Background and Aims:Upper gastrointestinal (GI) endoscopic procedures under total intravenous anaesthesia (TIVA) pose risks of sedation-related complications. This study compared the first-attempt endoscope insertion success between the Laryngeal Mask Airway® (LMA) Gastro™ and low-flow nasal cannula during upper GI endoscopy under TIVA.Methods:This prospective randomised controlled study involved 140 adult patients scheduled for upper GI endoscopy under TIVA. The participants were randomly assigned into two groups: Group L (LMA® Gastro™) and Group C (low-flow nasal cannula). In Group L, LMA® Gastro™ was inserted, and in Group C, oxygen was supplemented using a low-flow nasal cannula at 4 litres/min. The primary outcome was first-attempt success of endoscope insertion. Secondary outcomes included endoscope insertion time, endoscopist and anaesthesiologist satisfaction scores, and intra- and postoperative complications. Data were analysed using statistical package for social sciences (SPSS) 19.0, and P < 0.05 was considered statistically significant.Results:The first-attempt success rate for endoscope insertion was comparable between the groups (Group L: 92.6% vs. Group C: 95.7%, P = 0.44). However, the endoscopy insertion time was significantly prolonged in Group L (Median [interquartile range] (seconds): 30 [22-41] vs. 17.5 [13-22], P < 0.001). Anaesthesiologist satisfaction was comparable between the groups, but endoscopists were more satisfied with Group C (P < 0.001). Group L had significantly fewer intraoperative respiratory adverse events compared with Group C; however, a higher incidence of postoperative sore throat was observed in Group L (20.5%).Conclusion:The first-attempt endoscope insertion success rate was comparable between the LMA® Gastro™ and nasal cannula groups in patients undergoing upper GI endoscopy under TIVA.

Background and Aims:Emergency laparotomy is associated with substantial morbidity and mortality. This study assessed the impact of the structured intraoperative component of Singapore’s Emergency Laparotomy Audit (EMLA), inspired by the National Emergency Laparotomy Audit (NELA) conducted in the United Kingdom, in patients undergoing emergency laparotomy in an Asian context.Methods:This prospective, single-centre quality improvement study was conducted at a 700-bed tertiary hospital using iterative Plan–Do–Study–Act cycles. Adult patients (aged 18 years or older) who underwent emergency laparotomy between August 2020 and August 2024 were included (n = 586). The intraoperative bundle consisted of three components: consultant-delivered anaesthesia and surgical care, goal-directed haemodynamic therapy (GDHT) for high-risk patients (NELA score greater than 10), and maintenance of normothermia. Primary measures included consultant presence, GDHT adherence, and intraoperative normothermia. Secondary outcomes were complications, intensive care unit (ICU) admission, length of stay (LOS), and 30-day mortality.Results:The presence of a consultant anaesthesiologist increased from 89.6% to 98.8% (P < 0.0001). Adherence to GDHT remained high across all phases (94.6%, 88%, and 86.7%). Hypothermia persisted in 11–16% of cases and was independently associated with longer LOS and higher ICU admission rates. No significant change in 30-day mortality was observed.Conclusion:Implementation of the structured intraoperative EMLA bundle improved consultant coverage and maintained high adherence to GDHT. Consultant presence was associated with a 42% relative reduction in medical complications; however, causality cannot be established in this quality improvement project. Persistent hypothermia highlights the need for enhanced temperature management strategies.

