Background: With the rising prevalence of obesity, anesthesiologists are expected to increasingly encounter patients with obesity, which poses challenges for anesthetic management. The use of remimazolam, an intravenous anesthetic agent approved in 2020, may be beneficial in these patients. However, its use in patients with super-super obesity remains underexplored. Case Description: A 55-year-old woman with a body mass index (BMI) of 60.6 kg/m² and moderate obstructive sleep apnea (OSA) underwent laparoscopic sleeve gastrectomy under general anesthesia. The transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) technique was used along with the administration of remimazolam at a rate of 6 mg/kg/h based on the total body weight. The patient was sedated within 125 s without any signs of hemodynamic instability, and the surgery was completed successfully. Conclusions: This case study demonstrates the potential effectiveness of remimazolam infusion for inducing general anesthesia in patients with super-super obesity. The infusion rate, derived from the total body weight, yielded an outcome comparable with that observed in individuals without obesity. Further studies with larger cohorts are required to confirm these findings.

Background: Births at advanced maternal ages (≥ 35 years) are increasing. This has been associated with a higher incidence of placenta previa, which increases bleeding risk. Hybrid operating rooms, designed to accommodate interventions and cesarean sections, are becoming more prominent because of their dual capabilities and benefits. However, they have been associated with increased postoperative hypothermia in pediatric settings; moreover, this has not been studied in pregnant women with placenta previa. Methods: This retrospective cohort study included pregnant women diagnosed with placenta previa who underwent elective cesarean section under general anesthesia between May 2019 and 2023. The patients were categorized according to the operating room type. The primary outcome was to determine whether the hybrid operating room is a risk factor for immediate postoperative hypothermia, defined as a tympanic membrane temperature below 36.0°C. The secondary outcomes were the effects of immediate postoperative hypothermia on the durations of postanesthetic care unit and postoperative hospital stays and incidence of complications. Results: Immediate postoperative hypothermia (tympanic membrane temperature < 36.0°C) was more prevalent in the hybrid than in the standard operating room group (20% vs. 36.6%, p = 0.033), with a relative risk of 2.86 (95% confidence interval 1.24–6.64, p < 0.001). Patients undergoing surgery in the hybrid operating room who experienced immediate postoperative hypothermia stayed longer in the postanesthetic care unit (26 min vs. 40 min, p < 0.001) and in the hospital after surgery (4 days; range 3–5 vs. 4 days; range 4–11, p = 0.021). However, the complication rates of both groups were not significantly different (11.3% vs 7.3%, p = 0.743). Conclusion: Hybrid operating rooms may increase the risk of postoperative hypothermia. Postoperative hypothermia is associated with prolonged postanesthetic care unit and hospital stays. Preventing hypothermia in patients in hybrid operating rooms is of utmost importance.

Rationale: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is used in tracheostomy but not in cases of airway obstruction. This case report explores the use of THRIVE for managing airway obstruction during tracheostomy in patients with subglottic and tracheal stenosis, thereby addressing the current knowledge gap and exploring its potential for airway management. Patient concerns: A 63-year-old female with subglottic and tracheal stenoses underwent tracheostomy. Multiple attempts to establish a patent airway were unsuccessful, and oxygen saturation dropped to 56%. Diagnosis: Endotracheal tube was directed toward the tracheal wall, causing airway obstruction. Interventions: THRIVE was administered to the patient. Subsequently, the tube position was adjusted to enhance ventilation. Outcomes: The patient’s oxygen saturation increased to 99%. The postoperative complications, including subcutaneous emphysema, pneumothorax, pneumomediastinum and pneumopericardium, resolved. The patient was discharged on postoperative day 9. Lessons: THRIVE could be considered a temporary measure to enhance oxygenation before initiating a definitive treatment strategy.

