This consensus was developed to address the lack of standardized perioperative management protocols for left ventricular assist device (LVAD) implantation in China and to build on recently published national consensus documents addressing preoperative and postoperative care. Given the increasing clinical use of domestically developed LVADs, context-specific guidance is needed. This consensus aimed to standardize perioperative care, reduce procedure-related complications, and improve outcomes in adults with end-stage heart failure undergoing LVAD implantation. This expert consensus was jointly developed by the Chinese Society of Cardiothoracic Anesthesiology, the National Center for Cardiovascular Diseases Expert Committee, and the Beijing Medical Association. The consensus panel comprised 83 specialists from 41 clinical centers. The project development was registered on the Practice guideline REgistration for transPAREncy (PREPARE) platform (registration no. PREPARE-2025CN1348). Using the Population, Intervention, Comparator, and Outcomes (PICO) framework and the Delphi method, the panel systematically reviewed relevant international guidelines and peer-reviewed literature published through April 2026. Following evidence synthesis, multiple rounds of expert discussion, and formal voting, the panel developed 11 core recommendations. The certainty of the evidence and strength of the recommendations were assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The recommendations address three phases of perioperative care: preoperative assessment, intraoperative management, and postoperative recovery. Preoperative recommendations emphasize assessment of right ventricular function, prediction of postoperative right heart failure, and evaluation of indications for LVAD implantation to support appropriate patient selection. Intraoperative recommendations specify hemodynamic targets, strategies for optimizing right ventricular performance, and blood-conservation measures intended to minimize transfusion requirements. Postoperative recommendations address multimodal analgesia and enhanced recovery after surgery (ERAS) protocols adapted to individual patient characteristics and institutional resources. The consensus also summarizes clinically relevant differences in the design and management of durable LVADs developed domestically and internationally to support device-specific care. This consensus provides a structured, evidence-informed pathway for the perioperative management of adults undergoing LVAD implantation in China. By integrating international evidence with Chinese clinical experience and evidence involving domestically developed LVADs, the recommendations may improve the consistency and quality of perioperative care. Further evaluation is needed to determine their effects on postoperative complications and survival.
Junior physicians may experience critical competency gaps during the transition to unsupervised practice, particularly in high-risk specialties such as anesthesiology, where errors can compromise patient safety. Although large language models (LLMs) are being rapidly integrated into healthcare, their accuracy and safety in supporting junior physicians—who may lack sufficient experience to identify model errors—remain insufficiently quantified in high-stakes clinical settings. This study evaluated OpenAI-o1 (OA) and DeepSeek-R1 in English (DSE) and Chinese (DSC) to address this evidence gap. In this dual-axis evaluation, 30 anesthesia crisis scenarios were developed through Delphi consensus. Responses generated by OA, DSE, and DSC were assessed by 20 experts for accuracy using a 5-point Likert scale and for clinical logicality using an 8-point Situation–Background–Assessment–Recommendation (SBAR) scoring system, with each component rated from 0 to 2 points. Practicality was assessed by 20 junior physicians using a 5-point Likert scale across three subdimensions: step clarity, guideline applicability, and learning assistance. Accuracy and practicality were the two primary evaluation domains, while clinical logicality, qualitative feedback, and readability were examined as complementary outcomes. Performance was compared across nine pre-specified, order-constrained hypotheses using Bayes Factor Design Analysis (n = 600 per group), with outcomes expressed as posterior probabilities (PPs) and Bayes Factors (BFs). OA demonstrated superior accuracy (OA > DSE > DSC; PP = 0.94; BF₄ᵤ = 4.70, strong evidence), whereas DSC showed greater practicality (OA < DSE < DSC; PP = 0.82; BF₇ᵤ = 3.67). This inverse relationship was also observed in the practicality subdimensions, with DSC performing better in step clarity (PP = 0.75) and guideline applicability (PP = 0.82). For high-complexity tasks, such as urgent decision-making, all models failed to establish an effective SBAR Situation-to-Assessment linkage despite showing equivalent overall clinical logicality (PP = 0.59; BF₁ᵤ = 161.05, decisive evidence). Notably, 95.2
