Abstract Propofol is a widely used intravenous anesthetic agent known for its anticonvulsant properties and off-label use in refractory status epilepticus. However, paradoxical excitatory manifestations, collectively termed seizure-like phenomena (SLP), have been documented despite their central nervous system-depressant profile. These reactions are rare and often under-recognized. We report a case of a 28-year-old male with a remote history of spinal cord compression but no prior seizures, who developed seizure-like activity immediately after propofol administration during induction of general anesthesia for cystolithotomy. The episode was characterized by upward rolling of eyeballs, stiffening of extremities, generalized tonic–clonic seizures, and decorticate posturing, which resolved spontaneously. A second episode occurred during patient positioning, prompting the postponement of surgery. Laboratory tests, blood gases, and imaging revealed no metabolic or intracranial pathology. The patient was referred to the neurology service, which suggested a propofol-induced etiology in the absence of other causes. One week later, the procedure was completed under general anesthesia without propofol, and no recurrence of seizure-like activity was observed. Proposed mechanisms include modulation of GABAergic and glycinergic neurotransmission and suppression of cortical excitatory signals. The absence of seizure recurrence when propofol was avoided supports a likely causal relationship. This case underscores that although propofol is predominantly anticonvulsant, it may paradoxically induce SLP even in neurologically intact patients.

Abstract Total anomalous pulmonary venous drainage (TAPVD) represents a critical congenital heart defect requiring urgent surgical intervention. This case series presents two patients with different TAPVD presentations and outcomes from a tertiary cardiac center. Case 1 involved a 15-month-old boy with cardiac TAPVD and severe pulmonary hypertension (tricuspid regurgitation gradient: 84 mm Hg). He required aggressive management with multiple pulmonary vasodilators (nitroglycerin, milrinone, nebulized iloprost), triple inotropic support (dopamine, adrenaline, noradrenaline), and experienced prolonged intensive care with mechanical ventilation, peritoneal dialysis for acute kidney injury, and nosocomial pneumonia. Case 2 presented a 6-year-8-month-old boy with supracardiac TAPVD and only mild pulmonary hypertension (tricuspid regurgitation gradient: 24 mm Hg). He required minimal hemodynamic support with milrinone and a single inotrope (adrenaline), achieving an uneventful recovery with extubation on postoperative day 2 and intensive care unit discharge on day 4. Both patients underwent successful surgical correction with rerouting of pulmonary veins to the left atrium and atrial septal defect (ASD) closure using different techniques. The key determinants of outcome were the size of the ASD, the degree of pulmonary hypertension, and the prevention of postoperative pulmonary venous obstruction. A comprehensive multimodal diagnostic evaluation, utilizing echocardiography, cardiac catheterization, and computed tomography angiography, provided detailed anatomical characterization. These cases highlight the importance of early detection through pulse oximetry screening, timely surgical intervention, individualized perioperative pulmonary hypertension management based on severity, and consideration of sutureless techniques in high-risk patients. Long-term surveillance for pulmonary venous obstruction and arrhythmias remains essential for optimal outcomes in resource-limited settings.

Abstract Cornelia de Lange syndrome (CdLS) is a rare congenital disorder characterized by distinctive craniofacial dysmorphism, growth retardation, intellectual disability, ad multisystem anomalies. These features present substantial anesthetic challenges, particularly related to airway management. We report the case of a 6-year-old girl with CdLS who presented for emergency surgical drainage of a rapidly enlarging left-sided neck abscess following failure of medical therapy. Her medical history included severe developmental delay, cleft palate, chronic kidney disease, and oropharyngeal dysphagia. Airway examination revealed micrognathia, limited mouth opening, and midfacial hypoplasia, raising concern for both difficult mask ventilation and intubation. Given the anticipated airway risk and short duration of the procedure, the anesthetic team opted for monitored sedation using a target-controlled infusion (TCI) of ketofol, a combination of ketamine and propofol. Induction was initiated with sevoflurane via a T-piece circuit, followed by intravenous access and titration of TCI ketofol (1.0–2.5 mcg/mL). The patient remained spontaneously ventilating with a nasal airway and T-piece mask support throughout the 30-min procedure. No episodes of airway obstruction, desaturation, or hemodynamic instability were observed. The patient recovered uneventfully in the PACU and was returned to the ward without complication. This case demonstrates the feasibility of using a sedation-based strategy in a high-risk syndromic child undergoing emergency surgery. It highlights the role of TCI ketofol in preserving airway reflexes and respiratory drive. It reinforces the need for careful patient selection, multidisciplinary planning, and individualized anesthetic approaches in children with congenital syndromes.

