidocaine may provide complementary effects that improve cardiovascular stability and peripheral perfusion. This pilot study evaluated effects of adding ketamine and lidocaine to a propofol-based induction regimen using mean arterial pressure (MAP) and perfusion index (PI) as monitoring parameters. Materials and Methods: In this prospective observational pilot study, 30 adult patients undergoing elective surgery requiring general anesthesia and endotracheal intubation were allocated to either a standard induction regimen (Group 1: propofol 2 mg/kg and fentanyl 2 μg/kg) or an adjunctive regimen (Group 2: propofol 2 mg/kg, ketamine 0.4 mg/kg, lidocaine 1 mg/kg, and fentanyl 1 μg/kg). Hemodynamic variables and PI were recorded at baseline, after induction, and after intubation. Postoperative sore throat and cough-reflex responses were also assessed. Results: No significant differences between-groups were observed in heart rate, systolic blood pressure, diastolic blood pressure, MAP, or oxygen saturation at any time point. However, MAP decreased significantly within Group 1 after induction (94.9 ± 10.1 vs. 76.9 ± 13.8 mmHg, p < 0.001) and remained lower after intubation (p = 0.001), whereas no significant MAP changes occurred within Group 2. PI increased in both groups but was significantly higher in Group 2 after induction (5.35 ± 2.34 vs. 3.46 ± 2.90, p = 0.043) and after intubation (7.02 ± 2.89 vs. 4.71 ± 2.22, p = 0.020). Postoperative sore throat scores were lower in Group 2 (0.53 ± 0.91 vs. 1.67 ± 1.76, p = 0.035), and cough-reflex scores were also reduced (p = 0.024). Conclusions: The addition of low-dose ketamine and intravenous lidocaine to propofol-based induction was associated with higher perfusion index values and reduced airway-related adverse effects. No statistically significant between-group difference in mean arterial pressure (MAP) was detected. These findings are hypothesis-generating and warrant confirmation in larger randomized trials.

Background: Post-anesthesia care unit (PACU) duration after total hip arthroplasty (THA) is relevant for ward transfer, early mobilization, and perioperative flow, but is inconsistently reported as a distinct recovery outcome. This study evaluated PACU duration after primary THA under spinal anesthesia in routine hospital-based practice and interpreted the observed duration in relation to contemporary arthroplasty literature. Methods: This retrospective observational cohort study included adult patients undergoing primary THA under spinal anesthesia within two units of a regional hospital. PACU duration was defined as time from PACU arrival until discharge to the orthopedic ward. Demographic, anesthetic, perioperative, and recovery variables were extracted from electronic medical records. Univariate analyses and multivariable linear regression were used to explore factors associated with PACU duration. A focused contextual literature comparison was performed to interpret the observed duration in relation to reported early recovery endpoints, with direct comparison anchored to conventional PACU or recovery-room intervals before ward transfer or immediate pathway progression. Results: Ninety-seven of 150 screened patients were included. Mean PACU duration was 162.3 ± 58.5 min. PACU duration was numerically longer in Unit A than Unit S, but the difference was not statistically significant. Reported early recovery endpoints in the literature were heterogeneous. In univariate analysis, male sex and exploratory spinal local anesthetic dose > 13 mg were associated with longer PACU duration. In multivariable analysis, male sex remained associated with longer PACU duration, whereas spinal dose was not independently associated when analyzed as a continuous variable. Conclusions: PACU duration after THA under spinal anesthesia should be interpreted as a multifactorial, workflow-sensitive outcome rather than a purely anesthetic recovery measure. Differences in discharge criteria, recovery pathways, and endpoint definitions limit direct comparison across studies. PACU duration may be most meaningful as an operational recovery and flow indicator within broadly comparable clinical settings.

