PURPOSE OF REVIEW:Medical devices like physiologic monitors, anesthesia machines, and ventilators, are designed by biomedical engineers but used by clinicians. Advanced medical technology can be incorporated into clinical practice safely, but addressing alarm fatigue, resilience, automation complacency, and clinician wellbeing will help to maintain and improve patient safety. RECENT FINDINGS:The operating room is designed for efficient patient care but consideration is rarely given to the safety and well-being of clinicians. An increasing frequency of medical alarms is associated with greater rates of alarm fatigue and burnout. This extends to clinical alerts generated by electronic health records. The usability of a clinical decision support system also affects physicians' willingness to act on alerts. Automation complacency occurs when a clinician allows a system to act without considering its limitations or the possibility of a malfunction. Each of these factors may cause a problem to go unnoticed, leading to delays in diagnosis or treatment. Solutions include clinician training and consideration of ergonomics and human factors early in the design process. SUMMARY:A better understanding of human factors and ergonomics in anesthesia can improve usability and reliability of new technology, thus improving patient safety. These interventions present opportunities for potential research.
PURPOSE OF REVIEW:Patients with a tracheostomy or total laryngectomy are a distinct and high-risk population for perioperative airway emergencies. This review examines the recognition and management of acute airway emergencies in these patients, with emphasis on intraoperative hazards, equipment selection, and complications unique to the surgically altered airway. RECENT FINDINGS:The anatomical distinction between a tracheostomy and a total laryngectomy stoma remains widely underappreciated, with national registry data reporting a 26% mortality rate when oral intubation is attempted in laryngectomy patients. Common emergencies such as tube obstruction, accidental decannulation, and hemorrhage can be fatal. Intraoperative hazards including endobronchial tube migration, circuit disconnection, and inadvertent cannulation of a tracheoesophageal puncture tract represent an underrecognized category of harm. Structured algorithms, simulation-based training, and multidisciplinary quality improvement programs demonstrate measurable reductions in adverse events. SUMMARY:Patients with neck stomas are at risk for life-threatening airway compromise requiring prompt identification of airway anatomy and appropriate equipment. Clinicians must be prepared for complications like tube obstruction, tube migration, circuit instability, and bleeding. Preventing harm requires the use of cognitive aids, structured protocols, simulation-based training, and ongoing quality improvement programs.
PURPOSE OF REVIEW:Ketamine was introduced into medical practice in 1965 and is widely utilized to provide sedation and analgesia. Low-dose ketamine can be used in ambulatory surgery following an assessment of risks and benefits. RECENT FINDINGS:Ketamine is an N-methyl-D-aspartate receptor antagonist that decreases the firing rate of fast-spiking gamma-aminobutyric acidergic interneurons, leading to a disinhibition of pyramidal neurons and enhanced cortical and respiratory arousal. The consequences are an activation of the sympathetic nerve system and an increased drive to upper airway dilator and respiratory pump muscles. In parallel, low-dose ketamine has effects on cortical function which can be beneficial: delirium and posttraumatic stress disorder prevention through relief of pain and discomfort, and mood stabilization. However, higher doses increase airway secretions, predispose to laryngospasm, and desaturation. When given to anxious patients without concomitant use of benzodiazepines, ketamine increases the risk of frightening and delusional memories. SUMMARY:Low dose of intravenous ketamine (<0.5 mg/kg) expresses excellent analgesia, improves breathing and circulation, and stabilizes mood, which can help prevent postoperative delirium. Ketamine carries the risk of frightening and delusional memories, when given to anxious patients in the absence of concomitant premedications (eg, midazolam 0.03 mg/kg). Higher doses of ketamine increase the risk of respiratory complications.
PURPOSE OF REVIEW:The need to initiate culture change in perioperative medicine comes as a result of many internal and external factors. Anesthesia professionals, who habitually work in complex environments and continuously sense and adapt to change, are well-suited to be leaders of perioperative cultural change. RECENT FINDINGS:Recent literature on culture change reinforces the importance of communication and trust as the bedrock of change, being steadfast in the determination of the goal while remaining flexible about the pathway toward achieving it, and creating an environment of psychological safety to bridge the gap between the perception of leaders and the operational reality that team members experience. SUMMARY:Leaders are the architects of culture change, but even the most erudite among them are unlikely to achieve successful change without creating agency among the team they work with. In this review, universal strategies will be discussed that support culture change independent of the change model used. These strategies focus on reviewing the embedding mechanisms of change, communication, creating trust, narrowing the gap between leadership and the team, and building psychological safety.