Abstract Purpose Post-operative sleep disturbance affects more than 60% of surgical patients and impedes recovery. Although general anesthesia itself may profoundly remodel brain function and contribute to this pathology, the underlying neural mechanisms remain unclear. We previously identified the dorsomedial hypothalamus (DMH) as a key modulator of emergence and arousal. Here, we investigated the distinct roles of DMH glutamatergic neurons (DMH Glu ) and GABAergic neurons (DMH GABA ) in the pathophysiology of post-anesthesia sleep disturbance (PSD). Methods Using a mouse model of PSD induced by 2 h of 1.4% isoflurane anesthesia, we used chemogenetics to selectively activate or inhibit DMH neurons. Sleep–wake architecture was assessed using wireless electroencephalography (EEG) and electromyography (EMG) biotelemetry, complemented by fiber photometry for neuronal activity monitoring and single-nucleus RNA sequencing for molecular profiling. Results Isoflurane anesthesia induced a delayed-onset sleep disturbance characterized by increased wakefulness and reduced, fragmented sleep during the subsequent rest phase. Notably, DMH Glu neurons showed heightened activity specifically during rest-phase wakefulness, whereas DMH GABA neurons were predominantly active during wakefulness and non-rapid eye movement sleep in the post-anesthesia active phase. Activation of DMH Glu neurons reversed PSD in a circadian phase-dependent manner, while both activation and inhibition of DMH GABA neurons improved PSD without significant phase variation. Single-nucleus RNA sequencing revealed the involvement of retrograde endocannabinoid signaling in both DMH Glu and DMH GABA neurons. Administration of a type 1 cannabinoid receptor (CB1R) antagonist alleviated PSD, potentially by disinhibiting DMH Glu neurons and remodeling the integration of excitatory and inhibitory inputs onto DMH GABA neurons. Conclusions DMH Glu and DMH GABA neurons differentially regulate PSD through distinct, CB1R-mediated presynaptic modulation, providing novel mechanistic insights into PSD and identifying potential therapeutic targets for its treatment.
Abstract Background Epidural-related maternal fever has been attributed to non-infectious inflammatory mechanisms and thermoregulatory dysfunction. Its risk is hypothesized to increase with prolonged exposure to epidural analgesia; however, a comprehensive synthesis of evidence regarding the effect of epidural analgesia timing remains lacking. Methods This retrospective cohort study included 2,991 nulliparous women with term singleton pregnancies who received epidural analgesia at a single academic center between 2019 and 2020. Early initiation was defined as 0–2 cm cervical dilation, and late initiation as ≥ 3 cm. The primary outcome was maternal fever (≥ 38 °C). Propensity score matching and multivariable regression were performed to adjust for potential confounders. Results After propensity score matching, the incidence of maternal fever was significantly higher in the early epidural group than in the late epidural group (12.20% vs. 7.30%; P = 0.001). Multivariable logistic regression analysis showed that late initiation of epidural analgesia was associated with a reduced risk of maternal fever (aOR = 0.57, 95% CI, 0.41–0.80; P < 0.001), uterine inertia (aOR = 0.68, 95% CI, 0.48–0.96; P = 0.028), oxytocin use (aOR = 0.73, 95% CI, 0.60–0.88; P = 0.001), cesarean delivery (aOR = 0.51, 95% CI, 0.38–0.69; P < 0.001), and episiotomy (aOR = 0.41, 95% CI, 0.32–0.51; P < 0.001). In addition, late initiation of epidural analgesia was associated with lower log-transformed blood loss during the first 24 hours after delivery (adjusted coefficient = −0.12, 95% CI, −0.17 to −0.07; P < 0.001). Sensitivity analyses yielded consistent findings. Conclusion In this retrospective cohort study of nulliparous women with spontaneous labor, initiation of epidural analgesia (0–2 cm cervical dilation) was associated with an increased risk of intrapartum fever and several adverse maternal outcomes. These findings suggest a potential clinical relevance of epidural timing; however, causal inference cannot be drawn due to the observational study design. Prospective studies are warranted to confirm these associations and further clarify underlying mechanisms.
