BACKGROUND:The impact of cognitive impairment (CI) on perioperative quality of life (QoL) in older surgical patients remains under-explored. We compared longitudinal QoL trajectories by CI status and examined associations between preoperative QoL and postoperative outcomes. METHODS:Patients aged ≥65 years undergoing elective non-cardiac surgery at two academic hospitals were assessed for preoperative CI using the Ascertain Dementia 8-Item Questionnaire (AD8), Montreal Cognitive Assessment (MoCA), and Mini-Cog. QoL was measured preoperatively and at 30 and 90 days postoperatively using a 0-100 visual analogue scale (VAS). QoL trajectories were analyzed using linear mixed-effects models, with time and cognitive status as covariates. RESULTS:Among 370 participants (median age 73 years [IQR: 69-77]; 58% female), 292 and 289 participants completed 30- and 90-day follow-up, respectively. Compared to those without AD8-defined CI (CIAD8), participants with CIAD8 reported significantly lower QoL preoperatively (67 ± 3 vs. 78 ± 1, P < 0.001) and postoperatively at 30 days (59 ± 3 vs. 75 ± 1, P < 0.001) and 90 days (60 ± 3 vs. 77 ± 1, P < 0.001). Lower preoperative QoL was associated with greater all-cause complications, non-home discharge, and composite adverse outcomes within 30 days, as well as composite adverse outcomes at 90 days. Higher pain, frailty, anxiety/depression, and CIAD8 remained independently associated with lower perioperative QoL. CONCLUSION:Older patients with CIAD8 experienced persistently lower QoL throughout the perioperative period, compared to those without CIAD8. Although QoL transiently declined within the CIAD8 group at 30 days, longitudinal QoL trajectories did not differ significantly between participants with and without CIAD8. Brief preoperative screening of CI and QoL may nevertheless help identify patients at risk of poor QoL and adverse postoperative outcomes.
STUDY OBJECTIVE:To evaluate the effects of perioperative intravenous magnesium sulfate on postoperative pain, opioid consumption, recovery, and adverse events in patients undergoing spinal surgery. DESIGN:Systematic review with meta-analysis. SETTING:Perioperative setting. PATIENTS:Twenty-one randomized controlled trials including 1271 adult patients. INTERVENTIONS:Perioperative intravenous magnesium sulfate. MEASUREMENTS:Two researchers independently evaluated the risk of bias of included randomized controlled trials using the Cochrane Risk-of-Bias Tool 2.0 (RoB 2). Disagreements were settled by discussion or consultation with a third reviewer. We used funnel plots to detect publication bias when at least 10 studies were available, and adopted the leave-one-out sensitivity analysis to verify the robustness of pooled results. The certainty of evidence for each outcome was rated via the GRADE framework from five dimensions, with evidence classified into four grades: high, moderate, low and very low. MAIN RESULTS:Perioperative intravenous administration of magnesium sulfate can reduce postoperative 24-h pain scores (MD: -0.55, 95% CI: -1.01 to - 0.10, P = 0.02) and opioid consumption (MD: -4.95 mg, 95% CI: -8.74 to - 1.15 mg, P = 0.01). Furthermore, effect was more pronounced in the subgroup receiving a loading dose plus a maintenance dose. Perioperative intravenous magnesium administration significantly reduced intraoperative opioid consumption. Compared to the control group, magnesium sulfate was associated with a lower incidence of postoperative nausea and vomiting, but a higher incidence of hypotension. Meanwhile, intraoperative intravenous administration of magnesium sulfate appears to prolong the time to follow commands and the time to recovery of orientation. CONCLUSIONS:Perioperative magnesium sulfate improves analgesia and reduces opioid consumption in spinal surgery, especially with a bolus-plus-infusion regimen. However, it may delay emergence and increase hypotension risk. Careful hemodynamic monitoring is recommended for high-risk patients.
