Thai Journal of Anesthesiology

Intraoperative Hypotension in Non-cardiac Surgery: a Comprehensive Review of Contemporary Evidence and Management Strategies

2026-08-30T22:32:38+07:00

Background: Intraoperative hypotension (IOH) is a frequent and critical modifiable risk factor in patients undergoing non-cardiac surgery, exhibiting strong correlations with postoperative organ dysfunction and increased mortality. This comprehensive review synthesizes contemporary evidence regarding the definitions, pathophysio-logical mechanisms, risk factors, and proactive management strategies for IOH. Methods: A comprehensive literature review was conducted, analyzing pivotal clinical trials, systematic reviews, and international guidelines published up to 2026 (including ESAIC 2025, ACC/AHA 2024, and AAGBI/BIHS 2026) focusing on hemodynamic management in non-cardiac surgical populations. Results: The definition of IOH remains heterogeneous, although recent 2025 ESAIC guidelines recommend an absolute intraoperative mean arterial pressure (MAP) threshold of 60-65 mmHg to protect organ perfusion. Despite growing interest in individualized blood pressure targets, recent randomized controlled trials (such as PRETREAT and IMPROVE-multi) and meta-analyses demonstrate that strict individualization or higher MAP targets do not significantly improve long-term functional outcomes or reduce postoperative complications compared to standard targets (≥ 60-65 mmHg). In medication management, recent trial data (POISE-3, SPACE, STOP-OR-NOT) support the 2026 AAGBI/BIHS recommendations to continue ACEIs/ARBs on the day of surgery to mitigate postoperative hypertension without increasing severe complications. For intraoperative monitoring and intervention, goal-directed fluid therapy utilizing dynamic indices (SVV/PPV) and the implementation of AI-driven predictive analytics, such as the Hypotension Prediction Index, offer advanced frameworks to proactively detect and manage impending hypotensive episodes before organ injury occurs. Furthermore, the newly emerged concept of “Protective Hemodynamics” via the 5-step C.L.E.A.R. pathway provides a structured approach to multi-organ preservation. Conclusion: Effective management of IOH requires a paradigm shift from reactive treatment to proactive prevention. Maintaining a target MAP ≥ 60-65 mmHg, optimizing anesthetic techniques, implementing dynamic fluid protocols, and integrating AI predictive software constitute the core pillars to minimize adverse perioperative outcomes in non-cardiac surgery.

Exploring the Potential of Methadone in Postoperative Pain Management: a Comprehensive Review of Efficacy, Safety, and Dosing Strategies

2026-08-30T22:36:43+07:00

Postoperative pain management is crucial for ensuring patient comfort, promoting recovery, and preventing complications such as delayed mobilization and hospital readmission. While opioids are the standard of care for severe postoperative pain, issues such as opioid tolerance, hyperalgesia, and adverse effects like sedation and respiratory depression complicate their use. Methadone, a synthetic opioid with NMDA receptor antagonism properties, has emerged as a promising alternative due to its long elimination half-life and multi-target effects. This review evaluates the current evidence supporting methadone use in intraoperative analgesia and its subsequent impact on postoperative pain relief. We highlight the pharmacodynamics, clinical efficacy, dosing strategies, safety profile, and comparison with traditional opioids. Methadone offers sustained analgesia, reduces opioid consumption, and shows potential for opioid-sparing strategies. However, its use requires careful monitoring due to risks such as respiratory depression and arrhythmias, especially in certain populations, such as the elderly or obese. The variability in individual response due to genetic factors, such as polymorphisms in the CYP2B6 gene, must also be considered. Continued research is needed to optimize dosing protocols and fully establish methadone’s role in postoperative pain management.

Comprehensive Human Resource Management in Anesthesia Departments: Current Practices, Challenges, and Future Directions

2026-08-30T22:44:01+07:00

Human resource management is a critical yet often determinant of performance, safety, and sustainability in anesthesia departments. Modern anesthesia services operate within increasingly complex clinical and organizational environments, characterized by rising surgical volumes, higher patient acuity, expanding safety and regulatory requirements, and growing administrative demands. In parallel, anesthesia departments worldwide face persistent workforce challenges, including staff shortages, maldis-tribution, burnout, and limitations in data and training systems. This narrative review provides a comprehensive overview of human resource management in anesthesia departments, encompassing both clinical and non-clinical personnel. It synthesizes current practices related to recruitment, staffing models, workforce allocation, scheduling, education and training, data management, quality control, and operational support systems. Particular attention is given to the roles of coordinators, administrators, data and logistics personnel, and quality officers, whose contributions are essential to efficient service delivery but are frequently overlooked in workforce planning. The review also identifies key challenges affecting anesthesia human resources, including workforce shortages, workload intensity, fragmented information systems, educational gaps, and increasing quality and regulatory pressures. Building on these findings, future-oriented strategies for the next 5-10 years are discussed, emphasizing strategic workforce planning, digital and data-driven human resource management, career pathway development, role diversification, and staff well-being.