Abstract Purpose Perioperative metabolic vulnerability is an important contributor to postoperative morbidity, yet preoperative risk stratification relies largely on conventional glycemic measures such as hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG). Hemoglobin glycation index (HGI) quantifies interindividual discordance between HbA1c and contemporaneous glycemia and may capture metabolic phenotypes not reflected by absolute glucose values. We investigated the association between preoperative HGI and postoperative outcomes in adults undergoing non-cardiac surgery. Methods We conducted a retrospective single-center cohort study including adult inpatients who underwent non-cardiac surgery under general anesthesia between January 2013 and June 2024. Patients with both preoperative HbA1c and FPG measured within 60 days before surgery were included. HGI was calculated as the residual of observed HbA1c minus HbA1c predicted from FPG using a cohort-specific linear regression model. The primary outcome was any postoperative complication occurring before hospital discharge. Secondary outcomes included major complications (Clavien–Dindo grade ≥ III), organ-specific complications, deep-vein thrombosis, Intensive Care Unit (ICU) admission, hospital and postoperative length of stay, and in-hospital mortality. Associations were evaluated using multivariable regression models with HGI analyzed as a continuous variable (per 1–SD increase) and by quartiles (Q2 as reference), complemented by restricted cubic spline analyses and prespecified subgroup analyses. Results A total of 24,307 patients were included (mean age 58.8 ± 13.3 years; 51% women). Postoperative complications occurred in 8.4% of patients. In adjusted continuous models, higher HGI was independently associated with postoperative complications (odds ratio [OR] per 1–SD increase 1.068; 95% confidence interval [CI], 1.018–1.120; P = 0.007), urinary complications (OR 1.155; 95% CI, 1.024–1.301; P = 0.018), and longer total hospital length of stay (adjusted mean ratio 1.030; 95% CI, 1.017–1.043; P = 0.001). Quartile analyses demonstrated the lowest risk of postoperative complications in the mid-range HGI group, with higher risks observed at extreme HGI values. Restricted cubic spline models revealed an approximately linear association between HGI and overall postoperative complications, while outcome-specific nonlinear relationships were observed for major complications, ICU admission, and in-hospital mortality. Associations were generally consistent across subgroups, with no statistically significant interaction detected across prespecified strata. Conclusions Preoperative hemoglobin glycation index was independently associated with postoperative complications after non-cardiac surgery and identified nonlinear risk patterns for selected severe outcomes. HGI may serve as a complementary perioperative metabolic risk marker beyond HbA1c and fasting plasma glucose to provide incremental risk information.
Chronic pain represents a widespread and substantial clinical burden, yet existing therapeutic approaches frequently yield suboptimal outcomes, partly due to an incomplete understanding of its underlying pathogenic mechanisms. The glymphatic system, a brain-wide network involved in cerebrospinal fluid circulation and metabolic waste clearance, has been observed to exhibit progressive dysfunction during the development and maintenance of chronic pain. The relationship between chronic pain and glymphatic dysfunction appears multifaceted and complex. This perspective review systematically synthesizes emerging evidence to summarize the potential bidirectional interplay between glymphatic dysfunction and chronic pain pathogenesis, with an emphasis on glymphatic dysfunction as a plausible contributing mediator across diverse pain conditions. We specifically address how neuroinflammation-associated glymphatic dysfunction may contribute to the progression of chronic pain, and conversely, how persistent pain may further amplify neuroinflammation, thereby potentially establishing a self-sustaining vicious cycle. Furthermore, we outline rationales for putative clinical interventions targeting this pathological cascade, with the goal of providing conceptual insights for the development of novel therapeutic strategies for chronic pain. Collectively, this review advances current understanding of the potential links between chronic pain and glymphatic dysfunction and presents an alternative conceptual framework for the future management of chronic pain.