BACKGROUND:Postoperative shoulder dysfunction is a frequent and disabling complication following modified radical mastectomy (MRM), particularly in geriatric patients. Although pectoserratus plane block (PSPB) and serratus anterior plane blocks are well established for acute postoperative analgesia, their impact on long-term shoulder function remains unclear. METHODS:This retrospective cohort study included 147 women aged ≥65 years who underwent MRM for breast cancer. Patients who received PSPB combined with serratus anterior plane blocks formed the block group (n = 78), while those managed without regional anesthesia formed the control group (n = 69). Shoulder function at 6 months was assessed using Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Constant-Murley scores, and active range of motion. Secondary outcomes included persistent shoulder stiffness and chronic pain interference assessed by the Brief Pain Inventory (BPI) interference subscale. RESULTS:At 6 months, the block group demonstrated significantly better shoulder function with lower QuickDASH scores (7.8 ± 9.3 vs. 18.7 ± 8.8, p < 0.001) and flexion (138.9° ± 16.8 vs. 133.9° ± 17.1, p = 0.027), and abduction (131.1° ± 19.1 vs. 126.9° ± 18.1, p = 0.049) were also improved and persistent shoulder stiffness was significantly less frequent (42.3% vs. 69.6%, p = 0.002). Multivariable logistic regression analyses identified regional blockade as an independent protective factor against persistent stiffness (odds ratio 0.29, 95% CI 0.14-0.59, p = 0.001). Constant-Murley scores at 6 months did not differ significantly between groups (83.4 ± 6.9 vs. 84.0 ± 6.4, p = 0.682). CONCLUSION:Routine use of ultrasound-guided PSPB and serratus anterior plane blocks was associated with lower rates of long-term shoulder dysfunction after MRM in geriatric breast cancer patients. These findings suggest a potential association between regional anesthesia and improved postoperative functional recovery; however, causality cannot be established due to the retrospective design.
BACKGROUND:Difficult intubation and facemask ventilation in infants and small children can lead to rapid oxygen desaturation. An endotracheal tube (ETT) with its tip positioned in the hypopharynx is readily available and bypasses the soft palate, tongue, and epiglottis of the child, thus saving time by providing safe and efficient hypopharyngeal ventilation to ensure proper oxygenation. METHODS:This prospective, observational study included 85 infants and children aged >1 month and ≤ 6 years old, undergoing elective surgery under general anesthesia with orotracheal intubation. The effectiveness and safety of hypopharyngeal ETT ventilation performed by clinical anesthesia (CA) residents was evaluated. The primary objective of this study was to assess the efficacy of this technique in providing successful ventilation evidenced by visible chest rise, the presence of a sustained end-tidal capnography (EtCO2) waveform, stable oxygen saturation (SpO2) values, and an adequate expired tidal volume. Secondary outcomes included the incidence of severe hypoxemia (SpO2 < 85%), bradycardia, stomach insufflation, and laryngospasm. RESULTS:Successful ventilation by CA residents was achieved in 82 patients (96.5%) evidenced by visible chest rise, at least eight EtCO2 waveforms, stable SpO2 values, and adequate expired tidal volume. When stratified by CA resident groups, successful ventilation rates did not differ significantly (p = 0.407). Stomach insufflation occurred in 3 patients (3.5%) while severe hypoxemia (SpO₂ < 85%), bradycardia, and laryngospasm were not observed. CONCLUSIONS:Hypopharyngeal ETT ventilation performed by CA residents is an effective and safe technique of ventilation in infants and children ≤6 years old with normal airways. Its role as an alternative for facemasks or supraglottic airway devices in pediatric airway management may be subject for future trials. CLINICAL TRIAL NUMBER:NCT06449924. CLINICALTRIALS:com registry URL:https://clinicaltrials.gov/study/NCT06449924.
Accurate assessment of respiratory drive and effort is important in critically ill patients receiving invasive or noninvasive mechanical ventilation. This review summarizes the physiology of breathing, with particular emphasis on respiratory drive, inspiratory effort, and work of breathing and on the clinical significance of their measurement. Reference techniques are discussed, but the main focus is on noninvasive airway occlusion maneuvers (P0.1, Pocc, and PMI) as bedside surrogates of respiratory drive and effort. Patient variability and technical factors may lead to misinterpretation and limit patient-level precision. Nevertheless, these measurements may help identify abnormal respiratory drive or effort and support individualized ventilatory assistance. A sound understanding of the underlying physiology is essential for valid application. This review provides a framework for interpreting occlusion maneuvers as complementary monitoring tools and discusses the challenges involved in their bedside use. SUMMARY STATEMENT: This review assesses noninvasive methods for evaluating respiratory drive and effort as alternatives to invasive techniques during mechanical ventilation.
