Enhanced recovery after surgery (ERAS) is a structured, evidence-based, multimodal perioperative framework designed to reduce surgical stress and accelerate recovery. Although these pathways are widely established across surgical specialties, their implementation in neurosurgery presents unique challenges because recovery-enhancing interventions must be balanced against neurological protection, haemodynamic stability, intracranial physiology, and procedure-specific safety considerations. This narrative review synthesises current evidence regarding ERAS implementation across cranial and spinal neurosurgical procedures, including elective craniotomy, spine surgery, pituitary surgery, vascular neurosurgery, and selected paediatric and geriatric populations. While available studies consistently demonstrate reductions in hospital length of stay, opioid consumption, and resource utilisation without increasing perioperative complications, interpretation of these findings is limited by substantial heterogeneity in protocol design, outcome definitions, and adherence reporting, and by the scarcity of long-term neurological and patient-reported outcomes. Beyond summarising existing evidence, this review proposes a conceptual framework distinguishing two fundamentally different ERAS paradigms within neurosurgery: a function-driven model predominantly applicable to spine surgery, where recovery acceleration is the principal objective, and a safety-constrained model characteristic of cranial neurosurgery, where neurological monitoring, intracranial pressure management, and haemorrhagic risk frequently limit implementation of conventional ERAS elements. This distinction provides a physiological and clinical rationale for procedure-specific adaptation rather than uniform application of these principles. The review further argues that the benefits of ERAS arise primarily from pathway standardisation, multidisciplinary coordination, and high protocol adherence rather than from isolated perioperative interventions. By identifying the limitations of current evidence and highlighting the need for neurosurgery-specific outcome measures, standardised reporting, and protocol stratification by surgical pathology, this review offers a framework for future research and more tailored implementation of ERAS pathways within neurosurgical practice.
Objective:Preoperative anxiety is common in patients undergoing elective cesarean section and may worsen perioperative outcomes. This study evaluated whether a structured preoperative educational video (SPEV) reduces maternal anxiety, as measured by the Amsterdam Preoperative Anxiety and Information Scale (APAIS) and the quantitative electroencephalography (QEEG)-derived theta-beta ratio (TBR). Methods:Ninety primigravida women undergoing elective cesarean section with spinal anaesthesia were randomized to a video group (n = 45; SPEV plus routine counseling) or a control group (n = 45; routine counseling only). APAIS was measured at baseline and 30 minutes before surgery. Parietal TBR was recorded at baseline, 30 minutes before surgery, and 1 hour after surgery. Groups were compared using appropriate non-parametric tests, and the correlation between subjective and QEEG-derived measures was assessed. Results:Baseline characteristics were comparable between groups. At 30 minutes before surgery, APAIS scores were lower in the video group than in the control group [11.0 (9.0-12.0) vs. 14.0 (12.0-16.0); P < 0.001). TBR was also lower before surgery (1.20 vs. 1.90; P < 0.001) and at 1 hour postoperatively (1.20 vs. 1.80; P < 0.001). A positive correlation between APAIS scores and TBR was observed 30 minutes before surgery (P=0.48, P < 0.001). Intraoperative midazolam requirement was lower in the video group (11.1% vs. 33.3%, P=0.021). Conclusion:A SPEV significantly reduced preoperative anxiety in women undergoing elective cesarean section, as demonstrated by both subjective and QEEG-derived measures, and was associated with reduced intraoperative anxiolytic requirements.
