Hey there! I hope you’re all doing well. A warm welcome to our newcomers! This past week, I encountered a case that was too intriguing not to share. Below, I’ve detailed the presentation and initial investigations. I’ll leave the definitive diagnosis and management for next week’s edition—see if you can crack the case before then!

1. Patient History

A 30-year-old female was brought to the Emergency Department (ED) by paramedics after being found unconscious outside a store. No collateral information was available (identity and medical history unknown), and there were no visible signs of trauma or external injury.

2. Clinical Presentation

Upon arrival, the patient was in a deep coma with a Glasgow Coma Scale (GCS) of 6/15. However, the clinical team noted a striking set of paradoxical symptoms:

• CNS Depression: The patient was completely unresponsive to verbal commands.
• No Focal Signs: A neurological exam revealed no signs of CNS localization (no lateralizing signs or focal deficits), suggesting a global rather than a structural brain insult.
• Hyperexcitability: Despite the coma, she exhibited intense, generalized myoclonic jerks triggered by any physical contact or loud noises in the room with bilateral Babinski sign.
• Respiratory Status: RR 18, SpO2 90% on room air. Lungs were clear on auscultation with no signs of hypersecretion.
• Autonomic/Vitals: Temperature was 36.5°C, pupils were miotic, BP was 95/60 mmHg, and HR was 62 bpm.
• Other: Notably, there were no signs of tongue biting or urinary incontinence, making a typical post-ictal state less likely.

3. Diagnostic Findings

Initial lab work was surprisingly unremarkable, adding to the mystery:

• Labs: CBC, electrolytes (Na⁺, K⁺, Cl^-), blood glucose, urea, creatinine, and hemostasis were all within normal limits.
• Toxicology: Standard screens for opioids, benzodiazepines, and alcohol were negative.
• Imaging: A CT scan of the head showed no acute intracranial pathology.

The Challenge:

Our team considered several possibilities, but it took a specific clinical 'clue' (and some vital history from the family! :) ) to provide the definitive answer.

What’s your top differential? Comment below or wait until next week for the conclusion!

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Anesthesiology:

Systematic reviews & meta-analyses:

1- General:

1. Validation status of definitive airway management simulators: a systematic review, BJA, 12 March 2026, Link

2- Airway & Mechanical Ventilation:

2. High-Flow Nasal Oxygen and the Risk of Gastric Insufflation: A Systematic Review and Meta-Analysis Supplemented by Narrative Synthesis, A&A, 5 March 2026, Link

Clinical trials:

1- General:

3. Comparing Black Coffee to Coffee With Creamer in Gastric Emptying Time: A Nonrandomized Control Trial, A&A Practice, March 2026, Link
4. Postoperative Urinary Retention After Reversal of Neuromuscular Block by Neostigmine versus Sugammadex in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Controlled Trial, A&A, 6 March 2026, Link

2- Airway & Mechanical Ventilation:

5. The effect of high-flow nasal cannula oxygen therapy on preventing hypoxemia during deep sedation extubation after laparoscopic surgery: a prospective randomized controlled trial, BMC Anesthesiology, 11 March 2026, Link

3- Cardiovascular & Hemodynamics:

6. Sivelestat and Incidence of Acute Respiratory Distress Syndrome After Cardiovascular Surgery: A Randomized Clinical Trial, JAMA Open, 11 March 2026, Link

4- Thoracic:

7. Intravenous lidocaine reduces systemic inflammation but not myocardial injury following thoracic surgery for lung cancer: a randomized controlled trial, BMC Anesthesiology, 7 March 2026, Link

5- Neuro:

8. Multisensory virtual reality reduces postoperative delirium in elderly patients undergoing laparoscopic gastrointestinal surgery: A single-centre randomised controlled trial, EJA, 12 March 2026, Link

6- Obstetrics & Gynecology:

9. Transthoracic echocardiographic evaluation of maternal cardiac output: colloid preload versus crystalloid coload during cesarean delivery under spinal anesthesia: randomized clinical trial, BMC Anesthesiology, 12 March 2026, Link

7- Pediatric:

