Anaesthesia, Pain & Intensive Care

Rheumatologic diseases at the crossroads of anesthesia, pain medicine and intensive care: an under-recognized interface

Nauman Ismat Butt — Wed, 04 Feb 2026 00:00:00 -0700

Rheumatologic diseases present very specific but often unnoticed complexities for anesthesiologists, pain management specialists and critical care providers. The varied systemic consequences of rheumatologic diseases, chronic inflammation, pain processing abnormalities and immunosuppression impact perioperative care, pain management and critical care outcome. Patients with rheumatoid arthritis, axial spondyloarthropathy, systemic lupus erythematosus, systemic vasculitis and systemic sclerosis possess a high risk of perioperative complications related to intricate airway, cardiopulmonary and infectious disease issues, as well as chronic pain. This editorial focuses on the interplay between rheumatology and anesthesia as an ever-evolving field, with particular regard to the importance of a multi-disciplinary approach to perioperative pain management and critical care outcome.

Keywords: Anesthesia; Butt NI. Intensive Care; Pain; Pakistan; Rheumatologic Diseases; Rheumatology

Citation: Butt NI. Rheumatologic diseases at the crossroads of anesthesia, pain medicine and intensive care: an under-recognized interface. Anaesth. pain intensive care 2026;30(3):285-87. DOI: 10.35975/apic.v30i3.3161

Received: February 07, 2026; Accepted: March 02, 2026

Tumor microenvironment as the real immune checkpoint in intensive cancer care: are we targeting the wrong enemy?

Amna Batool, Maryum Sana — Thu, 02 Apr 2026 00:00:00 -0600

Immune checkpoint inhibitors have been termed a revolution in cancer treatment, with long-lasting benefits showing in a few cases, but recurrence and resistance are common. These constraints are seen to be associated with the tumor microenvironment (TME), which has been considered a complicated ecosystem that has an influence on immune activity in a suppressive manner. The phenomenon of escape from immunity has not been associated just with the presence of inhibitory receptors on Thymus-derived lymphocytes (T cells) but also with nutrient deprivation and stromal barriers, as well as the presence of suppressive immune cells. Provided that the receptor-ligand blockade continues to be taken as the sole solution, structural and functional obstacles in tumors can be neglected. In the case where the tumor microenvironment is viewed as the actual checkpoint, treatments can be guided towards more sustainable results.

Abbreviations: CTLA-4: Cytotoxic ECM: extracellular matrix, T-lymphocyte–associated antigen-4, PF-1: Programmed cell death protein-1, TME: tumor microenvironment

Keywords: Immune Checkpoint Inhibitors; Immunotherapy; T-Lymphocytes; Tumor Microenvironment

Citation: Batool A, Sana M. Tumor microenvironment as the real immune checkpoint in intensive cancer care: are we targeting the wrong enemy? Anaesth. pain intensive care 2026;30(3):288-90. DOI: 10.35975/apic.v30i3.3162

Received: October 01, 2025; Accepted: October 05, 2025

Prognostic model for delirium after cardiac surgery: insights from a surgical intensive care unit in a tertiary heart center

Nguyen Sinh Hien, Ngo Van Thanh, Nguyen Hong Hanh, Dinh Cong Pho — Wed, 04 Feb 2026 00:00:00 -0700

Background: Postoperative delirium complicates up to one-quarter of cardiac surgery patients and increases morbidity and mortality. In this study, we determine the incidence and risk factors of postoperative delirium after cardiac surgery and develop and internally validate a multivariable risk prediction model for postoperative delirium.

Methods: In this prospective observational study, 158 adults undergoing cardiac surgery were enrolled. Delirium was assessed daily for five days using CAM-ICU, RASS, and ICDSC. Univariate predictors (P < 0.05) entered multivariate logistic regression. Model discrimination was assessed by ROC analysis; internal validity by 500-sample bootstrapping and ten-fold cross-validation.

Results: The mean of age was 60.4 ± 10.8 years and 53.2% wass female. Delirium occurred in 38 patients (24.1%), peaking on day 1 (15.2%), with hyperactive subtype in 91.7%. Univariate risk factors: female gender (73.7% vs 15.6%, P = 0.004), minimally invasive surgery (44.2% vs 20.0%, P < 0.001), mechanical ventilation (36.7±34.3 vs 28.7±20.9 h, P = 0.002), sedation (32.3±31.7 vs 19.7±16.7 h, P < 0.001), propofol (25.9±20.1 vs 14.2±9.1 h, P < 0.001), infection (42.1% vs 24.2%, P = 0.033), stroke (18.4% vs 5.3%, P = 0.009). Multivariate independent predictors: Female gender (OR 2.68; P = 0.048; AUC 0.635; P = 0.012); Minimally invasive surgery (OR 4.14; P = 0.005; AUC 0.650; P = 0.005); Propofol duration per hour (OR 1.07; P = 0.011; AUC 0.747; P < 0.001); Postoperative infection (OR 3.45; P = 0.046; AUC 0.590; P = 0.096). Apparent model (female gender, minimally invasive surgery, propofol sedation duration, and postoperative infection) AUC was 0.828 (95% CI 0.759–0.897; P < 0.001). Bootstrap mean optimism was 0.038, yielding an optimism-corrected AUC of 0.790. Ten-fold cross-validation produced a mean AUC of 0.79 ± 0.04.

Conclusions: Postoperative delirium affects nearly one-quarter of cardiac surgery patients. A prognostic model including female gender, minimally invasive surgery, propofol sedation duration, and postoperative infection demonstrates robust discrimination (optimism-corrected AUC 0.790) and internal stability. Implementation may enable early risk stratification and optimization of sedation and infection-prevention protocols.