Objective:To determine the prevalence of burnout and to identify factors associated with it among anaesthesiology attendings and residents in Türkiye. Methods:We conducted a nationwide cross-sectional survey of anaesthesiology departments in Türkiye between September and December 2024. Burnout was assessed using the Maslach Burnout Inventory-Human Services Survey (Turkish version). Burnout syndrome was defined as high emotional exhaustion and depersonalization combined with low personal accomplishment; high-risk status was defined as high emotional exhaustion or depersonalization, regardless of personal accomplishment. Sociodemographic, occupational, and workplace factors were collected, and associations were analysed using univariable and multivariable logistic regression. Results:Among the 921 respondents (53% residents, 46% attendings; median age 33 years, interquartile range: 29-43; 53% female), 71.6% were at high-risk for burnout, and 36.7% met the criteria for burnout syndrome. Residents comprised a significantly greater proportion of physicians with burnout syndrome (68% vs. 45%; P < 0.001) and of those at high-risk for burnout (61% vs. 34%; P < 0.001). In the final multivariable model, younger age, female gender, low workplace satisfaction, perceived understaffing, and inadequate personal support were significantly associated with burnout syndrome. The combination of being female and being a resident is associated with higher odds of burnout (interaction P=0.034). Conclusion:The prevalence of burnout among the Turkish anaesthesiology workforce is extremely high and is especially pronounced among female residents and among those who are younger, work in understaffed settings, or experience job dissatisfaction. Targeted, system-level reforms that ensure fair pay, improved staffing, and supportive leadership, coupled with nationwide longitudinal monitoring, are needed to protect clinician well-being and patient safety.
Objective:Thoracotomy produces severe postoperative pain that limits deep breathing and coughing and may worsen recovery. Opioid-centred regimens can cause adverse effects; pre-emptive multimodal analgesia may reduce central sensitisation and opioid use. Methods:In this randomized, active-controlled, assessor-blinded trial (CTRI/2022/07/043800), adults aged 18-70 years (American Society of Anesthesiologists I-II) undergoing thoracotomy were randomized (39 per group) to receive oral pregabalin 2.5 mg kg-1 or oral naproxen 7 mg kg-1 (maximum 500 mg) 2 hours preoperatively. All patients received standardized general anaesthesia combined with thoracic epidural analgesia. Numerical rating scale (NRS) pain at rest and during deep breathing and coughing were assessed at 2, 6, 12, and 24 hours. A rescue opioid was administered when NRS exceeded 3. Time to first rescue, total 24-hour opioid consumption, number of rescue doses, sleep interference, and adverse events were recorded. Results:Baseline demographics and perioperative haemodynamics were comparable. Resting pain scores and sleep interference were similar between groups. Pregabalin reduced opioid requirement: fewer patients required rescue analgesia (46.2% vs. 69.2%; P=0.042), time to first rescue was longer (7.6±3.1 vs. 5.4±2.8 h; P=0.001), and 24-hour opioid consumption was lower (6.2±3.0 vs. 8.6±3.4 mg morphine equivalents; P=0.001). Dynamic pain during deep breathing and coughing was lower with pregabalin at early time points; sedation was slightly higher at 2 hours, without significant adverse neurocognitive events. Conclusion:Pre-emptive pregabalin improved functional analgesia and produced an opioid-sparing effect compared with naproxen after thoracotomy, with acceptable short-term safety, thereby supporting enhanced recovery pathways.
Advances in surgical techniques and perioperative care have driven increasing interest in regional anaesthesia as part of multimodal analgesia strategies. In liver and kidney transplantation, however, the adoption of regional techniques remains limited due to concerns regarding altered coagulation, cardiovascular instability, and graft perfusion. This narrative review aims to synthesize current evidence on the feasibility, safety, and clinical utility of neuraxial and fascial plane blocks in both transplant recipients and living donors. A narrative review of the literature was conducted, focusing on regional anaesthesia techniques used in transplantation. The review integrates anatomical considerations, sources of postoperative pain, patient-specific comorbidities, and clinical evidence related to neuraxial anaesthesia and ultrasound-guided fascial plane blocks, including erector spinae plane block, quadratus lumborum block, transversus abdominis plane block, modified thoracoabdominal nerve block, external oblique intercostal block, and emerging techniques. Neuraxial anaesthesia can provide effective analgesia in carefully selected transplant patients, particularly in living donors, but its use is constrained by dynamic coagulation abnormalities and hemodynamic instability, especially in recipients. Fascial plane blocks offer a favorable risk-benefit profile, providing effective somatic and, in some cases, visceral analgesia while preserving hemodynamic stability and minimizing bleeding risk. Evidence supports their opioid-sparing effects and feasibility across a range of transplant procedures. Regional anaesthesia represents a valuable component of multimodal analgesia in liver and kidney transplantation when tailored to surgical incision patterns, sources of pain, and patient-specific physiological considerations. Fascial plane blocks, in particular, appear well suited to transplant populations and may facilitate enhanced recovery while maintaining graft-protective priorities.
