Cezar Cristian Mihai Moisa

Background and Clinical Significance: Uterine atony is the most frequent cause of postpartum hemorrhage and remains a major contributor to maternal morbidity worldwide. Neuraxial opioids are routinely used as adjuvants for labor analgesia and cesarean delivery anesthesia; however, their possible influence on myometrial contractility remains incompletely clarified. We describe a severe case of refractory uterine atony after emergency cesarean delivery in a patient exposed sequentially to epidural fentanyl during labor and intrathecal morphine for cesarean anesthesia; Case Presentation: A 34-year-old primigravida at 39 weeks and 4 days of gestation presented with early labor that had begun less than one hour earlier. Epidural labor analgesia was provided with ropivacaine, and the total epidural fentanyl exposure was 100 mcg over an approximately 7 h catheter period. Labor was complicated by dysfunctional uterine activity and cervical dystocia despite 3 h and 30 min of oxytocin augmentation. Emergency cesarean delivery was performed under spinal anesthesia with hyperbaric bupivacaine and intrathecal morphine. After delivery of a healthy neonate and uncomplicated placental separation, the patient developed severe uterine atony with postpartum hemorrhage. Hemorrhage persisted despite uterotonic therapy, continuous uterine massage, hemostatic suturing, and B-Lynch compression suture. Blood loss, measured using the suction canister and estimated from surgical swabs, was approximately 3800 mL. Progressive hemodynamic instability required transfusion therapy, conversion to general anesthesia, norepinephrine support, and emergency total abdominal hysterectomy. The postoperative course was favorable, and the patient was discharged on the eighth postoperative day; Conclusions: This case illustrates the rapid progression and therapeutic complexity of refractory uterine atony after emergency cesarean delivery in the setting of dysfunctional labor, oxytocin augmentation, cesarean delivery, sequential neuraxial opioid exposure, and subsequent hemorrhagic instability. A possible contribution of sequential neuraxial opioid administration to impaired myometrial contractility cannot be excluded; however, causality cannot be established from a single case. Early recognition, structured escalation, transfusion support, and timely multidisciplinary surgical management remain essential in severe postpartum hemorrhage.

Background and Objectives: With the rising number of geriatric surgical patients, postoperative cognitive dysfunction (POCD) has become a major concern, linked to impairments in memory, attention, and executive function. POCD increases morbidity, prolongs hospitalization, and diminishes quality of life. This review examines the mechanisms underlying POCD, with emphasis on neuroinflammation, blood–brain barrier (BBB) disruption, and oxidative stress, and evaluates the impact of anesthetic techniques on cognitive outcomes in the elderly. Materials and Methods: This narrative review used a targeted literature search to identify relevant clinical, translational, and mechanistic evidence on POCD in older surgical patients. The evidence was synthesized qualitatively, with attention to heterogeneity in study populations, anesthetic techniques, cognitive assessment methods, and follow-up duration. Results: Neuroinflammation, BBB compromise, oxidative stress, perioperative stress responses, and patient vulnerability appear to contribute to POCD. Evidence comparing anesthetic techniques remains heterogeneous. Some studies suggest associations between general anesthesia, volatile agents, and early postoperative cognitive changes, whereas other comparative and randomized studies do not demonstrate consistent long-term cognitive differences between general, regional, neuraxial, volatile, and intravenous anesthetic approaches. Regional and neuraxial techniques may reduce anesthetic or opioid exposure in selected patients, but they should not be interpreted as definitively superior for POCD prevention. Adjunctive and multimodal strategies, including dexmedetomidine and non-opioid analgesics, show potential benefits, although evidence remains variable. Conclusions: Individualized anesthetic planning, early risk stratification, avoidance of excessive anesthetic depth, hemodynamic optimization, multimodal analgesia, and postoperative recovery strategies may help reduce modifiable contributors to POCD. Current evidence does not support a definitive hierarchy of anesthetic techniques for preventing POCD, and further high-quality studies are needed.