Keywords: Delirium; Cardiac Surgery; Prognostic Model

Citation: Hien NS, Thanh NV, Hanh HH, Pho DC. Prognostic model for delirium after cardiac surgery: insights from a surgical intensive care unit in a tertiary heart center. Anaesth. pain intensive care 2026;30(3):291-300. DOI: 10.35975/apic.v30i3.3163

Received: February 07, 2026; Revised: March 15, 2026; Accepted: March 15, 2026

Evaluation of oxidative stress and diagnostic value of cytokeratin fragment 21-1 in the lung cancer patients

Mohammed H. Mohammed, Shrouk A. Hassan, Ali A. Hassan — Sun, 05 Apr 2026 00:00:00 -0600

Background: Lung cancer is a leading cause of cancer mortality, linked to anti-oxidant and oxidative stress and epithelial damage. Biomarkers like superoxide dismutase (SOD), glutathione peroxidase (GPx), malondialdehyde (MDA), and cytokeratin fragment 21-1 (CYFRA 21-1) may indicate tumor progression.

Objective: To assess serum levels of oxidative stress markers (SOD, GPx, MDA) and CYFRA 21-1 in lung cancer patients versus controls used to monitoring and prognosis tool for the oxidative stress status.

Methodology: This case-control study was carried out from November 2024 to April 2025 at Nassiriya Teaching Hospital in Thi-Qar, Iraq. Sixty patients with lung cancer and 60 age-matched controls were included in the study. Venous blood samples were obtained, and serum was separated and stored to determine the concentrations of SOD, Gpx, MDA and CYFRA 21-1 using enzyme-linked immunosorbent assay (ELISA).

Results: There were no significant differences in age or BMI between the two groups. Lung cancer patients had significantly elevated levels of MDA (193.2 ± 18.6 vs. 158.6 ± 21.09 nmol/mL), SOD (90.15 ± 34.9 vs. 42.07 ± 13.78 ng/mL), GPx (65.4 ± 29.4 vs. 9.98 ± 5.6 µU/mL), and CYFRA 21-1 (15.1 ± 6.5 vs. 5.9 ± 2.7 ng/mL) compared to controls (P < 0.001 for all). Oxidative stress markers and CYFRA 21-1 levels did not differ significantly among age subgroups in patients with lung cancer.

Conclusions: This study highlights a significant elevation in oxidative stress markers and CYFRA 21-1 in patients with lung cancer, supporting their potential role as diagnostic and prognostic biomarkers. Monitoring these biomarkers may enhance early detection and management of lung cancer in clinical settings.

Keywords: Lung cancer, Oxidative stress, Cytokeratin fragment 21-1

Citation: Mohammed MH, Hassan SA, Hassan AA. Evaluation of oxidative stress and diagnostic value of cytokeratin fragment 21-1 in lung cancer patients. Anaesth. pain intensive care 2026;30(3):301-307. DOI: 10.35975/apic.v30i3.3166

Received: July 20, 2025; Revised: August 28, 2025; Accepted: September 01, 2025

Prevalence of preoperative anxiety among surgical patients and the associated factors; a one-year study at Al-Hilla Teaching Hospital, Iraq

Amani Alaa Saeed — Mon, 04 May 2026 00:00:00 -0600

Background & objective: Preoperative anxiety is an emotional state marked by heightened worry, tension, or fear, that most of the patients experience before surgery. Various factors have been mentioned in the literature, including age, gender, education and previous exposure to the surgery etc. The aim of our study was to evaluate and document the prevalence and determinants of preoperative anxiety among patients undergoing surgical procedures.

Methodology: This cross-sectional study was conducted to evaluate the preoperative anxiety level and its association with sociodemographic factors, knowledge, and previous anesthesia experience, in Al-Hilla Teaching Hospital from June 2024 to June 2025 (using the AMSTERDAMEI scale). 400 patients from either gender, were enrolled under convenient sampling. Structured questionnaires on demographic profiles, previous anesthesia and surgery experiences causing anxiety were used.

Results: Most participants were aged 30–39 years (34.0%). Gender distribution was equivalent (51.0% females, 49.0% males). The largest group of participants was employed (39.5%), followed by unemployed (32.5%). Over half (54.5%) experienced preoperative anxiety. The most frequent type of anesthesia in the previously exposed group was local anesthesia (18.0%), and 58.5% had never received any anesthesia. Psychological fears were high: fear of pain during operation (80.0%), fear of death (53.5%), and the concern regarding the experience of the anesthetist (52.0%). Anxiety was significantly associated with occupation (P = 0.0001) and educational level (P = 0.0001), but there were no significant relationships with age, gender, marital status, or anesthesia type using statistical analysis. Patients with increased levels of previous knowledge about anesthesia and surgery, had lower anxiety scores (5.40 ± 1.49 vs. 4.99 ± 1.61, P = 0.03).

Conclusion: Professional history and education have a big effect on how anxious the are the patients before surgery. On the other hand, informing patients about the conduct of the anesthesia can help lower their anxiety levels.

Keywords: Anxiety; Demographic; Knowledge; Preoperative anxiety.

Citation: Saeed AA. Prevalence of preoperative anxiety among surgical patients and the associated factors; a one-year study at Al-Hilla Teaching Hospital, Iraq. Anaesth. pain intensive care 2026;30(3):308-313. DOI: 10.35975/apic.v30i3.3167

Received: November 24, 2025; Revised: February 24; 2026; Accepted: February 28, 2026

A retrospective study of empirical transfusion of blood products during cardiac surgery measured by thromboelastometry; Is it time to change?

Ahmed Elsherbeny, Ibrahim AbdelAal, Ahmad Abuzaid, Ahmed Abdalwahab — Mon, 04 May 2026 00:00:00 -0600

Background & objective: Despite an international effort lead by the World Health Organization (WHO) many cardiac centers still continue the practice of empirical blood product transfusion. Current guidelines and published evidence strongly support the use of transfusion algorithms that are guided by point-of-care coagulation testing. The aim of this study is to determine the proportion of patients with normal coagulation parameters who still received empirical blood products during cardiac surgery. Secondary end point is the occurrence of transfusion-related adverse events.