Abstract Purpose The Montreal Cognitive Assessment (MoCA) is a validated screening tool for cognitive impairment (CI) in surgical populations that assesses multiple cognitive domains. The primary objective of this report was to characterize preoperative domain-specific performance on the MoCA in older surgical patients. The secondary objectives were to explore preoperative characteristics and adverse outcomes associated with poorer domain-specific performance. Methods This was a post hoc analysis of the Detection of Cognitive Impairment (Detect CI) study. The MoCA was administered preoperatively to assess seven cognitive domains: executive/visuospatial function, naming, attention, language, abstraction, delayed recall, and orientation. It was scored out of 30, with higher education-adjusted MoCA scores indicating better cognitive performance and scores $$\le$$ ≤ 25 classifying probable CI. Adverse outcomes were collected in 382 participants at 30 days and 379 participants at 90 days postoperatively. Results The 382 participants (median age, 73 years [IQR, 68, 77]; 58% female) had a mean MoCA score of 25.9 $$\pm$$ ± 2.8, with 35% screening positive for CI. Participants with probable CI performed significantly poorer across all seven cognitive domains (executive/visuospatial function, naming, attention, language, abstraction, delayed recall, and orientation) than those without CI. Having $$\le$$ ≤ 12 years of education was associated with poorer executive/visuospatial function, naming, language, abstraction, and delayed recall. Of all cognitive domains, exploratory analyses showed that only orientation was associated with 30-day adverse outcomes after adjusting for age, sex, education level, and/or American Society of Anesthesiologists status and within-domain multiplicity. Each one-point decrease in orientation score was associated with a longer length of stay (β = 0.5, 95% confidence interval [95% CI] 0.2–0.8; P $$=$$ = 0.012) and higher adjusted odds of postoperative delirium (adjusted odds ratio [aOR] = 11.4, 95% CI 2.6–46.8; P $$=$$ = 0.004), complications (aOR = 3.1, 95% CI 1.3–8.9; P $$=$$ = 0.035), non-home discharge (aOR = 4.1, 95% CI 1.5–11.4; P $$=$$ = 0.014), and composite adverse outcomes (aOR = 5.6, 95% CI 1.9–23.9; P $$=$$ = 0.014). Orientation remained associated with postoperative delirium after adjusting for multiplicity both within and across MoCA domains (aOR = 11.4, 95% CI 2.6–46.8; P $$=$$ = 0.031). Conclusions This analysis characterized preoperative domain-specific performance on the MoCA in older adults, with participants screening positive for CI exhibiting poorer performance across all cognitive domains. Exploratory findings suggested that orientation difficulties may be associated with early adverse outcomes, with postoperative delirium showing the most robust association.
Abstract Septic shock is a life-threatening syndrome characterized by profound circulatory dysfunction and disordered cellular metabolism, necessitating precise physiologic monitoring to guide resuscitation. In this context, sepsis-induced hemodynamic derangements range from early vasoplegia and hyperdynamic circulation to later-stage myocardial depression and microcirculatory failure. These dynamic changes create a heterogeneous perfusion landscape that challenges traditional approaches to oxygen transport assessment. Central venous oxygen saturation (ScvO2) has long been used as a surrogate marker of cardiac output and global tissue oxygenation; however, in sepsis, impaired cellular oxygen utilization may result in paradoxically normal or elevated ScvO2 despite ongoing tissue hypoxia. In contrast, the oxygen extraction ratio (O2ER) offers a more integrative assessment of oxygen transport by reflecting the balance between oxygen delivery and consumption. Unlike ScvO2, O2ER may remain informative in the presence of microcirculatory and mitochondrial dysfunction and may demonstrate greater sensitivity to changes in oxygen delivery, based on physiological reasoning and observational data. Accordingly, O2ER may provide complementary physiological insight in complex shock states, although this approach has not been validated in randomized interventional trials. This narrative review synthesizes foundational and contemporary evidence to propose a physiologically grounded framework for oxygen transport monitoring, delineating the strengths, limitations, and clinical utility of ScvO2, O2ER, and metabolic markers in guiding resuscitation strategies for patients with septic shock.
