The perioperative period induces unpredictable and significant alterations in coronary plaque characteristics which may culminate as adverse cardiovascular events in background of a compromised myocardial oxygen supply and demand balance. This “ischemic-imbalance” provides a substrate for perioperative cardiac adversities which incur a considerable morbidity and mortality. The propensity of myocardial injury is dictated by the conglomeration of various factors like pre-existing medical condition, high-risk surgical interventions, intraoperative hemodynamic management, and the postoperative care. Perioperative myocardial infarction (PMI) differs from myocardial infarction (MI) in a non-operative setting. PMI can often be notoriously ̶silent” demonstrating a conspicuous absence of the classic clinical symptoms. Moreover, myocardial injury following non-cardiac surgery (MINS) characterized by an elevation of the cardiac insult biomarkers has demonstrated an independent prognostic significance in the perioperative scenario despite the lack of a formal categorization as PMI. This has evoked interest in the meticulous characterization of MINS as a discrete clinical entity. Multifactorial etiology, varying symptomatology, close differential diagnosis, and a debatable management regime makes perioperative myocardial injury-infarction, a subject of detailed discussion.

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In recent anesthetic practice, peripheral nerve blocks (PNBs) are used extensively for surgical anesthesia and nonsurgical analgesia. PNBs offer many benefits over other anesthetic techniques in a certain population of patients, and in some specific clinical setting, that may contribute to faster and safer pain relief, increased patient satisfaction, reduced hospital stay, and decreased overall healthcare cost. The technique involves the injection of the anesthetic in the vicinity of a specific nerve or bundle of nerves to block the sensation of pain transmitting to a specific portion of the body. However, the length of analgesia when a single anesthetic is used for PNB may not last long. Therefore, the practice of adding an additional agent called adjuvant has been evolved to prolong the analgesic effect. There are many such adjuvants available that are clinically being used for this purpose imparting great efficacy and safety to the anesthetic process. The adjuvants molecules are generally classified as opioids, alpha-2 agonist, steroids, etc. Most of them are safe to use and show little or no adverse event related to neurotoxicity and tissue damage. Although there is extensive use of such adjuvants in the clinical field, none of the molecules is approved by the FDA and is used as an off-label drug. The risk to benefit ratio must be assessed while using such an agent. This review will try to delineate the basic need of adjuvant in peripheral nerve block and will discuss the advantages and limitations of using different adjuvants and will discuss the future prospect of such application.

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Post-operative knee pain management has become a challenge to provide early relief and pain-free postoperative care to the patient. The major objectives of post-operative analgesic treatment are to reduce opioid requirements, post-operative pain, and adverse events related to opioid intake. This narrative review aimed to document post-operative analgesia techniques after total knee arthroplasty (TKA). The traditional approach involved high-dose opioid-based regimen, though opioid is considered strong analgesic, but are associated with a number of unwanted side effects to seek for alternative techniques. The role of sciatic nerve block in TKA pain is doubtful. Femoral Nerve Block (FNB) is still considered as the gold standard; however, FNB is associated with quadriceps weakness and risk of fall and sciatic block with foot drop. To overcome these drawback more distal nerve block techniques has evolved, namely saphenous nerve block in adductor canal, selective tibial which are claimed to provide comparable analgesia to that of femoral and sciatic nerve block. The combination of pre-emptive and multi-modal analgesia and technically well-delivered regional nerve blocks and postoperative physical therapy are an essential component which not only minimize the side effects of traditional opioid-based analgesia but also speed up functional recovery, increases patient satisfaction, and reduces the overall length of hospitalization and cost.

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An 80-year-old male patient presented with 2 weeks history of low back pain undergoing posterior spinal fusion with laminectomy in the prone position. The patient was induced with fentanyl, propofol, and rocuronium, and then he was positioned in the prone position. After 6 h of starting the surgery, the patient started to be hypotension and bradycardia followed by pulseless electrical activity (PEA). Code blue was activated intraoperatively with immediate initiation of cardiopulmonary resuscitation (CPR) in the prone position and multiple epinephrine boluses. Fortunately, the patient had return of spontaneous circulation. After stabilization, he was taken for computed tomography scan which showed massive pulmonary embolization and management was continued in the intensive care unit. CPR in the prone position has shown to be effective for return of spontaneous circulation after PEA.