Methodology: This is a retrospective observational study of 100 pediatric patients scheduled for cardiac surgery. As part of the rotational thromboelastometry (ROTEM) introduction to the operating theatre, two ROTEM samples were collected, before and after blood products. The empirical blood products practice continued as usual and did not change based on those ROTEM samples.

Results: Among patients who received empirical blood products, 16% had normal fibrinogen levels (did not need Cryoprecipitates), 24% had normal clotting factors (did not need fresh frozen plasma) and 60% had normal platelets assessment. No significant adverse events attributable to blood products were observed.

Conclusion A proportion of pediatric patients had normal coagulation parameters prior to the administration of empirical blood products. The study highlights the value of viscoelastic point-of-care testing to avoid unnecessary transfusion during cardiac surgery. It underscores the urgent need to transition institutional practice towards algorithm-based approach and appropriate use of blood components.

Abbreviations: FFP: Fresh frozen plasma. ROTEM: rotational thromboelastometry, WHO: World Health Organization, TACO: Transfusion-associated circulatory overload, TRALI: Transfusion-related lung injury

Keywords: Blood coagulation; Cardiac surgery; Cardiopulmonary bypass; Fresh frozen plasma; Point of care; : Rotational thromboelastometry.

Citation: Elsherbeny A, AbdelAal I, Abuzaid A, Abdalwahab A. A retrospective study of empirical transfusion of blood products during cardiac surgery measured by thromboelastometry; Is it time to change? Anaesth. pain intensive care 2026;30(3):314-318. DOI: 10.35975/apic.v30i3.3168

Received: December 23, 2025; Revised: March 06, 2026; Accepted: March 11, 2026

The prevalence of dry eye syndrome in association with smartphone use in Saudi Arabia

Dina M. Abdulmannan — Mon, 04 May 2026 00:00:00 -0600

Background: Dry eye syndrome (DES) is the leading eye disease globally. Studies on the association of DES with smart device use and prevalence are limited in Saudi Arabia. Therefore, this study aims to investigate the prevalence and predictors of DES.

Methodology: This online cross-sectional survey was conducted in Saudi Arabia between January and July 2023. Schaumberg et al.'s questionnaire tool was used in this study. DES was determined according to WHS criteria (persistent or recurrent) by severe symptoms of dryness and irritation or a prior clinical DES diagnosis. Predictors of DES were identified using binary logistic regression analysis.

Results: This study involved 440 participants. The most used device was the mobile phone (93.0%). Approximately one-third (29.8%) of participants reported using their smart devices for an average of 4-6 hours daily. Social media was the most documented cause of smart device utilization (74.3%). The total of study participants with DES is estimated to be 43.4%. The potential to have DES was higher in females, those aged 24-35 and 41-50 years, divorced, unemployed, spectacle wearers, and contact lens users than others (P < 0.05).

Conclusion: DES is a prevalent health issue among the general Saudi population. Additional research is mandated to determine other DES-associated risk factors. Future studies should focus on recognizing approaches that could assist in reducing the incidence of DES, which results from the unavoidable prolonged digital device usage by considerable social groups.

Keywords: Dry eye syndrome; General public; Saudi Arabia; Smartphone

Citation: Abdulmannan DM. The prevalence of dry eye syndrome in association with smartphone use in Saudi Arabia. Anaesth. pain intensive care 2026;30(3):319-326. DOI: 10.35975/apic.v30i3.3169

Received: October 08, 2025; Revised: March 02, 2026; Accepted: March 02, 2026

Immunological evaluation of serum CXCL1 and interleukin-34 and their correlation with IL-34 gene polymorphism in patients with systemic lupus erythematosus

Athraa Abd ALnabi Musa, Aseel Shakir Mahmood — Mon, 04 May 2026 00:00:00 -0600

Immunological evaluation of serum CXCL1 and interleukin-34 and their correlation with IL-34 gene polymorphism in patients wi

Background & objective: Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease. The chemokine CXCL1 and interleukin-34 (IL-34) are implicated in inflammatory and immune responses, but their combined role and genetic regulation in SLE remain unclear. This study aimed to investigate serum levels of CXCL1 and IL-34, and the association of IL-34 gene polymorphism (rs7193968) with these markers and disease parameters in SLE patients.

Methodology: A case-control study was conducted on 50 SLE patients and 50 healthy controls. Serum levels of CXCL1 and IL-34 were measured by ELISA. Genotyping for the IL-34 rs7193968 G/C polymorphism was performed using PCR and sequencing. Statistical analyses included t-tests, chi-square tests, ROC analysis, and logistic regression.

Results: Serum levels of CXCL1 (125.42 ± 97.55 vs. 53.36 ± 34.60 pg/mL, (P < 0.0001) and IL-34 (23.30 ± 14.16 vs. 12.58 ± 9.89 pg/mL, P < 0.0001) were significantly elevated in SLE patients. The GG genotype and G allele of rs7193968 were significantly more prevalent in patients (P = 0.0020) and correlated with elevated levels of CXCL1, ANA, and anti-dsDNA. ROC analysis demonstrated significant diagnostic capability for CXCL1 (AUC=0.85) and IL-34 (AUC=0.81). Multivariate regression analysis identified all three biomarkers as autonomous predictors of SLE.

Conclusion: Elevated serum CXCL1 and IL-34 are significantly associated with SLE, and the IL-34 rs7193968 G allele is linked to increased disease susceptibility and severity. These molecules represent promising biomarkers and highlight a potential genetic-immunological axis in SLE pathogenesis.