10. The efficacy of gabapentin in reducing perioperative opioid requirements in pediatric open-heart surgery: a randomized double-blinded controlled study, Journal of Cardiothoracic and Vascular Anesthesia, 6 March 2026, Link

8- Orthopedic:

11. Effects of perioperative probiotic supplementation on postoperative gastrointestinal recovery in elderly hip fracture patients: a randomized controlled trial, BMC Anesthesiology, 6 March 2026, Link

9- Regional Anesthesia & Pain Management:

12. Analgesic efficacy of liposomal bupivacaine adductor canal block combined with periarticular infiltration after total knee arthroplasty: a prospective, double-blind, randomized controlled trial, BMC Anesthesiology, 12 March 2026, Link
13. Effect of preoperative ultrasound-guided stellate ganglion block on pain thresholds and postoperative nausea and vomiting in gynecological laparoscopy: a randomised clinical trial, BMC Anesthesiology, 11 March 2026, Link
14. Analgesic efficacy of blocking nerve to vastus lateralis muscle versus lateral femoral cutaneous nerve after knee surgeries: a randomized trial, BMC Anesthesiology, 7 March 2026, Link
15. Efficacy and safety of liposomal bupivacaine versus bupivacaine for retrolaminar block for postoperative analgesia in patients undergoing posterior lumbar interbody fusion: a randomized controlled trial, BMC Anesthesiology, 7 March 2026, Link
16. Comparison of erector spinae plane block and rhomboid intercostal block for postoperative pain management in patients undergoing unilateral breast surgery, BMC Anesthesiology, 6 March 2026, Link

Reviews:

1- AI:

17. Automation software for transesophageal echocardiography in cardiac patients: a scoping review, Journal of Cardiothoracic and Vascular Anesthesia, 11 March 2026, Link

2- General:

18. Prophylaxis and treatment of postoperative nausea and vomiting, BJA Edu, 11 March 2026, Link
19. 2025 Clinical Update in Liver Transplantation, Journal of Cardiothoracic and Vascular Anesthesia, 10 March 2026, Link

3- Neuro:

20. Anesthesia for patients with movement disorders, Current Opinion in Anesthesiology, 11 March 2026, Link

4- Obstetrics & Gynecology:

21. Strategies for preventing nerve injuries in obstetric anesthesia: a review, Current Opinion in Anesthesiology, 3 March 2026, Link

5- Pediatric:

22. Ecological sustainability in pediatric anesthesia: current evidence and future directions, Current Opinion in Anesthesiology, 26 February 2026, Link
23. Patient-reported outcome and experience measures in pediatric perioperative care, Current Opinion in Anesthesiology, 26 February 2026, Link

Critical Care:

Guidelines & Consensus:

1- Pediatric critical care:

1. Pediatric Intensive Care Core Outcomes–a modified Delphi consensus process (PIC-CO), Critical Care, 9 March 2026, Link

Systematic reviews & meta-analyses:

1- Cardiovascular & Hemodynamics:

2. Extracorporeal Life Support Use During Severe Anaphylaxis: A Systematic Review and Pooled Analysis of Individual Patient Data, Journal of Cardiothoracic and Vascular Anesthesia, 9 March 2026, Link

2- Neuro-muscular:

3. Surgical Interventions for Super-Refractory Status Epilepticus: A Systematic Review, Neurocritical Care, 12 March 2026, Link

Clinical trials:

1- Cardiovascular & Hemodynamics:

4. Sivelestat and Incidence of Acute Respiratory Distress Syndrome After Cardiovascular Surgery: A Randomized Clinical Trial, JAMA Open, 11 March 2026, Link
5. Bleeding Risk with Apixaban vs. Rivaroxaban in Acute Venous Thromboembolism, NEJM, 11 March 2026, Link
6. Effect of Low-Dose Dobutamine Infusion on N-Terminal Pro–B-Type Natriuretic Peptide in At-Risk Patients With Acute Myocardial Infarction (DOBERMANN-D): A Randomized Clinical Trial, JACC, 8 March 2026, Link
7. Effect of Tocilizumab on Pro–B-Type Natriuretic Peptide and Infarct Size in Patients With Acute Myocardial Infarction at Risk of Cardiogenic Shock (DOBERMANN-T), JACC, 8 March 2026, Link