PURPOSE OF REVIEW:This article aimed to examine the value of education and training within perioperative neuroscience and its development for supporting the delivery of high-quality, safe patient care. RECENT FINDINGS:Perioperative neuroscience is a rapidly evolving field in anesthesiology, with current research demonstrating the potential for neurological injury in patients undergoing nonneurological and neurological surgery. Expertise is essential to mitigate risk. Current evidence in perioperative neuroscience suggests a patient benefit with subspecialty training. Advanced training programs have continued to evolve with the development of global accreditation programs for fellowship training. SUMMARY:Advanced training within perioperative neuroscience is necessary to improve healthcare outcomes. Accreditation of training programs offers standardization and quality assurance.
PURPOSE OF REVIEW:Chronic pain management increasingly requires a patient-centered, adaptive approach. This review examines how shared decision-making (SDM) and individualized strategies develop and function in chronic pain care, emphasizing their relevance in practice. RECENT FINDINGS:Recent literature highlights that SDM improves patient satisfaction, engagement, and psychological outcomes across various chronic pain conditions. However, SDM is most effective when viewed as an ongoing, iterative process rather than a one-time decision. Studies show that alignment between patient and clinician expectations, effective communication, and recognition of patient preferences are key determinants of success. In opioid management, SDM may unintentionally sustain prescribing patterns, underscoring the need for balanced communication and clinician training. Decision aids and structured tools can support SDM by improving patient knowledge and involvement, although barriers such as health literacy and access to technology remain. Persistent discrepancies between patient and clinician perspectives, as well as contextual and socioeconomic factors, can challenge implementation. SUMMARY:SDM is an essential component of chronic pain management but is insufficient as a standalone strategy. Effective care requires continuous support, education, and adaptation within a strong therapeutic relationship. Future approaches should focus on flexible, context-sensitive interventions that integrate biopsychosocial principles and address individual patient needs.
PURPOSE OF REVIEW:The growing incidence of acute neurological disorders, has underscored the increasing global need for dedicated neurocritical care (NCC) services. The organization and delivery of NCC services in low- and middle-income countries (LMICs) continue to evolve from a fragmented care system toward a comprehensive care model. This article reviews the available literature on the delivery of NCC services in LMICs and examines key domains, including infrastructure requirements, education and training frameworks, and research capacity, to support organizational models of care. RECENT FINDINGS:Earlier publications from LMICs highlight the state of NCC services and the persistent rural versus urban disparities in access to specialized care. Authors have also discussed the organization of existing NCC units and have proposed minimum standards for establishing NCC units. In an effort toward standardized care for NCC patients, researchers have focused on strategies to increase education, training, and research capacity. They discuss pragmatic strategies and future directions aimed at strengthening and expanding NCC services across LMICs. SUMMARY:There is an urgent need to strengthen NCC facilities across LMICs to mitigate the ongoing variability in clinical practice and service delivery. Addressing NCC infrastructure together with disparities experienced by critically ill patients requires targeted, context-sensitive interventions.
PURPOSE OF REVIEW:To review and summarize the current clinical evidence supporting sympathetic neural blockade for recurrent and refractory ventricular arrhythmias and electrical storm. These conditions continue to be associated with substantial morbidity and mortality, despite advances in antiarrhythmic therapy, catheter ablation, and mechanical circulatory support. Sympathetic overactivity is a key driver of ventricular arrhythmogenesis, and cardiac autonomic neuromodulation should be recognized as an important tool in the therapeutic algorithms. RECENT FINDINGS:Clinical evidence and acceptance of percutaneous and neuraxial sympathetic blockade for ventricular tachyarrhythmias and electrical storm are rapidly accumulating. A dramatic increase in the amount of peer-reviewed publications indicates a transition from emergence and recognition to mainstream adoption and consolidation phases.Currently, most reports and strongest evidence support percutaneous stellate ganglion block (SGB), associated with rapid reductions in ventricular arrhythmia episodes and implantable cardioverter defibrillator shocks across systematic reviews and multicenter observational studies. Continuous block techniques may prolong benefit beyond a single-injection. Thoracic epidural anesthesia has also demonstrated clinically meaningful arrhythmia suppression, while evidence for thoracic paravertebral and proximal intercostal blocks is accumulating. SUMMARY:Sympathetic neural blockade is a clinically effective adjunct therapy for refractory ventricular arrhythmias, with SGB currently supported by the strongest clinical evidence.
PURPOSE OF REVIEW:Universal healthcare coverage (UHC) is a controversial political and financial topic in any healthcare system. Unfortunately, the best value-based care for patients is not always achievable in many healthcare systems and the impact of the presence or absence of UHC has significant ramifications for healthcare institutions, clinicians, and patients. This review provides an overview of the different universal healthcare funding models to equip clinicians with the tools needed to navigate and advocate for better general and perioperative care for patients. RECENT FINDINGS:The United Nations included UHC in the United Nations Sustainable Development Goals in 2015, with the goal of UHC by 2030. The race to achieve this goal has meant policy and system changes that translate to a system in which clinicians working to deliver care is constantly evolving and challenged by epidemics, multiple world economic crises, geopolitical unrest, change in philanthropic investment, and a change in legal frameworks in healthcare delivery. SUMMARY:The way clinicians navigate value-based care in a UHC system will always be ethically and professionally challenging. Perioperative neuroscience clinical teams are, however, uniquely positioned to produce better patient outcomes and to advocate at every level of care and society for UHC.
