Anesthesia Research doi: 10.3390/anesthres3020011

Authors: Paulo Warpechowski Bruna Eibel Gustavo Glotz de Lima Tiago Batista Warpechowski Ari Tadeu Lírio Santos Tiago Luiz Luz Leiria

Introduction: Propofol is one of the most commonly used intravenous anesthetics worldwide and is considered safe for all age groups. However, there have been reports that propofol can induce severe atrioventricular block in humans, and several studies have shown that propofol hinders or prevents the inducibility of arrhythmias during electrophysiological studies (EPS) and radiofrequency (RF) ablation. Objectives: To compare arrhythmia inducibility during electrophysiological study and radiofrequency ablation in pediatric patients with Wolff–Parkinson–White syndrome undergoing propofol-based sedation versus sevoflurane-based general anesthesia. Methods: We conducted a retrospective observational cohort study including 45 pediatric patients aged 0–18 years. Patients were identified through a review and analysis of a database of individuals with Wolff–Parkinson–White syndrome who were referred for electrophysiological study and/or radiofrequency ablation at the Electrophysiology Laboratory of the Institute of Cardiology (IC/FUC) in Porto Alegre over the past five years (2019–2024). Patients with prior ablation, structural heart disease, or ongoing antiarrhythmic therapy were excluded. The patients were divided into two groups and designated as group S (who received sedation) or group G (who received general anesthesia). Sedation (group S) was performed with midazolam (0.08–0.2 mg/kg), fentanyl (0.1–0.2 μcg/kg), and propofol 50–60 µg/kg/min in continuous infusion. General anesthesia (group G), in turn, was performed with sevoflurane at an average dose of 2% (1 MAC according to age). Results: From 4874 invasive electrophysiology procedures performed during the study period, 45 involved pediatric patients with WPW. The sedation group (n = 29) had significantly older patients (14.6 ± 2.5 vs. 10.3 ± 2.8 years, p < 0.001) with higher weight (65.9 ± 16.3 vs. 41.2 ± 7.8 kg, p < 0.001) compared to the general anesthesia group (n = 16). Arrhythmia was successfully induced in 15/29 (51.7%) patients in the sedation group compared to 13/16 (81.2%) in the general anesthesia group (p = 0.062, Fisher’s exact test). Although this difference did not reach statistical significance, it represents a clinically relevant 29.5% lower induction rate in the sedation group. Post hoc power analysis revealed the study was underpowered (49.8%), suggesting a possible Type II error. Analysis of the “procedure room time” revealed a longer duration in the general anesthesia group (97.8 ± 36.7 vs. 67.8 ± 24.4 min), and this difference was statistically significant (p = 0.002). Conclusions: This study compared propofol-based sedation with sevoflurane-based general anesthesia in pediatric WPW patients. While sedation with propofol did not show a statistically significant reduction in arrhythmia inducibility, there was a concerning trend toward lower induction rates (29.5% difference) that may be clinically relevant. The study’s limited statistical power (49.8%) suggests these findings should be interpreted cautiously, and larger prospective studies are needed to definitively establish whether propofol affects arrhythmia inducibility in this population. Propofol remains a viable option for these procedures, but clinicians should be aware of the potential for reduced inducibility, particularly in cases where arrhythmia induction is critical for diagnosis and treatment.

Anesthesia Research doi: 10.3390/anesthres3020010

Authors: Mahta Mousavi Dorothee Kübler-Weller Lisa Paulsen Friedrich Borchers Claudia Spies Andrea A. Kühn Benjamin Blankertz

Background: While providing enough sedatives to avoid pain and trauma during surgery is important, studies show a link between the received sedatives and the development of postoperative delirium (POD). Therefore, predicting POD from clinical or physiological data before or during surgery is highly advantageous. This capability enables healthcare providers to proactively implement necessary measures, thereby mitigating or preventing potential complications. Methods: In this study, we focus on patients with Parkinson’s disease undergoing deep brain stimulation surgery who are particularly susceptible to POD. We investigate what aspects of EEG’s power, functional connectivity and complexity during the course of the surgery are influenced by the amount of sedative. Furthermore, we aim to determine whether and to what extent the recorded brain activity during surgery can serve as a reliable means for the prediction of POD in this group of patients. Results and Conclusions: Our results show significant correlations between various power, connectivity and complexity features of EEG and the amount of sedatives. Even though single EEG features are not significantly different between the two groups who either developed or did not develop POD, we show that a classifier based on support vector machines using the selected EEG features could predict POD. Furthermore, our results provide evidence that a classifier trained only on the amount of sedatives is unable to predict POD. Accompanying this paper, our code is published as an open-source toolbox for the analysis of the EEG signal recorded with the four-channel SEDLine Root system, which is among the widely used EEG systems in operation rooms and its recorded data come with challenges that are addressed in our toolbox.

Anesthesia Research doi: 10.3390/anesthres3020009

Authors: Nabeelah Mukadam Lynne Emmerton Petra Czarniak Oksana Burford Stephanie W. K. Teoh Tamara Lebedevs

Background: Access to reliable medicines information is essential to support safe medicine use during pregnancy and breastfeeding, where concerns regarding fetal and neonatal safety complicate clinical decision-making. Analgesics are widely used during these periods, yet uncertainty regarding safety persists due to evolving evidence, regulatory changes, and inconsistent information sources. Obstetric medicines information services play a critical role in addressing these information needs. This study aimed to evaluate patterns of analgesic-related enquiries to a pharmacist-led specialist obstetric medicines information service over a 20-year period. Methods: A retrospective observational study was conducted using enquiry data from the King Edward Memorial Hospital Obstetric Medicines Information Service (KEMH OMIS), Western Australia. All enquiries recorded between 1 January 2001 and 31 December 2020 were extracted from the Microsoft Access® database. Records with incomplete data were excluded. Data were standardised, coded, and analysed using Microsoft Excel® and SPSS® Version 25. Descriptive statistics were used to summarise enquiry characteristics, caller type, the timing of exposure, and analgesic medicines involved. Trends over time were analysed. Results: A total of 48,458 enquiries were analysed, of which 4,978 (10.3%) related to analgesics, making this the third most common medicine class. Most enquiries related to breastfeeding (62.1%), followed by pregnancy (32.7%). The public accounted for 60.9% of calls, while health professionals contributed 39.1%. The highest frequency of breastfeeding enquiries occurred within the first four weeks postpartum, and pregnancy enquiries were most common in the second trimester. Paracetamol was the most frequently enquired analgesic (24.5%), followed by codeine (19.8%), ibuprofen (14.4%), diclofenac (7.2%), and tramadol (9.3%). Analgesic-related enquiries declined significantly over time (p < 0.001), particularly codeine-related enquiries following regulatory safety warnings. Conclusions: Analgesics represent a substantial proportion of medicines information enquiries in pregnancy and breastfeeding, reflecting widespread use and ongoing safety concerns. Pharmacist-led medicines information services play a critical role in supporting safe analgesic use.

Anesthesia Research doi: 10.3390/anesthres3020008

Authors: Edel Rafael Rodea-Montero Paulina Millán-Ramos Luis David Delgadillo-Mora Ricardo Garcia-Mora Miguel Ángel Aguayo-Preciado

Introduction: In adult patients undergoing deceased donor kidney transplantation, anesthesia management impacts graft function and survival and is influenced by various donor and recipient clinical factors. The aim of this study was to describe the perioperative factors and to evaluate their association with delayed graft function (DGF) during the first seven days after transplantation. Materials and Methods: This cross-sectional study of adult patients who underwent deceased donor kidney transplantation at a tertiary care hospital from 2022–2023 was performed to evaluate pre-, trans- and postoperative patient’s characteristics. Comparisons or association tests were implemented between patient characteristics grouped by the absence or presence of DGF. In the case of the variables with clinical relevance, univariate and multivariate logistic models were constructed to evaluate the predictive capacity of these variables to predict delayed graft function. Crude and adjusted odds ratio (ORs) with 95% confidence intervals were calculated for each variable. Results: DGF was present in 25/69 (36.23%) patients. The anesthesia time was significantly longer (310.28 vs. 273.55 min; p = 0.043) and the post-transplantation stay was significantly longer (11.04 vs. 8.11 days; p < 0.001) in patients with delayed graft function. In univariable analyses, male sex (p = 0.018), platelet count (p = 0.025), and surgical time (p = 0.062) showed significant or borderline associations with DGF. In the multivariable model, male sex remained independently associated with DGF (adjusted OR 10.64; 95% CI 1.23–92.1; p = 0.031). Platelet count (per 50 × 103 µL increase) demonstrated a borderline inverse association (adjusted OR 0.57; 95% CI 0.32–1.02; p = 0.057). Conclusions: Our results suggest that male sex was independently associated with delayed graft function after deceased donor kidney transplantation, while platelet count showed a borderline association.

Anesthesia Research doi: 10.3390/anesthres3010007

Authors: Kasim Qureshi Jason Schick Ahmedyar Hasan Muhammad U. Farooq Philip B. Gorelick

The growth of brain health initiatives in the United States and worldwide has led to a movement to protect the brain from avoidable injury across the lifespan. With the advancement of our armamentarium of neurologic treatments and preventives during the past several decades, the field of preventive neurology has spawned. Under the umbrella of preventive neurology is perioperative brain health, an under-addressed but important topic in the field of neurology. Perioperative brain health is important because perioperative mortality may be relatively high, and morbidity as quantified by brain injury biomarkers (e.g., MRI brain) and clinical phenotypic manifestations related to stroke can be common. In this perspective, in relation to periprocedural stroke, we review the stroke mechanisms, epidemiology and risk factors, risk stratification measures and long-term outcomes, and potential mitigation and treatment opportunities. As perioperative brain health crosses many medical disciplines, multidisciplinary action is needed to bridge the knowledge gaps and reduce brain injury and attendant neurologic complications. Anesthesiologists and other healthcare professionals working in the surgical and procedural field are well-positioned to make important contributions to this growing discipline of the prevention of brain injury in the perioperative period.

Anesthesia Research doi: 10.3390/anesthres3010006

Authors: Valentina Abba Amalie B. E. Nielsen Petra Buhr Karsten Pharao Hammelev Jens J. Holst Carolina B. Lobato

Background/Objectives: Insulin and glucagon are key hormones in metabolic regulation. There are limited comparative data on how common rodent anesthetic regimens influence hormone secretion, leading to misinterpretation of results. We aimed to compare the effects of several anesthetic regimens on insulin and glucagon secretion using the physiologically relevant isolated perfused rat pancreas model. Methods: Six commonly used rodent anesthetic regimens were assessed for their ability to induce surgical depth of anesthesia. Once achieved, the pancreas was vascularly isolated and perfused. After euthanasia, the pancreas was stimulated with glucose and glucagon-like peptide-1 (GLP-1). Insulin and glucagon were measured in the effluent using radioimmunoassay. Results: Anesthesia with Hypnorm® (fentanyl/fluanisone)/midazolam produced the most physiological responses, meaning that insulin was secreted in response to hyperglycemia and GLP-1, and glucagon was secreted under hypoglycemia. Ketamine/dexmedetomidine anesthesia abolished insulin dynamic secretion and blunted glucagon secretion. Isoflurane/buprenorphine anesthesia partially suppressed insulin secretion, but it still followed a physiological pattern in response to glucose fluctuations. However, it abolished the dynamic glucagon responses to glucose. Three additional anesthetic regimens failed to produce surgical depth anesthesia and were therefore not further analyzed. Conclusions: Different anesthetic regimens altered pancreatic hormone secretion. Fentanyl/fluanisone/midazolam was associated with dynamic insulin and glucagon secretion, whereas ketamine/dexmedetomidine and isoflurane/buprenorphine altered the pattern and/or magnitude of hormone secretion. Overall, the choice of anesthesia is a critical variable in animal experimentation for metabolic studies and may confound the interpretation of results.