Keywords: Chemokine CXCL1; Genetic Polymorphism. Interleukin-34; Lupus Erythematosus;

Citation: Musa AAA, Mahmood AS. Immunological evaluation of serum CXCL1 and interleukin-34 and their correlation with IL-34 gene polymorphism in patients with systemic lupus erythematosus. Anaesth. pain intensive care 2026;30(3):327-334. DOI: 10.35975/apic.v30i3.3170

Received: May 09, 2025; Revised: October 26, 2025; Accepted: January 01, 2025

th systemic lupus erythematosus

Effect of low dose intravenous dexmedetomidine on post anesthesia discharge after daycase breast cancer surgery: a randomized controlled trial

Yusra Saleem, Almas Iqbal, Allah Ditta Ashfaq — Mon, 04 May 2026 00:00:00 -0600

Background: In resource-limited, high-volume cancer centers, even small reductions in recovery times can yield meaningful clinical and economic benefits. Therefore, local validation of emerging international findings on dexmedetomidine’s role in enhancing recovery is warranted. This study assessed whether low-dose intraoperative dexmedetomidine in day-case breast cancer surgery could shorten PACU (post-anesthesia care unit), total discharge times and increase early-discharge rates compared with standard anesthetic care.

Methodology: A prospective double blinded randomized controlled trial was conducted at the Department of Anesthesia, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, between September 2023 and July 2025. 82 women aged 18–60 years, ASA (American Society of Anesthesiologists) class I-II, scheduled for same-day elective breast surgery, were randomly allocated into two equal groups. Group A received dexmedetomidine infusion (0.6 µg/kg/h) intra-operatively, while Group B was given placebo. The primary outcome included the frequency of patients achieving early discharge (≤120 minutes).

Results: Early discharge was achieved in all patients receiving dexmedetomidine (100%) and in 37 patients from the control group (90.2%); the difference was not statistically significant (P = 0.116, Fisher’s Exact). The dexmedetomidine group demonstrated a significantly shorter PACU discharge time (35.6 ± 11.0 min vs. 51.3 ± 20.5 min; P < 0.001), chair recovery time (28.1 ± 11.0 min vs. 38.9 ± 17.6 min; P = 0.01), and total discharge time (59.6 ± 18.5 min vs. 80.7 ± 27.4 min; P < 0.001).

Conclusion: Low-dose intraoperative dexmedetomidine enhances postoperative recovery and shortens discharge time without adverse effects, supporting its role as a useful adjunct for ambulatory breast surgery anesthesia.

Keywords: Dexmedetomidine, Day-case surgery, Breast cancer, Post-anesthesia care, Ambulatory anesthesia.

Citation: Saleem Y, Iqbal A, Ashfaq AD. Effect of low dose intravenous dexmedetomidine on post anesthesia discharge after daycase breast cancer surgery: a randomized controlled trial. Anaesth. pain intensive care 2026;30(3):xxxxxxxx. DOI: 10.35975/apic.v30i3.3171

Received: November 04, 2025; Revised: January 11, 2026; Accepted: February 27, 2026

Influence of psychological factors on emotional and behavioral outcomes among children with hearing impairment compared to hearing peers

Nabaa Hussein Eidan, Nuhad Mohammed Aldoori — Mon, 04 May 2026 00:00:00 -0600

Background & objective: Children with hearing impairment face multiple challenges affecting their behavioral development due to limitations in communication and social integration. Hearing impairment may lead to increased emotional symptoms and withdrawal or aggression compared to hearing children. This study compares the impact of psychological factors on emotional and behavioral outcomes in children with hearing impairment and their hearing peers.

Methods: A comparative study was conducted on a sample of 309 participants, including children and their parents. The sample was divided into two groups: the first group consisted of 100 children with hearing impairments enrolled in hearing and speech centers, and the second group consisted of 209 children with normal hearing enrolled in mainstream schools. The study used modified and developed questionnaire for the purpose of study. Data was collected through interviews and analyzed electronically by using SPSS 27.

Results: The study results indicated statistically significant differences in the levels of psychological factors between the two groups. A high percentage of children with normal hearing (88.5%) demonstrated good levels of psychological factors, while 59% of children with hearing impairments showed moderate levels. Furthermore, the emotional and behavioral outcomes were good for 79.4% of children with normal hearing and moderate for 55% of those with hearing impairments.

Conclusions: This study confirms that psychological factors play a crucial role in shaping the emotional and behavioral outcomes of hearing-impaired children compared to their hearing peers. It highlights the urgent need to develop psychosocial intervention programs aimed at improving self-esteem and enhancing self-efficacy.

Key-wards: Hearing impairment, psychological factors, emotional outcomes, behavioral problems and children.

Citation: Eidan NH, Aldoori NM. Influence of psychological factors on emotional and behavioral outcomes among children with hearing impairment compared to hearing peers. Anaesth. pain intensive care 2026;30(3):335-341. DOI: 10.35975/apic.v30i3.3172

Received: January 31, 2026; Revised: February 06, 2026; Accepted: February 10, 2026

Effectiveness of localized vibration therapy on restless legs syndrome severity and sleep quality in hemodialysis patients: a randomized controlled trial

Amjed Abdulabbas Shraida, Widad K. Mohammed — Sun, 05 Apr 2026 00:00:00 -0600

Background & objective: Restless legs syndrome (RLS) is a common sensory and motor issue in patients on regular hemodialysis that contributes to sleep disturbances and impairs quality of life. This study aimed to find out whether vibration therapy improves RLS and related sleep quality in patients receiving hemodialysis.

Methodology: This clinical randomized controlled trial included 70 patients undergoing hemodialysis equally distributed into a study (interventional) group (receiving vibration therapy) and a control group (receiving routine care only) using a block randomization technique. Arabic version of the Restless Legs Syndrome Rating Scale was used to assess the RLS severity, and the Brief Pittsburgh Sleep Quality Index was used to assessed the sleep quality. These scales were used over three period of measurements (pretest, posttest one and posttest two).

