Background/Objectives: Neuropathic and chronic centralized pain disorders remain difficult to treat because they involve central sensitization, maladaptive neuroplasticity, neuroimmune activation, affective amplification, and large-scale network dysfunction. Psilocybin, a serotonergic psychedelic acting primarily through 5-HT2A receptor agonism, has emerged as a candidate modulator of chronic pain states; however, clinical evidence remains preliminary. This review synthesizes preclinical, clinical, and mechanistic literature on psilocybin in chronic neuropathic and centralized pain, emphasizing biological plausibility, translational gaps, and future trial design. Methods: PubMed/MEDLINE, Google Scholar, bioRxiv, medRxiv, and targeted journal searches were reviewed through February 2026 and supplemented by reference screening. Thirty-seven peer-reviewed evidence sources were retained for mechanistic synthesis, and ClinicalTrials.gov records were reviewed separately to contextualize the registered clinical-trial landscape. Evidence was synthesized narratively because heterogeneity in study design, pain models, interventions, outcomes, and follow-up precluded meta-analysis. Results: Several preclinical studies reported psilocybin-associated reductions in allodynia, hypersensitivity, formalin-induced nociception, or pain-related affective behaviors in selected rodent models, with some effects linked to 5-HT2A signaling. However, findings were not uniform, and one rigorous null study found no immediate or persistent analgesic effect across multiple models. Human evidence remains limited and is primarily derived from one small open-label fibromyalgia pilot trial, case reports or case series, and survey studies, and has been summarized in recent systematic and narrative reviews. Collectively, these data remain insufficient to establish clinical efficacy. Four putative mechanistic domains were identified: descending serotonergic modulation, 5-HT2A- and TrkB/BDNF-related neuroplasticity, neuroimmune/microglial modulation, and affective-salience/default mode network reorganization. Conclusions: Psilocybin should not currently be regarded as an established analgesic. Available evidence supports a biologically plausible but clinically unproven model requiring phenotype-specific randomized trials with active controls, biomarkers, and long-term follow-up.
Background/Objectives: Gabapentin is a first-line treatment for neuropathic pain, classically understood to reduce neuronal excitability through binding to the alpha-2-delta-1 (α2δ-1) subunit of voltage-gated calcium channels. However, this neuron-centric model does not fully explain its variable clinical efficacy across pain syndromes. In parallel, chronic pain is increasingly conceptualized as involving neuron–glia–immune interactions, in which microglial activation, astrocytic signaling, and inflammatory mediators may contribute to central sensitization. Methods: A structured narrative review was conducted using PubMed, Web of Science, and Google Scholar for articles available through December 2025. The search focused on gabapentin/gabapentinoids, chronic and neuropathic pain, α2δ-1 mechanisms, neuron–glia interactions, neuroinflammation, central and peripheral sensitization, nociplastic pain, cytokine/chemokine signaling, and neuroimmune modulation. Basic science studies, animal models, translational studies, clinical trials, reviews, meta-analyses, and guidelines were narratively synthesized. Results: Preclinical evidence indicates that gabapentin reduces neuronal hyperexcitability and may secondarily attenuate neuron-to-glia signaling, glial activation, and cytokine- and chemokine-related pathways. However, these neuroimmune effects remain predominantly preclinical, model-dependent, and incompletely validated in humans. Clinical evidence supports gabapentin for selected neuropathic pain conditions, but human studies rarely evaluate glial activation, cytokine signaling, or neuroimmune biomarkers. Conclusions: Gabapentin remains best understood as a neuronal α2δ-1 modulator. Although preclinical and translational evidence suggests biologically plausible secondary effects on neuroimmune signaling, these mechanisms have not been validated as biomarkers or prescribing targets in humans. The conceptual framework presented in this review supports mechanism-informed clinical reasoning and individualized pain management but should not be interpreted as a biomarker-guided prescribing algorithm. Clinically, gabapentin should be prescribed selectively for patients with neuropathic or sensitized pain features, using predefined functional goals, appropriate renal dose adjustment, careful safety monitoring, and discontinuation when meaningful benefit is not achieved.