Anesthesia Research doi: 10.3390/anesthres3010005

Authors: Hector Katifelis Sofia Poulopoulou

Opioids represent one of the oldest classes of drugs in medicine and remain central to pain management to this day. However, their use is limited by a series of adverse effects, and they are notorious for their addiction potential and for contributing to the opioid epidemic in the US. Nanomedicine, the branch of nanotechnology that utilizes materials at the nanoscale for drug delivery, provides a unique platform that can potentially revolutionize conventional opioid treatment. The aim of this literature review is to summarize the latest research on opioid nanoformulations and their potential to increase analgesic efficacy while minimizing associated risks. Preclinical studies have already demonstrated that both liposomal and dendrimer-based opioid formulations allow for extended release and, consequently, more prolonged and stable analgesia. Moreover, nanoemulsions are currently being investigated for the delivery of opioid compounds, offering formulation versatility and improved bioavailability while maintaining an improved safety profile. At the same time, the use of nanomedicine for vaccines against opioids may enable novel therapeutic strategies to be developed for individuals with opioid addiction. However, several barriers need to be overcome for the promise of nanomedicine to be fulfilled, including the lack of clinical trials, difficulties in mass production of several nanoparticles, toxicity concerns, and regulatory issues.

Anesthesia Research doi: 10.3390/anesthres3010004

Authors: Kevin E. Salinas Samir Ghandour Jingyan Yue Ronald W. Mercer Zachary E. Stewart

Background/Objectives: Fluoroscopically guided cervical nerve root corticosteroid injections are used for the treatment and diagnosis of radicular pain. Including a local anesthetic with the injected corticosteroid may decrease the pain associated with the procedure and add immediate diagnostic value. However, little is known about the safety of including a local anesthetic with a corticosteroid in these injections. Methods: A total of 299 consecutive cervical nerve root injections, performed between 2016 and 2024, were reviewed. Demographic and injection information (level/laterality and inclusion/exclusion of 1% preservative-free lidocaine with dexamethasone injectate) were documented. Charts were reviewed for major complications and increased pain post-procedure. Categorical data were compared between groups using Fisher’s exact test or Chi-square testing. Results: Injections were performed with 10 mg of dexamethasone only in 263 cases and with a mixture of 10 mg of dexamethasone and 1 mL of 1% lidocaine in 36 cases. There was no statistically significant difference in the incidence of major complications (p ≈ 1) or immediately increased pain post-procedure (p = 0.799). Conclusions: With proper technique, there is no evidence from this case–control study or in the available literature to suggest that including lidocaine with corticosteroid increases risks associated with cervical nerve root injections. However, serious adverse events are theoretically possible with injection of local anesthetic into a radicular artery, the vertebral artery, or subdural space. Given that such risks are not associated with the use of non-particulate steroids alone, large multi-institutional studies are needed to draw confident conclusions on the risks and benefits of the inclusion of local anesthetics with non-particulate corticosteroids for cervical transforaminal epidural steroid injection to inform clinical practice.

Anesthesia Research doi: 10.3390/anesthres3010003

Authors: Tom Pisters Annemarie Akkermans Ignace H. J. T. de Hingh Misha D. P. Luyer Harm J. Scholten

Background: Epidural analgesia (EA) is widely used in pancreatic surgery but is associated with hypotension and delayed recovery. The shift towards minimally invasive surgery has led to the exploration of alternative multimodal analgesia strategies. Methadone, with its unique pharmacological properties, may further optimize recovery. Methods: This retrospective cohort study included 213 patients undergoing pancreatic resection, receiving EA (n = 63), multimodal analgesia without methadone (MA; n = 92), or with methadone (MM; n = 58). MA and MM included intravenous ketamine, lidocaine and continuous wound infiltration. Primary outcome was maximum daily postoperative pain scores. Secondary outcomes included opioid consumption, vasopressor use, mobilization, bowel recovery, urinary catheter duration, and ICU/hospital stay. Results: Compared with EA, pain scores were slightly higher in MM (mean difference 2.22; 95% CI 1.22–3.90; p = 0.01) and in MA (mean difference 2.06; 95% CI 0.99–4.30; p = 0.06). Opioid use was comparable between MM and EA (OR 0.99, 95% CI [0.98, 1.00], p = 0.20), and significantly lower in MA (OR 0.97, 95% CI [0.96, 0.98], p < 0.001). Both MA and MM demonstrated reduced vasopressor requirements (both 0 vs. 2.0 median days) and shorter urinary catheterization durations (MA 1.2 MM 1.9 vs. EA 4.0 median days). MA improved mobilization (0 vs. 1 median days; OR 0.52, p = 0.03) and bowel recovery (OR 0.76, p = 0.02). ICU stay was longer in EA due to routine ICU admission for open surgery. Conclusions: Multimodal analgesia, with or without methadone, offers alternative strategies in pancreatic surgery. While EA provides superior pain control, multimodal regimens are associated with improved functional recovery.

Anesthesia Research doi: 10.3390/anesthres3010002

Authors: Lerzan Dogan Zerrin Sungur Özlem Turhan Emre Sertac Bingul Berker Ozkan Hakan Gurvit Mert Senturk

Background: Postoperative cognitive dysfunction (POCD) is a significant complication following thoracic surgery. One-lung ventilation (OLV) during these procedures can lead to cerebral desaturation, potentially contributing to POCD. This study investigated the correlation between intraoperative cerebral oximetry, measured by near-infrared spectroscopy (NIRS), and neurocognitive function changes in patients undergoing thoracic surgery. Methods: In this prospective, observational pilot study, 54 adult patients undergoing OLV for thoracic surgery were enrolled. Cerebral oxygen saturation (rScO2) was monitored continuously using NIRS. Patients were categorized into two groups: Group N (normal NIRS values) and Group D (decreased NIRS values, defined as a drop of ≥20% from baseline or an absolute value <50%). Neurocognitive function was assessed preoperatively, on the 3rd postoperative day, and at 3 months using the Addenbrooke’s Cognitive Examination-Revised (ACE-R) battery. The correlation between intraoperative rScO2 values, postoperative complications, and neurocognitive outcomes was analyzed. Results: A significant association was found between intraoperative cerebral desaturation and a decline in ACE-R scores. Group D showed a significant decrease in ACE-R scores on the 3rd postoperative day and at 3 months compared to their baseline, while Group N showed no significant change. The most pronounced decline in Group D was observed in the “Fluency” cognitive domain. Interestingly, there was a significant difference in ICU admission rates (p = 0.004) between the two groups, with more admissions in Group D, despite no significant difference in intraoperative hypotension or peripheral desaturation. Patients with pre-existing hypertension were more likely to experience cerebral desaturation. Conclusion: Intraoperative cerebral desaturation, as detected by NIRS, is a strong predictor of both early and late postoperative neurocognitive decline and increased postoperative morbidity in thoracic surgery patients. This underscores the value of NIRS as a sensitive monitoring tool to identify patients at risk and guide timely interventions. These findings suggest a need for further research, including larger randomized controlled trials, to confirm these associations and evaluate the impact of a protocol-driven NIRS intervention strategy on patient outcomes.

Anesthesia Research doi: 10.3390/anesthres3010001

Authors: Wiriya Maisat Koichi Yuki

Damage-associated molecular patterns (DAMPs) are endogenous molecules released during cellular stress or injury that trigger sterile inflammation. In perioperative settings, common triggers include surgical trauma, ischemia–reperfusion injury, cardiopulmonary bypass, blood transfusion, and mechanical ventilation. When released extracellularly, DAMPs activate innate immune receptors such as Toll-like receptors (TLRs) and the receptor for advanced glycation end products (RAGE), initiating signaling cascades that amplify inflammation, disrupt endothelial integrity, and promote coagulation and metabolic imbalance. This sterile inflammatory response may extend local tissue injury into systemic organ dysfunction, manifesting clinically as acute lung injury, acute kidney injury, myocardial dysfunction, disseminated intravascular coagulation, and perioperative neurocognitive disorders. Recognizing the central role of DAMPs reframes these complications as predictable consequences of endogenous danger signaling rather than solely as results of infection or hemodynamic instability. This understanding supports the use of established strategies such as protective ventilation and restrictive transfusion to minimize DAMP release. Emerging evidence also suggests that anesthetic agents may influence DAMP-mediated inflammation: propofol and dexmedetomidine appear to exert anti-inflammatory effects, whereas volatile anesthetics show variable results. Although clinical data remain limited, anesthetic choice and perioperative management may significantly affect systemic inflammatory burden and recovery. Future research validating DAMPs as biomarkers and therapeutic targets may inform precision anesthetic strategies aimed at modulating sterile inflammation, ultimately enhancing perioperative outcome.

Anesthesia Research doi: 10.3390/anesthres2040027

Authors: Zafar Ullah Khan Gabriella Iohom Brian O’Donnell

The assessment of a conduction block following regional anaesthesia involves the clinical examination of motor and sensory neural pathways. Motor assessment includes the subjective evaluation of power, while sensory function is assessed using subjective perceptions of touch, cold and pain. There are considerable subjectivities and variabilities in the assessment of regional anaesthesia. Regional anaesthesia results in a blockade of not only somatosensory and motor nerve fibres but also sympathetic fibres. This results in vasodilation and an increase in blood flow, which leads to an increase in skin temperature. Multiple studies have demonstrated a high correlation between conduction block success and skin temperature changes at 10 min, detected using infrared thermography with a higher sensitivity and specificity and positive and negative predictive values up to 100%. Infrared thermography (IRT) is a non-invasive imaging tool which measures surface temperature. The role of IRT in assessing conduction blocks has been evaluated. We reviewed the literature to characterise the role of IRT in determining the onset of a conduction block following regional anaesthesia. This narrative review article synthesises the current evidence on the application of IRT in the evaluation of conduction block onset. In conclusion, IRT is a reliable tool to assess early block success as compared to routine assessment methods (touch, cold and pain perception). However, the limited studies and effects of environmental factors highlight the need for standardised protocols and multicentre studies to integrate into routine clinical practice. With further validation and integration into clinical practice, it has the potential to improve both patient safety and the reliability of block assessment.

Anesthesia Research doi: 10.3390/anesthres2040026

Authors: Juliet Miller Anne Minert Mary Koukoui Shaked Heller Roza Morein Mark Baron Kristina Vaso Marshall Devor

Background/Objectives: Chemogenetic excitation of a distinct subset of “effector-neurons” in the brainstem mesopontine tegmental anesthesia area (MPTA) is pro-anesthetic. GABAergic general anesthetics are believed to engage these neurons by disinhibition, thereby inducing loss-of-consciousness (LOC) and enabling pain-free surgery. The transition from wakefulness to LOC, however, does not occur intrinsically within the MPTA. Rather, evidence indicates that LOC is brought about (effected) by ascending and descending axonal projections of MPTA effector-neurons that terminate in a variety of downstream brain targets which, together, generate the various components of anesthesia. Previously we used anterograde and retrograde tracing to delineate the overall axonal trajectories of MPTA projection-neurons, to which targets they project. Effector-neurons, however, represent only a fraction of this neuronal pool. Which of these targets are also innervated by MPTA projecting effector-neurons? Methods: Here we marked MPTA effector-neurons with the adeno-associated virus (AAV) used in the discovery of this neuronal type, with retrograde labelling from the previously identified MPTA target structures, to establish which downstream brain structures receive direct input from effector-neurons. Results: Effector-neurons proved to contribute to all six of the major MPTA projection-targets: the prefrontal cortex, basal forebrain, intralaminar thalamus, zona incerta, rostro-ventromedial medulla and spinal cord. Conclusions: We conclude that a discrete population of projecting effector-neurons, probably representing only about 6% of all MPTA neurons, drive the multiple functional endpoints of surgical anesthesia: analgesia, atonia, amnesia and LOC. Further, we propose that these same neurons, via their associated axonal pathways, may also contribute to endogenous instances of LOC such as natural sleep, fainting, concussion, coma and hibernation.

