Purpose General anesthesia management for endoscopic submucosal dissection (ESD) of early-stage gastric cancer has been proposed to improve procedural outcomes and reduce complications compared to sedation management, but definitive conclusions have not yet been reached. We compared the efficacy and safety of general anesthesia versus conventional sedation management for gastric ESD. Results Of the 407 analyzed cases, 119 underwent general anesthesia (GA) and 288 underwent sedation. The median procedure time was significantly shorter in the GA group than in the sedation group (71 vs. 85 minutes, p < 0.001). Conversely, the median endoscopy room stay was longer in the GA group (123 vs. 113 minutes, p = 0.016). No significant differences were observed in procedure-related complications, including aspiration (0% vs. 1.4%, p = 0.326), perforation (0% vs. 0%), and bleeding (0.8% vs. 2.1%, p = 0.679). However, intraoperative vital signs revealed a significantly higher incidence of hypotension (77.3% vs. 15.6%, p < 0.001) and bradycardia (38.7% vs. 13.8%, p < 0.001) in the GA group. The personnel costs calculated using time-driven activity-based costing were 41,977.7 yen (USD 270.82) for the GA group and 26,449.5 yen (USD 170.64) for the sedation group. Conclusion GA for gastric ESD significantly reduces procedure time compared to conventional sedation, though it extends the overall endoscopy room stay, likely due to extubation and recovery protocols. While procedure-related complications remain rare in both approaches, GA is associated with higher rates of intraoperative hypotension and bradycardia. Further studies are required to comprehensively evaluate its efficacy and safety.
Background While Non-Operating Room Anesthesia (NORA) growth rapidly moves forward, safety research has trailed behind. Capturing provider perceptions may be instrumental to conquering safety in NORA. We surveyed anesthesia providers across the country to grasp practices and to elucidate if there are inconsistencies in resources and/or reporting of safety events in the procedural setting. In continuation with our previous work describing near misses, we also sought to determine if there is consensus on basic safety definitions. Methods Active members on the American Society of Anesthesiologists (ASA) listserv were contacted during February 2024, and included: Anesthesiology Attendings, Residents, Fellows, and Assistants. Questions focused on three areas: trends in NORA practice, the presence of NORA subdivisions, and provider experience with near miss events. Data was recorded in Qualtrics. Results Surveys were sent to 30,637 ASA members. We received 1,653 responses, with a 5.4% response rate (95% confidence level, margin of error of 2.3%). The majority were anesthesiologists, with 10+ years practice, who totaled more than 10 NORA cases/month. Top practice settings were endoscopy, interventional radiology, and interventional cardiology. Only 23.7% reported a NORA subdivision. Near miss events appeared common yet reported less than 50% of the time. Conclusions Nationally, NORA continues to expand, yet many institutions have no direct oversight by designated personnel, and practices appear to vary. Inconsistent and underdeveloped safety standards put both patients and providers at risk. Our results suggest developing a dedicated framework for systematic study of the procedural landscape to improve NORA safety and quality measures.
The psychometric validation of measurement instruments—whether questionnaires, rating scales, or performance assessment tools—is a foundational process in operating room management research. A pivotal, yet frequently misunderstood, step in this process is determining an appropriate sample size. An inadequate sample can lead to a cascade of methodological shortcomings: unstable factor structures, inflated or imprecise reliability estimates, underpowered hypothesis tests for validity, and ultimately, instruments whose scientific utility for evaluating surgical team performance, patient safety culture, or perioperative outcomes is questionable. This tutorial review provides a definitive synthesis of the widely cited rules of thumb, statistical formulas, and modern software-based methods for sample size determination across the full spectrum of psychometric evidence. We cover essential topics including face, content, criterion, and construct validity (via Exploratory and Confirmatory Factor Analysis), reliability (Cronbach's Alpha and McDonald's Omega), modern measurement models like Rasch, and Generalizability Theory for high-stakes performance assessments. For each topic, we provide clear rational, actionable guidelines, illustrative examples drawn from operating room management contexts (e.g., surgical team performance scales, perioperative safety culture surveys, and anesthesiologist workload assessment), and practical software implementation steps. The aim of this article is to serve as a primary resource for researchers, from students to seasoned practitioners in surgical and perioperative research, to make informed, justifiable, and robust decisions in the design of their psychometric studies.