Background: Pharmacokinetic/pharmacodynamic (PK/PD)-guided intravenous anesthesia and target-controlled infusion (TCI) have progressively transformed modern anesthetic practice from empirical drug administration toward individualized, model-informed precision anesthesia. Recent advances in neuromonitoring, closed-loop systems, and artificial intelligence (AI) are further expanding this paradigm. Methods: This Perspective article provides a conceptual and educational synthesis of the historical foundations, mathematical principles, clinical applications, and AI-based perspectives of PK/PD-guided intravenous anesthesia and TCI. Results: The concentration–effect relationship derived from Hill’s equation represents the conceptual basis of modern anesthetic pharmacology. Contemporary TCI systems integrate PK/PD models, effect-site targeting, synergistic drug interactions, and multimodal monitoring to improve anesthetic precision and safety. Recent evidence supports the advantages of total intravenous anesthesia (TIVA) in postoperative recovery outcomes, including reduced postoperative nausea and vomiting, emergence delirium, and improved quality of recovery. Emerging developments include increasingly generalizable PK “supermodels,” adaptive closed-loop control systems, multimodal AI integration, and patient-specific digital twins that may eventually support simulation of physiological responses and optimization of drug administration. However, biological variability, monitoring limitations, signal artifacts, model uncertainty, and the need for prospective validation, regulatory oversight, and continuous clinician supervision remain major challenges to the routine implementation of AI-assisted individualized anesthesia. Conclusions: PK/PD-guided anesthesia and TCI increasingly represent a clinically relevant framework for precision anesthesia, integrating pharmacology, monitoring, adaptive control, and AI-assisted systems. Future developments may progressively reduce the discrepancy between predicted and observed clinical effects, moving anesthetic practice toward continuously adaptive, feedback-driven, and individualized anesthesia care.
Background: Inguinal hernia repair is a high-volume procedure frequently performed in Day Surgery settings. While local anesthesia is often considered the gold standard, its feasibility is limited in complex cases or due to patient refusal, necessitating alternatives like general (GA) or spinal anesthesia (SA). This study evaluates the impact of these techniques on acute pain, complications, and chronic postoperative inguinal pain (CPIP). Methods: A retrospective observational study was conducted on 73 adult patients undergoing unilateral Lichtenstein hernioplasty (GA = 24; SA = 49). Pain was assessed using the Numeric Rating Scale (NRS) at discharge (T0), 24 h (T1), 7 days (T2), and 180 days (T3). Postoperative complications, rescue analgesic consumption, and perceived time to recovery were recorded. A multivariable linear regression analysis was performed to adjust pain outcomes for age, sex, and ASA status. Results: GA patients reported significantly lower median NRS scores at T0, T1, and T2 in univariate analysis (p < 0.05). However, the multivariable model did not show statistical significance for anesthetic technique as an independent predictor. Constipation was the most frequent complication (35.6%), while nausea occurred only in the SA group (10.2%). Descriptive data showed a trend toward lower rescue analgesic needs and a faster perceived time to recovery in the GA group compared to SA. CPIP incidence was remarkably low (2.7%). Conclusions: GA is a valid alternative to SA in Day Surgery, showing a clinical trend toward better early pain control, lower analgesic consumption, and improved recovery perception, although multivariable analysis did not reach statistical significance.
Background/Objectives: Low back and neck pain are common musculoskeletal complaints among healthcare workers, including anesthesia providers. This study aims to quantify the prevalence of back and neck pain amongst anesthesiology providers to identify risk factors, mechanisms of injury, and recovery practices to guide preventative measures. Methods: A cross-sectional survey of anesthesiology clinicians in a multi-site academic healthcare system in New York City was administered using REDCap version 12.5.9. The recorded survey results were aggregated to determine percentages for each question. Descriptive statistics were used to determine the nature of low back and neck pain and detail causes. Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores were calculated. Results: The survey instrument was distributed to 380 anesthesiology clinicians at four separate institutions and yielded 191 responses for a response rate of 50.3%. Fifty-three-point-nine percent of survey respondents reported having current back or neck pain, with the majority reporting that it was chronic (87.4%). A substantial proportion of respondents reported not having back or neck pain prior to training (58.3%), and the majority reported that their back or neck pain was work-related (54.1%). Only 14.1% of respondents reported having had training in back or neck pain prevention. The most common location of pain was lumbar (81.6%). The most common inciting event for work-related pain was patient transfer/transport (68.6%). For ODI scoring, 98% of clinicians within the health system were classified as minimal disability and 2% of clinicians as moderate disability. For NDI scoring, 95.8% of clinicians were classified as minimally disabled, with 2.6% classified as moderate disabled. Conclusions: Back and neck pain are common pathologies amongst anesthesia providers. For most clinicians, the pain began to occur during training. Common inciting events include patient transfer/transport, procedure performance, and room setup. This provides a framework with which preventative practices can take place to reduce the prevalence of back and neck pain in anesthesiology and other related health care disciplines.