Anesthesia Research doi: 10.3390/anesthres2040025

Authors: Alexandra Lyons Nathan Yii Leigh White Matthew Bright Gina Velli

Background: Hip fracture surgery in elderly patients carries significant risks of both bleeding and thrombotic complications. Anaesthetists frequently face a dilemma between neuraxial anaesthesia, which may reduce thrombotic risk but is often limited by contraindications, and general anaesthesia, which is widely applicable but may exacerbate bleeding. Previous reviews have not specifically addressed bleeding and thrombotic outcomes, leaving a critical gap that this meta-analysis seeks to answer. Study objective: To evaluate the effect of neuraxial anaesthesia compared to general anaesthesia on the incidence of bleeding and thrombotic complications in acute neck of femur fracture surgery. Methods: Relevant studies comparing neuraxial and general anaesthetic for hip fracture surgery were searched for through Medline, Embase, Scopus, CINAHL and PubMed. Inclusion criteria were randomised control trials of hip fracture surgery patients aged >16 years with relevant outcome data. In total, 24 randomised control trials were included, with 5479 patients. A meta-analysis was performed using RevMan 5.4 software. The study was registered with PROSPERO ID: CRD42022348039. Outcome measurement: Primary outcomes were intra-operative blood loss, intra- or post-operative blood transfusion and post-operative deep vein thrombosis. Secondary outcomes were post-operative pulmonary embolism, post-operative myocardial infarction and post-operative stroke. Results: Neuraxial anaesthesia reduced deep vein thrombosis incidence by 45% and reduced blood loss by 58 mL, both of which reached statistical significance (p < 0.05). Albeit not reaching statistical significance, neuraxial anaesthesia also had a 35% relative risk reduction in myocardial infarction, and a 35% relative decrease in stroke in current studies published after 2010. Despite practise evolution over the decades, protective neuraxial trends have remained. Conclusions: Patients undergoing acute hip fracture surgery under general anaesthesia have higher volumes of blood loss, without requiring increased blood transfusion. General anaesthesia is also associated with higher thrombotic complications, with a 45% increased relative risk of deep vein thrombosis, compared to neuraxial anaesthesia. Multi-modal thromboprophylaxis is important, as up to a third of DVT cases occur in the non-operative leg. In frail patients with a low cardiopulmonary reserve for bleeding or in high-thrombotic-risk patients, extra consideration and optimisation for neuraxial technique is advised. Future studies on comorbidities and operation type may reveal a subgroup of patients which would benefit from a specific anaesthetic type.

Anesthesia Research doi: 10.3390/anesthres2040024

Authors: Brandon Thai Hideaki Yamamoto Aristides Koutrouvelis Satoshi Yamamoto

Sepsis is a life-threatening syndrome marked by a dysregulated host response to infection, resulting in systemic inflammation, organ dysfunction, and high mortality globally. Despite advancements in supportive care, effective immunomodulatory therapies remain elusive, necessitating exploration of novel biological pathways and subsequent therapeutic development. The endocannabinoid system (ECS), which regulates immune function and homeostasis, has emerged as a key modulator of immunological and metabolic pathways central to sepsis pathophysiology. The ECS mediates its effects through endogenous ligands, G-protein-coupled cannabinoid receptors (CB1 and CB1), and regulatory enzymes that control its synthesis and degradation. Following PRISMA-ScR guidelines, this scoping review synthesizes current evidence on the mechanistic roles of ECS components in experimental and clinical models of sepsis, identifies knowledge gaps, and delineates future areas of work. A comprehensive literature search across multiple databases without restrictions on date or publication type was executed to ensure broad coverage of original studies investigating ECS mechanisms and their intersection with sepsis and septic shock. Across 53 studies, CB2 receptor activation was consistently associated with anti-inflammatory process, organ-protective outcomes, and increased survival rates against septic challenges in preclinical rodent models. CB1 receptor activation trends, however, showed context dependent outcomes. Central antagonism improved hemodynamics and survival rate, but peripheral effects varied with cell type and timing. Non-canonical ECS components (TRPV1, GPR55, PPAR-α, FAAH, MAGL) also contributed to neuroimmune and metabolic regulation. Limited clinical data linked ECS lipid profiles and gene expression with sepsis severity and outcomes. Collectively, ECS modulation, particularly CB2 agonism, TRPV1 activation, and FAAH/MAGL inhibition, shows promise in mitigating sepsis-induced inflammation and organ dysfunction. However, complex, context-dependent effects, especially involving CB1, highlight the need for precision-targeted therapeutic approaches. Further preclinical research is needed to expand generalizable trends to allow translational research to refine ECS-based interventions for sepsis management.

Anesthesia Research doi: 10.3390/anesthres2040023

Authors: Gabriele Melegari Federica Arturi Fabio Gazzotti Matteo Villani Elisabetta Bertellini Alberto Barbieri

Background: Sepsis is a life-threatening syndrome caused by a dysregulated host response to infection leading to organ dysfunction. Distinguishing sepsis from localized infection is crucial, as it guides clinical decision-making and biomarker interpretation. Biomarkers may support diagnosis, prognosis, and therapeutic choices, but their integration into practice remains debated. Methods: This narrative review was conducted in accordance with the SANRA (Scale for the Assessment of Narrative Review Articles) guidelines. A comprehensive literature search was performed in PubMed, Embase, and Cochrane CENTRAL (January 2000–September 2025). Studies evaluating sepsis-related biomarkers for diagnosis, prognostication, shock assessment, antimicrobial stewardship, and post-acute follow-up were considered. Findings: Established biomarkers such as procalcitonin (PCT), C-reactive protein (CRP), and lactate remain widely used for diagnosis, monitoring of inflammatory response, and assessment of severity. Emerging candidates include pancreatic stone protein (PSP), neutrophil gelatinase-associated lipocalin (NGAL), and monocyte HLA-DR (mHLA-DR), which may provide insights into infection dynamics, renal injury, and immune suppression, respectively. However, limitations in standardization and heterogeneous evidence hinder routine implementation. Interleukin-6 (IL-6), despite extensive study, shows limited specificity and inconsistent clinical applicability. Renin has been proposed as a marker of shock severity rather than infection. Comparative evidence highlights the need for stage-specific biomarker use across prehospital, emergency, ICU, and recovery phases. Conclusions: No single biomarker is universally applicable in sepsis. Their utility depends on timing, clinical setting, and patient phenotype. Combining classical and emerging biomarkers with point-of-care technologies and dynamic monitoring may enhance personalized management. Limitations include heterogeneity of evidence and lack of standardized thresholds. Future research should validate biomarker panels, integrate them into stewardship strategies, and explore their cost-effectiveness in clinical practice.

Anesthesia Research doi: 10.3390/anesthres2040022

Authors: Anuj K. Aggarwal

The teaching of medical history, once central to medical education, has been progressively displaced by science- and competency-focused curricula. In anesthesiology, despite the presence of historical scholarship and institutional resources, the history of this specialty is rarely used as a formal educational tool. This narrative review explores how historical narratives can support the development of professionalism and professional identity in anesthesia training. An exploratory search of the literature revealed no prior studies explicitly linking anesthesia history to professional identity formation, underscoring a gap in current scholarship. Drawing on the foundational literature in medical education and selected historical examples, including figures such as Crawford Long, Henry Beecher, and Virginia Apgar, this review illustrates how reflective engagement with historical episodes can deepen ethical awareness, foster identity formation, and contextualize the evolving role of the anesthesiologist. It proposes a theoretical framework and strategies for integrating historical content into anesthesia curricula and argues that historical reflection can complement existing methods for teaching professionalism. The history of anesthesia, when purposefully employed, offers a powerful means to humanize training, support critical reflection, and better prepare trainees for the ethical and professional challenges of contemporary practice.

Anesthesia Research doi: 10.3390/anesthres2040021

Authors: Laura DiVirgilio Jaime B. Long Sarah S. Boyd

Opioid use disorder remains a leading national cause of mortality. Physician opioid prescribing contributes to this crisis. In urogynecology, most of these prescriptions are aimed at addressing postoperative pain. This expert review examines the factors that contribute to postoperative pain and opioid use in urogynecologic patients. We discuss patient characteristics, physician interventions and alternative therapies that may influence postoperative pain and opioid use. By identifying patients at higher risk for postoperative pain and opioid use and utilizing evidence-based strategies to mitigate postoperative pain, physicians caring for urogynecology patients can both reduce postoperative opioid use while still providing adequate patient pain control.

Anesthesia Research doi: 10.3390/anesthres2030020

Authors: Hielke Markerink Geert-Jan van Geffen Lucas van Eijk Jörgen Bruhn

Background: Topical anaesthesia of the nasal mucosa is essential for comfortable and effective nasal instrumentation. However, current methods often result in uneven anaesthesia, which can cause discomfort. This study evaluates the clinical performance of a newly developed soft mist nasal atomiser (NAA: Nasal Atomiser Adapter) for nasal topical anaesthesia. Methods: Twenty healthy adult volunteers received 1 mL of 4% lidocaine via the NAA in two doses of 0.5 mL each, administered into one nostril. Five minutes after administration, a size 7 nasopharyngeal airway was inserted into the anaesthetised nostril to assess tolerance. Comfort and anaesthetic effectiveness were rated by both participants and the attending anaesthesiologist using numeric rating scales (1–10). Results: The median total spraying time was 177.5 s (range, 152–192 s), which included the 120 s waiting period between the two 0.5 mL doses. Insertion of the nasopharyngeal airway took a median of 8.0 s (range 2–25 s). Participants rated the comfort of nasal lidocaine administration at a median of 9/10, and anaesthesia levels were rated as good to very good by both participants and clinicians. In 85% of cases, no reaction was observed during insertion of the nasopharyngeal airway; minimal reactions occurred in the remaining 15%. No adverse events were reported. Conclusions: The NAA provided effective, reliable, and safe anaesthesia of the nasal cavity, with a high level of comfort for the subject. It enabled fast and comfortable nasal instrumentation. These findings support the NAA as a promising alternative to conventional nasal anaesthetic techniques.

Anesthesia Research doi: 10.3390/anesthres2030019

Authors: Debora Emanuela Torre Silvia Carbognin Domenico Mangino Carmelo Pirri

Cardiac surgery-associated acute kidney injury (CSA-AKI) is the most prevalent clinically significant complication in adult patients undergoing open heart surgery, closely linked to increased mortality and morbidity. Among intensive care unit (ICU) patients, CSA-AKI is the second most common type of acute kidney injury, surpassed only by sepsis-induced AKI. The Doppler-based Renal Resistive Index (RRI) measurement is a rapid and non-invasive diagnostic tool with potential for the early detection of acute kidney injury in intensive care unit patients and could also be useful as an early predictor of acute kidney injury (AKI) in the context of cardiac surgery, particularly when used in conjunction with novel biomarkers.

Anesthesia Research doi: 10.3390/anesthres2030018

Authors: Michelle Wu Brandon Park Xiang-Ping Chu

Nociceptin/orphanin FQ (N/OFQ) is a neuropeptide that activates the nociceptin opioid peptide (NOP) receptor, a G protein-coupled receptor structurally similar to classical opioid receptors but with distinct pharmacological properties. Unlike μ-opioid receptor (MOR) agonists, NOP receptor agonists provide analgesia with a reduced risk of respiratory depression, tolerance, and dependence. This review synthesizes current evidence from molecular studies, animal models, and clinical trials to evaluate the therapeutic potential of the N/OFQ–NOP system in pain management and anesthesia. A literature review was conducted through a PubMed search of English language articles published between 2015 and 2025 using keywords such as “nociceptin,” “NOP receptor,” “bifunctional NOP/MOR agonists,” and “analgesia.” Primary research articles, clinical trials, and relevant reviews were selected based on their relevance to NOP pharmacology and therapeutic application. Additional references were included through citation tracking of seminal papers. Comparisons with classical opioid systems were made to highlight key pharmacological differences, and therapeutic developments involving NOP-selective and bifunctional NOP/MOR agonists were examined. In preclinical models of chronic inflammatory and neuropathic pain, NOP receptor ago-nists reduced hyperalgesia by 30–70%, while producing minimal effects in acute pain as-says. In healthy human volunteers, bifunctional NOP/MOR agonists such as cebrano-padol provided significant pain relief, achieving ≥30% reduction in pain intensity in up to 70% of subjects, with lower incidence of respiratory depression compared with morphine. Sunobinop, another NOP/MOR agent, demonstrated reduced next-day residual effects and a favorable cognitive safety profile. Clinical data also suggest that co-activation of NOP and MOR may attenuate opioid-induced hyperalgesia and tolerance. However, challenges remain, including variability in receptor signaling and limited human trial data. The N/OFQ–NOP receptor system represents a promising and potentially safer target for analgesia and perioperative care. Future efforts should focus on developing optimized NOP ligands, incorporating personalized approaches based on receptor variability, and advancing clinical trials to integrate these agents into multimodal pain management and enhanced recovery protocols.