Objective:This study evaluated gender representation among speakers, session chairs, and society leadership roles at the Turkish Society of Anaesthesiology and Reanimation (TARK) Congresses between 2015 and 2024, focusing on temporal patterns and subspecialty-based variation. Methods:This retrospective observational analysis of conference sessions included all scientific sessions listed in official TARK congress programmes from 2015 to 2024. Names, roles, and session topics were extracted from publicly available documents. In the absence of self-identified gender data, participants were categorised as women or men using names, academic titles, congress documents, and publicly accessible institutional or professional information, when clarification was required. Gender proportions were compared using chi-square tests. Temporal patterns were evaluated using logistic regression analyses, and subspecialty-specific analyses were performed using intensive care as the reference category. The leadership composition of the society was evaluated descriptively. Results:A total of 2,627 congress roles were analysed, including 966 session chairs and 1,661 speakers. Women accounted for 50.3% of session chairs and 50.8% of speakers, with no statistically significant temporal change during the study period. Marked variation was observed across subspecialties. Women were least represented in intensive care sessions (30.9%) and most represented in obstetric and paediatric anaesthesia sessions (82.1%), reflecting a higher relative representation of women speakers in the latter than in intensive care. Leadership composition varied across terms, with no persistent predominance of either gender according to the descriptive assessment. Conclusion:Gender representation at TARK congresses remained numerically balanced over the ten-year study period; however, the absence of a significant temporal increase and the presence of persistent subspecialty clustering suggest a stable but uneven distribution across academic areas.
CHARGE syndrome is a rare congenital disorder with multisystem involvement, posing significant anaesthetic challenges. We report the perioperative management of an 11-month-old male who was diagnosed with anorectal malformation and CHARGE syndrome and who underwent posterior sagittal anorectoplasty. Key anaesthetic considerations included craniofacial asymmetry, facial nerve palsy, and anticipated airway difficulties. Inhalational induction with careful preoxygenation, video laryngoscopy, and caudal analgesia facilitated safe anaesthesia. Post-operative airway compromise was managed with continuous positive airway pressure, and the patient recovered without further complications or intervention. Ultrasound guidance may facilitate identification of relevant anatomy and real-time visualization of injectate spread during caudal block. This case highlights the importance of meticulous pre-anaesthetic planning and multidisciplinary evaluation in children with CHARGE syndrome.
Objective:This study aimed to analyze the association between preoperative diaphragmatic weakness in older adult patients and the need for postoperative mechanical ventilation after major surgery. We hypothesized that preoperative diaphragmatic weakness would significantly increase the need for postoperative mechanical ventilation. Methods:It was a single-center, prospective, observational study that included 90 older adult patients aged more than 50 years who underwent abdominal surgery under general anaesthesia. A portable ultrasound was used to assess the percentage increase in the diaphragm thickening fraction (TFdi) during a maximal inspiratory effort, preoperatively and before extubation. The perioperative change in diaphragmatic function, the development of outcomes, i.e., extubation/mechanical ventilation, and the optimal cut-off of TFdi to predict outcomes were analyzed. Results:The patients with a preoperative TFdi <35% had a higher requirement for mechanical ventilation (24.5% or 1:3) as compared to those with TFdi ≥35% (7.3% or 1:13). In multivariate linear regression analysis, TFdi (preoperative) was the only independent predictor of TFdi (before extubation), explaining a substantial proportion of the variance (adjusted R2=0.71). The optimal cut-off value of TFdi (preoperative) ≤28.9 predicted intensive care unit stay with 73% sensitivity and 73% specificity, and a high negative predictive value (93.2%). Conclusion:Our study found that a significant percentage of older adult patients had a preexisting diaphragmatic weakness that was associated with extubation failure and the need for postoperative mechanical ventilation.
