This review examines whether the traditional preoperative assessment clinic, designed primarily to reduce perioperative complications, improve patient safety, and prevent day-of-surgery cancellations, remains the appropriate model for perioperative care, and evaluates the evidence for a shift from preoperative evaluation to preoperative optimization. Virtual preoperative evaluation is non-inferior to in-person evaluation for cancellation prevention and patient satisfaction, but neither format addresses the underlying limitation of assessment without optimization. Screening programs organized around modifiable risk factors are achievable in routine practice, though compliance with optimization remains low without structured follow-through. Preoperative correction of anemia, hyperglycemia, impaired functional capacity, and tobacco use improves surgical outcomes. A tiered perioperative optimization pathway, combining universal virtual screening, modular specialist-led optimization, and anesthesiologist-coordinated planning for high-risk patients, offers a more clinically meaningful model than either traditional or virtual preoperative clinics. This framework treats the preoperative period as a treatment window rather than an administrative checkpoint.
Pain from chest wall trauma can worsen breathing in thoracic trauma patients and contribute to pulmonary complications. Standard analgesia with parenteral opioids and thoracic epidural analgesia can be very effective but cannot always be implemented safely. Alternative thoracic fascial plane blocks are emerging as alternative techniques. Truncal regional anesthesia uses ultrasound to administer a local anesthetic into an anatomic potential space adjacent to sensory nerves, providing pain relief to the areas supplied by those nerves. Catheter techniques can be an option for persistent pain relief. Posterior thoracic blocks include the paravertebral block and the erector spinae plane block and are proposed for posterior chest injuries. The serratus anterior plane block is a lateral wall block for anesthesia of the anterolateral chest. Intercostal nerve blocks and parasternal blocks are options for anterior sternal fractures. Experimental blocks have also been proposed. Fascial plane blocks of the chest wall have emerged as modalities to treat pain from thoracic wall trauma. These blocks may have a role as alternatives to thoracic epidurals for some patients.
Hemorrhage is the leading cause of preventable death in trauma, yet no transfusion volume reliably predicts inevitable mortality during ultramassive transfusion (UMT). This review examines whether UMT is ever futile and how that determination can be made systematically and ethically at the bedside. Survivors have been documented across the full spectrum of reported transfusion volumes, including thresholds previously described as uniformly fatal. Validated scoring frameworks — including the STOP criteria and the Futility of Resuscitation Measure (FoRM) — alongside machine learning models and structured multidisciplinary futility time-outs offer dynamic approaches that integrate hemorrhage control feasibility, physiological trajectory, neurological prognosis, and institutional resource stewardship. UMT is associated with significant complications and imposes considerable demands on blood product supply and clinical personnel throughout resuscitation. Futility in UMT cannot be determined by transfusion rate and volume alone. Decision making requires integration of injury severity, physiological response, hemostatic data, and patient-centered goals through periodic structured reassessment. Future priorities include prospective validation of futility decision frameworks and machine learning-based markers, standardization of UMT definitions, and longitudinal research capturing functional outcomes among survivors.