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Background: The aim of this study is to understand the effect of ultrasound (US) guided erector spinae plane block (ESPB) in improving the intraoperative and postoperative analgesia in patients undergoing mastectomies, decreasing the use of opioids and in reducing postoperative nausea and vomiting. Methods: After local ethics committee approval, 100 patients were divided randomly into two groups. Group A with 50 patients received US guided ESPB with 30 ml of 0.25% of bupivacaine under US guidance. Group B with 50 patients received no block. Visual analogue scale (VAS) was used to assess pain postoperatively. All patients received 1 g intravenous intravenous paracetamol 8th hourly and morphine was used as rescue analgesia if VAS score is more than 4. Patients were monitored for VAS scores, postoperative nausea/ vomiting and total morphine consumption for a 24-hour period in a high dependency unit. Results: Postoperative morphine consumption was found to be significantly less in patients who received US-guided ESPB compared to control group (0.12 mg ± 0.59 mg in ESPB group compared to 1.70 ± 2.29 mg which was statistically significant, p =0.000). Only 3 patients in ESP group received rescue analgesia in the form of morphine whereas 22 patients in the control group received morphine. There was no difference in PONV score in either groups. There were no complications like vascular puncture, pneumothorax, or respiratory depression in both groups. Conclusion: US guided ESPB is quite effective in reducing perioperative pain in patients undergoing mastectomy. The trial was registered prospectively with CTRI with registration number: CTRI/2018/09/015668.

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Background: Anesthesia trainee may initially take longer time to intubate and unintentionally place the endotracheal tube (ETT) in the esophagus. The present study determined if ultrasound is the fastest method of confirmation of correct placement of ETT compared to capnography, and chest auscultation in trainees. Methods: First year anesthesia residents performed intubation in 120 patients recruited after ethical clearance and informed consent. Time to visualize flutter in trachea, double trachea sign, time to appearance of first and sixth capnography, and time to execute chest auscultation was noted. Results: Ultrasonography was statistically fastest method to determine endotracheal intubation (36.50 ± 15.14 seconds) vs unilateral chest auscultation (50.29 ± 15.50 seconds) vs bilateral chest auscultation (51.90 ± 15.98 seconds) vs capnography first waveform (53.57 ± 15.97 seconds) vs capnography sixth waveform (61.67 ± 15.88 seconds). Conclusion: When teaching endotracheal intubation to novice anesthesia residents using conventional direct laryngoscopy, ultrasonography is the fastest method to confirm correct ETT placement compared to capnograph and chest auscultation. Mentor can guide trainee to direct ETT towards trachea and can promptly detect esophageal intubation by double trachea sign.

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Neoteric studies have called attention to the prominence of management in healthcare sectors. Positive relationship have been noticed between performance management, clinical performance, and clinical outcome. However, there is still debate related to which managers have to lead healthcare organizations, and what kind of management should be followed, we are now about to analyze. Systematic review of the literature is a starting point to present and discuss the current of information concerning with how management can affect the quality and perpetuity of health systems. Through in-depth analysis of 27 studies, we concluded that the performance of healthcare systems and organizations positively consistent with leadership, management practices, manager characteristics, and cultural features that are related to values and administrative approaches. There was also testimony that doctors who lead healthcare organizations show excellence in performance better than others. Finally, this review acting as roadmap which indicating how do the relationship between the management and performance of healthcare systems, and organizations can be furtherly investigated.