Objective: We aimed to evaluate whether deep neuromuscular blockade (DNMB) improves surgical conditions and facilitates low-pressure pneumoperitoneum compared with moderate neuromuscular blockade (MNMB) during minimally invasive surgery. Data Sources: PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, Scopus, Web of Science, and LILACS were searched from inception through May 2026. Study Selection: Randomized controlled trials comparing DNMB versus MNMB in adults undergoing laparoscopic or robot-assisted surgery were included. Data Extraction: Two reviewers independently screened studies, extracted data, and assessed risk of bias using the revised Cochrane Risk of Bias tool (RoB 2). Certainty of evidence was evaluated using the GRADE approach. Primary Outcomes: Primary outcomes were surgical workspace quality and intra-abdominal pressure requirements. Secondary Outcomes: Secondary outcomes included postoperative abdominal pain at 24 h and referred shoulder pain. Data Synthesis: Seventeen randomized controlled trials involving 1512 patients were included. DNMB consistently improved surgical workspace conditions and facilitated lower pneumoperitoneum pressures compared with MNMB. Pooled analyses additionally suggested reductions in postoperative abdominal pain and referred shoulder pain in selected studies, although postoperative outcomes demonstrated greater heterogeneity across procedures and perioperative protocols. Conclusions: Current evidence suggests that the principal clinical value of DNMB during minimally invasive surgery is optimization of surgical exposure and facilitation of low-pressure pneumoperitoneum strategies. Benefits related to postoperative abdominal pain may occur in selected settings but appear less consistent across procedures.
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.
Introduction: Uvular necrosis is a rare post-general anesthesia complication of airway instrumentation with an estimated 0.03% incidence characterized by delayed onset, disproportionate oropharyngeal pain, and uvular discoloration. Case Description: A 24-year-old male developed uvular necrosis following elective septoplasty–turbinoplasty under general anesthesia. Pain escalated 24–72 h post-operatively (8/10) and was refractory to oral analgesics (acetaminophen and tramadol). Topical 1% viscous lidocaine provided significant relief but required frequent application (q1–2 h). Pain decreased after day 6, with complete resolution by day 10. Conclusions: Uvular necrosis is an uncommon post-intubation complication. The take-home points of this study are as follows: (1) Uvular necrosis is characterized by delayed, disproportionate oropharyngeal pain and discoloration of the uvula. (2) Recommended treatments (oral analgesics, oral steroids, and topical lidocaine among others) are based on limited case reports. (3) Topical viscous lidocaine (1%) was an effective option in this case. Application with a cotton swab reduced dose and toxicity risk (20 to 2 mls) with no loss in analgesic efficacy. (4) Potential causes in this case include oral secretion suctioning, midline placement of endotracheal tube, and oropharyngeal manipulation. (5) Uvular necrosis is under-recognized and under-reported in anesthesia.
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.
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.
Background/Objectives: Opioids are widely used for perioperative analgesia in small animal practice; however, their administration is associated with dose-dependent adverse effects, regulatory restrictions, and increasing stewardship concerns. Evidence supporting opioid-free anesthesia protocols in cats remains limited. The aim of this study was to evaluate the analgesic efficacy of a dexmedetomidine constant rate infusion as part of an opioid-free anesthetic protocol in cats undergoing ovariectomy, as well as to determine its effect on intraoperative opioid requirements. Methods: This prospective, randomized clinical trial included forty healthy female cats (mean age 1.9 ± 0.7 years; mean body weight 3.5 ± 0.6 kg; body condition score 5 [range 4–5]/9) undergoing elective ovariectomy. Cats were randomly assigned to receive either a dexmedetomidine constant rate infusion (CRI) at 1 mcg kg−1 h−1 (GR-E) or a control protocol without dexmedetomidine CRI (GR-C). Anesthesia was induced and maintained using standardized protocols in both groups. Intraoperative fentanyl (5 mcg kg−1 IV) was administered as rescue analgesia when two of three physiological parameters (heart rate, respiratory rate, mean arterial pressure) increased by ≥20% compared to the previous recorded value. Cardiovascular and respiratory variables, rescue opioid requirements, and recovery quality were recorded. Results: The requirement for rescue analgesia was significantly lower in GR-E (4/20; 20%) compared to GR-C (13/20; 65%) (p = 0.0097). Cats receiving dexmedetomidine showed greater intraoperative cardiovascular stability during ovarian pedicle manipulation. No clinically relevant adverse effects were observed. Recovery was smooth in all cats, and all resumed feeding within eight hours postoperatively. Conclusions: A low-dose dexmedetomidine CRI effectively reduced intraoperative opioid requirements during feline ovariectomy while maintaining physiological stability and satisfactory recovery. This opioid-free anesthetic protocol represents a safe and clinically applicable alternative in settings where opioid use is restricted or limited.