Intrathecal morphine (ITM) is a promising analgesic option for major abdominal surgery, but its clinical efficacy, potential adverse events and optimal dosing require further investigation. We searched MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) for data from 1990 until July 2024 to identify studies comparing a preoperative intrathecal dose of hydrophilic opioid to alternative analgesia in adult patients undergoing abdominal surgery under general anaesthesia. The Cochrane Risk of Bias 2 (RoB 2) tool was used to assess risk of bias in individual studies. Meta-analyses were conducted using a random-effects model. The primary outcomes were opioid consumption and pain intensity. Additional outcomes included incidence of opioid related adverse effects and hospital length of stay. A total of 59 studies were included, with 2005 patients that received ITM (dose range 0.04 − 3.75 mg). Four comparator groups were identified based on analgesic strategy. Substantial heterogeneity was present across all reported data (I2 > 75
Health care disparities are an important challenge in anesthesiology, affecting a wide range of patient populations. This review examines disparities in the anesthesiology workforce, their influence on patient outcomes, and strategies aimed at improving diversity within the field. Although anesthesiology plays a critical role in patient outcomes, the workforce remains insufficiently diverse, with many underrepresented groups, including African Americans, Hispanics, and women. These disparities may translate into clinical care, as minority patients often receive fewer anesthetic technique options and experience higher rates of perioperative complications. Such inequities may be influenced by both implicit and explicit bias, which can be more pronounced in less diverse professional environments. Strategies to improve diversity and reduce disparities include strong mentorship, community outreach programs, global health education initiatives, structured and blinded interviews, recruitment of diverse faculty, and the support of diversity champions. Persistent disparities in anesthesiology continue to affect both workforce representation and patient care. Although efforts have been made to improve diversity, further longitudinal research is needed to better understand how a diverse workforce influences patient outcomes and how diversity initiatives can be more effectively supported by institutions and professional organizations.
Postpartum hemorrhage (PPH) is the leading cause of maternal morbidity and mortality worldwide, primarily due to uterine atony. Although oxytocin remains the first-line uterotonic, its short half-life and storage requirements limit effectiveness. Alternatively, carbetocin, a long-acting analogue, provides sustained uterine tone after a single dose without refrigeration; however, its superiority over oxytocin in cesarean delivery (CD) remains uncertain. We systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing carbetocin and oxytocin for PPH prevention in CS. A Bayesian random-effects model was applied for the primary outcomes - PPH, blood transfusion, and need for additional uterotonics. Secondary outcomes, including adverse effects, uterine atony, estimated blood loss, and hemodynamic parameters were assessed using frequentist methods and Trial sequential analysis (TSA). Forty-two RCTs involving 7,552 patients were included, with 3,781 randomized to carbetocin. Bayesian analysis indicated a 99.9
Post traumatic stress disorder (PTSD) is common after traumatic injuries and has significant long-term consequences. The neurobiology of PTSD is rooted in the fear memory system, and many of the analgesics, sedatives, and anesthetics used in the care of trauma patients have effects on this circuitry. Several recent studies have looked at the effects of perioperative medications on PTSD. Data on ketamine and midazolam are mixed, but propofol appears to increase PTSD. Conversely, cortisol, dexmedetomidine, and selective serotonin re-uptake inhibitors appear to reduce the incidence of PTSD. The neurocircuitry associated with PTSD contains multiple targets affected by medications commonly used to treat trauma patients. Current data suggest that many of these medications have the potential to reduce PTSD, but most studies are either small or not generalizable. Given PTSD’s profound impact on quality of life, additional studies have the potential to have significant impact on trauma survivors.
Cesarean Delivery (CD) often causes moderate to severe postoperative pain. The transversus abdominis plane (TAP) block reduces somatic pain after lower abdominal surgeries; however, its duration is limited when local anesthetics are used alone. Adjuvants like dexmedetomidine and dexamethasone are used to prolong analgesia, but their comparative efficacy in TAP block for CD remains uncertain. We systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing dexmedetomidine and dexamethasone as adjuvants in patients undergoing CD. Primary outcomes were postoperative pain scores (VAS) and time to first analgesia request. Secondary endpoints included heart rate (HR) and postoperative nausea and vomiting (PONV). Pooled mean differences (MD) and risk ratios (RR) were calculated with 95
This narrative review, using peer-reviewed literature supplemented by authoritative government, military, news, and professional-society sources when relevant factual information was not otherwise available, examines the role of anesthesiologists in disasters and large-scale emergencies, with emphasis on large-scale combat operations (LSCOs), Medical Operations Coordination Centers, and National Disaster Medical System coordination. Although prior literature has described anesthesiologists’ value in disasters and mass-casualty incidents, LSCO casualty planning introduces distinct challenges in casualty distribution, operative throughput, critical care surge, blood stewardship, and civil-military coordination. Recent literature also suggests that evolving hybrid threats may further complicate preparedness planning. Anesthesiologists’ expertise in resuscitation, perioperative medicine, critical care, and hospital-wide coordination makes them essential to LSCO preparedness and response. The review concludes with practical recommendations to strengthen readiness through education, training, planning, and greater engagement in preparedness systems and emergency response frameworks.