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Objective: Postoperative nausea and vomiting (PONV) is a daily phenomenon, to which less attention has been paid in a variety of surgeries. Despite the individual studies, there is no comprehensive study on the prevalence of PONV. The aim of this study was to determine the global prevalence of PONV. Materials and Methods: In this systematic and meta-analysis study, descriptive studies of four databases (PubMed, Web of Science, Scopus, and Google Scholar) were searched for relevant texts from the time they were created until 31 December 2018. The random effects model was used for meta-analysis of studies included. All the steps were carried out by two individuals. Hoy et al.'s tool was used to evaluate its risk bias. Results: A total of 23 studies that were performed on 22,683 people from 11 countries were entered into the final phase. The prevalence of PONV, nausea, and vomiting was 27.7%, 31.4%, and 16.8%, respectively. The prevalence of PONV was higher during the first 24 h in European countries. Conclusion: Considering the high prevalence of PONV and our goal to better control it, it is necessary to use high cost-effective approaches and recommendations and to educate health caregivers and patients.

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Background and Aims: This study aims to trans oesophageal echo cardiographically (TOE) measure inferior venacava diameter (IVCD) during inspiration and expiration in poor left ventricular ejection fraction (LVEF) patients undergoing cytoreductive oncosurgery, to ascertain if any correlation exists between, caval index (DeltaIVCD), and stroke volume variation (SVV), and to compare DeltaIVCD-guided versus SVV-guided fluid therapy. Methods: In this prospective, parallel group, interventional study, seventy American Society of Anesthesiologists-III patients, aged 30-75 years, weighing 40-90 kg, with LVEF ≤40% undergoing cytoreductive surgery were included and randomised to group-D (DeltaIVCD-guided fluid therapy) and group-S (SVV-guided fluid therapy). Patients with oesophageal lesions were excluded. After standard endotracheal anaesthesia, arterial and internal jugular vein catheters were placed. A TOE probe was inserted in the interventional group-D. Quantification of IVCD respiratory variations was done. Heart rate (HR), arterial oxygen saturation (SPO₂), mean arterial pressure, end tidal carbondioxide (EtCO₂), central venous pressure, SVV, IVCD, and urine output (UO) were recorded every 30 min. Post-operative arterial blood gas analysis, lung-ultrasound, chest-radiograph, and serum creatinine were done. Statistical Analysis: Pearson's correlation coefficient as measure of strength of linear relationship, calculation of regression equation, and unpaired t-test for normally distributed continuous variables were used. Results: A positive correlation between DeltaIVCD and SVV (r = 0.751) was observed. A regression equation was obtained for SVV (SVV = [0.317 × DeltaIVCD] + 5.877). Serum lactate, estimated glomerular filtration rate, HR, and UO were within normal limits in group-D. There was no pulmonary oedema. Conclusion: DeltaIVCD-guided intravenous fluid therapy is valuable in low LVEF patients where tight fluid control is essential and any fluid overload may precipitate cardiac failure.

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Background: Total knee arthroplasty is associated with intense pain postoperatively. Thus, adequate pain relief is essential in the immediate postoperative period to enable ambulation, initiation of physiotherapy, and prevention of postoperative complications. The objective of this study was to compare the effectiveness and early outcomes of adductor canal blockade (ACB) and continuous epidural analgesia (CEA) in patients who underwent a unilateral total knee replacement (TKR). Materials and Methods: This is a retrospective cohort study that was conducted in Riyadh with 80 patients receiving a unilateral total knee arthroplasty from August 2017 to July 2018. Forty patients received ACB, and 40 received CEA exclusively. The primary outcomes measured were the degree of knee flexion and extension in physiotherapy sessions on postoperative day 1 and discharge, how soon patients walked after surgery, length of hospital stay (LOS), local anesthetic and total opioid consumption, postoperative blood drainage output, incidence of nausea and vomiting, and pain scores. Results: Significantly more patients receiving ACB could flex their knee in the first 24 h postoperatively (P <0.05), and the total drain output was also significantly less (P <0.05). Pain in the first 8, 24, and 48 h was less in the ACB group using a Visual Analog Scale (P <0.05). In addition, LOS, total opioid consumption, postoperative blood drain output, incidence of nausea and vomiting, and pain scores were significantly decreased after using ACB compared with epidural analgesia. Conclusion: This study provided evidence that ACB as postoperative analgesia after TKR is associated with better outcomes in terms of facilitating early functional recovery and mobility, and consequently prevents major postoperative complications.