Background: Hemodynamic instability during anesthesia induction and endotracheal intubation remains a clinically important concern. Low-dose ketamine and intravenous lidocaine may provide complementary effects that improve cardiovascular stability and peripheral perfusion. This pilot study evaluated effects of adding ketamine and lidocaine to a propofol-based induction regimen using mean arterial pressure (MAP) and perfusion index (PI) as monitoring parameters. Methods: In this prospective randomized pilot study, 30 adult patients undergoing elective surgery requiring general anesthesia and endotracheal intubation were allocated to either a standard induction regimen (Group 1: propofol 2 mg/kg and fentanyl 2 μg/kg) or an adjunctive regimen (Group 2: propofol 2 mg/kg, ketamine 0.4 mg/kg, lidocaine 1 mg/kg, and fentanyl 1 μg/kg). Hemodynamic variables and PI were recorded at baseline, after induction, and after intubation. Postoperative sore throat and cough-reflex responses were also assessed. Results: No significant differences between-groups were observed in heart rate, systolic blood pressure, diastolic blood pressure, MAP, or oxygen saturation at any time point. However, MAP decreased significantly within Group 1 after induction (94.9 ± 10.1 vs. 76.9 ± 13.8 mmHg, p < 0.001) and remained lower after intubation (p = 0.001), whereas no significant MAP changes occurred within Group 2. PI increased in both groups but was significantly higher in Group 2 after induction (5.35 ± 2.34 vs. 3.46 ± 2.90, p = 0.043) and after intubation (7.02 ± 2.89 vs. 4.71 ± 2.22, p = 0.020). Postoperative sore throat scores were lower in Group 2 (0.53 ± 0.91 vs. 1.67 ± 1.76, p = 0.035), and cough-reflex scores were also reduced (p = 0.024). Conclusions: The addition of low-dose ketamine and intravenous lidocaine to propofol-based induction was associated with greater MAP stability, higher perfusion index values, and reduced airway-related adverse effects. These findings are hypothesis-generating and warrant confirmation in larger randomized trials.

Background: The American Society of Anesthesiologists Physical Status (ASA-PS) classification is widely used for perioperative communication and research with known variation in agreement amongst assessors. Large language models (LLM) are increasingly considered for uniform decision making due to agreement challenges within clinicians under identical inputs. The study compared four contemporary LLMs against clinician-derived consensus and quantified within-model stability across repeated assessments. Methods: In a cross-sectional vignette study, 228 anesthesiologists from Denmark, England, and India classified 20 standardized perioperative vignettes through online survey. The modal response per vignette was considered as clinician consensus. Four LLMs (ChatGPT-5.2 Plus, Gemini 3 Pro, Perplexity AI Pro, Claude 4 Sonnet) received same set of vignettes through identical prompts. Temporal stability was assessed by repeating each vignette query nine times per model (three-time windows across three nonconsecutive days) in fresh sessions. Primary outcome was exact agreement with clinician consensus. Results: Consensus agreement for modal LLM classifications was 18/20 (90%) for ChatGPT, 17/20 (85%) for Gemini, 17/20 (85%) for Claude, and 15/20 (75%) for Perplexity. Disagreement is clustered in vignettes with weak or split clinician consensus. Stability differed by model: Claude was fully stable across all vignettes (20/20), Gemini 19/20, ChatGPT 18/20, and Perplexity 14/20; instability typically involved adjacent-class shifts. Conclusions: Contemporary LLMs often match clinician modal judgement and are largely temporally stable, with discordance concentrated in clinically ambiguous boundary cases.

Ischemic heart disease (IHD) is, despite improvement last decades, still a leading cause of death globally. Clinical IHD guidelines do not distinguish betw