Anesthesia Research doi: 10.3390/anesthres2030017

Authors: Andrew J. Warburton Randal A. Serafini Adam Von Samek

This case report describes the acute and multidisciplinary management anesthesiologists performed for an intra-operative bronchobiliary fistula during a routine endoscopic retrograde cholangiopancreatography for a patient with intrahepatic cholangiocarcinoma. During the procedure, an unexpected rapid airway deterioration was encountered due to bile infiltration of the right bronchus and anesthesia circuit, necessitating (1) emergent extubation and reintubation with bronchoscopy, (2) extubation and reintubation with double-lumen endotracheal tube with right-bronchial blocker, and (3) transportation of the patient from endoscopy to interventional radiology for biliary drain placement. Overall, this case highlights a rare but serious consideration for patients with intrahepatic cholangiocarcinoma who may present with a bronchobiliary fistula and the steps taken to prevent total airway compromise and ensure rapid patient stabilization through coordination with advanced gastroenterology, interventional pulmonology, and interventional radiology.

Anesthesia Research doi: 10.3390/anesthres2030016

Authors: Paulo Warpechowski Rodrigo B. Warpechowski Barbara A. De Lima Emanuella F. A. Pinto Mariana L. S. Bastos Bruna Eibel Rubens D. Trindade Tiago L. Leiria

Introduction: Propofol is a widely used sedative drug in electrophysiological studies (EPS). However, literature has shown that this drug may interfere with the cardiac conduction system (CCS). Our objective is to evaluate whether propofol interferes with CCS and the inducibility of arrhythmias during EPS. Method: A systematic review and a meta-analysis were performed. The databases were PubMed, Embase, Web of Science, and Scopus. Rayyan software was used to select the studies. Three Mesh terms were used: Propofol, Cardiac arrhythmias, Electrophysiologic Study, and Cardiac. Cohort studies and randomized clinical trials were included. Results: Only one of the six studies showed four cases where it was impossible to induce arrhythmia. We found no significant difference between propofol and the control group in the analyzed variables: cycle length, atrial-His, His-ventricular, corrected sinus node recovery time, atrial effective refractory factor, and ventricular effective refractory period, with low heterogeneity (I2 = 0% to a maximum of I2 = 8%). A significant difference in favor of the control group was found in the analysis of the atrioventricular node effective refractory period (MD:18.67 {95% CI 4.86 to 32.47} p = 0.008, I2 = 44%). Discussion: The meta-analyzed data in this study showed that propofol possibly does not interfere with CCS, making it a safe drug for this type of procedure. Conclusions: However, extra care should be exercised with pediatric patients when the arrhythmia’s mechanism is automatic. More robust studies are still needed in this class.

Anesthesia Research doi: 10.3390/anesthres2030015

Authors: Jonathan S. Jahr Ronald Jubin Zhen Mei Joseph Giessinger Rubie Choi Abe Abuchowski

Background: PP-007 (SANGUINATE®, PEGylated carboxyhemoglobin, bovine) is under development to treat conditions of ischemia/hypoxia. Hemorrhagic/hypovolemic shock (H/HVS) becomes a life-threatening comorbidity due in part to hypotension and hypoxia. Blood transfusions are indicated, but supply and compatibility issues may limit subject access or when blood is not an option due to religious restriction or concern for clinical complications. PP-007 is universally compatible with an effective hydrodynamic radius and colloidal osmotic pressure facilitating perfusion without promoting extravasation. Methods: A review of previous clinical trials was performed and revealed an Open-Label Phase 1 safety study of acute severe anemia (hemoglobin ≤ 5 g/dL) in adult (≥18 y) patients unable to receive red blood cell transfusion (NCT02754999). Primary outcomes included safety events with secondary efficacy measures of organ function and survival at 1, 14, and 28 days. Additionally, a retrospective review of published, peer-reviewed case reports was performed, evaluating the administration of Sanguinate for Expanded Access in those patient populations where blood was not an option over the past 12 years. Results: A total of 103 subjects were enrolled in the Phase I safety study with significant co-morbidities that most commonly included hypertension (n = 43), acute and chronic kidney disease (n = 38), diabetes mellitus (n = 29), gastrointestinal bleeds (n = 18), and sickle cell disease (n = 13). Enrollment characteristics included decreased hemoglobin and severe anemia (mean baseline hemoglobin of 4.2 g/dL). Treatments included an average of three infusions [range 1–17]. Secondary efficacy measures were mean Hb levels, respiratory support, and vasopressor requirements, all demonstrating clinically relevant improvements. Fourteen additional cases were identified in the literature. Though one patient died due to pre-treatment conditions, all patients but one were discharged home in stable condition. Conclusion: Collectively, these observations are encouraging and provide support for the continued evaluation of PP-007 in advanced clinical trials in severe anemia including H/HVS. The review of published case reports underscored the potential of Sanguinate to reduce early mortality. Adverse effects included transient hypertension, lethargy, dizziness, and troponin elevation. These findings highlight the need for continued research and funding of blood alternatives to improve outcomes when standard blood transfusions are unavailable or contraindicated.

Anesthesia Research doi: 10.3390/anesthres2020014

Authors: Iacopo Cappellini Elena Schirru Laura Vannucci Federico Scandagli Vittorio Pavoni

Background/Objectives: Prone positioning is a key strategy to improve oxygenation in ARDS patients, particularly used during the COVID-19 pandemic. However, its impact on visual function remains poorly investigated. This study assesses the effect of prone positioning on self-perceived visual acuity and functional vision in ARDS patients after ICU discharge. Methods: A single-center observational study was conducted at Santo Stefano Hospital (Prato, Italy) from March 2020 to April 2023. We included adult COVID-19 ARDS patients, ventilated invasively, and subjected to at least one prone positioning cycle. Patients with pre-existing visual disorders were excluded. Visual function was evaluated through the CATQUEST-9SF questionnaire administered via telephone follow-up. Rasch analysis was applied to generate a linear visual function scale. Logistic regression was used to identify predictors of reduced visual function. Results: Out of 300 ICU admissions, 182 met the inclusion criteria, and 39 completed the follow-up. Older age (OR 1.148, p < 0.05), female sex (OR 0.066, p < 0.05), and increased number of prone cycles (OR 3.576, p < 0.05) were significantly associated with reduced visual function. The model’s predictive performance was excellent (AUC = 0.8997). Conclusions: Prone positioning improves respiratory outcomes but may have unintended visual consequences. Monitoring visual function should be integrated into ICU follow-up programs to mitigate long-term visual impairment.

Anesthesia Research doi: 10.3390/anesthres2020013

Authors: Katarina Tomulić Brusich Mia Šestan Zdravko Jurilj Ana Čipak Gašparović

Background/Objectives: The management of patients with severe systemic comorbidities undergoing radiologic interventional procedures presents a significant challenge for anesthesiologists. Selecting an appropriate combination of anesthetic drugs is crucial to ensure a safe, painless procedure, facilitate rapid recovery, and minimalize complications. Here, we present a case of a 68-year-old female patient of ASA V status with a history of diabetes, coronary artery disease, and severe chronic obstructive pulmonary disease due to lung emphysema and dependence on a home oxygenator, requiring sedation for CT-guided percutaneous drainage of the aortic graft infection. Methods: After on-site emergent patient preparation and several position adjustments, sedation was initiated and maintained using continuous infusions of remimazolam and esketamine. Results: Throughout the procedure, the patient remained sedated, comfortable, and free of unwanted movements. The patient was hemodynamically stable and maintained oxygen saturation between 92 and 96%. Conclusions: In our opinion, the combination of remimazolam and esketamine demonstrated an effective and safe profile for procedural sedation. This approach holds the potential to influence standard operating protocols, particularly for patients with severe and multiple comorbidities requiring personalized anesthetic management.

Anesthesia Research doi: 10.3390/anesthres2020012

Authors: Ekin Daplan Luca Turin Efthimios M. C. Skoulakis

Objectives: Comparative analyses of anesthetic agents on mutants with altered anesthetic sensitivity remain limited in the current literature. This study examines the sensitivity of various Drosophila melanogaster wild-type strains and mutants to the volatile anesthetics chloroform and isoflurane. We utilized recently identified mutants in ion channel-encoding genes and others historically selected for anesthetic resistance, such as AGAR (autosomal general anesthesia resistant) and har (halothane-resistant). Method: Based on the principles of the conventional inebriometer assay used to isolate these mutants, we developed a new, simpler method to measure the anesthetic response in these flies. Results: Interestingly, we discovered that wild-type flies exhibit varying levels of anesthetic resistance. Contrary to previous reports, AGAR and har mutants showed little resistance to anesthesia using our method. Several ion channel mutants displayed increased resistance or sensitivity. Across all strains, isoflurane was more potent than chloroform. To ensure objectivity, all experiments were conducted double-blind. These findings highlight the variability in anesthetic sensitivity among both wild-type and mutant flies and underscore the importance of assay design in assessing resistance.

Anesthesia Research doi: 10.3390/anesthres2020011

Authors: James Paul Amir Hamid Heung Kan Ma Thomas Kim Lehana Thabane Thuva Vanniyasingam

Background/Objectives: Postoperative delirium has not been well explored in patients undergoing elective hip and knee arthroplasty. This study assessed the incidence of delirium in these patients in the postanesthetic care unit (PACU) and throughout their hospital admission. Predictors of postoperative delirium and impact of delirium on length of stay were also analyzed. Methods: This prospective observational study recruited patients (n = 978) with normal cognitive function presenting for elective primary hip or knee arthroplasty at a single tertiary academic center. Delirium was assessed using the Nursing Delirium Scoring Scale (NuDESC) in the PACU, and twice daily after that on postoperative days 1, 2 and 3, or until discharge, whichever came first. Results: In total, 26 (2.7%) patients developed delirium postoperatively. Unadjusted logistic regression analyses revealed that age; history of cardiovascular, central nervous system, hematologic, endocrinologic, psychiatric disease; postoperative opioid use; and ASA level were associated with an increased risk of delirium, with odds ratios (95% confidence interval) of 1.7 (1.35 to 2.11), 3.6 (1.09 to 12.25), 3.5 (1.53 to 8.03), 2.7 (1.09 to 6.45), 2.3 (1.04 to 4.97), 4.7 (2.10 to 10.70), 0.4 (0.17 to 0.89), and 2.37 (1.05 to 5.33), respectively. A Mann–Whitney U test showed no difference in PACU or hospital length of stay between patients who did and did not have delirium in the PACU (within the first hour). Conclusions: Age, ASA > 3, a history of cardiovascular disease, central nervous system disease, hematologic disease, endocrinologic disease, psychiatric disease and postoperative opioid use are individually associated with postoperative delirium. A future study with an even larger sample size is needed to further evaluate these factors in an adjusted analysis.