Results: the study results demonstrate that the vibration therapy had a consistent and significant effect in reducing the RLS severity (P < 0.001) as well as enhancing sleep quality (P < 0.001) within the study group over time. While the control group did not present significant improvement across all three measures.

Conclusion: The study results demonstrates that vibration therapy was effective in significantly reducing the severity of RLS and improving sleep quality among the study group participants, while the control group showed no meaningful change over time.

Keywords: Hemodialysis, End Stage Renal Disease, Sleep quality, Restless legs syndrome

Citation: Shraida AA, Mohammed WK. Effectiveness of localized vibration therapy on restless legs syndrome severity and sleep quality in hemodialysis patients: a randomized controlled trial. Anaesth. pain intensive care 2026;30(3):342-349. DOI: 10.35975/apic.v30i3.3173

Received: January 26, 2026; Revised: January 30; 2026; Accepted: January 31, 2026

Comparison of pain relief by bupivacaine with or without dexmedetomidine in transversus abdominis plane block for postoperative analgesia in patients undergoing abdominal surgeries

Rameesha Musharaf, Sairah Sadaf, Amjad Siddique, Tahreem Saeed — Mon, 04 May 2026 00:00:00 -0600

Background & objective: Post-operative pain management is crucial for recovery and daily function. The transversus abdominis plane (TAP) block is a common regional anesthesia technique that effectively relieves abdominal wall pain. This study evaluates the effect of combining dexmedetomidine and bupivacaine in TAP blocks for pain control in abdominal surgery patients and the need for rescue analgesia. We assessed the effect of combining dexmedetomidine into bupivacaine in the TAP block on postoperative analgesia.

Methodology: A randomized controlled trial was conducted at Sheikh Zayed Hospital, Rahim Yar Khan, including 80 patients undergoing abdominal surgeries: exploratory laparotomy (20), ileostomy reversal (25), laparoscopic cholecystectomy (12), open cholecystectomy (10), and paraumbilical hernia mesh repair (13). Patients were randomized into Group A (20 mL of 0.25% bupivacaine with 0.25 mcg/kg dexmedetomidine) and Group B (20 mL of 0.25% bupivacaine alone). Ultrasound-guided TAP blocks were performed, and postoperative pain, hemodynamics, sedation, nausea, and rescue analgesia requirements were monitored.

Results: Age and gender were comparable between groups, while BMI was significantly lower in Group A (P = 0.001). Group A showed better pain control on VAS at 6 hours (P = 0.002) and 12 hours (P = 0.025). Sedation levels and rescue analgesia use were similar in both groups; however, patient satisfaction was higher in Group A (70.1% vs. 37.4%, P = 0.003), with a lower incidence of hypertension (10.0% vs. 25.0%, P = 0.011). Group A exhibited elevated SpO2 values prior to TAP block injection (P = 0.048), although no significant differences were seen at subsequent time intervals. The incorporation of dexmedetomidine did not influence postoperative nausea or sedation.

Conclusion: This study illustrates that the combination of dexmedetomidine and bupivacaine in TAP blocks yields improved analgesia and increased patient satisfaction relative to bupivacaine alone in individuals undergoing abdominal surgery.

Keywords: Abdominal Surgery; Anesthesia; Bupivacaine; Dexmedetomidine; Pain Management; TAP Block

Citation: Musharaf R, Sadaf S, Siddique A, Saeed T. Comparison of pain relief by bupivacaine with or without dexmedetomidine in transversus abdominis plane block for postoperative analgesia in patients undergoing abdominal surgeries. Anaesth. pain intensive care 2026;30(3):350-356. DOI: 10.35975/apic.v30i3.3174

Received: December 16, 2025; Revised: January 05, 2026; Accepted: January 06, 2026

Efficacy and safety of botulinum toxin injection for occipital neuralgia: a systematic review

Mon, 04 May 2026 00:00:00 -0600

Background: Occipital neuralgia (ON) is a rare condition characterized by stabbing pain along the greater and lesser occipital nerves. Standard treatments often provide limited relief. Botulinum toxin type A (BoNT-A), previously used for headache, is being explored as a potential treatment for ON. This study aims to assess its safety and effectiveness.

Methodology: A comprehensive literature search was carried out in PubMed, EuropePMC, ScienceDirect, and Google Scholar using keywords such as “Occipital Neuralgia,” “Greater Occipital Nerve,” “Botulinum Toxin A,” “Onabotulinum Toxin A,” “Botulinum Toxin Type-A,” “BoNT-A,” “Botox,” and “Pain,” covering publications up to April 2025. The primary outcome was the Visual Analog Scale (VAS) score, while secondary outcomes included reported adverse events.

Results: This systematic review encompasses six studies with 69 participants. Despite variations in follow-up durations (2, 4, and 12 weeks), all studies reported significant reductions in VAS. Furthermore, no adverse effects related to BoNT-A administration were observed.

Conclusion: In summary, this review indicates that BoNT-A effectively alleviates pain in occipital neuralgia, with benefits observable as early as two weeks post-injection and lasting up to 12 weeks. However, due to variations in dosage, injection techniques, and study methodologies, further well-controlled trials are necessary to confirm its efficacy.

Keywords: Occipital Neuralgia, Botulinum Toxin Type-A, Pain

Citation: Siahaan YMT, Pradhana TM, Arjuna YYE, Hartoyo V, Purnomo AE, Darmawan RO. Efficacy and Safety of Botulinum Toxin Injection for Occipital Neuralgia: A Systematic Review. Anaesth. pain intensive care 2026;30(3):357-364. DOI: 10.35975/apic.v30i3.3175

Recevised: May 29, 2025; Revised: August 29, 2025; Accepted: December 15, 2026

Ethics and ethical issues in medical writing

Areeba Naseer, Qurba Kiran, Humera Mubashar — Sun, 05 Apr 2026 00:00:00 -0600

Background: Medical writing is an important aspect of healthcare communication because it makes it easier to share clinical information and research findings. Medical writing is essential when it comes to conveying clinical and scientific knowledge. But the field is facing more and more ethical issues that might compromise public confidence and scientific integrity. For medical literature to be transparent, accurate, and trustworthy, ethical norms must be upheld.