Abstract Background This study aims to compare the internal intercostal membrane-origin block (IIMOB) with the thoracic paravertebral block (TPVB), analyzing the postoperative analgesic efficacy and safety in patients undergoing video-assisted thoracoscopic surgery (VATS). Methods A total of 236 patients were enrolled. Patients undergoing uniport VATS were randomized to uniport TPVB (UP) or uniport IIMOB (UI) (n = 54 each), and those undergoing multiport VATS were randomized to multiport TPVB (MP) or multiport IIMOB (MI) (n = 54 each). Postoperatively, patients in UP and MP groups received TPVB, while those in UI and MI groups received IIMOB. Additional VATS patients were randomly divided into two groups (n = 10 each), methylene blue TPVB (BP) and methylene blue IIMOB (BI) groups, to assess injectate spread. The primary outcome was postoperative analgesic efficacy, quantified as the area under the curve (AUC) of Numerical Rating Scale (NRS) scores at rest and during coughing from 3 to 48 h after surgery. Results Compared with TPVB, IIMOB was associated with lower postoperative NRS-AUC values at rest and during coughing (all P < 0.05), reduced sufentanil consumption within 48 h, delayed first pump use, and smaller increases in plasma levels of perioperative inflammatory and neuroendocrine stress biomarkers at 24 h post operation. Additionally, patients received IIMOB experienced fewer incidences of back pain, hypotension, vascular injury, and block failure. There was no significant difference in the methylene blue diffusion gaps between the BI and BP groups. However, the BP group had a larger blue-dyed area in the ventral region of spinal column and higher 90-min dye color change rate compared with the BI group. Conclusion These findings revealed that IIMOB provided superior analgesia with fewer adverse events than TPVB after VATS. Clinical trial registration Chinese Clinical Trial Registry, ChiCTR2400082500. Registered on 29 March 2024, http://www.chictr.org.cn/ChiCTR2400082500 .
Abstract Background Single-dose intrathecal hydromorphone or transversus abdominis plane (TAP) block has garnered growing interest as components of multimodal analgesia for gastrectomy. However, the spinal mechanisms of intrathecal hydromorphone and its optimal dosing remain unclear. This study aimed to confirm the spinal mechanism of intrathecal hydromorphone using animal models, precisely determine its 95% effective dose (ED95) in clinical settings, and compare its analgesic efficacy with TAP block. Methods In a rat model of acute pain, we determined the dose–response relationship of intrathecal hydromorphone. Clinically, the ED95 of hydromorphone for patients undergoing gastrectomy was identified through a double-blind, biased-coin sequential trial involving 51 patients aged 18 years or older who were classified as ASA I-III. In subsequent randomized controlled trial (RCT), 96 gastrectomy patients were randomly assigned to receive either intrathecal hydromorphone at its ED95 dose or a four-point TAP block (15 mL of 0.2% ropivacaine per point). The primary outcomes were ED₉₅ and cumulative pain intensity during mobilization within 24 postoperative hours. Results Animal studies demonstrated that intrathecal hydromorphone produces dose-dependent antinociceptive effects primarily mediated by spinal μ-receptors. Clinically, the calculated ED95 for intrathecal hydromorphone in gastrectomy was 131.67 μg (95% CI 113.19–150 μg). Based on these findings, we selected 150 μg (the upper limit of the 95% CI) as the intervention dose for the subsequent RCT to ensure analgesic coverage in at least 95% of patients. In this RCT, 89 patients completed the modified intention-to-treat analysis. Patients in the intrathecal hydromorphone group reported significantly lower cumulative pain intensity (65.0 [48.0–89.0] cm·h) compared to the TAP block group (93.0 [64.0–131.0] cm·h; P = 0.001). Furthermore, rescue opioid consumption was reduced at both 24 and 48 h postoperatively in the intrathecal hydromorphone group (P < 0.05). Trajectory analysis showed that the TAP group had a higher incidence of inadequate early pain control, while the intrathecal group maintained better initial analgesia but demonstrated mild rebound pain after 24 h. Recovery profiles and adverse events were comparable between groups. Conclusion Intrathecal hydromorphone exerts dose-dependent antinociceptive effects through spinal μ-receptor mechanisms. At a dose of 150 μg (upper 95% CI of the ED95) for gastrectomy, intrathecal hydromorphone provides superior postoperative analgesia compared to TAP block, with reduced opioid consumption. Trial registration ChiCTR2300069163 Part I for the dose-finding trial on March 8, 2023; ChiCTR2300073827 for the randomized controlled trial on July 21, 2023. ( http://www.chictr.org.cn ).