Background Opioid-free anesthesia (OFA) is a type of multimodal anesthetic technique that substitutes standard opioids with drugs that include dexmedetomidine, ketamine, lidocaine, magnesium, and clonidine in combination with regional nerve blocks to reduce the adverse effects of opioids whilst providing sufficient analgesia. Rationale The proposed study aimed to perform a systematic review of the evidence of randomized controlled trials (RCTs) on the topic of opioid-free anesthesia versus opioid-based anesthesia regarding postoperative pain control, postoperative nausea and vomiting (PONV), opioid intake, quality of recovery, and safety outcomes in surgical patients. Methods A systematic literature review was done on PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Web of Science, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), and Google Scholar between January 2015 and June 2025. There were twelve randomized controlled trials that passed the eligibility criteria. The Cochrane Risk of Bias 2 (RoB 2) tool was used to assess the risk of bias. Extraction and synthesis of study characteristics, results, and quality measures were done systematically. Results 12 RCTs on 1,147 adult surgical patients were considered. Opioid-free anesthesia was proven to be effective in the prevention of postoperative nausea and vomiting incidence in various types of surgery (laparoscopic abdominal surgery, thoracoscopic surgery, bariatric surgery, and thyroid surgery). Control of pain was similar or less in OFA groups, and postoperative opioid use was less. The metrics of quality of recovery improved under opioid-free protocols. There was no difference in adverse profiles. The overall methodological quality was good, as 83% of the studies were at the low risk of bias. Conclusion The available evidence indicates that opioid-free anesthesia (OFA) is an efficient and safe replacement of the traditional opioid-based anesthesia, especially in the case of minimally invasive procedures and patients at risk of postoperative nausea and vomiting. The opioid-free approaches to anesthesia are consistent with Enhanced Recovery After Surgery (ERAS) and institutional opioid stewardship programs. Nevertheless, the standardization of OFA procedures and testing in patients of different surgical groups can be discussed as significant aspects of future studies.
BACKGROUND AND AIMS The parasagittal approach has been used as a classical approach for erector spinae plane block (ESPB). The transverse approach of ESPB has been suggested with the advantage of better visualization of anatomical landmarks. The aim of the study was to compare postoperative analgesia between these two approaches. METHODS This randomized controlled trial included 78 patients, aged > 18 years, undergoing modified radical mastectomy (MRM), randomized into two groups of 39 each. In group A, the parasagittal approach, and in group B, the transverse approach, was used, to perform the block. Both groups received 20 ml (0.25%) of bupivacaine with 8 mg of dexamethasone. The primary objective was to compare postoperative analgesia in terms of opioid consumption in a 24-hour postoperative period. Secondary objectives were to compare postoperative numerical rating scale (NRS) scores, the number of attempts, time taken for the completion of block, and complications in both groups. RESULTS Mean tramadol consumption was 0.38 mg/kg and 0.23 mg/kg (p=0.232) (total 23.23 ±39.50 and 12.43 ± 26.32 mg, p=0.160) in groups A and B, respectively. NRS and number of attempts to perform the block were comparable in both groups. The mean time to complete the block was 6.41 ± 2.13 minutes in the parasagittal group and 5.35 ± 1.28 minutes in the transverse group. (p=0.011) CONCLUSION We conclude that the two approaches of ESPB provide comparable analgesia. A transverse approach is an appropriate alternative to a parasagittal approach to administer an erector spinae plane block with good postoperative analgesia in patients undergoing a modified radical mastectomy.
Background Iraq is known for its high standards of medical education, but is facing serious challenges now because of limited resources. The aim of this study is to investigate the effect of hospital infrastructure issues and bed availability on the quality of clinical training and skills of fresh medical graduates. Methods An online questionnaire was administered using Google Forms. Responses were received from clinical year medical students, healthcare trainees and early career doctors training in teaching hospitals across Iraq. The survey concentrated on hospital infrastructure, bed capacity and the effectiveness of clinical training. Results A total of 106 valid responses were analyzed. The majority of the participants reported major problems in their clinical training, mainly lack of beds (81.13%) and limited opportunities to see patients (73.58%). Many felt supervision was lacking, with only 11.32% feeling there was clear guidance and 33.02% feeling that busy clinicians stopped supervision. A small number of students felt confident to complete skills alone (11.32%) or ready for independent practice (18.87%) There were also large deficiencies in overall preparation, with many having difficulties with communication (93.4%) and time management during rotations (79.25%). Summary The lack of beds, the non-availability of hands-on training and the excess number of students have resulted in limited scope for skill development and adequate supervision. This means that doctors coming out of training are less ready and less confident.