Anesthesia Research doi: 10.3390/anesthres2020010

Authors: Edel Rafael Rodea-Montero Magali Yuyitzi Linarte-Guerra Ricardo Garcia-Mora Paulina Millán-Ramos Sergio Manuel Orozco-Ramírez

Introduction: In recent years, a greater number of adults have been undergoing spinal surgery. The main complications in the postanesthetic care unit (PACU) include respiratory and cardiovascular problems, pain, and nausea or vomiting. The aim of this study was to describe the preoperative characteristics and intra-anesthetic management of adult patients who underwent elective spinal surgery with balanced general anesthesia and to identify the predictive factors associated with supplemental oxygen requirement upon discharge from the PACU. In addition, we sought to develop a risk index on the basis of multivariable analysis allowing stratification of the probability of supplemental oxygen requirement upon discharge from the PACU. Materials and Methods: In this cross-sectional, retrospective, observational study, the pre- and intra-anesthetic characteristics of adult patients who underwent spinal surgery at any vertebral level under balanced general anesthesia in a tertiary hospital were retrieved. Descriptive statistics are provided, and comparison (Kruskal–Wallis) or correlation analyses (chi-square) were conducted between the characteristics of the patients grouped according to the need for supplemental oxygen upon discharge from the PACU. Receiver operating characteristic (ROC) curves and a multivariate logistic regression model were generated. All tests were performed at the α = 0.05 level. Results: Among 349 patients initially considered, only 211 were included in the analysis. A total of 45.50% of the patients who underwent spinal surgery under balanced general anesthesia required supplemental oxygen upon discharge from the PACU; these patients had significantly greater age, body mass index (BMI), surgery time, and anesthesia time. In addition, the use of norepinephrine and the use of fentanyl were associated with the need for supplemental oxygen. Our proposed risk index for predicting the need for supplemental oxygen upon discharge from the PACU, according to the implementation of a multivariable logistic model based on three simple variables (age ≥ 48 years, BMI ≥ 26.5, and use of fentanyl infusion), achieved an area under the curve (AUC) of 0.740. Conclusions: Age, BMI, and the use of fentanyl can be used to predict the need for supplemental oxygen upon discharge from the PACU. Multicenter and/or longitudinal studies with large sample sizes are needed to confirm the results of this study and improve the prediction of the need for supplemental oxygen upon discharge from the PACU.

Anesthesia Research doi: 10.3390/anesthres2020009

Authors: Sarah R. Peppard Jayshil J. Patel

Background/Objectives: Propofol is a preferred agent for ICU sedation. Hypertriglyceridemia occurs in up to 45% of patients on propofol and has been linked with adverse effects. Data extrapolated from acute pancreatitis suggests intravenous (IV) insulin infusions may be effective in reducing serum triglyceride (TG) values in patients with propofol-induced elevated TG. The objective is to describe and compare serum TG levels in critically ill patients receiving concomitant insulin infusions and propofol versus propofol alone. Methods: This is a retrospective cohort study of mechanically ventilated adult patients admitted to a medical intensive care unit who received a propofol infusion alone or propofol and IV insulin infusions and who had a minimum of two serum TG levels while on propofol infusion. The primary outcome was median change in the serum TG concentration in patients receiving concomitant propofol and IV insulin infusions, as compared to those receiving propofol alone. Results: A total of 263 patients were screened and 32 met inclusion criteria (16 in each group). The median change between first and last obtained TG level was 0.35 (−0.31–1.33) vs. −0.07 (−1.08–+0.42) mmol/L (p = 0.051) in the propofol vs. propofol and IV insulin groups, respectively. Each day on propofol was associated with an estimated 0.21 mmol/L (95% confidence interval (CI) 0.0.004 to 0.41, p = 0.046) increase in TG, and each additional day of IV insulin was associated with a 0.14 mmol/L (95% CI −0.63 to 0.35, p = 0.571) decrease in TG. Conclusions: Each additional day of propofol was associated with an increase in serum TG levels. IV insulin infusions did not lead to a significant difference in triglyceride values.

Anesthesia Research doi: 10.3390/anesthres2020008

Authors: Jacob Rosenberg Thomas Fuchs-Buder

Background: Neuromuscular blocking agents play an important role in modern anesthesia by facilitating optimal surgical conditions through deep muscle relaxation. Additionally, neuromuscular monitoring and reversal ensure swift and reliable recovery from neuromuscular blockade. The evolution of neuromuscular blocking agents, from early curare derivatives to contemporary agents such as rocuronium and cisatracurium, has significantly enhanced the safety and efficacy of anesthesia. Methods: This review examines the historical development, pharmacological mechanisms, clinical applications, and innovations in managing neuromuscular blockade. Results: It underscores key milestones in the advancement of neuromuscular blockade, including the introduction of neuromuscular monitoring techniques like Train-of-Four, which improve patient safety by reducing residual neuromuscular blockade. Pharmacological advancements, particularly the emergence of sugammadex, have further revolutionized clinical practice by enabling rapid and reliable reversal of steroidal neuromuscular blocking agents. The discussion covers the role of deep neuromuscular blockade in optimizing surgical conditions, especially in minimally invasive procedures. Conclusion: Comparative analyses of standard versus deep blockade reveal potential advantages in certain surgical scenarios, although patient-specific factors and associated risks must be carefully evaluated. Future directions involve developing innovative neuromuscular blocking agents and reversal agents aimed at achieving faster onset, shorter duration, and fewer side effects. The management of neuromuscular blockade continues to evolve, propelled by advancements in pharmacology and monitoring technology. Anesthesiologists should embrace a personalized approach, integrating advanced monitoring tools and customized pharmacological strategies to enhance patient outcomes. Ongoing research into next-generation neuromuscular blocking agents and reversal agents holds the promise of further improving safety and efficiency in anesthesia practice.

Anesthesia Research doi: 10.3390/anesthres2010007

Authors: Hyun Seong Seo Amanda J. Tsao Michael I. Kim Betty M. Luan-Erfe

Background: Language discordance occurs when the patient and the healthcare provider are not proficient in the same language. Language discordance in the critical care setting is a significant global issue because of its implications in the quality of care and outcomes of patients who do not speak the primary language of the country in which they receive healthcare. Studies show that language-discordant, critically ill patients have increased use of restraints during mechanical ventilation, increased length of stay, and more frequent complications. Communication challenges are magnified in the intensive care unit because of the medical complexity and frequent need for challenging conversations regarding goals of care. To address language-based disparities in critical care, numerous qualitative studies in recent years have attempted to understand the barriers that providers face when caring for language-discordant patients. Our systematic review is the first to analyze this developing body of literature and identify barriers for which solutions must be sought to ensure equitable care. Methods: This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, Embase, and Scopus from inception up to 20 February 2024. From among 2150 articles, nine articles were selected, which included eight qualitative studies and one cross-sectional study. Three studies were high quality, five were moderate quality, and one was low quality. Results: We found four major barriers to caring for language-discordant patients in the critical care setting. These included limitations in providers’ knowledge of best practices in professional medical interpreter use, challenges in navigating interpreters’ multiple roles, and limitations with different interpretive modalities and system constraints. These barriers caused clinicians distress due to clinicians’ desire to provide empathic care that respected patients’ autonomy and ensured patients’ safety and understanding. Conclusion: Interventions to increase providers’ knowledge of best practices, integrate interpreters into the critical care team, strategize the use of interpretation modalities, and address system-based barriers are needed to improve the care of language-discordant, critically ill patients worldwide.

Anesthesia Research doi: 10.3390/anesthres2010006

Authors: Alex Hunter Matthew Roche Moheb Robeel Luke Hodgson

Introduction: Cardiopulmonary exercise testing (CPET) is the gold-standard assessment of functional capacity and predicts postoperative outcomes in major abdominal and thoracic surgery, as well as in older individuals undergoing elective surgery for colorectal cancer. However, CPET is resource-intensive and not universally available. Simpler objective assessments of functional capacity, such as Clinical Frailty Scale (CFS) scoring, predict postoperative complications and may be useful in aiding shared decision and perioperative planning. Objectives: This study aimed to assess local cohort data and investigate the association between Clinical Frailty Scoring, CPET outcomes, and length of hospital stay. Methods: We conducted a retrospective cohort analysis of all patients who had received a cardiopulmonary exercise test as part of their preoperative assessment for major abdominal and thoracic surgery between May 2018 and December 2022 in four district general hospitals. Results: This study featured 174 patients, age 73 (mean), CFS 3 (mean), who underwent CPET with associated CFS scoring. The CFS scores were weakly correlated with the anaerobic threshold, VO2 peak, and ventilatory equivalents, coefficients measuring −0.34, −0.36, and 0.31 (all p < 0.001), respectively. Linear regression demonstrated a negative coefficient for the association of CFS with the VO2 peak and the AT, measuring −1.22 and −1.70, respectively, both p < 0.001. The CFS score was not predictive of 1-year mortality in this group. In a subgroup analysis (n = 59), there was no association between the CFS score and the length of stay. Conclusions: Our data suggest a weak relationship between the CFS score and the CPET results. Further investigations with larger prospective datasets are required to explore the use of CFS as a surrogate for CPET and its use as an independent predictor for perioperative outcomes. This study supports the limited literature available on this subject.

Anesthesia Research doi: 10.3390/anesthres2010005

Authors: Richard L. Witkam Jörgen Bruhn Nico Hoogerwerf Rebecca M. Koch Lucas T. van Eijk

Introduction: Difficult airway management is a critical challenge in anesthesia, often necessitating advanced techniques to ensure patient safety. A patient presented with a malignant lesion on the epiglottis, significantly altering the airway anatomy. Flexible rhinolaryngoscopy revealed a laryngeal carcinoma affecting the entire epiglottis, causing thickening and displacement, which suggested the potential for difficult intubation. Methods: Given the expected feasibility of bag-mask ventilation and front-of-neck access, an asleep intubation technique was selected. The combined use of a McGrath video laryngoscope and C-MAC video stylet allowed for fast and easy atraumatic intubation on the first attempt. The anesthetic and surgical course was uneventful. Discussion: This case report highlights the successful use of a combined approach involving a video laryngoscope and video stylet for intubation in a patient with known difficulties in airway management, providing insights into the benefits of enhanced visualization and maneuverability. The rigid design and steerable tip of the C-MAC video stylet provide advantages over traditional flexible optics, offering better maneuverability and reducing the need for a second operator. Although this technique was successful in this case, its use in patients with complex airway pathologies warrants careful preoperative assessment and collaboration with an experienced airway management team.

Anesthesia Research doi: 10.3390/anesthres2010004

Authors: Jeevan Avinassh Ratnagandhi Praghya Godavarthy Mahindra Gnaneswaran Bryan Lim Rupeshraj Vittalraj

Background/Objectives: The rapid development of Large Language Models (LLMs) presents promising applications in healthcare, including patient education. In anesthesia, where patient anxiety is common due to misunderstandings and fears, LLMs could alleviate perioperative anxiety by providing accessible and accurate information. This study explores the potential of LLMs to enhance patient education on anesthetic and perioperative care, addressing time constraints faced by anesthetists. Methods: Three language models—ChatGPT-4, Claude 3, and Gemini—were evaluated using three common patient prompts. To minimize bias, incognito mode was used. Readability was assessed with the Flesch–Kincaid, Flesch Reading Ease, and Coleman–Liau indices. Response quality was rated for clarity, comprehension, and informativeness using the DISCERN score and Likert Scale. Results: Claude 3 required the highest reading level, delivering detailed responses but lacking citations. ChatGPT-4o offered accessible and concise answers but missed key details. Gemini provided reliable and comprehensive information and emphasized professional guidance but lacked citations. According to DISCERN and Likert scores, Gemini had the highest rank for reliability and patient friendliness. Conclusions: This study found that Gemini provided the most reliable information, followed by Claude 3, although no significant differences were observed. All models showed limitations in bias and lacked sufficient citations. While ChatGPT-4o was the most comprehensible, it lacked clinical depth. Further research is needed to balance simplicity with clinical accuracy, explore Artificial Intelligence (AI)–physician collaboration, and assess AI’s impact on patient safety and medical education.