Anti-MDA5-positive clinically amyopathic dermatomyositis (CADM) is closely linked to rapidly progressive-interstitial lung disease (RP-ILD) and is associated with high mortality rates. This report discusses a 60-year-old female patient diagnosed with anti-MDA5-positive CADM who developed RP-ILD that was resistant to pulse steroid therapy, tacrolimus, and intravenous immunoglobulin. As her respiratory condition worsened alongside rising inflammatory markers, therapeutic plasma exchange (TPE) was initiated. Following four sessions of TPE administered on alternate days, significant clinical and laboratory improvements were observed. This case underscores the potential life-saving impact of early TPE for patients with anti-MDA5-positive CADM and RP-ILD who do not respond to traditional immunosuppressive treatments.
Objective:Only two devices [air-Q® intubating laryngeal airway (ILA) and AmbuAura-i] have been studied previously for blind endotracheal intubation (ETI) in paediatric patients. The aim of the study was to compare the success rate of blind ETI through BlockbusterTM laryngeal mask (LM) and air-Q® ILA in paediatric patients. Methods:Eighty patients with the American Society of Anesthesiologists' physical status I and II, aged between six months and 10 years, were enrolled in this randomised controlled trial. The patients were intubated through either of the supraglottic airway devices (SADs) by visualised, blind intubation. The primary outcome was the first- attempt success rate of ETI. Secondary outcomes were the overall success rate of ETI, the oropharyngeal leak pressure, the fiberoptic glottic view, the time to intubation, and the complication rate. Results:BlockbusterTM LM was having significantly higher first attempt success rate without any manipulation as compared to air-Q® ILA (55% vs. 32.5%; P value =0.042). Overall success rate was also significantly higher in BlockbusterTM LM (77.5% vs. 55%; P value =0.03). In subgroup analyses, BlockbusterTM LM demonstrated significantly higher first-attempt and overall intubation success rates in children aged 6 months to 5 years, while success rates were comparable between devices among children older than 5 years. Conclusion:BlockbusterTM LM, having more than 50% success rate of first-attempt blind intubation through SAD, can be a helpful device in crises during airway management of children and, thus, an ideal SAD for difficult airway carts.
Aim:Post-sepsis outcomes remain poorly defined, with recurrent infections and late mortality posing significant clinical challenges. To identify clinical and laboratory predictors of 90-day post-sepsis mortality and to evaluate infection site and pathogen similarity in recurrent sepsis. Methods:This retrospective cohort study included 300 adult patients hospitalized with sepsis or septic shock at a tertiary care center (2018-2022). Demographic, clinical, laboratory, and microbiological data were analyzed. Multivariate bootstrap logistic regression identified independent predictors of mortality, and receiver operating characteristic analysis assessed diagnostic performance. Recurrent episodes were examined for infection site and for microbial concordance with the index hospitalization. Results:Of 183 discharged patients, 60 (32.8%) died within 90 days. Non-survivors were older, had higher Charlson Comorbidity Index scores, had longer intensive care unit (ICU) stays, had lower albumin and procalcitonin levels, and were less likely to achieve microbiological clearance by day 7. In multivariate analysis, only hypoalbuminemia independently predicted mortality (P=0.012). Receiver operating characteristic analysis showed the highest area under the curve for 1/procalcitonin (0.694), followed by age (0.665) and 1/albumin (0.647). Among recurrent sepsis cases, 55.9% had infections at the same site, but identical pathogens were detected in only 5.9%. Conclusion:Advanced age, comorbidity burden, prolonged ICU stay, delayed microbiological response, and hypoalbuminemia are associated with increased 90-day post-sepsis mortality. Although pathogen concordance was uncommon, a low culture yield indicates that some recurrent episodes may be relapses caused by undetected similar pathogens. When culture-negative episodes are also considered, the true similarity rate between initial and recurrent infections is likely even higher.