Abstract Perioperative acute kidney injury is known to carry significant morbidity and mortality, yet it is a disease that is poorly recognized and misdiagnosed. Here, we present a case of a middle-aged female, a known case of Type 2 diabetes mellitus and recently diagnosed hypertension. She underwent transforaminal lumbar interbody fusion under general anesthesia. The intraoperative blood loss volume was around 1700 mL. There was no requirement for inotropes or vasopressors intraoperatively. A decrease in the urine output was noted, with a total urine output of 200 mL in the intraoperative period. The patient was extubated after the surgery and was maintaining stable vitals. However, 1 hour after the surgery, the patient became drowsy and hypotensive, and a fall in oxygen saturation was noted. Arterial blood gas at that time was suggestive of combined respiratory and metabolic acidosis. The patient was immediately intubated, resuscitated, and shifted to the critical care unit. Our patient developed acute kidney injury (AKI) following the surgery owing to massive intraoperative blood loss and multiple transfusions. Consequent metabolic acidosis resulted in a compensatory increase in the respiratory drive. However, due to respiratory muscle fatigue, the residual effect of anesthetic administration and postoperative pain, the acidosis gradually worsened. The patient developed drowsiness and presented with type II respiratory failure in the immediate postoperative period. So the patient was shifted to the critical care unit, and hemodialysis was immediately instituted. A high index of suspicion and early intervention were necessary for early diagnosis and timely management in our patient.

Abstract The aging process is a multilayered biological phenomenon influenced by genetic, environmental, and lifestyle factors, with dietary protein intake playing a crucial role in maintaining cellular integrity and overall health. Among dietary choices, the impact of plant- vs. animal-based protein consumption on aging and telomere length has gained increasing scientific interest. Telomere length serves as a biomarker of cellular aging, and emerging evidence suggests that dietary composition may influence its maintenance. Plant-based diets, particularly those rich in legumes, whole grains, nuts, seeds, and vegetables, have been associated with longer telomeres and a reduced rate of biological aging. These effects are believed to stem from plant-derived nutrients’ anti-inflammatory and antioxidant properties. In contrast, excessive consumption of animal-based proteins, particularly red and processed meats, has been linked to telomere shortening, increased oxidative stress, and a higher prevalence of age-related diseases. Beyond aging, protein source selection is a critical factor in specialized medical settings, such as intensive care unit (ICU) nutrition therapy. Critically ill patients require adequate protein intake to support immune function, wound healing, and muscle preservation. While animal proteins have traditionally been preferred due to their high biological value and essential amino acid content, plant-based protein sources, when appropriately combined and supplemented, may serve as viable alternatives, reducing pro-inflammatory risks associated with critical illness. This review examines the comparative effects of plant- and animal-based protein diets on aging, telomere length, and ICU nutrition therapy, providing insights into optimizing dietary strategies for longevity and clinical recovery.

Abstract Background: Muscle wasting and weakness are frequent findings in critically ill patients and are associated with worse short- and long-term outcomes. We aimed to assess the efficacy of combined high protein intake with early physical exercise on the rectus femoris (RF) muscle cross-sectional area (CSA) assessed by ultrasound in a patient undergoing mechanical ventilation in the intensive care unit (ICU). Patients and Methods: This randomized controlled study was carried out on 70 mechanically ventilated patients of both genders aged 18–60 years old. Patients were randomly allocated into two groups; Group Ι received protein in a dose (1.2 g/kg/day) in addition to usual ICU physical exercise intervention, and Group ΙΙ received protein in a dose of 2 g/kg/day in addition to the physical exercise intervention. Results: The measurements of CSA at day 20 and day 30 were significantly improved in Group Π compared to Group Ι (P = 0.012 and 0.007, respectively). The measurements of muscle thickness of the RF muscle at day 20 and day 30 were significantly improved in Group Π compared to Group Ι (P < 0.001). The CSA and muscle thickness of the RF muscle showed no significant differences at baseline, day 5, and day 10. There was a significant decrease in the length of ICU stay and the incidence of infection in Group Π as compared to Group Ι (P = 0.030 and 0.029, respectively). Conclusions: Early protocolized physical therapy along with high protein nutritional supplementation in critically ill, mechanically ventilated patients attenuated the decrease in the CSA and thickness of the RF muscle when compared to standard medical care and standard protein supplementation.