PURPOSE OF REVIEW:Perioperative antimicrobial prophylaxis (PAP) is a cornerstone in the prevention of surgical site infection. As an increasing share of procedures shifts to the ambulatory setting, this review examines aspects of PAP that are of particular relevance to ambulatory anesthesiology. RECENT FINDINGS:Empirical data show suboptimal use of PAP (e.g. unnecessary indication, substance choice, and excessive duration) in many settings, including ambulatory surgery. Focusing on substance choice, penicillin allergy remains a frequent, largely unverified barrier to β-lactam use in PAP. Recent evidence supports structured risk-stratification to safely expand cephalosporin use despite penicillin allergy, in order to reduce adverse effects of second-line antibiotics. Logistically, the widely used 60-min preincision timing rule for PAP was established for intravenous administration and cannot be directly applied to oral prophylaxis, where bioavailability varies substantially between agents and must inform both substance choice and timing. Lastly, the peri-interventional use of endocarditis prophylaxis is part of recent European guidelines on infective endocarditis, including some modifications to previous iterations. SUMMARY:Ambulatory anesthesiology presents structurally different conditions from inpatient care - high case turnover, limited time for allergy work-up, variable use of intravenous access, and no postoperative in-house monitoring after discharge. Addressing PAP overuse, allergy label mismanagement, and oral-versus-intravenous administration challenges specifically in this setting offers a concrete pathway toward safer and more evidence-based ambulatory surgical care.
PURPOSE OF REVIEW:This review examines the current use and limitations of patient-reported outcome measures (PROMs) in pediatric regional anesthesia research. Despite the increasing emphasis on patient-centered outcomes, existing pediatric outcome assessment frameworks may inadequately capture the pain experience and interference with daily living. RECENT FINDINGS:Across 17 identified randomized controlled trials and 15 ongoing studies, PROM use remains highly variable, with consistent reliance on observational pain scales such as the Face, Legs, Activity, Cry, and Consolability scale and limited incorporation of standardized, longitudinal health-related quality-of-life measures. SUMMARY:Current pediatric PROM frameworks remain fragmented, limiting comprehensive evaluation of recovery. Greater standardization and incorporation of developmentally appropriate, longitudinal outcome measures are needed to better align clinical research with meaningful patient-centered endpoints and to improve assessment of functional and psychosocial recovery.
PURPOSE OF REVIEW:ICU procedures are increasingly complex, often requiring deeper sedation or general anesthesia, and are increasingly performed at the bedside to avoid transport risk. This trend has expanded the role of anesthesiologists in ICU nonoperating room anesthesia (NORA). This review summarizes practical anesthetic considerations for these procedures, focusing on optimization, monitoring, and systems issues. RECENT FINDINGS:ICU patients frequently have shock, hypoxemia, right ventricular failure, metabolic acidosis, organ dysfunction, and neurologic injury that change anesthetic pharmacokinetics and hemodynamic responses. Bedside tracheostomy, percutaneous endoscopic gastrostomy, extracorporeal membrane oxygenation cannulation, bronchoscopy, thoracic interventions, and selected neurosurgical and interventional radiology procedures are feasible in the ICU but carry higher rates of cardiorespiratory events than operating room cases, largely because of illness severity and environmental constraints. Short-acting sedatives, noninvasive respiratory support, point-of-care ultrasound, and structured checklists, simulation, and dedicated ICU NORA pathways can reduce complications. Emerging artificial intelligence and machine learning tools that process physiologic and waveform data may further improve risk stratification, early detection of instability, and decision support. SUMMARY:Bedside ICU procedures blur the boundaries between sedation, monitored anesthesia care, and general anesthesia. Effective practice requires individualized plans, clear rescue pathways, and coordination between anesthesia, ICU, and procedural teams, supported by advanced monitoring and data-driven decision support.