Objective: The purpose of this narrative review is to examine the basic principles of ethics and prevalent ethical issues in medical writing, emphasizing the significance of maintaining accuracy, accountability, and transparency.

Methodology: A systematic search of MEDLINE/PubMed and Google Scholar databases, then thoroughly reviewed the articles, focusing on those published in the last 10 years. Ethical issues, including use of AI, plagiarism, ghostwriting, and disputes over authorship, data falsification, and conflicts of interest, were analyzed.

Conclusion: Maintaining the integrity of scientific papers and safeguarding patient welfare depend heavily on ethical medical writing. Preventing misbehavior and ensuring responsible communication in medical literature requires awareness, adherence to ethical principles, and appropriate training for researchers and authors.

Keywords: Authorship; Ethics; Ghostwriting; Medical writing; Plagiarism; Publication ethics; Scientific integrity

Citation: Mubashar H. . Anaesth. pain intensive care 2026;30(3):365-369. DOI: 10.35975/apic.v30i3.3176

Received: May 09, 2025; Revised: October 26, 2025; Accepted: January 01, 2026

The essential role of teaching in transforming medical practitioners into effective clinicians

Mon, 04 May 2026 00:00:00 -0600

Converting health care to competent clinicians will depend on full teaching plans which connection practice along with theory. Medical education is pretty much a crux in learning clinical skills, critical thinking and decision-making in addition to basic science knowledge for patient care. The goal of this review is to highlight how teaching methodologies such as problem-based learning, simulation and mentor ship accomplish the task of bringing academic knowledge into clinical practice. Good clinical educators should provide more than just a technical skill but the ability to assess and progressively develop to be at least better than baseline as practitioners in teaching future recruits, this way the intern can cope with the modern healthcare system. In addition, the added value of lifelong learning and mentorship to clinical care is highlighted, highlighting how good medical education leads to better health outcomes.

Keywords: Clinical skills; Continuous learning; Critical thinking; Medical education; Problem-based learning (PBL); Professional development; Simulation-based learning; Teaching methodologies.

Citation: Zahid MA, Parkash J, Kala C, Izhar HMF, Sheikh Z, Rehman MA. The essential role of teaching in transforming medical practitioners into effective clinicians. Anaesth. pain intensive care 2026;30(3):370-376. DOI: 10.35975/apic.v30i3.3177

Received: October 02, 2024; Revised: October 26, 2024; Accepted: January 01, 2025

Anesthetic challenges in peroral endoscopic myotomy (POEM) in bizarre parosteal osteochondromatous proliferation (Nora lesion)

Shweta Khatri, Smita Ubhe, Rohit Nagrik — Mon, 04 May 2026 00:00:00 -0600

Peroral endoscopic myotomy (POEM) is a novel technique that utilizes natural orifice transluminal endoscopy to address esophageal motility disorders. This method, which is performed under general anesthesia in an endoscopy suite, has shown effectiveness similar to that of Heller myotomy. A pivotal part of the POEM procedure involves the creation of a submucosal tunnel within the esophageal wall. However, the ongoing insufflation of CO? can inadvertently extend into nearby tissues, leading to Complications such as capnomediastinum, capnothorax, capnoperitoneum, and subcutaneous emphysema. An anesthesiologist faces several challenges, including administering anesthesia in remote locations, managing the heightened risk of aspiration during induction, and promptly identifying and addressing these complications with specific emergency measures. Consequently, the anesthesiologist on duty must be knowledgeable about these frequent complications and the necessary emergency responses, such as compensatory hyperventilation, percutaneous needle decompression, and thoracic drainage. While peroral endoscopic myotomy (POEM) is generally conducted under general anesthesia, there is a scarcity of reports that elaborate on its anesthetic management and associated complications.

Keywords: POEM, NORA, Aspiration, ventilation

Citation: Ubhe S, Khatri S, Nagrik R. Anesthetic challenges in peroral endoscopic myotomy (POEM) in bizarre parosteal osteochondromatous proliferation (Nora lesion). Anaesth. pain intensive care 2026;30(3):377-379. DOI: 10.35975/apic.v30i3.3180

Received: Sep 09, 2025, Revised: November 25, 2025, Accepted: December 06, 2025

Frozen no more: conquering painful rehabilitation in refractory adhesive capsulitis through continuous interscalene block with PCA

Martien Silviandy Setiawan, Erwin Mulyawan, Hori Hariyanto — Sun, 05 Apr 2026 00:00:00 -0600

Adhesive capsulitis, commonly known as frozen shoulder, is a progressive painful condition characterized by limited active and passive range of motion (ROM) in all planes of glenohumeral joint movement due to inflammation, fibrosis, and capsular contracture. Frozen shoulder is divided into 3 main phases: freezing, frozen, and thawing. Conventional management of frozen shoulder often yields suboptimal results. Severe pain intensity can hinder the patient's rehabilitation process, necessitating innovative analgesic methods. A 50-year-old male with a history of frozen shoulder phase adhesive capsulitis for one month, experiencing rest pain VAS 6/10 and active movement pain VAS 9/10, had received conventional therapy including intra-articular steroid injections and nerve blocks with PRF. The patient experienced severe pain during rehabilitation, so a Continuous Interscalene Brachial Plexus Block (CISB) guided by ultrasound, connected to patient controlled analgesia (PCA) as an analgesic modality, was performed. Rehabilitation continued with passive and active shoulder manipulation. CISB with PCA represents a valuable analgesic strategy in adhesive capsulitis, allowing early physiotherapy and functional recovery when conventional therapies fail.