Anesthesia Research doi: 10.3390/anesthres2010003

Authors: Muhammad Aishat Alicia Segovia Throy Campbell Lorrainea Williams Kristy Reyes Tyler Hamby David Farbo Meredith Rockeymoore Brooks Artee Gandhi

Background: While multimodal analgesia is the standard of care for postoperative pain relief, opioid medications continue to be a part of the treatment regimen, especially for more invasive surgeries such as spinal fusion, craniofacial reconstruction, laparotomy, and others. In pediatric patients, safe usage, storage, and dosing are especially important, along with clear instructions to caregivers on how to manage their child’s pain. Combination opioids such as hydrocodone with acetaminophen and acetaminophen with codeine are the most commonly prescribed opioid medications for postoperative pain control. However, these combination products can lead to acetaminophen toxicity, limit the ability to prescribe acetaminophen or ibuprofen, and add to caregiver confusion. Administering acetaminophen and ibuprofen individually rather than in combination products allows the maximal dosing of these nonopioid medications. The primary aim of this quality improvement (QI) project was to increase the utilization of single-agent opioids for postoperative pain control, primarily oxycodone, by the various surgical groups here at Cook Children’s Medical Center (CCMC). Methods: The project setting was a tertiary-level children’s hospital with a level 2 trauma center, performing over 20,000 surgeries annually. The opioid stewardship committee (OSC) mapped the steps and overlapping activities in the intervention that led to changes in providers’ prescription practices. A Plan–Do–Study–Act continuous improvement cycle allowed for an assessment and modification of implementation strategies. Statistical control process charts were used to detect the average percentage change in surgical specialties using single-agent opioid therapy. Data were monitored for three periods: one-year pre-intervention, one-year post-intervention, and one-year sustainment periods. Results: There were 4885 (41%) pre-intervention procedures, 3973 (33%) post-intervention procedures, and 3180 (26%) sustainment period procedures that received opioids. During the pre-intervention period, the average proportion of single-agent opioids prescribed was 8%. This average shifted to 89% for the first five months of the post-intervention period, then to 91% for the remainder of the study. Conclusions: The methodical application of process improvement strategies can result in a sustained change from outpatient post-surgical combination opioid prescriptions to single-agent opioid prescriptions in multiple surgical departments.

Anesthesia Research doi: 10.3390/anesthres2010002

Authors: Julia Alexandra Simons Steffen B. Wiegand Lisa Thiehoff Patrick Winnersbach Gereon Schälte Anna Fischbach

Background: In Germany, over 16 million pre-anesthesia consultations (PAC) are conducted annually, which is associated with a significant investment of time and high costs. However, some PACs do not lead to surgery, which is inefficient and results in wasted resources. This study evaluates the costs and time loss associated with PACs that did not result in anesthesia-required surgery or diagnostic procedures and identifies the predictors of these cancellations. Methods: A total of 1357 PACs conducted in September 2023 at the University Hospital Aachen were retrospectively analyzed. The study groups included patients whose PACs resulted in anesthesia-required surgery or diagnostic procedures (SURG group) and those whose PACs did not (NoSURG group). The primary outcomes were costs in EUR and the hours lost due to PACs not resulting in anesthesia for patients in the NoSURG group, and the secondary outcomes included the predictors of surgery cancellations, the frequency of missing test results, necessary pre-anesthesia re-consultations due to missing tests, and hospital length of stay for NoSURG patients. Results: In September 2023, 7.3% (99/1357) of PACs did not result in anesthesia-required procedures. ASA scores were higher in the NoSURG group, with almost two-thirds classified as ASA III or higher (p = 0.001). The NoSURG group had more planned postoperative IMC stays (16.2% vs. 9.3%; p = 0.027) and fewer medical report letters available (50.5% vs. 97.1%; p < 0.001). The reasons for surgery cancellation were often undetermined (47.5%). Other reasons included surgeons opting for a conservative approach (19.2%), patient decisions (9.1%), surgery no longer indicated (8.1%), hospital capacity constraints (5.1%), patient transfers (3.0%), and high surgical risk (8.1%). The annual projected cost for the NoSURG group was EUR 29,182, with 888 h of time loss. The median hospital length of stay for the NoSURG group was 5 (2; 15) days. Conclusions: PACs that were carried out but were not followed by anesthesiology services led to substantial costs and time loss. Improving medical report availability and assessing procedure necessity beforehand might help to reduce these expenses and time losses.

Anesthesia Research doi: 10.3390/anesthres2010001

Authors: Rakesh P. Patel Joo-Yeun Oh Karina Ricart Fazlur Rahman Kristal M. Hock Royal R. Smith Jack H. Crawford

Background/Objectives: Hemolysis has been associated with acute kidney injury (AKI) in infants and neonates after surgery involving cardiopulmonary bypass (CPB). Erythrocyte hemolysis and subsequent end-organ injury have been shown to be a complex process involving the liberation of multiple molecules that mediate the loss of nitric oxide and oxidative damage. This study assesses the association of multiple products of erythrocyte hemolysis with the evolution of AKI in neonates and infants undergoing CPB surgery. Methods: Blood and urine samples were collected at multiple time points before and after CPB and stored within an institutional biorepository. Twenty-one patients with AKI were matched with twenty-one non-Aki patients based on demographic and case complexity data. Results: Samples were analyzed for cell-free hemoglobin, heme, non-transferrin-bound iron, haptoglobin, hemopexin, and nitrite/nitrate. NGAL and KIM-1 were measured to index AKI. Cell-free hemoglobin was higher, haptoglobin was lower, and haptoglobin:hemoglobin ratio was lower in AKI compared to non-AKI patients. Conclusions: AKI in neonates and infants after CPB is associated with a pre and postoperative decrease in serum haptoglobin. These results confirm the need for future studies to prevent injury from hemolysis during CPB and potentially identify at-risk patients with decreased haptoglobin levels before surgery if delay is an option.

Anesthesia Research doi: 10.3390/anesthres1030022

Authors: Robin Peter Alston Ida Pui Ka Ho Cameron Semple Nayandra Sooraj

(1) Background: chronic pain following thoracic surgery is associated with dysaesthesia, which may be caused by intraoperative damage to intercostal nerves. This study’s primary aim was to compare, in the early postoperative period, the total area of dysaesthesia on the operated vs. the non-operated side of the thorax. Our secondary aims were to compare the total area of dysaesthesia between thoracotomy and video-assisted thoracic surgery (VATS) and to determine whether the area was associated with acute pain. (2) Methods: adult patients undergoing thoracic surgery underwent sensory examinations of the thorax using a monofilament and pin. Identified areas of hypoalgesia, hyperalgesia, allodynia and hypoaesthesia were marked on the skin, then copied onto tracing paper. Areas of dysaesthesia were estimated by weighing the cut-out, traced areas of paper and multiplying the weights by the paper’s known weight per area. Acute pain was assessed using a verbal rating score. (3) Results: the total area of dysaesthesia on the operated side [89 interquartile range (IQR) 8–167) cm2] was significantly greater than the non-operated side [0 (IQR 0–22) cm2] (p = 0.017), but not significantly different between thoracotomy [126 (IQR 16–392) cm2] and VATS [79 (IQR 4–161) cm2] (p = 1.0).The total area of dysaesthesia was not significantly correlated with acute pain severity after inspiration (r = 0.1, p = 1) or at rest (r = 0.1 p = 0.6). Conclusions: in the early postoperative period, thoracic surgery was associated with a larger total area of dysaesthesia on the operated compared to the non-operated side and the area was unrelated to acute pain, nor was it different between thoracotomy and VATS.

Anesthesia Research doi: 10.3390/anesthres1030021

Authors: Roets Michelle David Sturgess Melinda Dean Andre Van Zundert Jonathen H. Waters

Background: In this manuscript, the challenges encountered during research into patient outcomes following transfusion during spine surgery are explored. Method: A narrative review of transfusion research over decades. Results: An estimated 310 million major surgeries occur in the world each year, and 15% of these patients experience serious adverse outcomes (the United States of America, n 5,880,829). Many adverse outcomes are associated with allogeneic blood transfusion (ABT) and are potentially avoided by intraoperative cell salvage (ICS). The incidence of perioperative transfusion in patients who undergo spine surgery varies between 8 and 36%. Conclusions: Knowledge gaps remain due to the complexity of the field of study, confounding factors, the inability to define optimal transfusion triggers, challenges countered in study design, requirements for large sample sizes, and the inability to conduct randomised controlled trials (RCTs). The surgical complexity, subtle patient factors, and differences in policies and procedures across hospitals and countries are difficult to define and add further complexity. Solutions demand well-designed prospective collaborative research projects.

Anesthesia Research doi: 10.3390/anesthres1030020

Authors: George Leonard Ettel James Allen Hughes Kelly Nicole Drago Eric Francis-Jerome Jotch

Background/Objective: POCUS is an invaluable tool for anatomical variation assessment, guidance of invasive interventions, and diagnosis of critical conditions that may change the anesthesiologist’s plan of care. This technology increases success rate, decreases time to surgery, and maximizes outcomes. The objective of this pilot program evaluation was to identify the anesthesiologists’ systems and processes for utilizing POCUS in clinical decision-making for patients during the perioperative phases of care for improved outcomes. Materials/Methods: A Multivariate Analysis of Variance (MANOVA) was conducted to identify differences across groups (scan type). The independent variable was the type of POCUS examination. The dependent variables included the patient’s: (1) Perioperative Status; (2) Cardiothoracic Anesthesiologist’s Review of Patient History and Formulating the Clinical Question; (3) Overall Risk Potential; (4) Aspiration Potential; (5) Issues Related to Cardiovascular Hemodynamics; (6) Issues Related to Volume Status; (7) Clinical Question Answered by POCUS; (8) Change in Plan of Care; (9) Interventions; and (10) Pharmacological Interventions. Results: MANOVA findings (Wilks’ λ) identified a statistically significant interaction between POCUS scan type and the cardiothoracic anesthesiologist’s clinical decision-making (p < 0.0001). The following four criteria were statistically significant: (1) patients (64%) were examined with POCUS preoperatively (p < 0.05); (2) patients (95%) identified as having some type of overall risk potential (p < 0.05); (3) patients (36%) specifically identified as an aspiration risk (p < 0.0001); and (4) patients (41%) identified with issues related to cardiovascular hemodynamics (p < 0.001). Conclusions: POCUS is a proven imaging modality that is easy, portable, sensitive, and specific for identifying various anatomical landmarks. POCUS utilization in the perioperative setting has potential to have a profound impact on successful surgical completion.

Anesthesia Research doi: 10.3390/anesthres1030019

Authors: Nobuyasu Komasawa

Thoracic surgery is a highly complex field requiring collaboration between surgeons, anesthesiologists, pulmonologists, and other specialists. Successful outcomes depend on thorough preoperative evaluations that consider the patient’s overall health, lifestyle habits, and surgical risks. Key elements include proper intraoperative anesthesia management, postoperative pain control, and the integration of enhanced recovery after surgery (ERAS) protocols to optimize recovery. Double-lumen tubes (DLTs) are essential for one-lung ventilation during thoracic procedures, although they can be invasive. Recent advancements, such as video-assisted laryngoscopes, have improved the success of DLTs and reduced the invasiveness of DLT intubation and extubation. Postoperative pain management is crucial for minimizing complications and enhancing recovery. Techniques like epidural analgesia, nerve blocks, and patient-controlled analgesia improve patient outcomes by allowing early mobility and deep breathing. Dexmedetomidine (DEX), a sedative with minimal respiratory impact, has shown promise in reducing delirium and aiding recovery. This review highlights the importance of teamwork, pain management, and emerging technologies in improving thoracic surgery outcomes. Advances in these areas, particularly within ERAS protocols, continue to enhance patient care and overall surgical success.