BACKGROUND:Postoperative cognitive dysfunction (POCD) is a frequent complication after cardiac surgery. Exercise-based prehabilitation may enhance functional reserve and reduce vulnerability to perioperative cerebral insults. We hypothesized that multimodal prehabilitation reduces POCD 3 months after cardiac surgery. METHODS:This prespecified substudy of a single-center randomized controlled trial (NCT03466606) included patients aged ≥50 years undergoing elective coronary artery bypass grafting and/or valve surgery. Participants were randomized 1:1 to 4-6 weeks of multimodal prehabilitation (exercise training, nutritional support, and psychological support) or standard preoperative care. Cognitive function was assessed at baseline and 3 months postoperatively using an age- and education-adjusted neuropsychological battery. POCD was defined as performance ≥1.5 standard deviations below normative values in at least 2 cognitive tests, excluding the Mini-Mental State Examination. Logistic regression analyses were performed to evaluate factors associated with POCD. RESULTS:Of 160 participants screened from the parent trial, 134 met eligibility criteria for the substudy and were randomized; 116 completed 3-month follow-up (prehabilitation n = 53; control n = 63). POCD occurred in 29 patients (25%), including 15/53 (28%) in the prehabilitation group and 14/63 (22%) in controls (odds ratio [OR] 1.37, 95% confidence interval [CI] 0.54-3.50, P = 0.52). In multivariable analysis, preoperative cognitive impairment was independently associated with POCD (OR 13.28, 95% CI 4.06-43.41, P < 0.001), whereas prehabilitation was not (OR 1.09, 95% CI 0.35-3.45, P = 0.877). Higher physical activity levels at 3 months were associated with lower odds of POCD (OR 0.97, 95% CI 0.95-1.00, P = 0.047). CONCLUSIONS:In this randomized controlled trial, a 4-6-week multimodal prehabilitation program did not reduce postoperative cognitive dysfunction 3 months after cardiac surgery. Although the intervention did not achieve measurable cognitive protection, the observed association between postoperative physical activity levels and postoperative cognitive dysfunction warrants further investigation.
BACKGROUND:Multimodal anesthesia (MMA) is widely used to reduce opioid use and improve postoperative recovery. However, evidence for bundled MMA regimens-defined as opioids plus ≥2 adjunct analgesic modalities-has not been systematically synthesized across patient-centered outcomes. METHODS:We performed a systematic review and meta-analysis of randomized controlled trials comparing MMA (opioids plus ≥2 adjuncts, including regional techniques and/or systemic agents such as dexmedetomidine, ketamine, intravenous lidocaine, clonidine, or magnesium) with opioid-based general anesthesia in adults undergoing elective surgery. MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Library were searched to 28 October 2025. Primary outcomes were postoperative pain, PONV, QoR-15, and pulmonary complications. Secondary outcomes included opioid consumption in Morphine Milligram Equivalent (MME) and PACU length of stay. Risk of bias was assessed with RoB 2 and certainty with GRADE. Registered in PROSPERO (CRD42024470056). RESULTS:Twenty-one RCTs (n = 1828) were included. At 24 h, no clear effect of MMA on pain intensity was observed (10 trials, n = 785; MD -0.6, 95% CI -1.5 to 0.2; very low certainty). MMA reduced PONV incidence (4 trials, n = 352; RR 0.59, 95% CI 0.44 to 0.77; low certainty). For secondary outcomes, MMA reduced opioid consumption (10 trials, n = 915; MD -7.0 mg MME, 95% CI -12.8 to -1.3; moderate certainty), with the opioid-sparing effect persisting at 48 h (MD -14.0 mg MME) and study end (MD -16.0 mg). Data for QoR-15, PACU stay, and pulmonary complications were insufficient for pooling. CONCLUSIONS:MMA shows no clear effect on postoperative pain at 24 h but reduces PONV incidence and opioid consumption. Evidence certainty ranges from moderate to very low. Larger, standardized trials are needed to define optimal MMA regimens and patient selection.