Abstract Background Perioperative electroencephalogram (EEG) alpha power has been proposed as a marker of brain vulnerability and a candidate biomarker for postoperative delirium (POD). However, reported associations between preoperative or intraoperative EEG alpha power and POD remain inconsistent. Methods We performed a PRISMA-guided systematic review and meta-analysis of observational studies in adults (≥ 18 years) undergoing non-neurological surgery that reported resting-state preoperative or intraoperative EEG alpha power and POD assessed with validated tools. PubMed, Ovid MEDLINE, Embase, Web of Science, and the Cochrane Library were searched to December 26, 2025. Standardized mean differences (Hedges's g) between groups of POD and without POD were pooled using random-effects models. Results Twelve studies (1637 patients) met inclusion criteria. Intraoperative EEG alpha power was lower in patients who developed POD compared to those without POD (g = −0.57, 95% CI [−0.92, −0.22], P = 0.006). Sensitivity analyses further supported the robustness of this association—after excluding a cardiac cohort with cognitive impairment, heterogeneity decreased (I 2 reduced from 85.3% to 57.1%) and the result remained robust in an extended analysis (I 2 = 0, g = −0.44). In contrast, preoperative alpha power showed substantial heterogeneity. Sensitivity analyses identified baseline cognition as an essential source of variability, and after adjustment, a significant association between higher preoperative alpha power and POD was observed (I 2 = 0, g = 0.27, P = 0.037). Conclusions Lower intraoperative alpha power was consistently associated with subsequent POD across diverse surgical populations, supporting its potential as a marker of intraoperative cerebral vulnerability. In contrast, associations between preoperative alpha power and POD were variable and were influenced by baseline cognitive status. Further studies incorporating cognition alongside more standardized perioperative EEG are needed. Protocol registration Registered at PROSPERO on February 10, 2025 (CRD42024599991).
Abstract Enhanced Recovery After Cesarean (ERAC) protocols represent a significant advance in standardizing perioperative care to improve maternal outcomes. This narrative review synthesizes current evidence through a critical lens, arguing that the translation of ERAC principles into equitable, global practice is hindered by a predominant focus on high-resource contexts and a lack of integration with local cultural paradigms of postpartum recovery. We conducted a targeted literature search to identify major international ERAC guidelines and patient-reported outcome measures (PROMs). We then propose and apply an analytical "Framework for Contextualized ERAC Implementation" to evaluate this literature. Our analysis reveals that while guidelines from societies like Enhanced Recovery After Surgery (ERAS), Society for Obstetric Anesthesia and Perinatology (SOAP), and National Institute for Health and Care Excellence (NICE) provide robust evidence-based recommendations, their development processes and implicit assumptions often limit direct applicability worldwide. Similarly, PROMs like Obstetric Quality of Recovery (ObsQoR) and Stanford Obstetric Recovery Checklist (STORK), though validated, may not capture recovery domains prioritized in diverse cultural settings, such as those influenced by traditions like zuo yuezi (a traditional period of postpartum confinement and rest in Chinese culture). Successful implementation depends on moving beyond direct translation of protocols to active adaptation across two spectra: resource stratification (from low to high) and cultural integration (from translation to adaptation). Future efforts must prioritize the co-design of tiered, resource-sensitive protocols and the development of culturally competent metrics to ensure ERAC fulfills its promise of optimized, patient-centered recovery for all postpartum individuals.