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Objective: To investigate the effect of maxillary single and multiple rooted teeth on the success rate of buccal infiltration anesthesia. Subjects and Methods: This clinical study was performed by dividing the participants into three groups. Group one included 30 patients with upper anterior teeth, group two 23 patients with upper premolars teeth and group three 39 patients with upper molars for extraction. Onset time of anesthtic action was evaluted by using electronic pulp tester. Pulp testing assessments were carried out immediately before the injection and at the intervals of 2 mins following the injection until the anesthetic success obtains. Results: Seventy-nine patients in this study secured anesthetic success within study duration time (10 min). However, there were 13 patients with dental anesthesia failures (3 patients with single rooted teeth and 10 patients with multiple rooted teeth). There were no significant differences in the mean onset time of pulpal anesthesia between the anterior, middle and posterior teeth (P value = 0.449). Clinically, patients with single rooted teeth reported faster dental anesthesia and earlier teeth extraction than patients with multiple rooted teeth. Conclusion: This study showed that the single rooted teeth have faster pulpal anesthesia and early extraction than teeth with multiple roots but not statistically significant. Administration of extra local anesthetic cartridge or using intraseptal injection technique can be a solution to overcome the failure of anesthesia in the maxillary posterior teeth.

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Purpose: This study is undertaken to examine the factors that influence Saudi Board anesthesia residents' preferences in terms of future practice location, fellowship training, and research. Methods: A cross-sectional study was conducted. Data on fellowship training, research, and future practice location preferences, as well as demographics, were collected using surveys distributed to all anesthesia residents enrolled at Saudi anesthesiology residency program (N = 302). Results: A total of 117 residents (38.7%) responded to the survey. Of those 88.5% of residents planned on further subspecializing. The most highly sought fellowships were acute and chronic pain, regional anesthesia, simulation, and pediatric anesthesia. Residents pursuing fellowship training were mostly affected by personal interest, improving employment prospects, and future income. Only 11.5% of residents intended to incorporate research into their next practice—personal interest, employability, and lifestyle were the most influential in their decision. Conclusion: Most anesthesia residents training in Saudi Arabia choose to pursue fellowship training. However, less than one-fifth have an interest in incorporating research into their future careers.

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Hoarseness of voice following supraclavicular brachial plexus block is a rare complication and is seen in 1.3% of cases. It has been reported in cases of right supraclavicular brachial block exclusively. The reason for this is the course of recurrent laryngeal nerve which is not the same in the left and right sides. Here we report a case of left supraclavicular brachial plexus block following which the patient developed hoarseness of voice.

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Context: Spread of local anesthetic within adductor canal to peroneal and tibial nerves is described in literature. This spread could be volume-dependent. Aims: In this study, we compared the diffusion of two volumes of 0.375% ropivacaine to popliteal fossa. Settings and Design: This was a prospective, randomized controlled, single-blind study conducted in Kassab Orthopaedic Institute of Tunis for 1 year (2018). Materials and Methods: A total of 42 patients, American Society of Anesthesiologists I/II scheduled for knee arthroscopy under spinal anesthesia scheduled to receive adductor canal block, were randomized into two groups: group N received 20 mL of ropivacaine 0.375% and group H received 40 mL. We evaluated sensory motor blocks of both peroneal and tibial nerves at 30 and 60 min. Statistical Analysis Used: Chi-square or Fisher's exact test was used to compare the number and percentage.P<0.05 was significant. Results: At 60 min, complete sensory block of the peroneal nerve was obtained for 16 patients in group H versus 15 patients in group N with no statistically significant difference (P = 0.60). The difference was also not significant (P = 0.27) for the tibial nerve: 14 patients for group H versus 16 for group N. Motor blockade was rare in the two nerve territories. Conclusion: Spread of 0.375% ropivacaine to popliteal fossa resulted in high rate of complete sensory blockade of both peroneal and tibial nerves. Diffusion of local anesthetic was not volume-dependent.