Aortic dissection in pregnant patients results in an inpatient mortality rate of 8.6%. Owing to the pronounced mortality rate and speed at which aortic dissections progress, efficient early detection methods are crucial. Here, we highlight the importance of early chest computed tomography (CT) for differentiating aortic dissection from pulmonary embolism in pregnant patients with dyspnea. We present the unique case of a 38-year-old pregnant woman with elevated D-dimer and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, initially suspected of having a pulmonary embolism. Initial transthoracic echocardiography did not indicate aortic dissection. Surprisingly, after an emergency cesarean section, a chest CT scan revealed a DeBakey type I aortic dissection, indicating a diagnostic error. Our findings emphasize the need for early chest CT in pregnant patients with dyspnea and elevated D-dimer and NT-proBNP levels. This case report highlights the critical importance of considering both aortic dissection and pulmonary embolism in the differential diagnosis of such cases, which will inform future clinical practice.

Background and Objectives: Deep brain stimulation (DBS) requires sedation strategies that enable rapid and reliable awakening during intraoperative electrophysiological testing. Although propofol and dexmedetomidine are commonly used, their lack of pharmacological antagonists might delay recovery. In this retrospective case series, we assessed the effects of using remimazolam, a short-acting benzodiazepine that is reversible with flumazenil. No existing research has determined whether this may represent a clinically advantageous alternative. Materials and Methods: Six patients who underwent DBS surgery with monitored anesthetic care between May and August 2024 were included. Two patients received dexmedetomidine and propofol combined, whereas four received remimazolam for initial sedation. The time from sedation discontinuation to intraoperative electrophysiological examination, postoperative hospital stays, and perioperative complications were evaluated. Results: Patients who received remimazolam had shorter awakening intervals (median 17 min) compared to those who received dexmedetomidine and propofol (median 50 min), with a large effect size difference (Cliff’s delta −1.00). In all cases of remimazolam, patients were administered flumazenil to facilitate awakening, and transient hypertension requiring nicardipine was observed in some patients. Among the patients who underwent unilateral DBS, those who received remimazolam had shorter postoperative hospital stays (5–7 days) than the patient who received dexmedetomidine and propofol (9 days). No patient had complications. Conclusions: This small retrospective case series indicated that remimazolam, when reversed with flumazenil, was associated with rapid awakening compared with dexmedetomidine and propofol in patients undergoing DBS surgery. However, these findings require validation in larger prospective studies due to the small sample size.

Background/Objectives: Severe aortic stenosis (AS) poses major anesthetic challenges because cardiac output is highly dependent on preload and heart rate, and abrupt afterload reduction or tachycardia may precipitate ischemia and cardiovascular collapse. Coexisting myelodysplastic syndrome (MDS) with severe thrombocytopenia further increases the perioperative bleeding risk, which we considered particularly important in the anesthetic planning for this patient. We report a case of laparoscopic anterior resection in a patient with severe AS and thrombocytopenia, highlighting a transfusion strategy adjusted according to the patient’s response and remimazolam-based anesthesia. To the best of our knowledge, there have been no previous reports describing remimazolam-based total intravenous anesthesia achieving stable hemodynamics without vasopressor support in a patient with severe AS and MDS–related thrombocytopenia. Method: A 78-year-old man with previously diagnosed MDS and chronic pancytopenia, whose baseline platelet counts (PLTs) ranged from 20,000 to 40,000/μL, was found to have severe AS (aortic valve area, 0.73 cm²; mean pressure gradient, 42 mmHg) during preoperative evaluation for laparoscopic anterior resection. After platelet transfusions titrated to his response, the patient’s PLT increased to 93,000/μL before surgery. Anesthesia was induced and maintained with remimazolam and remifentanil, which were chosen to prevent afterload reduction associated with propofol. Results: Hemodynamics, including arterial pressure, cardiac index, systemic vascular resistance index, and cerebral oxygen saturation, remained stable without vasopressor support. Transient systolic hypertension during surgical stimulation was controlled using remifentanil titration and esmolol. Recovery and the postoperative course were uneventful, and the patient was discharged in a stable condition. Conclusions: Remimazolam-based total intravenous anesthesia can provide hemodynamic stability without vasopressors in high-risk patients with severe AS, and a transfusion strategy adjusted step by step according to the patient’s response can be effective for optimizing PLTs while minimizing the transfusion-related risks of MDS-associated thrombocytopenia.