Abstract Neuropathic pain (NP) is a chronic pain syndrome caused by a lesion or disease of the somatosensory nervous system. It is characterized by complex clinical manifestations and limited therapeutic efficacy, markedly impairing quality of life. Traditional analgesics often show variable effectiveness, and are associated with significant adverse effects. To address these challenges in pain research, long non-coding RNAs (lncRNAs) have attracted interest due to their key roles in gene transcription, epigenetic regulation, and cellular signaling networks. LncRNAs can modulate multiple structures related to pain, including peripheral nerves, the spinal cord, and higher central nervous system regions, by regulating neuronal excitability, ion channel function, neuroinflammatory responses, glial cell activation, and synaptic plasticity. Notably, they may also participate in central mechanisms underlying the comorbidity of pain and emotional disorders. Nascent intervention strategies targeting lncRNAs, such as antisense oligonucleotides, RNA interference, gene editing, small molecule modulators, and lncRNA replacement therapy, are increasingly demonstrating therapeutic potential. However, constraints on potential clinical translation include limited species conservation of lncRNAs, high tissue and cell specificity, and challenges in delivery efficiency and long-term safety. LncRNAs provide novel molecular insights into NP mechanisms and offer significant opportunities for the development of precise analgesic strategies. Future studies should focus on cross-species validation, targeted delivery system optimization, and integrative mechanistic analyses, to advance clinical translation of lncRNA-based interventions. Graphical Abstract
Abstract Purpose Earlier, patients developed surgical site infection for 2.0% of cases without Staphylococcus aureus transmission through anesthesia work areas, 11% with S. aureus transmitted susceptible to prophylactic antibiotic, and 18% with transmission of antibiotic-resistant isolates. A randomized trial and an effectiveness study both found that anesthesiologists who used basic preventive measures (e.g., alcohol releasing intravenous caps) and received feedback on colony-forming units per surface area sampled (CFU) had reduced S. aureus transmission and postoperative healthcare-associated infections. We used prospectively collected data to evaluate whether CFU would be a reliable criterion for hospitals to assess anesthesiologists’ contributions to postoperative infections. Methods During the summer of 2025, reservoirs (e.g., anesthetist’s hands at case start/end) were sampled during 81 cesarean delivery cases performed in the same operating room. There were ≤ 15 reservoirs sampled per case. Results 52/1016 reservoir samples had S. aureus detected, more often with greater CFU (P = 0.0063). The 159/1016 samples with < 100 CFU had no S. aureus. Total CFU of all reservoirs for each case to total S. aureus isolates was 2.50 × 109 per S. aureus (standard error 0.53 × 109, N = 81 cases). CFU and S. aureus transmission were uncorrelated (all 15 reservoirs’ unadjusted P ≥ 0.12, Holm-Bonferroni P > 0.99). Conclusions With substantive contamination (≥ 100 CFU), so few isolates are S. aureus that surrogate measures of insufficient disinfection (e.g., ATP bioluminescence) are inaccurate markers both of S. aureus isolation and transmission. The lack of association between contamination and transmission shows that feedback on CFU provides information on the effectiveness of disinfection, not on S. aureus transmission.
Abstract Purpose Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) are common complications in surgical patients, which contribute to longer hospital stays, poorer functional outcomes and reduced quality of life. As a potential intervention to address this significant burden, remote ischemic conditioning (RIC)—a low cost, non-invasive therapy involving inducing brief cycles of ischemia and reperfusion—has gained interest. The aim of this systematic review and meta-analysis was to synthesise current evidence on the effects of perioperative RIC on neurocognitive outcomes. Methods This systematic review was conducted in accordance with PRISMA guidelines and was registered with PROSPERO (CRD420251041823). A literature search was performed using MEDLINE, Embase, and Web of science from inception to March 16, 2025. Eligible studies included randomized controlled trials (RCTs) assessing the use of perioperative RIC in human adults (≥ 18 years of age) undergoing surgery. Outcomes of interest included incidence of POD and POCD, and performance on global and domain-specific cognitive measures (e.g., Mini Mental State Examination [MMSE], Montreal Cognitive Assessment [MoCA], and Trail Making Test [TMT]). Study screening, data extraction, and risk of bias assessment using the Cochrane risk of bias tool (ROB-2) were performed by independent reviewers. The DerSimonian-Laird model was used to analyze outcomes, while study heterogeneity was evaluated using Cochran’s Q. Results Out of 4,664 records screened, 16 publications from 15 RCTs (2,912 patients) were included. POD incidence at < 30 days (odds ratio [OR]: 0.77, 95% confidence interval [CI] 0.50 to 1.20, n = 6), POCD incidence at < 30 days (OR: 0.79, 95% CI 0.53 to 1.20, n = 5) and POCD incidence at ≥ 30 days groups (OR: 1.06, 95% CI 0.62 to 1.80, n = 3) were not significantly different between groups. Conversely, patients who received RIC had better MoCA (standardized mean difference [SMD] = 0.48, 95% CI 0.19 to 0.76, n = 2), Stroop test part 1 (SMD = 0.38, 95% CI 0.13 to 0.64, n = 2) and part 2 (SMD = 0.26, 95% CI 0.05 to 0.48, n = 2) scores at < 30 days, and better MMSE (SMD = 1.16, 95% CI 0.81 to 1.50, n = 2) scores at ≥ 30 days. RIC did not significantly improve TMT A and B completion time, Digit Symbol Substitution Test scores, Stroop part 3, Verbal Fluency Test semantic/phonemic, digit span forward/backward, and immediate/delayed verbal memory at any time point. Conclusion We found no support for a preventative effect of perioperative RIC on the incidence of short- and long-term post-operative neurocognitive disorders. Whereas there was no clear benefit of RIC for domain-specific cognitive performance, results indicated the intervention may improve global cognitive function, although there were only a limited number of trials in this regard.