Purpose of review The prevalence of opioid tolerance, dependence, and use disorder is increasing among patients presenting for surgical care, yet perioperative management strategies for these patients remain inconsistent. This review examines the impact of preoperative opioid exposure on surgical outcomes, the scope of untreated opioid use disorder (OUD) among surgical patients, and advances in clinical and systems-level approaches to perioperative care. Recent findings Preoperative opioid exposure independently predicts worse surgical outcomes, including higher opioid consumption, readmissions, complications, and mortality, in a dose-dependent manner. Perioperative opioid exposure predicts persistent opioid use after surgery, with the duration of exposure a stronger predictor of subsequent OUD than daily dose. Data-driven prescribing guidelines and structured opioid tapering reduce overprescribing without compromising pain control. Among surgical patients with diagnosed OUD, approximately two-thirds do not receive medications for opioid use disorder (MOUD), though treatment engagement and maintenance substantially improve outcomes. Evidence now clearly supports perioperative buprenorphine continuation over interruption. Summary Effective perioperative management of opioid-complex surgical patients requires systematic screening, evidence-based prescribing, MOUD continuation, and institutional infrastructure. The primary barrier is shifting from evidence generation to implementation.
Purpose of review Neuroanesthesia practice in low- and middle-income countries is constrained by workforce shortages, limited infrastructure, and variability in clinical practice. Growing global interest in collaboration makes it timely to evaluate how international partnerships can address these gaps and improve equity in care, education, and research. Recent findings Recent literature highlights substantial variability in neuroanesthesia practice and limited access to context-appropriate guidelines and advanced technologies. International collaborations, including training partnerships, scholarship programs, and research networks, have improved knowledge exchange, workforce development, and the adoption of standardized practices. Evidence suggests that specialized training is associated with improved clinical outcomes. However, persistent inequities in research participation, authorship, and leadership, as well as concerns regarding sustainability and ‘parachute research’, remain. Summary International collaboration is a key strategy for advancing neuroanesthesia in resource-constrained settings. Sustainable, equitable partnerships that prioritize local ownership, capacity building, and contextual adaptation are essential to improving clinical practice, strengthening education, and enhancing global research representation.
Purpose of the review Chronic postsurgical pain (CPSP) and persistent postoperative opioid use (PPOU) are two of the most common complications of a number of surgical interventions, which can cause significant personal and economic negative consequences. This review outlines known and potential risk factors for CPSP and PPOU and approaches to reduce these risk factors. Recent findings Modifiable risk factors for developing CPSP include psychological distress, preoperative pain intensity, and perioperative opioid exposure. Although less studied, psychological comorbidities are also risk factors for PPOU. Evidence-based mitigation strategies include psychological interventions and perioperative opioid sparing. Summary A number of perioperative risk factors for developing CPSP and PPOU have been identified, and anesthesiologists should be cognizant of these risk factors and potential risk mitigation strategies. Additional prospective studies are needed to further develop easily adoptable, evidence-based interventions to reduce the incidence of CPSP and PPOU.
PURPOSE OF REVIEW:Patients with head and neck cancer tend to be older, frailer and have more comorbidities than the general surgical population and frequently necessitate wide resections requiring complex reconstructions with free flaps. Preoptimization approaches, airway management protocols, intraoperative fluid administration, blood pressure goals, and use of pressors have been extensively evaluated, and while consensus has been substantially achieved on previously controversial aspects such as intraoperative use of vasopressors, standardized approaches to perioperative care are still evolving. RECENT FINDINGS:Recent literature has focused on perioperative optimization and enhanced recovery pathways, especially in the care of frail and elderly patients. Airway management in adults and children and optimization of pain management to cover multilocalized pain (resection and free tissue donor site) have been additional topics of interest, as well as the value and applicability of risk scores for postoperative complications and predictive models of delayed recovery. SUMMARY:The perioperative management of reconstructive head and neck cancer surgery presents unique challenges. The prevalence of frailty, elevated comorbidity burden and high-risk airway management in this patient population, combined with the complexity of the procedures, require careful individualized planning and specialized care.
PURPOSE OF REVIEW:The incidence of oropharyngeal cancer is increasing. Traditional treatments, including major open surgical resection, chemotherapy, and radiotherapy, are associated with significant patient morbidity - affecting the cosmesis, structure, and function of the head and neck. Transoral robotic surgery (TORS) is a minimally invasive technique that maximizes surgical visualization, accessibility, and maneuverability, avoiding transfacial or transmandibular access procedures (often involving tracheostomy and gastrostomy insertion), potentially resulting in improved long-term patient outcomes. Previously limited to specialist centers only, TORS has now been adopted by many institutions, such that all anesthesiologists should be aware of the unique requirements so that optimal perioperative care can be delivered wherever it is undertaken. RECENT FINDINGS:This article provides an up-to-date overview of the indications, contraindications, and potential benefits of TORS, preoperative considerations that distinguish it from anesthesia for other head and neck surgery, and the priorities for intraoperative and postoperative care (including prevention of complications such as bleeding and tongue edema). SUMMARY:While TORS appears to offer better functional and surgical long-term benefits to patients, its distinct perioperative requirements necessitate a thorough understanding, coupled with meticulous planning and implementation by a highly skilled, cohesive multidisciplinary team so that the advantages can be fully realized.