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The anesthetic management of dilated cardiomyopathy (DCM) is challenging and is associated with a high mortality rate. We present a case of a 44-year-old pregnant female known for DCM with low ejection fraction who underwent an elective cesarean section and tubal ligation. The patient was transferred to the intensive care unit in a stable condition with a favorable outcome. Awareness about the appropriate anesthetic management for this type of patients is of paramount importance because similar cases are likely to be encountered with the advances in modern medicine.

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Parkinson's disease (PD) is a neurodegenerative disorder that affects the extrapyramidal system, and respiratory dysfunction has also been noted in patients with PD. However, acute upper airway obstruction due to bilateral vocal cord paralysis is a very rare finding in PD. Here, we describe a rare life-threatening respiratory failure caused by bilateral vocal cord paralysis in an elderly woman with PD during emergence from general anesthesia. The tracheostomy was performed on the postoperative period because the condition persisted. The general anesthesia in PD may have aggravated vocal cord impairment. We recommend when a patient with PD is scheduled for general anesthesia that the anesthesiologist performs careful preoperative examinations, strictly monitors respiratory function, and rapidly manages acute upper airway obstruction.

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Background: Potentiation of neuromuscular blocking agents by local anesthetics has been described in various clinical and experimental studies. This study assessed the influence of epidural ropivacaine on pharmacodynamic characteristics of rocuronium. Design: This was a prospective randomized clinical trial at the women's hospital, an university tertiary hospital in Brazil. Sixty-two patients underwent elective abdominal surgeries requiring general anesthesia. Intervention: Patients were distributed into two groups: Group 1 (general anesthesia and epidural anesthesia) and Group 2 (general anesthesia). In Group 1, 0.2% ropivacaine at a dose of 40 mg (20 ml) was associated with 2 mg (2 ml) of morphine in a single epidural injection. The following parameters were assessed: clinical duration (DC₂₅) and time for recovery of the train-of-four (TOF) 0.9 ratio (T4/T1 = 90%) after an initial 0.6 mg/kg dose of rocuronium. The primary outcomes were DC₂₅and TOF 0.9 ratio (T4/T1 = 90%). Secondary outcomes were total propofol and remifentanil consumption. Results: Values were presented as median and interquartile range. The results for DC₂₅and TOF 0.9 of rocuronium were, respectively, 41.5 35.0–55.0 (25.0–63.0) in Group 1 and 44.0 37.0-51.0 (20.0–67.0) in Group 2 (P = 0.88); 88.0 67.0–99.0 (43.0–137.0) in Group 1; and 80.0 71.0-86.0 (38.0–155.0) in Group 2 (P = 0.83). There was no significant difference between the groups, in terms of pharmacodynamic characteristics of rocuronium. Propofol consumption did not show any difference between the groups. However, remifentanil consumption was significantly lower in Group 1 (P < 0.01). Conclusion: Epidural ropivacaine, in the dose studied, did not prolong the duration of rocuronium-induced neuromuscular blockade. Trial Registry Number: ReBEC (ref: RBR-7cyp6t).

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Iliac crest bone grafting is very common associated procedure in various bone fixation surgery. We report here successful use of Transversalis fascia plane (TFP) block for iliac crest bone harvesting in a Polytrauma patient with difficult airway.

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Conjoined twins are one of the most fascinating human malformations. Here, we report the anesthetic management and challenges faced in performing the successful separation surgery of 4-day-old thoraco-omphalopagus conjoined twins, born at term to a multigravida by elective caesarean section weighing 3.5 kg with APGAR score of more than 7. Computerized tomography scan revealed fused anterior surface of the left lobe of liver with common left portal vein. Confirmation of cross-circulation between the twins was done by giving intravenous midazolam to one of the conjoined twins, but no effect seen in the other one. We highlighted the responsibility of anesthesia team in anesthetizing sequentially the two patients who are joined together, technical difficulty of intubating the twins facing each other, need of careful monitoring, anticipation of complications such as massive blood loss, hemodynamic instability, desaturation, and hypothermia, and preparedness for their management and vigilant postoperative care.