The thoracolumbar interfascial plane (TLIP) block is a relatively new fascial plane block technique. It involves the injection of local anesthetic into the interfascial plane between the multifidus and longissimus muscles or between the longissimus and iliocostalis muscles in the lumbar region. This approach achieves analgesia by blocking the dorsal rami of the thoracolumbar spinal nerves and their branches that traverse these fascial layers. The TLIP block has been effectively applied in perioperative pain management for spinal surgery and in the treatment of chronic pain conditions. This expert consensus systematically reviews the anatomical basis, blocking techniques, distribution of blockade, choice of local anesthetics, potential complications, and clinical applications of TLIP block, providing evidence-based guidance for its safe and effective clinical use. Practice guideline registration Practice Guideline Registration for Transparency (PREPARE-2025CN203).
Sphenopalatine ganglion (SPG) neurostimulation has emerged as a promising therapy for patients with refractory cluster headache and selected cases of migraine. This narrative review provides a comprehensive synthesis of the current evidence on SPG neurostimulation as a novel therapeutic strategy for headache management. As a key parasympathetic ganglion involved in the trigeminal autonomic reflex, the SPG constitutes a logical and clinically relevant target for neuromodulation in the treatment of severe headache disorders. Clinical evidence supports the efficacy of SPG neurostimulation in aborting acute cluster headache attacks and reducing attack frequency in chronic cases, while limited data suggest potential acute pain relief in migraine. Long-term follow-up indicates sustained efficacy in cluster headache, including improved quality of life and reduced medication use. Adverse effects are mostly mild and transient. Serious complications are rare, but include procedure- or device-related events such as infection or venous injury reported in some studies. Future research should prioritize optimizing electrode placement, stimulation parameters, and long-term outcome evaluation, and further clarify the underlying mechanisms to improve clinical efficacy and safety.
Chronic postsurgical pain (CPSP) poses substantial therapeutic and preventive challenges as a common postoperative complication. Identifying predictive biomarkers could enable early intervention in high-risk patients. Preclinical evidence indicates that the nucleus accumbens (NAc) plays a key role in pain chronification, yet human neuroimaging data for CPSP are scarce. This prospective cohort study characterized longitudinal structural and functional alterations in NAc subregions as potential biomarkers for CPSP development after thoracoscopic surgery. Forty patients underwent multimodal magnetic resonance imaging (MRI), including resting-state fMRI, diffusion tensor imaging, T1-weighted imaging) and clinical assessments at acute (≤ 1 week) and chronic (12 weeks) postoperative phases. Based on the diagnostic criteria for CPSP, thirteen patients developed CPSP at 12 weeks. CPSP group patients displayed elevated pain catastrophizing scores despite comparable acute pain intensity, indicating maladaptive affective processing. Compared to non-CPSP controls, CPSP patients exhibited significantly reduced slow-5 band fractional amplitude of low-frequency fluctuation (fALFF) in bilateral NAc shell and core subregions during both phases. Decreased functional connectivity between shell and core emerged specifically at 12 weeks. Reduced gray matter density (GMD) and inferomedial atrophy were observed in bilateral NAc of CPSP patients at both timepoints. Early postoperative bilateral NAc GMD and NAc shell fALFF correlated with subsequent pain intensity and predicted CPSP development with high discriminative accuracy, particularly when combined. These findings establish NAc structural and functional alterations as promising neuroimaging biomarkers for CPSP susceptibility, revealing a unified neurobiological mechanism underlying affective dysregulation and pain chronification. Registered at the Chinese Clinical Trial Registry ( https://www.chictr.org.cn/showproj.html?proj=131606 ) with No. ChiCTR2100049631, on August 7, 2021.