Sugammadex Uncovered: Balancing Clinical Efficacy, Safety and Cost

2026-08-30T22:18:00+07:00

Sugammadex is a selective relaxant binding agent that has fundamentally changed the reversal of neuromuscular blockade produced by the aminosteroidal neuro- muscular blocking agents rocuronium and vecuronium. Unlike acetylcholinesterase inhibitors, sugammadex acts by encapsulating free molecules of these neuromuscular blocking agents in plasma, thereby reducing their availability at the neuromuscular junction and promoting diffusion of the drug away from the effect site. This unique mechanism allows rapid, predictable, and effective reversal of shallow, moderate, and deep neuromuscular blockade. Sugammadex has important practical applications in routine anesthesia, rapid-sequence induction, ambulatory surgery, patients at increased risk of postoperative pulmonary complications, and situations in which rapid restoration of neuromuscular function is desirable. Its major advantages include faster recovery compared with neostigmine, reliable reversal of deep blockade, absence of muscarinic adverse effects requiring anticholinergic coadministration, and potentially improved operating room efficiency and postoperative recovery. However, sugammadex is not without limitations. Important concerns include its relatively high acquisition cost, risk of residual neuromuscular blockade when underdosed, hypersensitivity and anaphylaxis, marked bradycardia or cardiac arrest in rare cases, recurrence of blockade after administration of an insufficient dose, and interactions with hormonal contraceptives. Dosing should therefore be guided whenever possible by quantitative neuromuscular monitoring rather than by elapsed time or clinical signs alone. Cost-effectiveness remains context dependent. Although the drug is substantially more expensive than neostigmine on a per-dose basis, its economic value may improve when reductions in recovery time, operating room occupancy, postoperative respiratory complications, and unplanned escalation of care are considered.

Efficacy of Benzydamine Hydrochloride in Reducing Postoperative Sore Throat after General Anesthesia with Endotracheal Tube: a Randomized Controlled Trial

2026-08-30T22:22:35+07:00

Background: Postoperative sore throat (POST) is a common complication following general anesthesia with endotracheal intubation and adversely affects patient satisfaction. Benzydamine hydrochloride (BH), a topical nonsteroidal anti-inflammatory drug, has been proposed to prevent POST; however, evidence regarding its efficacy and optimal application remains inconsistent. This study is to evaluate the efficacy of benzydamine hydrochloride spray applied to the endotracheal tube (ETT) cuff alone or in combination with oropharyngeal administration in reducing postoperative sore throat. Methods: This randomized, double-blind, controlled trial enrolled adult patients undergoing elective surgery under general anesthesia with endotracheal intubation. Participants were randomized into three groups: group A received BH spray applied to both the ETT cuff and the oropharynx; group B received BH spray applied to the ETT cuff and placebo spray applied to the oropharynx; and group C received placebo spray applied to both sites. Endotracheal tube cuff pressure was maintained below 25 cmH2O. The incidence and severity of POST and hoarseness were assessed at 1, 6, and 24 h postoperatively. Results: A total of 156 patients completed the study. The overall incidence of POST was 46.2%, with no significant differences among group A (48.1%), group B (50.0%), and group C (40.0%). POST severity scores were low and comparable among groups at all time points. No significant differences were observed in hoarseness, other throat-related symptoms, or adverse effects. Conclusion: Under appropriate ETT size selection and strict cuff pressure control, 0.3% benzydamine hydrochloride spray did not reduce the incidence or severity of postoperative sore throat.

Effects of Head and Neck Rotation on Internal Carotid Artery Blood Flow Velocity in Infants Undergoing General Anesthesia: assessment by Transfontanelle Ultrasonography

2026-08-30T22:26:42+07:00

Introduction: Head and neck position can alter cerebral blood flow in infants. While cerebral perfusion is vital, intraoperative monitoring of cerebral blood flow velocity (CBFV) during head tilt has not been previously studied. Understanding this impact is crucial for optimizing infant head positioning during anesthesia. This study is to evaluate the effect of head and neck rotation at 30 and 45 degrees from neutral on internal carotid artery CBFV using transfontanelle doppler ultrasonography, and to assess its association with intraoperative blood pressure in infants undergoing elective surgery. Methods: This quasi-experimental study included 18 infants aged 1-3 months undergoing elective surgery under general anesthesia. Transfontanelle ultrasonography measured CBFV at head and neck positions of 0, 30, and 45 degrees. Results: Significant reductions in peak systolic flow velocity (PSFV), end diastolic flow velocity (EDFV), and mean flow velocity (MFV) were observed when tilting the head and neck from 0 to 30 degrees (PSFV P<0.001; EDFV P=0.004; MFV P=0.015) and from 0 to 45 degrees (PSFV P<0.001; EDFV P<0.001; MFV P=0.003). Tilting from 30 to 45 degrees also significantly decreased PSFV (P<0.001) and MFV (P=0.015), though EDFV did not significantly change (P=0.092). Conclusion: Head and neck tilt at 30 and 45 degrees significantly reduced cerebral blood flow velocity in infants.