BACKGROUND:Total hip arthroplasty is a painful surgical procedure; therefore, it is a challenge to manage effective pain control during the perioperative period. STUDY OBJECTIVES:We compared the analgesic efficacy of the pericapsular nerve group block and the anterior quadratus lumborum block in patients undergoing unilateral hip arthroplasty. DESIGN:Randomized controlled trial. SETTINGS:Operating room of a tertiary care center. PATIENTS:92 adult patients of >18 years who underwent elective, unilateral total hip arthroplasty under spinal anesthesia were randomized to either Group P (USG guided PENG block with 30 ml 0.25% ropivacaine +4 mg dexamethasone) or Group Q (USG guided QL block with 30 ml 0.25% ropivacaine +4 mg dexamethasone) 20 min before surgery. MEASUREMENTS:We compared the total perioperative fentanyl consumption between the two groups in the first 24 h as the primary outcome. Other outcomes included time to first rescue analgesia in the postoperative period, NRS scores at rest and on movement at 0, 2, 4, 6, 12, and 24 h, incidence of intraoperative hemodynamic changes, and incidence of postoperative PONV. MAIN RESULTS:There was no significant difference in the total fentanyl consumption between the two groups: 237.5 (150-450) μg in the P group and 250 (125-400) μg in the Q group; p = 0.617. The time to first rescue analgesia was similar in both groups: the P group (198 [123-268] minutes) and the Q group (241 [180-318] minutes); p = 0.120. There was also no difference in pain scores, intraoperative hemodynamic changes, or PONV. CONCLUSION:There was no difference in the perioperative opioid consumption, pain scores, and adverse event rates between the pericapsular nerve group block and anterior quadratus lumborum block in adult patients undergoing unilateral hip arthroplasty. TRIAL REGISTRATION:Clinical Trials Registry of India (CTRI number: CTRI/2023/08/057157).
BACKGROUND:Anesthesiologists vary in their desired balance between clinical workload, compensation, and personal time. Interventions that allow clinicians to individualize their work commitments have been associated with improved employee satisfaction. However, such flexibility relies on knowing when clinical responsibilities are likely to end on a given day. Without accurate predictions of when they expect to finish, clinicians cannot reliably individualize their scheduling decisions. METHODS:We performed a retrospective observational study of daily times at which the final patient left the Phase I recovery over a multi-year period at an ambulatory surgery center. Using rolling historical windows, exact percentile-based prediction limits were calculated from prior observed days. Prediction limits are predefined upper bounds for future daily observations. For each window, the prediction limit was computed as the exact order statistic corresponding to the selected percentile of the makespan, avoiding parametric assumptions about the underlying distribution. A pragmatic rolling window size was selected based on the stability of the prediction limit. Predictions with lower day-to-day variation were expected to be more useful for clinicians' day-to-day planning. RESULTS:Accuracy of exact percentile prediction limits was similar across candidate window sizes, ranging from 5 to 100 days, with observed exceedance rates remaining close to the nominal 20% level for the 80th-percentile prediction limit. The coefficient of variation of estimates decreased with increasing window size before approaching a gradual plateau, with little additional reduction in variability beyond 60 workdays. A 60-workday window provided stable 80th-percentile prediction limits while preserving the expected exceedance rate, where 80% means expected to be exceeded at most 1 day out of 5. Application of this approach to a separate synthetic log-normal dataset demonstrated comparable accuracy and variability behavior across window sizes. Example application was made to a single-specialty orthopedic hospital. CONCLUSIONS:A rolling, distribution-free prediction method based on exact order statistics provides stable and interpretable estimates of when the Phase I recovery is likely to close and the last anesthesiologist can leave for the day. Using a 60-workday historical window, this approach preserves expected upper-tail exceedance behavior while reducing day-to-day variability of the prediction limit. Such estimates enable anesthesiologists to better anticipate late work and align their daily scheduling decisions with more data-based predictions of when their workday is likely to end.
BACKGROUND:Obese patients are prone to rapid oxygen desaturation during induction of general anesthesia due to reduced functional residual capacity and atelectasis formation. Transnasal humidified rapid insufflation ventilatory exchange (THRIVE) prolongs safe apnea time; however, its effects on lung volume dynamics during apnea remain unclear. METHODS:In this single-center randomized controlled trial, adults with body mass index ≥35 kg/m2 undergoing elective surgery were assigned to apneic oxygenation with THRIVE or facemask oxygen following induction of general anesthesia. Electrical impedance tomography was used to assess changes in end-expiratory lung impedance (ΔEELI), a surrogate of lung volume. The primary outcome was mean global ΔEELI during an early apneic window (2-6 min). RESULTS:Thirty-two patients were analyzed. Mean global ΔEELI during early apnea was significantly better preserved with THRIVE than with facemask oxygen (-0.22 ± 0.03 vs. -0.89 ± 0.07; mean difference 0.67, 95% CI 0.55-0.80; P < 0.001). THRIVE attenuated the rate of ΔEELI decline and was associated with greater preservation of lung volume, particularly in mid-ventral and mid-dorsal regions. Safe apnea time was significantly prolonged in the THRIVE group (median 600 vs. 319 s). CONCLUSIONS:In obese patients, THRIVE transiently preserves lung volume during early apnea by slowing the decline in end-expiratory lung volume. These findings provide physiological insight into the mechanisms underlying improved oxygenation during apneic oxygenation.