Background and Objectives: Surgical stress during robotic-assisted radical prostatectomy (RARP) elicits a measurable systemic inflammatory response despite the minimally invasive approach. Intravenous lidocaine has been increasingly investigated for its potential anti-inflammatory, analgesic, and immunomodulatory benefits, but evidence in robotic urologic oncology remains limited. This study aimed to evaluate whether intraoperative lidocaine infusion attenuates postoperative inflammation, improves analgesic outcomes, and accelerates early recovery following RARP. Materials and Methods: This prospective non-randomized observational study included 80 patients undergoing elective RARP, divided into a Lidocaine Group (n = 40) receiving an intraoperative bolus and continuous infusion, and a Control Group (n = 40) receiving standard anesthesia without lidocaine. Serum IL-6, TNF-α, CRP, and fibrinogen were measured at baseline, end of surgery, and 24 h postoperatively. Postoperative pain scores, opioid consumption, gastrointestinal recovery, ambulation, and length of stay were recorded. Statistical analyses included repeated-measures ANOVA, correlation testing, and between-group comparisons. Results: Baseline characteristics were similar between groups. At 24 h postoperatively, lidocaine administration was associated with a significantly attenuated inflammatory response, with lower levels of IL-6 (45.7 ± 10.8 vs. 68.9 ± 12.6 pg/mL, p < 0.01) and TNF-α (20.5 ± 5.1 vs. 27.2 ± 6.4 pg/mL, p < 0.01) compared with controls. Patients receiving lidocaine reported lower postoperative pain scores and required significantly less opioid analgesia, with a total 24 h consumption of 8.9 ± 3.4 vs. 14.8 ± 5.2 mg morphine milligram equivalents (p < 0.001). Lidocaine was also associated with faster recovery, including earlier oral intake and a shorter length of hospital stay (2.9 ± 0.7 vs. 3.6 ± 0.9 days, p = 0.003). No lidocaine-related adverse events were observed. Conclusions: In this prospective observational study, intraoperative intravenous lidocaine was associated with attenuated early postoperative inflammation, improved analgesic outcomes, and enhanced early recovery following RARP. These findings support the potential role of intravenous lidocaine as a safe adjunct in multimodal perioperative management; however, given the non-randomized observational design, causal inferences should be interpreted with caution. Further randomized controlled trials are warranted to confirm causality and to validate long-term clinical and mechanistic effects. Potential residual confounding inherent to the observational design should be considered when interpreting these findings.

Background and Objectives: Effective perioperative pain management remains a key goal of enhanced recovery protocols, especially in minimally invasive urologic surgery, where optimizing comfort while limiting opioid exposure is essential. Intravenous lidocaine has gained attention for its multimodal analgesic and anti-inflammatory properties, yet evidence in robotic prostatectomy remains limited. This study evaluated whether intraoperative lidocaine infusion was associated with lower early postoperative pain scores and reduced opioid use in patients undergoing robotic-assisted radical prostatectomy. Materials and Methods: A retrospective, single-center analysis was conducted at Pelican Clinical Hospital, Oradea, Romania, including 112 patients operated on between January 2020 and December 2023. All procedures were performed by the same surgical and anesthetic teams using standardized ERAS-based protocols. Patients were divided into two groups: the Lidocaine Group (LG, n = 51), who received a bolus of 1.5 mg/kg lidocaine followed by an infusion of 1.5 mg/kg/h during surgery, and the Control Group (CG, n = 61), who received standard anesthesia without lidocaine. Postoperative pain was measured using the visual analog scale (VAS) at 0, 4, 12, and 24 h, and opioid use was converted into morphine milligram equivalents (MME). Secondary outcomes included time to ambulation, gastrointestinal recovery, oral intake, hospital stay, and complications. Results: Pain intensity was significantly lower in the lidocaine group at 4 h postoperatively (VAS 3.5 ± 1.1 vs. 4.3 ± 1.3; p = 0.01), with similar scores later. Total opioid use was reduced by about 18% in the lidocaine group (25.7 ± 9.4 vs. 31.2 ± 10.5 MME; p = 0.03). Recovery parameters and complication rates were comparable between groups, and no lidocaine-related adverse events were recorded. Conclusions: Intraoperative intravenous lidocaine was associated with lower early postoperative pain scores and reduced opioid requirements after robotic-assisted radical prostatectomy without affecting recovery or safety. Its favorable profile and low cost support its inclusion as a practical adjunct in multimodal analgesia within ERAS pathways.