Dear Editor, Perioperative pain management in patients on maintenance therapy for substance abuse, particularly naltrexone, presents a unique clinical challenge due to its opioid receptor antagonism. Naltrexone, a competitive antagonist at the μ-opioid receptor, is commonly used in alcohol deaddiction programmes and impedes the analgesic efficacy of standard opioids during surgery. We share our experience of using intranasal dexmedetomidine as an effective alternative for analgesia in such a scenario. A 32-year-old male weighing 60 kg, 5’10” in height, with a history of chronic alcohol dependence, was scheduled for debridement and split thickness skin grafting of the right forearm following post-traumatic cellulitis and fasciotomy. He was on oral naltrexone 50 mg once a day for the past 18 days. Given the high likelihood of attenuated opioid response and the need to avoid high-dose opioids, we opted for an opioid-free anaesthesia strategy. General anaesthesia was induced with intravenous (IV) midazolam 1 mg, ketamine 1 mg/kg, propofol 0.5 mg/kg, and atracurium 0.5 mg/kg. The airway was secured with Ambu© laryngeal mask airway size#3. Intranasal dexmedetomidine (180 µg, 3 µg/kg, 90 µg in each nostril) was administered after intubation along with IV paracetamol 1g. Anaesthesia was maintained with isoflurane in a 50% oxygen–air mixture targeting a minimum alveolar concentration (MAC) of 0.8–0.9%. The depth of anaesthesia was monitored keeping a bispectral index of 40–60. Supplemental IV ketamine boluses of 0.5 mg/kg were planned as rescue analgesia; however, no rescue analgesics were required intraoperatively or postoperatively. The patient was haemodynamically stable and pain-free, with numeric pain scores below 3 for 48 hours on IV paracetamol given 6-hourly. Patients on opioid antagonists like naltrexone pose unique challenges for pain management. Higher opioid doses can overcome naltrexone blockade but increase risks of respiratory depression and haemodynamic instability.[1] Thus, opioid-sparing and non-opioid alternatives become crucial in such settings. This involves the use of non-opioid medications and regional anaesthetic techniques to achieve effective analgesia and anaesthesia. Non-opioid medications include alpha-2 adrenergic agonists like dexmedetomidine, N-methyl-D-aspartate receptor antagonists like ketamine, local anaesthetics, and non-steroidal anti-inflammatory drugs. Feenstra et al.,[2] in their meta-analysis, quoted studies comparing dexmedetomidine with opioids as well as other non-opioids. Dexmedetomidine has shown lower pain scores, minimal respiratory depression, lesser emergence agitation, and reduced incidence of postoperative nausea and vomiting. Unlike opioids, which act through multiple receptors (mu, kappa, and delta), dexmedetomidine is a highly selective alpha-2 adrenergic agonist that acts on the locus coeruleus, explaining its sedative and anxiolytic effects. It augments the release of substance P through the posterior horn of the spinal cord, resulting in effective analgesia.[3] As its mechanism involves different sets of receptors and modes of antinociception, its effects are not blocked by naltrexone. The role of dexmedetomidine in opioid-free anaesthesia and the significant advantage of its opioid-sparing nature in the postoperative period is not unfamiliar[2] The intranasal route has gained popularity due to ease of administration, patient comfort, and effective systemic absorption through the nasal mucosa, achieving peak plasma levels within 30–45 minutes.[4] Several studies have reported its use in premedication in a dose of 1–2 µg/kg and procedural sedation, especially in paediatric and geriatric populations.[5] We chose a dose of 3 µg/kg to provide perioperative analgesia and the intranasal route to avoid IV loading-related bradycardia and hypotension to ensure smoother sedation and analgesia.[6] Uusalo et al.[5] reported its feasibility in managing postoperative agitation and pain in geriatric orthopaedic patients. In our patient, intranasal dexmedetomidine not only managed perioperative pain effectively but also contributed to haemodynamic stability, minimal emergence agitation, and high patient satisfaction. Our limitations include the use of intranasal dexmedetomidine in a single case and that there is need to compare intranasal dexmedetomidine with traditional opioid-based regimens, for which large-scale studies need to be conducted. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient consented to the publication of his images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Presentation at conferences/CMEs and abstract publication Nil. Study data availability Not applicable. Disclosure of use of artificial intelligence (AI)-assistive or generative tools The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references. Declaration of use of permitted tools Not applicable. Supplementary material None. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.