2- Thorax/Lungs/Airways/Mechanical ventilation:

8. Effect of the extubation predictive score (ExPreS) on reintubation in the ICU: a randomized controlled trial, Critical Care, 12 March 2026, Link
9. Effect of Continuous High-Frequency Oscillation Therapy on Lung Aeration in Mechanically Ventilated Patients With Impaired Consciousness: A Multicenter Randomized Controlled Trial, CHEST, March 2026, Link

3- Neuro-muscular:

10. Targeted Multidomain Treatment for Mild Traumatic Brain Injury: A Randomized Clinical Trial, JAMA Open, 12 March 2026, Link
11. Serum biomarkers of postanoxic encephalopathy in relation to ghrelin treatment. A secondary analysis of the GRECO trial, Resuscitation, March 2026, Link

4- Pediatric critical care:

12. High-Frequency Oscillation vs Mechanical Ventilation for Neonatal Acute Respiratory Distress Syndrome: A Randomized Clinical Trial, JAMA Open, 9 March 2026, Link

5- Other:

13. Barriers to adopting evidence from Bayesian adaptive clinical trials in critical care: a randomized experiment in United States intensivists, CHEST Critical Care, 7 March 2026, Link

Reviews:

1- Thorax/Lungs/Airways/Mechanical ventilation:

14. Mechanical ventilation in ARDS: navigating the fine line with real-time monitoring, Critical Care, 7 March 2026, Link

2- Nutrition:

15. Feeding the injured brain: nutrients, dose, timing, and monitoring, Intensive Care Medicine, 9 March 2026, Link

3- Infectious Diseases:

16. Antibiotic Considerations in the Critically Ill: Empiric Choices and Dosing, Critical Care Clinics, 9 March 2026, Link
17. Research progress of sepsis immunotherapy: a bibliometric analysis, Shock, 26 February 2026, Link

4- Pediatric critical care:

18. Corrective steps during neonatal mask ventilation – a narrative review of the evidence behind the MR SOPA acronym, Resuscitation Plus, 12 March 2026, Link

5- Other:

19. Critical Care Organization as an Acute Care Learning Health System: Integrating Clinical and Academic Research Missions, Critical Care Clinics, April 2026, Link
20. The Future of Critical Care, Critical Care Clinics, April 2026, Link
21. Organization and Management of Critical Care Services: Unexpected Challenges in Leading a Critical Care Organization, Critical Care Clinics, April 2026, Link
22. How to Start and Sustain a System-Based High-Reliability Medicine Venture for Your Critical Care Organization, Critical Care Clinics, April 2026, Link
23. Intensive Care Unit Quality Metrics: Leveraging Advancing Analytics for Meaningful Improvement, Critical Care Clinics, April 2026, Link
24. Critical Care Billing: Doing it Right, Every Time, Critical Care Clinics, April 2026, Link
25. ICU Capacity Management and Surge Preparedness, Critical Care Clinics, April 2026, Link
26. Innovation, Technology, and Telemedicine in Critical Care, Critical Care Clinics, April 2026, Link
27. Regionalization of Critical Care in Community Settings, Critical Care Clinics, April 2026, Link
28. Pharmacists in Interprofessional Critical Care: Optimizing Medication Management, Critical Care Clinics, April 2026, Link
29. Advanced Practice Provider Leadership in Critical Care: Building High-performance Teams, Improving Outcomes, and Future Planning, Critical Care Clinics, April 2026, Link
30. Assessing Workforce Competencies for Physicians and Advanced Practice Providers, Critical Care Clinics, April 2026, Link
31. Challenges in Creating a Critical Care Organization at Your Institution, Critical Care Clinics, April 2026, Link
32. Principles of Critical Care Organization and Management, Critical Care Clinics, April 2026, Link

Feedback & Suggestions

Don't hesitate to share your thoughts and suggestions in the comments below; they'll be a great help in improving future issues of the newsletter.

Disclaimer

See you next time :)

Benhalima Othmane.

Anecrit.com