Background Optimal pain management strategies following emergency abdominal surgeries remain inadequately defined. This study evaluated the impact of two standardized pain protocols on patients undergoing major abdominal surgery as part of the OMEGA study. Methods This prospective cohort study included patients who underwent major emergency abdominal surgery at a large university hospital in Denmark. Patients were to receive two different multimodal analgesic regimens depending on whether an epidural catheter was possible or not. Data was collected over the first four postoperative days from September 25, 2018, to December 13, 2018. The primary outcome was IV morphine (eqv) consumption on the following individual postoperative days 1- 4 for the cohort with an epidural (COHORT EPI) and the cohort without an epidural (COHORT NO-EPI). Secondary outcomes included pain on the numerical rating scale (NRS), adverse effects, adherence to the protocol, and the extent of sensory coverage provided by the epidural. Results Sixty-six patients were enrolled. Forty-five received pain treatment for COHORT EPI and 21 received pain treatment for COHORT NO-EPI. Epidural anaesthesia was administered to 68% of all patients, most epidurals did not achieve full coverage of the entire surgical wound. The median morphine consumption for the postoperative days 1/2/3/4 for the COHORT EPI was 0/0/0/2 mg, and the COHORT NO-EPI was 15/13/13/12 mg respectively. Despite sub-optimal adherence to the non-opioid analgesic treatment plan, pain was mild at rest and moderate to severe during movement, with infrequent adverse effects for patients for both analgesic plans. Conclusions The implementation of the OMEGA standardized protocol lacked adherence but was accompanied by generally low pain levels at rest and low opioid consumption. These observations may suggest a greater attention towards adherence in the future after implementing a new pain protocol for patients following major abdominal emergency surgery.
Background Caesarean section rates have increased from 8% in 2005 to 21.5% in 2021. Effective postoperative analgesia is crucial for maternal mobility, breastfeeding, and neonatal care while reducing complications like postpartum depression and thromboembolic events. This study was conducted to compare the effectiveness of ultrasound-guided quadratus lumborum block (QLB) versus transversus abdominis plane (TAP) block for postoperative analgesia following elective cesarean section. Methodology A Prospective, randomized controlled trial was conducted at a tertiary medical teaching institute. Sixty ASA I-II parturients aged 20–40 years undergoing elective cesarean section were randomized into two groups: Group Q (n = 30) received bilateral QLB with 0.25% ropivacaine 20 ml each side; Group T (n = 30) received bilateral TAP block with identical medication. The primary outcome was 24-hour morphine consumption via IV-PCA. Secondary outcomes included VAS pain scores at rest and movement, time to first analgesic request, and adverse events. Results Mean age was comparable between groups (28.10±3.925 vs 29.53±3.963 years, p > 0.05). The QLB group demonstrated significantly lower VAS scores at 8 h and 12 h at rest, as well as at 1 hour and 12 h during movement. Total 24-hour morphine consumption was significantly lower in the QLB group (8.23 mg) compared to the TAP group (11.47 mg), representing a 28% reduction. Time to first morphine request was longer in the QLB group (3.608 h) versus the TAP group (3.033 h), but not statistically significant (p > 0.05). Post-operative nausea and vomiting incidence was higher in the TAP group. Conclusion QLB provides superior postoperative analgesia compared to TAP block following cesarean section, with significantly reduced opioid consumption and lower pain scores, suggesting longer duration of analgesic action and better overall pain management.
Purpose This study aimed to systematically examine the nursing literature on surgical site infections (SSIs) using bibliometric methods in order to identify research trends, thematic structures, collaboration patterns, and knowledge production dynamics. Design A longitudinal bibliometric design was employed to analyze the evolution of SSI-related nursing research over time. Methods Data were retrieved from the Web of Science database on November 26, 2025, without time restriction. A total of 2,137 publications met the inclusion criteria. Bibliometric analyses were conducted using Bibliometrix and its web interface Biblioshiny. Performance analysis and science mapping techniques were applied, including co-authorship, co-citation, and keyword co-occurrence analyses, as well as Bradford’s and Lotka’s laws. Findings The results revealed a steady growth in publications, particularly over the past decade, with an annual growth rate of 10.53%. Research output was concentrated in a limited number of core journals and driven by a small group of highly productive authors. Thematic analyses showed that the literature primarily focuses on prevention, surgical care, management, and risk factors, while topics such as transmission and contamination remain underexplored. Geographically, publications were predominantly produced in high-income countries, with the United States leading in both output and collaboration networks. Conclusions This study provides a comprehensive overview of the structure and evolution of SSI nursing literature. The findings highlight the need for broader international collaboration, increased nursing-focused research dissemination, and greater attention to emerging thematic areas to support the advancement of evidence-based perioperative care.