Postoperative acute kidney injury (AKI) remains a leading cause of morbidity after cardiac surgery. This review examines right ventricular (RV) dysfunction and systemic venous congestion as primary, underrecognized mediators of perioperative renal injury, operating through mechanisms largely independent of arterial hypoperfusion. Human hemodynamic studies consistently demonstrate that central venous pressure is a stronger predictor of renal impairment than cardiac index across cardiovascular disease populations. Intraoperative venous congestion independently predicts postoperative AKI in cardiac surgery, and dynamic intraoperative deterioration of RV function is among the strongest predictors of cardiac surgery-associated AKI identified to date. Elevated renal venous pressure erodes the renal perfusion pressure gradient, producing congestive nephropathy — a potentially reversible renal dysfunction phenotype distinct from ischemic injury. RV dysfunction and venous congestion should be recognized as primary mediators of perioperative AKI. Postoperative oliguria with elevated venous pressure warrants decongestion rather than fluid administration. Preoperative RV assessment, intraoperative CVP surveillance, and bedside venous congestion phenotyping using tools such as Venous Excess Ultrasound represent practical and immediately applicable perioperative strategies.
This review summarizes the most recent literature on the association between the administration of blood products with acute kidney injury (AKI). The multifactorial nature of AKI is reviewed and the potential mechanisms for the association are explored. In addition, immunological causes of AKI after transfusion are addressed. We also provide recommendations for transfusion practice and perioperative management to minimize the risk of AKI. Several recent studies have demonstrated a consistent association between the administration of blood products and AKI. Restrictive blood transfusion protocols have however failed to reduce the incidence of AKI. Transfusion of blood products is definitively associated with AKI. Considering current evidence however it is still unknown if there is a cause-and-effect relationship underlying this association. Notwithstanding the uncertainty, blood products should be employed with great caution in patients who are at significant risk of AKI until further evidence becomes available to clarify the situation. The etiology of AKI is multifactorial, and factors other than transfusion may be more important. Intraoperative hypotension must be prevented. The use of drugs which have the potential for renal toxicity like intravenous contrast agents, aminoglycoside antibiotics and non-steroidal analgesic drugs should be minimized. Adequate fluid resuscitation is also necessary to guarantee adequate cardiac output and renal perfusion. Goal-directed fluid management should be considered in high-risk patients. Transfusion of incompatible blood products must also be avoided as at all costs because this can lead to severe AKI.
Prehabilitation has become a central perioperative strategy in cancer surgery, but definitions, intervention components, delivery models, outcome measures, and target populations remain variable across studies and services. This review examines exercise as the core therapeutic element while also addressing the other pillars of contemporary multimodal prehabilitation: nutrition, psychological support, and behaviour change. In cancer surgery, the strongest contemporary evidence comes from high-fidelity multimodal programmes, respiratory prehabilitation for thoracic or upper abdominal surgery, risk-enriched cohorts, and carefully supported home-based or hybrid models. Recent component analyses across surgical trials also suggest that exercise and nutrition are the most consistently beneficial components, with additional signal for multimodal programmes that include psychosocial support. The 2025 Macmillan Cancer Support guideline reframes cancer prehabilitation as a needs-based, multimodal intervention delivered before and during treatment and supported by behaviour-change techniques. Exercise remains the cornerstone of prehabilitation, but it is rarely sufficient as a stand-alone strategy. Nutrition, psychological support, and behaviour-change techniques help patients complete and benefit from exercise, particularly when malnutrition, distress, or access barriers limit participation. The most defensible current model is therefore exercise-centered, multimodal, risk-stratified, and integrated across the cancer pathway rather than confined to a short preoperative window.