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We report a case of a patient operated for shoulder rotator cuff injury under interscalene brachial plexus block and general anesthesia, who developed neurological deficit in the nonoperative upper limb in the immediate postoperative period. As our patient developed neurological deficit on the nonoperative side, it was clear from the beginning that neither the nerve block nor the operative procedure was responsible for it. However, had he developed neurological symptoms on the operative side after having a peripheral nerve block, it would have possibly delayed the timely investigation and diagnosis. This case report underlines the need to keep an open mind when investigating neurological symptoms arising in the perioperative period, rather than assuming it to be secondary to either nerve block or as a complication of surgical procedure.

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General anesthesia is the gold-standard for laparoscopic procedures. Spinal anesthesia is usually not used and hypotension and impairment of spontaneous breathing are the most feared complications. A 86-year-old patient with a history of stage four chronic obstructive pulmonary disease (FEV1 28%) underwent emergent surgery for acute abdominal pain. A combined spinal-epidural anesthesia was successfully performed, surgery lasted ninety minutes without any surgical difficulties. Patient was discharged from the hospital on the third postoperative day. Our case depicts well how spinal anesthesia may be a viable option for high risk patients undergoing emergent laparoscopic surgery.

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Background: Anesthetists deal with many situations where they decide whether proceeding with anesthesia is safe or not. These are termed “go or no-go” decisions. Although guidelines have been developed to ensure safe anesthesia, many factors affect anesthetists' decision in practice. Therefore, we aimed to assess the variability in risk tolerance when making “go or no-go” decisions among anesthetists in Saudi Arabia. Materials and Method: A questionnaire-based study that included anesthetists practicing in Saudi Arabia from 1--14^th October 2017 was conducted. The questionnaire presented 11 clinical scenarios that involved deviation from guidelines, followed by four questions where the participants were asked to decide whether they would proceed with administering anesthesia, write a comment explaining their decision, to predict whether a colleague would make the same decision, and if they had a previous similar experience. Results: A total of 124 anesthetists responded, of which 56.5% were consultants. There was no absolute consensus over the decision to proceed in any scenario. Most of the respondents who would proceed (67.35%) expected a colleague to make the same decision. Anesthetists who encountered a previous similar experience were more likely to proceed (P = 0.000). There was no significant difference among the respondents' decisions according to years of experience (P = 0.121). Analysis of the comments showed that procedure urgency and presence of alternatives to deficient resources were the most frequent factors that dictated anesthetists' decision. Conclusion: There is a wide variation in risk tolerance among anesthetists. Further simulation-based studies are needed to identify and address factors that affect anesthetists' decisions.

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Spontaneous Adrenal Hemorrhage is a rare disease. It's one of the rare causes of abdominal pain late in pregnancy. I present a case with near term Spontaneous Adrenal Hemorrhage and concurrent severe preeclampsia, aiming to address the anesthetic considerations and management of such challenging presentation.

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Background: Rocuronium-induced injection pain causes withdrawal movements. These movements may cause accidental disruption of indwelling needles. Generic rocuronium contains low-acid concentration buffer solution compared with original rocuronium. In animal experiments, it has been suggested that the difference of the buffer solution may alleviate injection pain. The purpose of this study was to identify the difference of injection pain between original and generic rocuronium in pediatric population. Material and Methods: Patients ranging in age from 1 to 15 years, American Society of Anesthesiologists physical status I or II, undergoing elective surgeries were randomly allocated to two groups; generic rocuronium group (Group R) and original rocuronium (Eslax®) group (Group E). Following anesthetic induction with oxygen, nitrous oxide, and sevoflurane, original or generic rocuronium (1 mg/kg) was administered via intravenous catheter. The difference of vital signs and withdrawal movement associated with rocuronium injection were evaluated. Results: A total of 64 patients were included in the study. Three patients were excluded. Twenty-nine patients were assigned to Group E and 32 patients to Group R. There was no significant difference in mean arterial pressure and heart rate. No withdrawal movements were observed in both groups. Conclusion: There was no significant difference in injection pain between original and generic rocuronium under inhalational induction.

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