Anesthesia Research doi: 10.3390/anesthres1030018

Authors: Samantha A. Miller Salma Farag Karen L. Cobos Xiangyu Long Nivez Rasic Laura Rayner Catherine Lebel Melanie Noel Andrew Walker Jillian V. Miller

Background: Approximately 25% of adolescents live with chronic pain, with many reporting symptoms of functional impairment and poor sleep quality. Both chronic pain and poor sleep quality can negatively impact brain functional connectivity and efficiency. Better sleep quality may improve pain outcomes through its relationship with brain functional connectivity. Methods: This pilot prospective cohort study used data from 24 adolescents with chronic pain (aged 10–18 years) participating in an Intensive Interdisciplinary Pain Treatment (IIPT) at the Alberta Children’s Hospital. Data were collected within the first couple of weeks prior to starting IIPT and on the last day of the 3-week IIPT program. Sleep quality was assessed using the modified Adolescent Sleep-Wake Scale. Resting-state functional MRI data were obtained, and graph-theory metrics were applied to assess small-world brain networks. Questionnaires were used to obtain self-reported functional disability data. Paired t-tests were applied to evaluate changes in outcomes from pre- to post-IIPT, and moderation analyses were used to examine the relationships between sleep, small-world brain network connectivity, and functional disability. Results: Total sleep quality (p = 0.005) increased, and functional disability (p = 0.020) decreased, between baseline and discharge from IIPT. Small-world brain networks did not change pre- to post-IIPT (p > 0.05). Unlike adolescents with high small-worldness (p = 0.665), adolescents with low to moderate small-world brain characteristics (1SD below or at the mean) who reported better sleep quality reported less functional disability (all p ≤ 0.001) over time. Conclusions: The IIPT program was associated with improvements in sleep quality and functional disability. Better sleep quality together with greater small-worldness was associated with less pain-related disability. This suggests that it is equally important for IIPTs to target sleep problems in adolescents with chronic pain, as this may have a key role in producing long-term improvements in pain outcomes.

Anesthesia Research doi: 10.3390/anesthres1030017

Authors: Antonio Fioccola Ana Marta Pinto Rachel Nolan Ross Free Wajeeha Tariq Tommaso Pozzi Gianluca Villa Alessandro Di Filippo Stefano Romagnoli Omar Tujjar

Background: Meta-analyses and randomized controlled trials were inconclusive regarding the role of gabapentinoids in patients undergoing joint arthroplasties. The aim of the present study was to investigate the effect of a preoperative low dose of gabapentin in patients undergoing total hip (THA) and knee arthroplasties (TKA). Methods: A retrospective observational study was conducted on 135 patients undergoing THA and TKA at the National Orthopedic Hospital Cappagh, Dublin, from July to December 2022. The primary outcome was the assessment of numerical rating scores (NRS) for postoperative pain at various time intervals. Results: During the observation period, 55 patients received a preoperative dose of gabapentin, while 80 patients did not. Statistically significant differences in numerical rating scores (NRS) were found at 6 (3 vs. 0, p < 0.001), 12 (4 vs. 2, p < 0.001), 18 (4 vs. 3, p < 0.001), and 24 h (4 vs. 3, p = 0.010) after surgery, in favor of the group receiving gabapentin. A reduction in opioid consumption, measured as morphine equivalents, was also noted in the gabapentin group (40 vs. 30 mg, p = 0.040). Conclusions: A low preoperative dose of gabapentin was associated with reduced postoperative pain and opioid consumption in patients undergoing TKA and THA, without impacting hospital stay. Prospectively designed trials are encouraged to assess the safety and effect on pain control of a preoperative low dose of gabapentin.

Anesthesia Research doi: 10.3390/anesthres1030016

Authors: Iacopo Cappellini Elena Schirru

Background: Climate change has been identified as the greatest global health threat of the 21st century, with the healthcare sector contributing approximately 4–5% of global greenhouse gas (GHG) emissions. Within this sector, anesthetic practices are significant contributors due to the use of inhaled anesthetic gases such as desflurane, sevoflurane, and isoflurane, which possess high Global Warming Potentials (GWPs) and long atmospheric lifetimes. As concerns over climate change intensify, the anesthesia community must reassess its practices and adopt more sustainable approaches that align with environmental goals while maintaining patient safety. Methods: This manuscript reviews the environmental impacts of commonly used anesthetic gases and explores sustainable strategies, including the adoption of anesthetics with lower GWPs, enhancement of recycling and waste reduction methods, transition to intravenous anesthesia, and implementation of low-flow anesthesia techniques. Barriers to these strategies, such as technological limitations, resistance to change, policy restrictions, and educational gaps within the anesthesia community, are also examined. Results: The analysis indicates that transitioning to anesthetics with lower GWPs, such as replacing desflurane with sevoflurane and employing low-flow anesthesia, can significantly reduce GHG emissions. Although recycling and waste reduction pose logistical challenges, they offer additional environmental benefits. Transitioning to intravenous anesthesia can eliminate direct GHG emissions from volatile anesthetics. However, overcoming barriers to these strategies requires comprehensive education, advocacy for research and innovation, strategic change management, and supportive policy frameworks. Conclusions: Continuous monitoring and evaluation are essential for the success of sustainable practices in anesthesia. Establishing robust Key Performance Indicators (KPIs) and leveraging advanced analytical tools will enable adaptation and refinement of practices within the anesthesia community. Collaborative efforts among clinicians, policy makers, and stakeholders are crucial for reducing the environmental impact of anesthesia and promoting ecological responsibility within healthcare.

Anesthesia Research doi: 10.3390/anesthres1030015

Authors: Viet Tran James Whitfield Natasha Askaroff Giles Barrington

Background: Procedural sedation and analgesia (PSA) is commonly performed in emergency departments (EDs) to reduce anxiety, discomfort, or pain during a procedure. The primary goal of PSA is to produce a state of relaxation and drowsiness without eliminating the patient’s protective reflexes. Despite the discovery of new techniques and medications to deliver PSA, there is a paucity of research evaluating PSA in EDs over the last decade. We aim to describe the current practice of PSA in an Australian tertiary mixed ED with 75,000 presentations per year. Methods: A retrospective study of the initial 3 months of a PSA registry, which was part of the Tasmanian Emergency Care Outcomes Registry, was analyzed; Results: All told, 80 consecutive cases were entered over a 3-month period, with pediatric patients (<14 years old) making up 35% of all cases. Joint reductions (17, 39%) and fracture reductions (13, 29%) were the most common indications for the adult population, whilst fracture reductions (9, 36%), laceration repairs (7, 28%), and other distressing procedures (7, 28%) were the most common indications in the pediatric cohort. Pharmacological approaches also differed between groups, with ketamine (25, 92%) preferred in the pediatric cohort whilst the combination of propofol and fentanyl (22, 42%) was preferred in the adult cohort. No adverse events were recorded in the pediatric cohort whilst 6 (8%) minor events occurred in the adult population, with no severe events occurring for either cohort. PSA also occurred more frequently at 0900–1000 and the incidence was reduced between 0000 and 0800. Conclusions: PSA is commonly performed in our tertiary mixed ED and is both safe and effective, with non-severe complication rates similar to those in the reported literature. Severe complications are rare and therefore a larger cohort will be required to assess this aspect. The approach to ED PSA is also different between pediatric and adult populations and therefore research needs to differentiate both populations.

Anesthesia Research doi: 10.3390/anesthres1020014

Authors: Loizos Roungeris Guram Devadze Christina Talliou Panagiota Griva

Background: Lung resection is the primary treatment option for many patients with lung cancer; however, it is a high-risk surgery with many potentially lethal perioperative complications. The aim of this review is to examine the capability of forced expiratory volume in one second (FEV1), diffusing capacity of the lung for carbon monoxide (DLCO), maximal oxygen uptake in exercise (VO2max), and maximal inspiratory and expiratory pressures (PImax and PEmax, respectively) to predict postoperative lung function. Methods: A literature review was performed using PubMed and the Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) guidelines. The research included articles after 2000. Experimental studies on animals, studies before 2000, and studies in a language other than English were excluded. Results: A total of 11 studies were included in this review. The main findings were highlighted. In addition, the optimal threshold values of FEV1, DLCO, VO2max, and PImax as well as PEmax were discussed. Conclusions: Preoperative FEV1, DLCO, VO2max, and PImax as well as PEmax have all proven to be independent risk factors for the prediction of postoperative morbidity, mortality, and cardiopulmonary complications after lung resection surgery.

Anesthesia Research doi: 10.3390/anesthres1020013

Authors: Francesca Innocenti Vittorio Palmieri Riccardo Pini

Sepsis is a complex syndrome with heterogeneous clinical presentation and outcome, characterized by an abnormal inflammatory response, potentially leading to multiorgan damage and hemodynamic instability. Early resuscitation with fluids and timely control of the source of sepsis are key treatment targets in septic patients. Recommendations on when to add vasopressors and inotropes are mostly empirical and anecdotal, therefore remaining a topic of debate. This narrative review was developed to present and discuss current options in the early management of hemodynamic derangement induced by sepsis. We discuss the strengths and drawbacks of the recommended treatment with fluids and how to optimize volume resuscitation in order to avoid fluid overload or under-resuscitation. The choice and timing of vasopressor use represent hot topics in the early management of septic patients. We describe the advantages and limitations of the early introduction of vasopressors and new catecholamine-sparing strategies. We conclude with a description of the inotropes, considering that the heart plays a key role in the pathophysiology of septic shock.

Anesthesia Research doi: 10.3390/anesthres1020012

Authors: Risako Chida Sana Yamaguchi Syogo Utugi Yukito Sashide Mamoru Takeda

Although astaxanthin (AST) has demonstrated a modulatory effect on voltage-gated Ca2+ (Cav) channels and excitatory glutamate neuronal transmission in vitro, particularly on the excitability of nociceptive sensory neurons, its action in vivo remains to be determined. This research sought to determine if an acute intravenous administration of AST in rats reduces the excitability of wide-dynamic range (WDR) spinal trigeminal nucleus caudalis (SpVc) neurons in response to nociceptive and non-nociceptive mechanical stimulation in vivo. In anesthetized rats, extracellular single-unit recordings were carried out on SpVc neurons following mechanical stimulation of the orofacial area. The average firing rate of SpVc WDR neurons in response to both gentle and painful mechanical stimuli significantly and dose-dependently decreased after the application of AST (1–5 mM, i.v.), and maximum suppression of discharge frequency for both non-noxious and nociceptive mechanical stimuli occurred within 10 min. These suppressive effects persisted for about 20 min. These results suggest that acute intravenous AST administration suppresses the SpVc nociceptive transmission, possibly by inhibiting Cav channels and excitatory glutamate neuronal transmission, implicating AST as a potential therapeutic agent for the treatment of trigeminal nociceptive pain without side effects.

Anesthesia Research doi: 10.3390/anesthres1020011

Authors: Richard L. Witkam Jörg Mühling Rebecca Koch Jörgen Bruhn Lucas T. van Eijk

The C-MAC video stylet (Karl Storz KG, Tuttlingen, Germany) is proposed as a successor to the familiar retromolar intubation endoscope. With its flexible tip, it may be especially useful for patients with a limited mouth opening. An awake or sedated airway management technique is often preferred when a difficult airway is anticipated. Due to the challenges in preparation, sedation, topical airway anesthesia and the execution of such an airway management technique itself, these techniques are often clinically underused. The C-MAC video stylet seems to be well suited for an awake or sedated airway approach, as its handling is easier and faster than a flexible fiberscope. It does not exert pressure on the tongue as direct laryngoscopy or video laryngoscopy do. We report two cases of a difficult airway in which intubation was performed by using the C-MAC video stylet in sedated, spontaneously breathing patients. After a low dose of 3 mg midazolam IV, remimazolam was administered continuously (0.46–0.92 mg/kg/h). This was supplemented with a low dose of remifentanil (0.04–0.05 µg/kg/min). The Trachospray device (MedSpray Anesthesia BV, Enschede, The Netherlands) was used for topicalization of the upper airway by means of 4 mL of lidocaine 5%. In addition, a further 5 mL of lidocaine 5% was sprayed via an epidural catheter advanced through the oxygenation port of the C-MAC video stylet for further topicalization of the vocal cords and proximal part of the trachea. The well-coordinated steps described in these two cases may represent a blueprint and a good starting point for future studies with a larger number of patients.