Background/Objectives: Spinal anesthesia, frequently used in cesarean deliveries, can have a significant impact on newborns. This study aims to evaluate the effects of spinal anesthesia with morphine or fentanyl as adjuvants on neonatal outcomes. Methods: A retrospective study was conducted over a specific period on 170 newborns delivered via cesarean section at the Pelican Clinic, Medicover Hospital, Romania. The neonatal parameters assessed included Apgar scores at 1 and 5 min, oxygen saturation, respiratory rate, and heart rate in two groups of newborns whose mothers underwent spinal anesthesia with bupivacaine combined with either morphine or fentanyl (group M_n and group F_n). Statistical analysis was performed using IBM SPSS Statistics (version 29.0.2.0 (20)). Results: Newborns in the M_n group had significantly higher Apgar scores at 1 min compared to those in the F_n group (9.63 ± 0.57 vs 9.40 ± 0.65, p = 0.010); however, at 5 min, the scores were comparable between groups. Regarding oxygen saturation, male neonates born to mothers who received morphine had significantly higher values than those in the fentanyl group (96.08 ± 4.14% vs. 94.50 ± 4.36%, p = 0.026), whereas no significant differences were observed in female neonates. Conclusions: The use of morphine in maternal spinal anesthesia may improve immediate neonatal adaptation, particularly in male newborns.

Background: Spinal anesthesia is considered the method of choice for elective cesarean sections; however, it is not without maternal–fetal risks. Materials and Methods: This study compared the effects on maternal hemodynamics of intrathecal administration of fentanyl or morphine in parturients undergoing spinal anesthesia with 0.5% hyperbaric bupivacaine, with doses varied between 7.5 and 11 mg, depending on the patient’s height. Data from a cohort of 170 parturients were analyzed. The administered doses were intrathecal morphine at 0.1 mL (100 µg, solution of 1 mg/mL) or fentanyl at 0.25 mL (25 µg, solution of 50 µg/mL). This study included 80 patients in the fentanyl (F) group and 90 in the morphine (M) group. Results: Group F showed significantly higher post-intervention systolic blood pressure values than group M (95.30 ± 12.99 mmHg vs. 90.58 ± 14.75 mmHg, p = 0.032). The incidence of vomiting was significantly less frequent in group F compared to group M (1, 1.3% vs. 10, 11.1%, p = 0.011). The total dose of ephedrine required for hypotension correction was significantly lower in the F group (12.75 ± 13.26 mg vs. 17.72 ± 16.73 mg, p = 0.035). Conclusions: The addition of fentanyl as an adjuvant alongside the local anesthetic in cesarean section is associated with enhanced hemodynamic stability compared to morphine, requiring lower doses of ephedrine and contributing to increased patient safety during elective cesarean surgery.

Background: Spinal anesthesia is considered the method of choice for elective cesarean sections; however, it is not without maternal-fetal risks. Materials and Methods: This study compared the effects on maternal hemodynamics of intrathecal administration of fentanyl (F) or morphine (M) in pregnant women undergoing spinal anesthesia with 0.5% hyperbaric bupivacaine, with doses varied between 7.5 mg - 11 mg, depending on the patient's height. Data from a cohort of 170 pregnant women were analyzed. The administered doses were intrathecal M at 0.1 mL (100 µg, solution of 1 mg/mL) or F at 0.25 mL (25 µg, solution of 50 µg/mL). The study included 80 patients in group F and 90 in group M. Results: The group F showed significantly higher post-intervention systolic blood pressure values than the group M (95.30 ± 12.99 mmHg vs. 90.58 ± 14.75 mmHg, p = 0.032). The incidence of vomiting was significantly less frequent in group F compared to group M (1, 1.3% vs. 10, 11.1%, p = 0.011). The total dose of ephedrine required for hypotension correction was significantly lower in the F group (12.75 ± 13.26 mg vs. 17.72 ± 16.73 mg, p = 0.035). Conclusions: The addition of F as an adjuvant alongside the local anesthetic in cesarean section is associated with better hemodynamic stability compared to M, requiring lower doses of ephedrine, and thus increasing patient safety during elective cesarean surgery.