Background Perioperative physiological stress contributes to postoperative pulmonary morbidity following elective urologic surgery. Carboxyhemoglobin (COHb) and methemoglobin (MetHb), measured by routine arterial blood gas co-oximetry, may reflect dyshemoglobinemia, oxidative stress, and impaired oxygen transport, and could serve as biomarkers of perioperative physiological vulnerability. Methods This post hoc secondary analysis included prospectively collected data from 120 consecutive adults undergoing elective urologic surgery under general anesthesia at a tertiary-care center. Perioperative COHb and MetHb fractions were measured at predefined time points using arterial blood gas co-oximetry. The primary outcome was the occurrence of clinically relevant postoperative pulmonary complications during hospitalization. Associations between dyshemoglobin fractions and postoperative pulmonary complications were evaluated using univariate and parsimonious multivariable logistic regression analyses. Findings Clinically relevant postoperative pulmonary complications occurred in 30 patients (25.0%). Patients who subsequently developed postoperative pulmonary complications already demonstrated significantly higher baseline (T0) COHb and MetHb concentrations before induction of anesthesia. They also exhibited higher mean COHb (2.08 ± 1.32% vs 0.72 ± 0.51%, p < 0.001) and MetHb levels (0.69 ± 0.31% vs 0.24 ± 0.12%, p < 0.001). After multivariable adjustment, elevated MetHb remained independently associated with postoperative pulmonary complications (adjusted OR 2.04 per 0.1% increase, 95% CI 1.31–3.15, p = 0.001), as did elevated COHb (adjusted OR 3.28 per 1% increase, 95% CI 1.33–8.06, p = 0.010). MetHb demonstrated excellent discriminatory performance for postoperative pulmonary complications (AUC 0.91). Conclusions Elevated baseline and perioperative COHb and MetHb fractions were independently associated with clinically relevant postoperative pulmonary complications following elective urologic surgery. Dyshemoglobin fractions derived from routine perioperative co-oximetry may represent accessible adjunctive biomarkers for perioperative risk stratification. Prospective multicenter studies are warranted to validate these findings and determine their clinical utility.
Purpose This study aimed to evaluate whether nursing care based on Kolcaba’s Comfort Theory reduced the incidence of postoperative delirium in patients undergoing coronary artery bypass grafting (CABG). Design Quasi-experimental pre–post comparative study. Methods This single-center quasi-experimental pre–post study was conducted between May and December 2023 at a tertiary healthcare institution. A total of 72 patients undergoing CABG were included in this study, with 36 patients in the control group and 36 in the intervention group. The control group received routine hospital care, and data were collected. Following this phase, 25 nurses working in the clinical and intensive care units received training on Comfort Theory–based care delivered by the researcher. The intervention group subsequently received theory-based nursing care and preoperative education using a structured booklet developed by the researchers. Outcomes included incidence of delirium, scale comfort, pain, sleep quality, and delirium risk factors. Findings The rates of delirium development were 16.7% in the control group and 2.8% in the intervention group. The difference was statistically significant (p < 0.05). (p < 0.05). The effect size of Comfort Theory-based care for delirium was large (V = 0.466). The total score of the Perianesthesia Comfort Scale used to assess perceived comfort was 109.67±11.34 in the control group and 124.50±10.55 in the intervention group. The implemented protocol significantly increased perceived comfort in the intervention group (p < 0.001). Conclusion Kolcaba’s Comfort Theory-based care reduces the incidence of post-CABG delirium by increasing perceived comfort. Structuring nursing care plans according to Comfort Theory principles may reduce delirium incidence, particularly in high-risk surgical patients. Therefore, comfort-enhancing interventions should be integrated into routine clinical protocols to improve patient outcomes.
Objective Surgical smoke is an inevitable by-product of energy-based surgical procedures and poses potential occupational health risks to operating room personnel. Despite continuous exposure, protective practices against surgical smoke remain inconsistently adopted in perioperative settings. This study aimed to examine Health Belief Model–based perceived barriers and cues to action associated with protective practices against surgical smoke among operating room staff in perioperative care settings. Methods A cross-sectional survey was conducted among full-time multidisciplinary surgical team members working in the operating rooms of five branches of a regional teaching hospital in northern Taiwan between March and April 2024. A structured questionnaire based on HBM constructs was administered, and data from 324 respondents were analyzed. Descriptive statistics and multivariable linear regression analyses were performed to identify factors associated with the adoption of personal protective equipment, system-based environmental protection measures, and defensive preventive strategies. Results Participants generally reported moderate to high awareness of the health risks associated with surgical smoke exposure, particularly regarding respiratory diseases. However, protective practices were not uniformly implemented. Multivariable analyses showed that perceived benefits and cues to action were consistently associated with greater adoption of both personal and system-level protective measures. In contrast, perceived barriers, especially those related to interference with surgical performance, were significantly associated with lower use of protective goggles. Differences in protective practices were also observed across professional roles and exposure contexts within the surgical team. Conclusions Although awareness of surgical smoke hazards was relatively high, perceived barriers and cues to action played a more decisive role than risk perception alone in shaping protective practices among operating room staff. These findings suggest that strategies to improve surgical smoke protection in perioperative care should prioritize reducing perceived workflow-related barriers and strengthening institutional cues to action to support consistent adoption of protective measures. Because this cross-sectional study was conducted within a single hospital system using self-reported data, causal inference cannot be established and the generalizability of the findings may be limited.