Abbreviations: AC: Adhesive capsulitis, CISB: Continuous Interscalene Block, PCA: patient controlled analgesia, ROM: range of motion,

Keywords : Adhesive Capsulitis, Continuous Interscalene Block (CISB), Frozen Shoulder, Pain Management, Patient Controlled Analgesia (PCA),

Citation: Setiawan MS, Mulyawan E, Hariyanto H. Frozen no more: conquering painful rehabilitation in refractory adhesive capsulitis through continuous interscalene block with PCA. Anaesth. pain intensive care 2026;30(3):380-383. DOI: 10.35975/apic.v30i3.3181

Received: December 2, 2025; Revised: January 11, 2026; Accepted: February 21, 2026

Spinal anesthesia for thigh sebaceous cyst removal in a deaf-mute female patient

Faris Suleiman Saleh Aldobekhi — Mon, 04 May 2026 00:00:00 -0600

Introduction: Anesthesia for the congenitally deaf/mute patients are complicated in the perioperative phase because deaf/mute patients have difficulties communicating regarding obtaining consent, understanding their level of anxiety and recognizing their discomfort/pain. Using techniques of regional anesthesia (for example, spinal), allows for continued communication with the patient, eliminates the need for manipulating the airways of the patient and provides for an improved quality of care to this population.

Case presentation: A 32-year-old female patient, who is deaf/mute, received excellent anesthesia care for an elective removal of a sebaceous cyst on her thigh. Communication between the patient and the staff was achieved using simple hand motions/gestures and the assistance of a family member acting as a translator before the surgery. The patient received spinal anesthesia with 2.5cc of 0.5% hyperbaric bupivacaine at the L3-4 interspace, resulting in a sensory blockade to T10 allowing the surgeon to complete the operation without needing to administer sedation to the patient. During the time the patient underwent surgery, monitoring of the patient's non-verbal symptoms of pain/anxiety were assessed by the anesthesiologist. Post-operative recovery from the surgical procedure was uneventful with the sensory block resolving completely at 2.5 hours after the injection of the local anesthetic. There were no complications identified post-operatively or during the perioperative period.

Conclusion: The case study illustrates that spinal anesthesia can be safely administered and provide effective patient centered care for deaf/mute patients undergoing lower extremity surgeries. In order to provide an appropriate perioperative experience for deaf/mute patients, the anesthesiologist must develop communication skills that accommodate the individualized needs of the deaf/mute patient. Providing thorough education/communication to the patient and their families prior to the surgery and maintaining close attention to detail during the intraoperative period will result in a positive perioperative experience for these patients.

Keywords: Deaf-Mute Patient; Lower Extremity Surgery; Perioperative Management; Regional Anesthesia; Sebaceous Cyst; Spinal Anesthesia.

Citation: Aldobekhi FSS, Khatoon F. Spinal anesthesia for a 32-year-old female deaf-mute patient undergoing thigh sebaceous cyst removal. Anaesth. pain intensive care 2026;30(3):384-388. DOI: 10.35975/apic.v30i3.3182

Received: January 06, 2026; Revised: February 04, 2026; Accepted: February 08, 2026

Supraclavicular approach central line catheterization in low-birth weight premature neonate

Alegra Rifani Masharto, Bambang Pujo Semedi, Teuku Aswin Husain — Sun, 05 Apr 2026 00:00:00 -0600

Introduction: Intravenous catheterization is challenging in neonates, especially in the low-birth-weight population. Most patients were referred to the anesthesiologist after several failed attempts at central vein catheterization. In this case report, we would like to share an unusual approach with a higher success rate.

A one-day old female child, 1.7 kg, with gastroschisis and neonatal sepsis. The patient's general condition was weak and lethargic, with HR 135 bpm, RR 50 tpm, SpO₂ 95% on ventilator and prolonged hemostatic function. The patient was prepared for central venous catheter insertion. The right neck was disinfected, and lidocaine (2%, 0.1 ml) was administered. It started with the insertion of a 24 G IV catheter, which was then aspirated with blood. Guidewire was advanced then dilated before the insertion of CVC 3 Fr for 10 cm. The catheter was then fixed using a 3.0 silk suture. Postoperatively, the patient was radiographed without further bleeding.

The patient was given midazolam 1,5 mg, fentanyl (30 mcg), and sevoflurane (8 vol%) in 100% oxygen with a face mask size 2 until an adequate level of anesthesia with spontaneous ventilation was achieved. The patient was then placed in the left lateral decubitus position. The insertion site was marked at L1 to cover T6–S2. A catheter was inserted 10 cm before the test dose and an incremental dose of ropivacaine 0.2% 7 ml, then maintenance at 3 ml/h. Hemodynamics were stable with SpO2 97-100%, HR 97–103 bpm, SBP 80-90/45-47 mmHg. Postoperatively, the patient was transferred to the PACU.

The supraclavicular approach can be used for neonates in whom it is difficult to find other sites for CVC insertion, as it is easier for the physician to reach the deeper vein from easier approach.

Keywords: Central Venous Catheter, Supraclavicular Approach, Pediatric Anesthesia

Citation: Rifani A, Ahmad B, Husain TA, Semedi BP. Supraclavicular approach central line catheterization in low-birth weight premature neonate. Anaesth. pain intensive care 2026;30(3):389-394. DOI: 10.35975/apic.v30i3.3183

Received: April 24, 2025; Revised: October 30, 2025; Accepted: January 01, 2026

Acute normovolemic hemodilution as a blood conservation strategy in a Jehovah’s Witness undergoing above-knee amputation: a case report

Akhmad Fauzan Firdaus, Reza Widianto Sudjud, Budiana Rismawan — Mon, 04 May 2026 00:00:00 -0600

Major surgery is frequently associated with significant blood loss, and allogeneic transfusion remains standard therapy. Jehovah’s Witness patients may refuse blood products for religious reasons, creating major perioperative challenges. Acute normovolemic hemodilution (ANH) is a blood conservation strategy that may be acceptable to these patients when performed using a closed-circuit system.