OBJECTIVE:To evaluate the effect of intraoperative low-dose intravenous esketamine (<1 mg/kg) on acute postoperative pain, opioid consumption, adverse events, and anesthetic requirements through a systematic review and meta-analysis of randomized controlled trials. METHODS:We systematically searched PubMed, Cochrane Central, and Embase (to Apr 28, 2025) for RCTs on intraoperative low dose IV esketamine (<1 mg/kg) for acute postoperative pain. Data was analyzed in R using mean differences or risk ratios (95% CIs). Risk of bias followed Cochrane methods. Sensitivity used leave-one-out and meta-regression. RESULTS:Thirty-five RCTs (3831 patients; 1663 control, 2168 esketamine) showed low-dose IV esketamine significantly reduced pain at rest at 4 h (MD -1.40; p < 0.0001), 12 h (-0.84; p < 0.0001), 24 h (-0.54; p < 0.0001), and 48 h (-0.39; p = 0.0014). Pain on movement was lower at 12 h (-0.62; p = 0.0111), 24 h (-0.63; p = 0.0003) and 48 h (MD -0.40, 95% CI -0.74 to -0.06; p = 0.0212; I2 = 75.5%). No significant differences in overall or individual adverse events (nausea, agitation, dizziness, hallucinations) were observed between groups. Postoperative morphine consumption was reduced at 4, 24 and 48 h, with no significant difference at 12 h. Rescue analgesia requirements were reduced (RR 0.52; p = 0.0001), and intraoperative propofol use was modestly lower (-18.47 mg; p = 0.0047). No significant dose-response relationship was identified (p = 0.0571). CONCLUSION:Intraoperative low-dose esketamine modestly reduces postoperative pain at rest (4-48 h) and during movement (12-48 h), decreases opioid and rescue analgesia requirements, and slightly lowers propofol use. However, the magnitude and consistency of these effects are uncertain due to heterogeneity and study limitations. Adverse events did not differ significantly, though evidence remains limited. Esketamine may be considered as an adjunct in perioperative pain management with appropriate monitoring.
OBJECTIVE:Structural and functional metabolism are closely linked in the cholinergic system, and associations between cholinergic neurotransmission and atrophy of cholinergic nuclei, i.e., the nucleus basalis of Meynert (NBM), have been described for neurodegenerative conditions. Impaired cholinergic neurotransmission, as shown by alterations in cholinesterase (ChE) activity of patients undergoing anaesthesia, may contribute to perioperative disorders of cognition. In this secondary analysis, we evaluated a potential association between perioperative ChE activity and postoperative NBM atrophy and studied its potential role in postoperative delirium (POD) and cognitive dysfunction (POCD). We further explored how postoperative inflammation, liver injury and anaesthetic toxicity may contribute to this relationship. METHODS:We conducted a secondary analysis in a subsample from the BioCog cohort study. N = 170 cognitively healthy (MMSE≥24) patients ≥65 years provided ChE activity, inflammatory markers and transaminase activity before elective surgery and on the first postoperative day, as well as magnetic resonance imaging data before surgery and at follow-up three months after surgery for volumetry of the NBM. Patients were screened for delirium until the 7th postoperative day. POCD was assessed three months after surgery and was defined according to the reliable change index. The data were analysed in linear regression models of postoperative NBM volume adjusted for age, sex, MMSE score and preoperative NBM volume. RESULTS:Lower postoperative activity of butyryl-ChE (BuChE) was associated with lower baseline-adjusted NBM volume (B [95% CI]: 0.0141 [0.0055; 0.0227] mm3 per U/L), which was driven by the perioperative change in butyryl-ChE activity (B [95% CI]: 0.0205 [0.0088; 0.0321] mm3 per U/L) rather than preoperative activity (B [95% CI]: 0.0109 [0.0014; 0.0203] mm3 per U/L). We observed no relationship between BuChE activity, NBM atrophy and POD or POCD. Postoperative inflammatory response was associated with BuChE inhibition, but not NBM atrophy. In patients undergoing anaesthesia maintained with sevoflurane, duration of surgery was significantly associated with BuChE inhibition and NBM atrophy. DISCUSSION:We observed an association between plasma BuChE activity and postoperative NBM atrophy. Our findings point towards a potential neurotoxic effect of sevoflurane on the cholinergic system. However, the involvement of this mechanism in postoperative cognitive disorders will require further well powered studies to evaluate causality.