Background/Objectives: Postoperative pulmonary complications (PPCs) significantly contribute to surgical morbidity, mortality, and healthcare costs, yet their definition remains heterogeneous in clinical literature. We aimed to develop and apply a standardized system for defining and measuring PPCs and their severity among a general, low-risk surgical population. Methods: A retrospective, observational design evaluated data from 95,808 adult patients undergoing elective surgery with general anesthesia between 2015 and 2023 at a large tertiary medical center. PPCs were identified using a curated list of ICD-10 codes based on the StEP-COMPAC consensus and were categorized into mild, moderate, or severe based on the intensity of postoperative oxygen delivery. Multivariable logistic and ordinal regression models were utilized to identify risk factors for the occurrence and clinical severity of PPCs. Results: The overall incidence of PPCs was 7.52% (n = 7206), with mild cases accounting for the majority (5.65%), followed by moderate (1.47%), and severe (0.40%) cases. Key risk factors for PPCs included ASA class 3 or 4, OSA, COPD, increased case duration, and the use of home oxygen devices. Higher mean pre-operative oxygen saturation was identified as a protective factor against PPCs. Conclusions: A feasible and promising framework for standardizing PPC measurement using EHR data and interprofessional collaboration is presented for use in ongoing initiatives aimed at reducing rates of PPCs. Identified risk factors may serve as critical triggers for implementing perioperative strategies to mitigate complications in the general surgical population.
Background: Exercise prehabilitation may improve physiological resilience before colorectal cancer (CRC) surgery. However, patient acceptance, reflected by recruitment, retention and adherence, is variably reported. Understanding how acceptance is captured and described is essential for designing effective, equitable interventions. Objectives: Map how CRC prehabilitation programmes report recruitment, retention and adherence, and identify characteristics associated with high acceptance. Methods: A scoping review was conducted following published guidance. MEDLINE, Embase, CINAHL, PsycINFO and Cochrane databases were searched. Studies of unimodal or multimodal prehabilitation interventions including an exercise component were included. Data relating to recruitment processes, retention, adherence and engagement-enhancing strategies were extracted and summarised using descriptive and content analysis. Reporting quality and variation were mapped. Results: Thirty-four studies were included: 15 randomised controlled trials, 12 prospective cohorts, four retrospective comparative cohorts, two non-randomised trials, and one quality-improvement project. Recruitment rates varied widely (3.8% to >90%), with four studies not reporting the proportion of eligible patients who declined and no study providing demographic characterisation of patients not recruited. Retention was reported in 31 of 34 studies and was generally high, including seven studies reporting 100% retention, although no consistent definition was used. Adherence was not reported in nine studies; among those reporting it, supervised programmes achieved attendance rates of 68–100% and unsupervised programmes 78–98%. Only four studies quantified adherence to prescribed exercise intensity or volume. No consistent association emerged between programme format (location, supervision, and digital support) and patient acceptance. Conclusions: Substantial variability exists in how CRC prehabilitation studies report recruitment, retention and adherence, constraining understanding of acceptance. Future research should prioritise standardised, detailed acceptance reporting and consider behaviour change theory informed, patient-centred intervention design to ensure effective and equitable CRC prehabilitation.
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.
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.
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.
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.
Correction of Institutional Review Board Statement and Informed Consent Statement in back matter [...]
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.
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.
