The coronavirus disease 2019 (COVID-19) pandemic is currently recognized as a global health crisis. This viral infection is frequently associated with hypercoagulability, with a high incidence of thromboembolic complications that can be fatal. In many situations, the standard coagulation tests (SCT) fail to detect this state of hypercoagulability in patients with COVID-19 since clotting times are either not or only mildly affected. The role of viscoelastic tests such as rotational thromboelastometry (ROTEM®) during this pandemic is explored in this review. COVID-19-associated coagulopathy, as measured using the rotational thromboelastometry parameters, can vary from hypercoagulability due to increased fibrin polymerization and decreased fibrinolysis to bleeding from hypocoagulability. The use of a multimodal diagnostic and monitoring approach, including both rotational thromboelastometry and SCT, such as plasma fibrinogen and D-dimer concentrations, is recommended. Rotational thromboelastometry provides comprehensive information about the full coagulation status of each patient and detects individual variations. Since COVID-19-associated coagulopathy is a very dynamic process, the phenotype can change during the course of infection and in response to anticoagulation therapy. Data from published literature provide evidence that the combination of rotational thromboelastometry and SCT analysis is helpful in detecting hemostasis issues, guiding anticoagulant therapy, and improving outcomes in COVID-19 patients. However, more research is needed to develop evidence-based guidelines and protocols.

Inhaled sedation was recently approved in Europe as an alternative to intravenous sedative drugs for intensive care unit (ICU) sedation. The aim of this narrative review was to summarize the available data from the literature published between 2005 and 2023 in terms of the efficacy, safety, and potential clinical benefits of inhaled sedation for ICU mechanically ventilated patients. The results indicated that inhaled sedation reduces the time to extubation and weaning from mechanical ventilation and reduces opioid and muscle relaxant consumption, thereby possibly enhancing recovery. Several researchers have reported its potential cardio-protective, anti-inflammatory or bronchodilator properties, alongside its minimal metabolism by the liver and kidney. The reflection devices used with inhaled sedation may increase the instrumental dead space volume and could lead to hypercapnia if the ventilator settings are not optimal and the end tidal carbon dioxide is not monitored. The risk of air pollution can be prevented by the adequate scavenging of the expired gases. Minimizing atmospheric pollution can be achieved through the judicious use of the inhalation sedation for selected groups of ICU patients, where the benefits are maximized compared to intravenous sedation. Very rarely, inhaled sedation can induce malignant hyperthermia, which prompts urgent diagnosis and treatment by the ICU staff. Overall, there is growing evidence to support the benefits of inhaled sedation as an alternative for intravenous sedation in ICU mechanically ventilated patients. The indication and management of any side effects should be clearly set and protocolized by each ICU. More randomized controlled trials (RCTs) are still required to investigate whether inhaled sedation should be prioritized over the current practice of intravenous sedation.

Liver transplantation is a complex surgical procedure in which various forms of coagulation dysfunction can occur, including perioperative hypercoagulability. The hemostasis balance in liver graft recipients with end-stage liver disease can shift to thrombosis or haemorrhage, depending on the associated risk factors and clinical conditions. Hypercoagulability can result in serious complications such as thromboembolism, which can affect the vessels of the newly transplanted liver graft. Standard coagulation tests (SCTs), such as prothrombin time and activated partial thromboplastin time (aPTT), have a poor ability to diagnose and monitor an early stage of hypercoagulability. Recent studies demonstrated that viscoelastic hemostatic elastic tests (VETs), such as rotational thromboelastometry (ROTEM) and thromboelastography (TEG), are promising alternative tools for diagnosing hypercoagulability disorders. VETs measure clotting and clot formation time, clot strength (maximum clot firmness), fibrin and platelet contribution to clot firmness, and fibrinolysis, which makes them more sensitive in identifying liver graft recipients at risk for thrombosis as compared with SCTs. However, developing evidence-based guidelines for the prophylaxis and treatment of hypercoagulability based on VET results is still needed.

Background & objective: Little is known about Malignant Hyperthermia (MH); as serious hypermetabolic response to anesthetic-related agents regarding its existence inside Saudi Arabia (KSA). Few MH incidents have been reported in periodic medical journals. To our knowledge, this nineteen-questionnaire survey is the first to be performed in KSA regarding MH. The main objective was to report suspected MH patients and the secondary objectives were to assess the availability of dantrolene vials, the management and outcome of the suspected patients. Methodology: Google Forms were sent to the anesthesiologists working in Ministry of Health hospitals at three geographical districts in KSA (Eastern Province, Riyadh, and Western Province) through anesthesiologists’ social platforms. The electronic link was accessible from October 10, 2022, to April 02, 2024. Results: Most of the 174 anesthesiologists, who replied, were consultants (65.5%), and 70.7% had more than 10 years of experience. 32 (18.4%) anesthesiologists reported having dealt with suspected MH patients during their careers, of which 21 were inside KSA hospitals. Anesthesiologists reporting having six or more vials of dantrolene were 113/174 (64.9%), whereas 23 (13.2%) reported having 3 to 6 vials and 13 (7.5%) 1 to 3 vials. Only 25 (14.4%) reported no vials. Of the anesthesiologists, 66 (37.9%) were aware of the locations of dantrolene in their city. According to 51.7% of respondents, 120 mg of dantrolene may be prepared in 30 min. Conclusion: Our survey sheds light on susceptible MH cases in Saudi Arabia that remain unpublished or inadequately reported. Establishing a dedicated MH management and database center is a pressing need. The current low number of reported MH cases should not be used as a justification to delay such an initiative, particularly given the absence of accurate statistics. Moreover, the study demonstrates variability in hospital preparedness for MH emergencies, which needs to be addressed urgently. Hospitals with inadequate monitoring systems or insufficient dantrolene supplies need to meet the required standards for optimal patient safety. Keywords: Anesthesia; Dantrolene; Malignant Hyperthermia; Perioperative Complications Citation: Yassen KA, Al Herz PM, Alnami MS, ALmana AA, Osama AMK, Dur I Shahwar, AlSubaie RS, Saleh S, Khan I. Query malignant hyperthermia patients in Saudi Arabia; A questionnaire-based mini-survey. Anaesth. pain intensive care 2025;29(5):328-337. DOI: 10.35975/apic.v29i5.2637 Received: December 27, 2024; Revised: January 23, 2025; Accepted: May 17, 2025