Abstract Landau–Kleffner syndrome (LKS), also known as acquired epileptic aphasia, is a childhood disease associated with acquired aphasia and epileptiform abnormalities on the electroencephalographic. We report the uneventful anesthesia management of a 17-year-old female patient with LKS syndrome. Her vital signs and laboratory results were normal, and plasma levels of valproic acid (73.6 µg/mL) were within therapeutic limits. She had mild micrognathia, short thyromental distance, and normal neck movements and mouth opening. An intravenous induction was performed with 100 mg lidocaine, 100 µg fentanyl, 200 mg propofol, and 60 mg rocuronium intravenously. After preoxygenation with 80% O2 for 3 min, she was intubated without complications with a number 7.5 mm endotracheal tube connected to a ventilator. Anesthesia maintenance was provided with 2.2% sevoflurane and 50% oxygen–50% air mixture, 0.01–0.05 μg/kg/min infusion of remifentanil. The target partial pressure of carbon dioxide was 30–35 mm Hg. Care was taken to ensure that intra-abdominal pressure did not exceed 14 mm Hg. Spontaneous breathing returned in 5 min after discontinuation of sevoflurane. She was extubated after following commands and transferred to the post-anesthesia care unit. It is unknown whether general anesthesia has a short- or long-term effect on patients with LKS. Since epileptic seizures are essential in patients with LKS, the correct selection of anesthetic agents is significant. In addition, hypoxemia, hypercarbia, hypocapnia, high positive end-expiratory pressure, and acidosis should all be avoided as they may trigger seizure activity.

Background: Patient-controlled intravenous analgesia (PCIA) remifentanil is being increasingly adopted for labor analgesia despite efficacy and safety concerns. This retrospective observational study aimed to describe factors associated with high versus low parturient satisfaction, adverse effects, and parturient and neonatal outcomes in a specialist maternity hospital in Singapore. Materials and Methods: Database review of patients who received PCIA remifentanil for labor analgesia between 2014 and 2020 were analyzed retrospectively. Parturient and clinical characteristics, adverse events, parturient and neonatal outcomes, satisfaction, PCIA remifentanil settings, and usage characteristics were analyzed. Results: There were 177 parturients who received PCIA remifentanil during the study period, with a trend of increasing utilization. After excluding 31 parturients, 146 were analyzed, of whom 99 (67.8%) reported satisfaction scores of ≥80 out of 100, with a mean ± standard deviation of 89.5 ± 8.9. Univariate analysis showed that higher pain scores at delivery was associated with low satisfaction scores (unadjusted odds ratio 1.39, 95% confidence intervals 1.02–1.88). None of the parturients or neonates required ventilation or cardiopulmonary resuscitation. Oxygen desaturation (SpO2 < 95%) was observed in 10.3% of parturients (n = 15), all of which were self-limiting. Conclusion: PCIA remifentanil for labor analgesia resulted in high satisfaction with no severe adverse events. Standardized protocols for PCIA settings and close monitoring may improve parturient and fetal safety. Future research should focus on improving the analgesic efficacy of PCIA remifentanil and monitoring practices to reduce the risk of severe adverse events.

Background: We aimed to compare erector spinae plane block (ESPB) and caudal block (CB) with ultrasound guidance as regards time of first request of rescue analgesia, opioid consumption, degree of postoperative pain relief, and incidence of complications in pediatric patients undergoing open renal surgeries such as nephrectomy and pyeloplasty. Materials and Methods: Fifty children were recruited to undergo unilateral open renal surgeries and divided into two-equal groups randomly. The age of both genders ranged from 2 to 6 years . After general anesthesia had been induced, blocks were given. After the surgical procedure and during the first 12 h of the postoperative period, the quality of analgesia was assessed immediately postoperative and then at 1, 2, 3, 4, 6, 8, and 12 h postoperatively using Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS). Opioid was intravenously given as rescue analgesia (0.05 mg/kg) when needed in both groups if CHEOPS pain score exceeded 6. It could be given every 8 h if needed. Results: As regards the time of the first request of rescue analgesia and total morphine consumption postoperatively, there was a marked difference between the two groups in favor of erector spinae plane block as no rescue analgesia was needed during the first 12 h in the postoperative period. It was proved that both blocks under ultrasound guidance were safe with no recorded complications were noted either intra or postoperatively. Conclusion: ESPB provided effective prolonged analgesia postoperatively with lower pain scores as compared with the CB in children undergoing open renal surgeries.