Background/Objectives: Intensive postoperative pain is a common challenge after knee surgeries such as total knee arthroplasty, arthroscopy, cruciate ligament or meniscus repair, and fixation of tibial plateau or distal femoral fractures. This scoping review mapped and summarized non-regional postoperative analgesia strategies to provide an overview of available approaches when regional blocks or neuraxial anesthesia are not feasible. Methods: We followed established methodological guidance for scoping reviews and report the data in accordance with the PRISMA-ScR checklist. We searched PubMed/MEDLINE, EMBASE, Scopus, and ClinicalTrials.gov in January 2025. Eligible designs included randomized controlled trials, non-randomized trials, observational studies, case series, and pilot studies. Results: We screened 3390 records and assessed 332 in full text. A total of 43 studies met the inclusion criteria, and the literature was grouped into: (1) arthroplasty, (2) arthroscopy, (3) cruciate ligament or meniscus repair, and (4) tibial plateau or distal femoral fractures. We identified substantial heterogeneity in interventions, comparators, and outcome measures across the first three sets of literature but found no focused articles for tibial plateau or distal femoral fractures. Most studies evaluated multimodal approaches combining systemic analgesics with local periarticular or intraarticular techniques. Evidence on functional recovery and mobilization was limited. Conclusions: Current evidence on non-regional postoperative analgesia in knee surgery is fragmented and varies considerably in design, intervention, and reported outcomes. Multimodal regimens and pre-emptive NSAID use were frequently associated with reduced early postoperative pain and lower opioid requirements, although comparability across studies remains limited. As existing evidence largely focuses on outcomes during hospitalization, future research should prioritize standardized pain and functional outcome reporting and directly compare systemic and local multimodal strategies, while extending follow-up beyond discharge to better characterize sustained clinical relevance.

Background and Objectives: Despite huge reductions in the incidence and mortality of cardiovascular disease (CVD) during the last decades, ischemic heart disease (IHD) is globally still a leading cause of death. Although females experience higher mortality, the clinical IHD guidelines do not distinguish between sexes, and despite added diagnostic procedures after introduction of computed coronary arteriography (CTA) the differences remain. This study aimed to describe and evaluate the effect, outcomes and sex disparities of the large number of diagnostic procedures not leading to invasive treatments. Materials and Methods: The study included 274,617 first-entry patients submitted to invasive coronary arteriography (ICA) or CTA 2000–2020, from the mandatory Western Denmark Heart Registry. Mortality was evaluated with Kaplan–Meier curves and further compared to background population. Results: Females constituted 34.1% of all first-entry diagnostic procedures but only 25.5% of those who subsequently underwent invasive treatment, demonstrating a substantially lower treatment rate compared to males. All-cause 10-year mortality was higher in females after treatment 1.26 (1.23–1.30) but lower in the non-treated patients 0.71 (0.67–0.72) at all time points. Comparing to the background population, all non-treated patients revealed lower mortality in all indications, except valves. Conclusions: Despite being referred for coronary diagnostication according to their CVD prevalence, females received less invasive treatments than males and presented with substantially higher mortality after invasive treatments. In variance, non-invasive treated females demonstrated significantly better survival than men both in intra-study comparisons and in assessment with background population mortality.

Background Electroconvulsive therapy (ECT) is an established treatment for depression and mania, with its therapeutic effect deriving from the induced seizure rather than the electrical stimulus itself. Anaesthetic agents are routinely used to reduce procedural discomfort, requiring assisted ventilation. However, these agents may raise the seizure threshold, necessitating higher stimulus doses and potentially increasing adverse effects. Although various strategies have been explored, pre-ECT hyperventilation—despite its known ability to lower the seizure threshold—remains insufficiently investigated. This review aims to examine the various ventilation approaches employed during anaesthesia for ECT, assess how hyperventilation has been applied to augment ECT, explore their impact on clinical outcomes and identify the outcome parameters most frequently investigated in ECT studies. Methods The reporting of the scoping review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A comprehensive literature search will be conducted in Medline, EMBASE, Scopus and PsycINFO. Grey literature, along with national and international guidelines, will also be included. Studies investigating any form of ventilation during anaesthesia for ECT will be included. An information specialist and a medical librarian will support the development and refinement of the search strategy. Two reviewers will independently screen eligible studies and perform data extraction according to predefined headings. Disagreements will be resolved by a third reviewer. Data will be organised under the following headings: details of the included studies, ventilation strategies investigated, outcome measures studied. Results will be presented narratively and in table form and discussed in relation to the relevant literature. Ethics and dissemination Ethical approval is not necessary, as the review synthesises evidence from the existing literature. The results will be disseminated through publication in a peer-reviewed journal and presentation at relevant academic conferences. Findings will also be shared with ECT clinicians to support clinical awareness and inform practice.