Purpose We aimed to determine the incidence of poor sleep quality on postoperative day 1 and to evaluate its association with perioperative factors, including patient demographics and the degree of surgical invasiveness. Methods This prospective observational study included inpatients aged ≥18 years who were scheduled for elective surgery under general anesthesia and were transferred to a general ward postoperatively without receiving sedatives. The primary outcome was self-reported sleep quality assessed using the Richards–Campbell Sleep Questionnaire (RCSQ), with scores <50 indicating poor sleep quality. Risk ratios for poor sleep quality were estimated using generalized estimating equations. The analysis included surgical invasiveness categorized by the Operative Stress Score, which evaluates non-cardiac surgery on a 5-point scale (1 indicating the lowest and 5 the highest invasiveness), as well as other clinically relevant factors. Results Of the 301 eligible patients, 246 (81.7%) were included in the analysis. The mean (standard deviation) RCSQ score was 37.2 (28.4), and 65.8% (95% confidence interval: 59.7–71.4%) of patients met the criteria for poor sleep quality. No statistically significant association was observed between poor sleep quality and the degree of surgical invasiveness. However, age (risk ratio: 1.01; 95% confidence interval: 1.00–1.01) and body mass index (risk ratio: 1.01; 95% confidence interval: 1.002–1.02) were independently associated with an increased risk of poor sleep quality. Conclusion Poor subjective sleep quality on postoperative day 1 was highly prevalent among patients undergoing elective surgery and was independently associated with age and body mass index, but not with surgical invasiveness.
Background Postoperative pulmonary complications (PPCs) remain a major determinant of morbidity after thoracotomy. While incentive spirometry is routinely employed in the postoperative period, evidence supporting structured preoperative usage as part of perioperative optimization remains limited, particularly in high-burden infectious disease settings. Objective To evaluate whether a structured preoperative incentive spirometry program reduces postoperative respiratory morbidity in patients undergoing elective thoracotomy. Methods A prospective controlled cohort study with risk-adjusted analysis was conducted, including 213 patients undergoing elective thoracotomy. Patients were allocated into intervention and control groups based on exposure to a structured preoperative spirometry program lasting at least ten days. PPCs were defined using modified Melbourne Group Scale criteria. Multivariable logistic regression was performed to adjust for potential confounders, including age, smoking status, serum albumin, and baseline pulmonary disease. Results PPCs occurred significantly less frequently in the spirometry group compared with the control group (18.1%vs 32.7%, p = 0.012), corresponding to a relative risk of 0.55 (95% CI 0.33–0.90) and an absolute risk reduction of 14.6%. Patients receiving preoperative spirometry also had shorter chest drain duration (4.2 ± 1.3 vs 6.1 ± 2.2 days, p < 0.001) and reduced length of hospital stay (7.9 ± 2.8 vs 10.4 ± 3.6 days, p < 0.001). On multivariable logistic regression analysis, structured preoperative spirometry remained independently associated with a reduced risk of PPCs (adjusted OR 0.46, 95% CI 0.28–0.74, p = 0.001). Conclusion Structured preoperative incentive spirometry significantly improves perioperative respiratory outcomes following thoracotomy and should be incorporated into routine perioperative care pathways.
Artificial intelligence (AI) is rapidly entering medical education, yet its impact on graduate medical training, and particularly on the development of clinical judgment in anesthesiology, remains insufficiently examined. This Focal Point article argues that AI should be used not merely to accelerate information access, but to strengthen heuristic learning, critical appraisal, and decision-making under uncertainty. AI can expand case exposure and enhance synthesis, but without explicit guidance, residents may confuse generated output with validated knowledge and erode the very reasoning skills the specialty depends on. We propose a practical framework for AI-augmented heuristic learning that positions AI as a catalyst for inquiry rather than a substitute for thought. Used intentionally, AI can help cultivate more adaptable clinicians; used passively, it risks narrowing their judgment. Residency programs must adopt deliberate strategies to ensure AI supports, not supplants, the cognitive work that defines anesthesiology.