Objective:This study aimed to evaluate the effectiveness of the ultrasound-guided ilioinguinal-iliohypogastric (II-IH) nerve block under mild intravenous sedation as a sole anaesthetic technique for open inguinal hernia repair and to identify factors independently associated with clinical inadequacy. The central research question was whether the II-IH block alone, when combined with intravenous sedation, could provide adequate anaesthesia for this procedure in a day-case setting. Methods:In this prospective observational study conducted at a university hospital, 342 adult patients undergoing unilateral open inguinal hernia repair with II-IH block were enrolled. The primary outcome was a composite of the need for intraoperative opioid supplementation, additional local anaesthetic, or conversion to general anaesthesia. Logistic regression was used to assess predefined predictors of clinical inadequacy. Results:Out of 342 patients, 233 (68.2%) successfully completed surgery with an II-IH block and mild intravenous sedation as the sole anaesthetic technique. In the remaining 109 patients (31.8%), only 9 (2.6%) required conversion to general anaesthesia. Logistic regression identified anaesthetic volume-but not dose-as significantly associated with clinical inadequacy (P < 0.001). Conclusion:The II-IH block, when combined with sedation, is a feasible and effective anaesthetic approach for a substantial proportion of appropriately selected patients undergoing open inguinal hernia repair. This approach may represent a practical alternative to spinal or general anaesthesia.
Objective: This study aimed to identify prognostic factors affecting recurrence after internal urethrotomy (IU) performed without adjuvant therapy in patients with urethral strictures shorter than 2 cm. Materials and Methods: We retrospectively analyzed the records of 263 patients who underwent IU for the first time between January 2018 and June 2024. Patient characteristics, including age, comorbidities, stricture length, etiology, location, postoperative complications (hematuria, urinary tract infection), and catheterization duration were recorded. Recurrence was defined as the need for re-intervention within the first year. Statistical analyses were performed using chi-square, Fisher’s exact, Student’s t-test, Mann-Whitney U, and Kruskal-Wallis tests. Results: The mean patient age was 68.2±18.9 years. Recurrence rates were 29.6% at 3 months and 64.2% at 1 year. Advanced age, diabetes mellitus (DM), coronary artery disease (CAD), and postoperative complications (hematuria, urinary tract infection) significantly increased the risk of recurrence (all p<0.001). No significant association was observed between recurrence and stricture length, etiology, location, or catheterization duration. Conclusion: Advanced age, DM, CAD, and postoperative complications (hematuria, urinary tract infection) are independent risk factors for recurrence after IU. Evaluation of these parameters may aid in planning early surgical strategies for high-risk patients. This study was retrospectively conducted and was not registered in a clinical trial registry as it did not meet the criteria for prospective registration.