To summarize the current state of quality improvement for trauma anesthesia. While the basics of quality improvement (QI) in anesthesiology have been understood for some time, trauma care is a multidisciplinary, multi-specialty effort. QI for the trauma anesthesia service therefore includes both the traditional metrics and outcomes for any anesthesia service, such as success with airway management, as well as team-based metrics that capture the holistic reality of trauma care. Anesthesia care impacts global metrics such as risk-adjusted probability of survival, patient length of stay, resuscitative requirements, timely access to the operating room, and overall patient satisfaction. Continuous improvement is frequently through team-based educational and practice initiatives that include all the stakeholders in trauma patient outcomes and not just anesthesia clinicians. Anesthesia QI for trauma patients consists of both anesthesia-specific QI initiatives and team-based multidisciplinary efforts. Recommendations and suggested metrics for both domains are presented with examples of QI projects from the current literature.
Regional anesthesia (RA) provides effective analgesia and reduces systemic opioid requirements, but emerging evidence suggests it also alters local microvascular physiology. This review synthesizes mechanistic and clinical data describing how RA modulates the microcirculation — the capillary and arteriolar network responsible for tissue perfusion and oxygen delivery. Human and animal studies using laser Doppler flowmetry, transcutaneous oximetry, and near-infrared spectroscopy demonstrate consistent increases in cutaneous and subdermal perfusion following peripheral and plexus blocks. Sympathetic blockade reduces α-adrenergic vasoconstriction, while local anesthetics may enhance endothelial nitric oxide release and attenuate inflammatory responses. In ischemic limbs, continuous sciatic blockade increased transcutaneous oxygen pressure by approximately 70
Point-of-care gastric ultrasound (gastric POCUS) has provided clinicians with a tool for individualized aspiration risk assessment, moving beyond broad fasting guidelines and addressing the need for precise, bedside judgment in diverse surgical populations. Gastric POCUS utilizes a transducer probe to examine the gastric antrum in the supine, semirecumbent, or right lateral decubitus positions. The latter offers superior visualization of fluid volumes by allowing fluids to settle into the antrum of the stomach. The technique reliably distinguishes between empty, fluid-filled, and solid-filled stomachs. An empty antrum appears flat with hypoechoic layers, described as a “bullseye,” while solids may produce a heterogeneous hyperechoic “frosted-glass” pattern. Quantitative assessment via antral cross-sectional area has demonstrated high diagnostic accuracy, with a sensitivity of 100
Endoscopic retrograde cholangiopancreatography (ERCP) often requires deep sedation with propofol, which carries a risk of dose-dependent cardio-respiratory complications. Intravenous lidocaine (IVL) has been proposed as an adjuvant to enhance sedative safety and efficiency. Following PRISMA guidelines, a systematic search of PubMed, Scopus, Web of Science, and Cochrane Library was conducted for randomized controlled trials (RCTs) comparing IV lidocaine plus propofol versus propofol alone during ERCP. Outcomes included total propofol consumption, recovery time, pain scores, and sedation-related adverse events (hypoxia, hypotension, involuntary movement, and post-ERCP pancreatitis). The risk of bias was assessed using the RoB2 tool, and the certainty of the evidence was evaluated using the GRADE approach. A random-effects meta-analysis was performed using RevMan software. Four RCTs comprising 402 patients were included. IV lidocaine significantly reduced total propofol consumption (mean difference = − 72.95 mg; 95
The application of music intervention to enhance the patient’s hospitalization experience has a long-standing history. Music intervention, as a non-pharmacological treatment, is being used in various clinical settings such as wards, outpatient surgical centers, intensive care units (ICU), and surgical theatres. The aim of this review is to summarize the extensive research on the influence of music intervention on perioperative patients. Additionally, we intend to explore the benefits associated with such an intervention. Numerous clinical studies have investigated the impact of music intervention on patient anxiety, pain, hemodynamic variables, depth of sedation, and postoperative recovery. However, due to a multitude of factors, the findings from these studies remain inconsistent. Music intervention is a non-pharmacological treatment widely used in different clinical areas. The accelerated rehab surgery model aims to protect patients from physiological and psychological stress during the perioperative period, reduce postoperative complications, and promote recovery. Although the effects of music intervention on perioperative patients have been studied extensively, the results are still not conclusive. Further research is needed to better understand the role and optimal application of music intervention in the perioperative care of patients.