Anesthesia Research doi: 10.3390/anesthres1020010

Authors: Debora Emanuela Torre Carmelo Pirri

Background: Neurological injury poses a significant challenge in aortic surgery, encompassing spinal cord injury from thoraco-abdominal aorta intervention or stroke post-surgery on the arch and ascending aorta. Despite ample literature and proposals, a fully effective strategy for preventing or treating neurological injury remains elusive. This narrative review aims to analyze the most common neuroprotective strategies implemented for aortic arch surgery and aortic surgery. Results: Results from the reviewed studies showed that several strategies, including deep hypothermia cardiac induction (DHCA) and cerebral perfusion techniques (retrograde cerebral perfusion, RCP, and selective anterograde cerebral perfusion, SACP) aim to mitigate these risks. Monitoring methods such as electroencephalogram (EEG), somatosensory evoked potential (SEPs), and near-infrared spectroscopy (NIRS) offer valuable insights into cerebral function during surgery, aiding in the management of hypothermia and perfusion. Pharmacological agents and blood gas management (pH stat vs. alpha stat, hematocrit level, glycemic control) are crucial in preventing post-operative complications. Additionally meticulous management of atheromatous debris is essential to minimize embolic risks during surgery. Methods: For this narrative review, PubMed, Scopus, and Medline have been used to search articles about neuroprotection strategies in aortic and aortic arch surgeries. The search was narrowed to articles between 1975 and 2024. A total of 3418 articles were initially identified to be potentially relevant for this review. A total of 66 articles were included and were found to match the inclusion criteria. Conclusions: While an overabundance of neuroprotection strategies exists for cardiac surgery, particularly in procedures involving the aorta and the arch, their efficacy varies, with some well-documented and others still under scrutiny. Further research is imperative to advance our comprehension and refine prevention techniques for cardiac-surgery-related brain injury. This is crucial given its substantial contribution to both mortality and, notably, post-operative morbidity.

Anesthesia Research doi: 10.3390/anesthres1020009

Authors: Olivia Nelson Lezhou Wu Jessica A. Berger Ian Yuan Asif Padiyath Paul A. Stricker Fuchiang Rich Tsui Allan F. Simpao

Background: Infants are at risk of cerebral hypoperfusion from low blood pressure during anesthesia. We conducted a retrospective observational study to determine the patient and perioperative factors associated with low systolic blood pressure (SBP) in healthy infants. Methods: We obtained perioperative data of 266 infants aged 0–6 months who underwent inguinal hernia repair between January 2015 and March 2019 at our institution. SBP was analyzed during two phases: the preparation phase (20 min before procedure start until incision) and the surgical phase (15 to 35 min after procedure start). Low SBP was defined as a value lower than two standard deviations below the 50th percentile for a phase- and weight-specific reference value. Results: Low SBP was observed in 11% (29/265) and 5% (13/259) of patients during the preparation and surgical phases, respectively. Neuromuscular blockade use was associated with normal SBP in both phases (regression coefficient β = 6.15 and p = 0.002, regression coefficient β = 6.52 and p < 0.001, respectively). SBP was more strongly associated with weight than with age (ratio of adjusted standardized regression coefficient = 2.0 in both phases). After controlling for covariates, patients given neuromuscular blockade had significantly fewer low SBP measurements during the preparation phase (regression coefficient β = −1.99 and p < 0.001). Conclusions: With respect to patient factors, in healthy infants under general anesthesia, weight was more strongly associated with SBP than age. A neuromuscular blocking agent administered during anesthesia induction was associated with fewer low SBP measurements in the preparation phase.

Anesthesia Research doi: 10.3390/anesthres1020008

Authors: Eliodoro Faiella Elva Vergantino Domiziana Santucci Amalia Bruno Giuseppina Pacella Vincenzo Panasiti Bruno Beomonte Zobel Rosario Francesco Grasso

Digital mucous cysts (DMCs) are common soft tissue tumors affecting interphalangeal joints. Various treatment options exist, with surgical excision being the standard. Ultrasound-guided cortisone (CC) injection into the distal interphalangeal (DIP) joint has been proposed as a therapeutic alternative. This study aims to assess the technical success and clinical efficacy of US-IPI in terms of swelling resolution and pain control. Fifty-two patients with DMCs underwent CCs DIP joint ultrasound-guided infiltration. Eighty-three percent of patients exhibited a positive response to US-IPI, with a significant reduction in NRS pain scores (p < 0.01). Persistent pain in 17% of patients was effectively managed with marked improvement after a secondary infiltration. Joint swelling was reduced in 68% of patients within 1 month, with complete resolution by 3 to 6 months. No recurrence was reported at the 6-month follow-up. Pain assessment using the Numeric Rating Scale and joint swelling evaluation were conducted at follow-ups of 2 weeks, 1, 3, and 6 months. Statistical analysis was performed to compare pre- and post-procedure NRS pain scores. Here, we show that US-IPI of DMCs is an effective therapeutic option that provides immediate pain relief and long-term aesthetic improvement, resulting in an alternative option to surgical excision.

Anesthesia Research doi: 10.3390/anesthres1020007

Authors: Devon M. O’Brien Anahat K. Dhillon Betty M. Luan-Erfe

Background: Pediatric intensive care units (ICUs) face shortages of intensivists, posing challenges in delivering specialized care, especially in underserved regions. While studies on telecritical care in the adult ICU have demonstrated decreased complications and mortality, research on telemedicine in the pediatric ICU setting remains limited. This systematic review evaluates the safety and efficacy of audiovisual telemedicine in pediatric ICUs, assessing patient-centered outcomes when compared to in-person intensivist care. Methods: Two reviewers independently assessed studies from PubMed, MEDLINE (Ovid), Global Health, and EMBASE on the pediatric population in the ICU setting that were provided care by intensivists via telemedicine. Studies without a comparison group of in-person intensivists were excluded. Selected studies were graded using the Newcastle–Ottawa scale and the Levels of Evidence Rating Scale for Therapeutic Studies. Results: Of the 2419 articles identified, 7 met the inclusion criteria. Strong evidence suggested that telemedicine increases access to intensive care. Moderate evidence demonstrated that telemedicine facilitates real-time clinical decision-making, reliable remote clinical assessments, improved ICU process measures (i.e., days on a ventilator, days on antibiotics), and decreased length of stay. Weaker evidence supported that telemedicine decreases complications and mortality. Conclusions: Telemedicine may serve as a promising solution to pediatric ICUs with limited intensivist coverage, particularly in low-resource rural and international settings.

Anesthesia Research doi: 10.3390/anesthres1020006

Authors: Zachary E. Stewart Ronald W. Mercer Steven Staffa F. Joseph Simeone Ambrose J. Huang

Transforaminal epidural steroid injections are commonly used for the treatment of radicular pain. Some providers opt for an antero-superior approach and others a postero-inferior approach. In this retrospective cohort study, we evaluated MRI evident anatomic differences between the antero-superior and postero-inferior neural foramen at L5-S1 that may be relevant when choosing an approach for injections. A total of 29 L5-S1 neural foramina that were targeted for transforaminal epidural steroid injections were included. Pre-procedure MRIs were assessed for the distribution of the fat within the foramen. Additionally, the presence of foraminal vessels and foraminal stenosis and the presence/absence of anterolisthesis was also observed. Final imaging data were obtained by majority opinion of three or four radiologists. There was a statistically significant difference in the distribution of foraminal fat between the postero-inferior foramen and the antero-superior foramen (p < 0.001), with more fat generally in the postero-inferior foramen. Foraminal vessels were not consistently visualized. There was weak inter-reader reliability for the presence of vessels. In conclusion, this study suggests that there is a difference in the distribution of foraminal epidural fat between the postero-inferior and antero-superior foramen at L5-S1. Through MRI, vessels are inconsistently visualized and cannot be reliably detected on conventional MRI between readers.

Anesthesia Research doi: 10.3390/anesthres1010005

Authors: Nobuyasu Komasawa

This article examines the intersection of simulation-based education and the AI revolution in anesthesia medicine. With AI technologies reshaping perioperative management, simulation education faces both challenges and opportunities. The integration of AI into anesthesia practice offers personalized management possibilities, particularly in preoperative assessment and monitoring. However, the ethical, legal, and social implications necessitate careful navigation, emphasizing patient data privacy and accountability. Anesthesiologists must develop non-technical skills, including ethical decision-making and effective AI management, to adapt to the AI era. The experience-based medical education (EXPBME) framework underscores reflective learning and AI literacy acquisition, fostering lifelong learning and adaptation. Learner-centered approaches are pivotal in anesthesia education, promoting active engagement and self-regulated learning. Simulation-based learning, augmented by AI technologies, provides a dynamic platform for technical and non-technical skills development. Ultimately, by prioritizing non-technical skills, embracing learner-centered education, and responsibly leveraging AI technologies, anesthesiologists can contribute to enhanced patient care and safety in the evolving perioperative landscape.

Anesthesia Research doi: 10.3390/anesthres1010004

Authors: Marceli Lukaszewski Kamil Nelke

Introduction: Monitoring cerebral perfusion in patients with brain injury is a major clinical challenge. Monitoring cerebral oxygenation (rSO2) via NIRS was introduced in the early 1980s, and many clinicians believed it to be a valuable method for assessing cerebral perfusion and subsequent measures to optimize cerebral flow. The main problem with the use of NIRS is the presence of intermediate structures—the skin, skull, meninges, cerebrospinal fluid—and their influence on the test result. Therefore, it seems that NIRS assessment performed on a patient during brain death can give an idea of the magnitude of the influence of these intermediate structures on the monitoring result. Case presentation: We present a case study of cerebral oxygenation measurements in a patient undergoing a brain death diagnostic procedure. A clinical situation in which cerebral blood flow is stopped can give an idea of the specificity of this method, in particular of the influence of intermediate structures on the monitoring result. In this case, the result obtained using NIRS is increased by the patient’s oxygenation before the apnea test. The influence of chromophores in the tissues surrounding the CNS and reflections and scattering of the light wave spectrum have a very significant effect on the final result of cerebral saturation measurement. Discussion: The majority of observations in existing research describing changes in cerebral perfusion or its optimization may be burdened by the problem described here, i.e., by the significant influence of measured intermediate structure oxygenation. The specificity of NIRS in assessing cerebral perfusion requires careful analysis. The therapeutic implications of monitoring cerebral oxygenation with NIRS are of great importance, and based on the example presented and the literature provided, this method should be used with caution. It has been shown that in a patient with brain death, the result of NIRS oxygenation measurements depends on the structures surrounding the brain.

Anesthesia Research doi: 10.3390/anesthres1010003

Authors: Hui-Shan Pan Tiffany Corey Hsiang-Ning Luk Jason Zhensheng Qu Alan Shikani

The purpose of this case series report is to demonstrate the current state of the art regarding tracheal intubation of an evoked electromyography-endotracheal tube (EMG-ET tube) for continuous intraoperative recurrent laryngeal nerve monitoring (IONM) in patients undergoing thyroid surgery. Both direct laryngoscopy (DL) and videolaryngoscopy (VL) are popular for routine tracheal intubation of an EMG-ET tube. A new intubating technique (styletubation), using a video-assisted intubating stylet (VS), provides less traumatic and swift intubation. Styletubation combined with VL ensures the precise placement of the EMG-ET tube. This novel intubation technique improves the outcome of intubating an EMG-ET tube for IONM.

Anesthesia Research doi: 10.3390/anesthres1010002

Authors: Iacopo Cappellini Laura Campiglia Lucia Zamidei Guglielmo Consales

Background: Electrical impedance tomography (EIT) is a non-invasive, radiation-free imaging method that enables the continuous bedside monitoring of regional ventilation and lung volume changes. The technique is based on the estimation of the resistivity changes that occur across the lungs with breathing. Methods: We present two case reports of patients affected by acute respiratory distress syndrome successfully managed with prone-positioning-based regional ventilation shown on EIT. Results: Both patients were submitted to cycles of prone-positioning-guided EIT and were successfully extubated and discharged from intensive care unit. Conclusions: EIT is a functional imaging method that has the potential to improve respiratory care by providing real-time, continuous monitoring of regional ventilation and lung volume changes at the bedside. Further research is needed to evaluate its efficacy in different clinical scenarios and to optimize its use in respiratory care.

Anesthesia Research doi: 10.3390/anesthres1010001

Authors: Marco Ranucci

Anesthesia Research (ISSN 2813-5806) is the new open-access journal published by MDPI [...]