Objective: The objective of this study was to find the relationship between Patient State Index (PSI) and Richmond Agitation Sedation Scale (RASS) for sedation in critically ill patients. Methods: This was a prospective, observational study. Thirty-five patients were recruited to assess the correlation between PSI and RASS scores of 0 to -3 for sedation in mechanically ventilated, critically ill patients. Paired observations (RASS and PSI) were made for each patient every 4 hours for at least 72 hours or until discontinuation of monitoring, whichever occurred earlier. Appropriate statistical analyses were applied; a P < 0.05 was considered significant. Results: Out of the expected 665 pairs of observations, only 608 pairs were observed. The median PSI value with all sedation regimen was 72 with an interquartile range of 60 and 86 (1st and 3rd quartile) respectively. There was significant and strong correlation between PSI and RASS 0 to -3 with Spearman correlation coefficient of 0.822; R2=0.675 (P < 0.001) which dropped to 0.786 with repeated measures correlation. The sensitivity and specificity were 88.66% and 88.57%, respectively, with an area under the receiver operating characteristic curve of 0.947; these improved to 100% and an area under the curve of 1 when analysed per patient. To maintain RASS between 0 and -3, the PSI cutoff was found to be 50-52. Conclusion: PSI correlates well with RASS across sedation regimens in critically ill patients and assists in monitoring of sedation. Adequate sedation to reach an RASS of 0 to -3 may be achieved at a PSI of 50-52. However, these findings are preliminary and require validation in larger cohorts.
Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and dual glucose-dependent insulinotropic polypeptide GLP-1 RAs are increasingly prescribed for diabetes and obesity, leading to a growing number of surgical patients receiving these agents. Their ability to delay gastric emptying has raised concerns about residual gastric contents (RGCs) and potential aspiration during anaesthesia. Available evidence from mechanistic studies, clinical investigations, and case reports indicates that GLP-1-based therapies consistently impair solid-phase gastric emptying and may increase RGC, particularly during early treatment and dose escalation, with effects that can persist despite standard fasting and short-term drug interruption. Although clinically apparent aspiration events remain uncommon, multiple reports have described perioperative regurgitation or unexpected solid gastric contents at induction. Early guidance favoured routine preoperative drug interruption; however, more recent multisociety recommendations increasingly support continuation of therapy in most asymptomatic patients and endorse enhanced perioperative mitigation strategies, such as dietary modification, strict adherence to fasting, selective use of point-of-care gastric ultrasound, preference for regional anaesthesia when feasible, and tailored airway management. Overall, current data support an individualised, risk-adapted approach rather than uniform interruption of GLP-1 therapy. Continuation of structured mitigation appears reasonable for many patients, whereas heightened caution and full-stomach precautions remain appropriate in higher-risk situations. Further prospective studies are required to define true perioperative aspiration risk and to establish evidence-based management pathways.
Objective: To investigate whether drinking-water-moistened oropharyngeal packing during nasal surgery is associated with ultrasound-assessed gastric fullness and postoperative nausea and vomiting (PONV), compared with no packing. Methods: This single-center, retrospective before-after cohort study included 118 adults undergoing nasal surgery, following an institutional protocol change on December 1, 2024. Sixty patients received oropharyngeal packing moistened with drinking water, and 58 received no packing. All patients received standardized anaesthesia and PONV prophylaxis with dexamethasone 4 mg IV administered after intubation. Packing was placed before surgery and removed before extubation. PONV and throat-related symptoms were recorded at 30 minutes, 2 hours, and 24 hours postoperatively. Gastric fullness was assessed ultrasonographically by measuring gastric antral cross-sectional area (GCSA) and gastric volume before and after extubation. Results: At 30 minutes, PONV was more frequent in the no-packing group (58.6% vs. 18.3%, P < 0.001), as was sore throat (41.4% vs. 26.7%, P=0.035). At 2 hours, PONV remained more frequent in the no-packing group (31.0% vs. 13.3%, P=0.026), but there was no difference at 24 hours. GCSA and gastric volume decreased in the packing group but increased in the no-packing group (GCSA: -14.14% vs. 20.86%; gastric volume: -15.67% vs. 22.00%; both P < 0.001). Demographics, surgical variables, dysphagia, hoarseness, and analgesic/rescue antiemetic use were similar. Conclusion: Drinking-water-moistened oropharyngeal packing was associated with lower postoperative gastric fullness and a lower incidence of early PONV, without increased throat-related symptoms or rescue medication use. These findings indicate associations, not causal effects, and require confirmation in randomized trials.