This article examines anesthetic management strategies for percutaneous lung interventions, specifically percutaneous transthoracic needle biopsy (PTNB) and image-guided thermal ablation (IGTA). The primary objective is to analyze the evidence for different anesthetic choices to improve procedural precision, patient safety, and clinical outcomes. The article synthesizes current literature to clarify procedure-specific physiological considerations and to define evidence-based approaches to peri-procedural management. Current evidence demonstrates that anesthetic approaches must be tailored according to lesion characteristics, procedural complexity, and patient risk profile. While PTNB and cryoablation may be performed under local anesthesia with monitored anesthesia care, more technically demanding lesions, prolonged procedures, or heat-based ablation techniques often require deep sedation or general anesthesia. Advances in respiratory motion control such as high-frequency jet ventilation, apneic oxygenation, and intermittent apnea techniques have improved targeting accuracy, particularly for subpleural, diaphragmatic, and centrally located tumors. Complications including pneumothorax, hemorrhage, and systemic air embolism remain clinically significant and necessitate early recognition and coordinated multidisciplinary management. Anesthetic management for percutaneous lung interventions remains variable across institutions. Evidence-based, individualized strategies that address respiratory motion control and procedure-specific risks are crucial to improve procedural accuracy, minimize complications, and enhance outcomes in PTNB and IGTA.
Perioperative coagulopathy diagnosis and management are essential. When performed in a timely manner, they improve patient outcomes and reduce healthcare costs. A well-established, rapid and efficient coagulation testing tool can help achieve this goal. Viscoelastic coagulation testing (VET) evaluates multiple components of the coagulation cascade simultaneously and rapidly. It can provide a real time and dynamic assessment of coagulopathy and help tailor treatment specific to the underlying cause. The most common VETs available for use in the perioperative period are rotational thromboelastometry (ROTEM; Bedford, MA) and thromboelastography (TEG; Haemonetics. Boston, MA). A newer, second-generation device using sonorrheometry (Quantra; Hemosonics, LLC, Durham, NC) is also starting to be used in the perioperative period. Viscoelastic coagulation testing remains a valuable tool in multiple clinical settings. Its ability to provide real-time, comprehensive assessments of coagulation status offers unique advantages, particularly in complex surgical cases or patients with coagulopathy. However, its limitations underscore the importance of judicious utilization, ongoing education, and further research to optimize its clinical utility in the perioperative period.
A fundamental task of anaesthetists is to ensure optimal end-organ perfusion managing the complex physiological processes that occur at the level of both the macro and microcirculation. The importance of maintaining blood pressure is clear, yet the patient and economic impacts of post-operative complications remain significant and constitute the ‘hidden pandemic’, with 30-day postoperative mortality the third leading cause of death globally. Work to optimise perioperative outcomes must continue if this is to be addressed. Evidence and particularly more recent findings targeting personalised haemodynamic goals and monitoring in at risk patients may reduce perioperative cardiovascular morbidity and mortality. This review advocates for personalized, advanced haemodynamic monitoring and goal-directed therapy, based on cardiovascular endotypes and extending this into the post-operative period. Advances in technology including continuous post-operative monitoring delivered in enhanced care units and automation have significant potential to assist in delivering this approach. Rigorously evaluating perioperative haemodynamic management will require complex studies and efficient trial methodologies such as adaptive trial designs. We believe the shift from reductionist, reactionary care to pre-emptive, precision care has the potential to address the hidden pandemic of postoperative morbidity and mortality.