A 65-year-old woman with acute right lower-limb ischemia, initially classified as Rutherford grade IIA (marginally threatened limb), with rapid clinical progression requiring emergency above-knee amputation under general anesthesia. The patient, a Jehovah’s Witness, refused allogeneic blood transfusion. Preoperative hemoglobin was 9.7 g/dL with a hematocrit of 32.1%. After induction of general anesthesia and achievement of hemodynamic stability, acute normovolemic hemodilution was performed using a sterile closed-circuit system via a right internal jugular large-bore catheter. A total of 500 mL of whole blood (approximately 12% of estimated total blood volume) was withdrawn gradually with simultaneous colloid infusion to maintain normovolemia, and autologous blood was reinfused after surgical hemostasis. Surgery lasted 4 hours with an estimated blood loss of 1,000 mL. Intraoperative management included balanced general anesthesia, antifibrinolytic therapy, strict hemodynamic control, active warming, and reinfusion of autologous blood after surgical hemostasis. Hemodynamics and oxygenation remained stable throughout. Postoperative hemoglobin was 8.4 g/dL, and the patient remained hemodynamically stable without vasopressor support, with an uncomplicated clinical course.

ANH reduces red blood cell loss while preserving oxygen delivery through physiologic compensatory mechanisms. In patients with cardiovascular risk factors, conservative hemodilution targets are recommended. This case highlighting the importance of meticulous anesthetic planning, a conservative and reproducible ANH protocol, objective outcome reporting, explicit adverse-event monitoring, and formal ischemia severity classification to define urgency and perioperative risk.

Acute normovolemic hemodilution can be a feasible and safe blood conservation strategy in selected Jehovah’s Witness patients undergoing high-risk surgery, provided it is carefully planned, performed using a closed-circuit system, and supported by meticulous anesthetic management and close perioperative monitoring.

Keywords: Acute normovolemic hemodilution; blood conservation; Jehovah’s Witness; acute limb ischemia; anesthesia; case report.

Citation: Firdaus AF, Sudjud RW, Rismawan B. Acute normovolemic hemodilution as a blood conservation strategy in a Jehovah’s Witness undergoing above-knee amputation: a case report. Anaesth. pain intensive care 2026;30(3):395-399. DOI: 10.35975/apic.v30i3.3184

Received: January 10, 2026; Revised: January 15, 2026; Accepted: January 27, 2026

Pioneering experience with awake craniotomy in a resource constrained environment

Sheema Siraj — Mon, 04 May 2026 00:00:00 -0600

Awake craniotomy (AC) enables maximal tumor resection near eloquent cortex, but its implementation in resource-limited settings presents distinct anesthetic challenges. We describe the establishment of an AC program in a low-resource neurosurgical center, emphasizing constraints related to team inexperience, limited patient literacy, absence of neuronavigation and cortical mapping, and restricted availability of short-acting anesthetic agents. Adaptive strategies included multidisciplinary training, simplified patient education materials, use of dexmedetomidine and ropivacaine for conscious sedation and scalp block, continuous intraoperative communication to compensate for lack of neurophysiologic monitoring, and dose conversions compatible with older infusion pumps. Despite these limitations, five ACs were successfully completed with stable sedation, adequate analgesia, and favorable patient cooperation. This article provides practical insights for anesthesiologists working in similar environments to help ensure successful and safe awake craniotomy practices in resource-constrained settings.

Keywords: Awake craniotomy; Neuronavigation; Neurosurgical center

Citation: Siraj S. Pioneering experience with awake craniotomy in a resource constrained environment. Anaesth. pain intensive care 2026;30(3):400-401. DOI: 10.35975/apic.v30i3.3185

Received: November 20, 2025; Revised: January 28, 2026; Accepted: January 31, 2026

Paracervical block with lignocaine: an underutilized adjunct to enhanced recovery in laparoscopic hysterectomy and myomectomy

Sampath Gnanarathne, Ashani Ratnayake, U.A. Isurindi — Mon, 04 May 2026 00:00:00 -0600

Enhanced Recovery After Surgery (ERAS) protocols are increasingly adopted in all types of surgeries including laparoscopic gynaecological procedures. They are particularly effective in reducing surgical stress, opioid consumption, and hospitalization duration. However, perioperative pelvic and referred back pain remain a significant barrier to early ambulation and discharge. This perspective highlights the potential value of reintroducing paracervical block (PCB) with lignocaine as an underutilized, simple, and effective analgesic technique that complements ERAS goals. Drawing from our institutional experience, PCB has demonstrated a reduction in opioid use, faster mobilization, and improved patient satisfaction with minimal risk. This perspective calls for wider adoption, systematic evaluation, and integration of PCB in laparoscopic gynaecological surgery. Observed benefits were confined to laparoscopic hysterectomy and myomectomy, particularly procedures involving uterine manipulation and colpotomy.

Keywords: Paracervical block; Lignocaine; Enhanced Recovery After Surgery; ERAS; Laparoscopy; Gynaecological surgery; Opioid-sparing analgesia

Citation: Gnanarathne S, Ratnayake A, Isurindi UA. Paracervical block with lignocaine: an underutilized adjunct to enhanced recovery in laparoscopic hysterectomy and myomectomy. Anaesth. pain intensive care 2026;30(3):402-404. DOI: 10.35975/apic.v30i3.3186

Received: January 29, 2026; Accepted: March 06, 2026