BACKGROUND: Preoperative anxiety affects 30% to 80 % of ambulatory surgery patients and is associated with increased anesthetic requirements, postoperative pain, and delayed recovery. Virtual reality (VR) is a promising nonpharmacological anxiolytic, but evidence remains limited in the ambulatory setting. METHODS: The AMBLUMEEN (AMBulatory LUMEEN) trial is a single-center, randomized, open-label, superiority trial conducted in an adult ambulatory surgery unit. Patients with moderate-to-severe preoperative anxiety (State-Trait Anxiety Inventory Form Y-A [STAI-YA] > 45) were randomized 1:1 to standard care alone (control) or standard care and a single 20-minute preoperative VR session (immersive 360° natural contemplative scenes). The primary end point was the change in STAI-YA score from arrival in the ambulatory unit (baseline) to immediately before operating room transfer (presurgery), analyzed under the intention-to-treat principle with a linear mixed model. Secondary end points included preoperative benzodiazepine use, postoperative morphine requirement, unplanned overnight admission, patient satisfaction, and device acceptability. RESULTS: Of 106 randomized patients (53 per group) with a median [interquartile range] baseline STAI-YA of 49 [46–55] and 49 [46–58] respectively in the control and VR group, the VR group experienced a markedly greater reduction in state anxiety than controls. Adjusted mean between-group difference in STAI-YA change from baseline to presurgery was −18.7 95% confidence interval (CI) [−21.4 to −16.1] points in favor of VR. Although benzodiazepine requirement, postoperative pain, and unplanned overnight admission were comparable between groups, the morphine requirement in postanesthesia care unit was lower in the VR group (6/53 [11.3% 95% CI, 11.3 {4.3–23.0}] vs 0/53 [0.0%, 95% CI, {0.0–6.7}]; P = .027). Global perioperative satisfaction was high in both groups (median 8 [8–9] on 10). CONCLUSIONS: A single 20-minute session of medical-grade VR significantly reduced preoperative anxiety in ambulatory surgery patients, with high acceptability and an excellent safety profile.
BACKGROUND: Patients referred for postoperative care within enhanced care units in the United Kingdom are less likely to have their surgery canceled than those referred to critical care. Presently, it is unclear whether this association remains when examined at an individual hospital level, and whether specific structure and process features of enhanced care services influence cancelation rates within a facility. METHODS: We conducted a nationwide, retrospective, observational study documenting clinical and organizational features of enhanced and critical care facilities in the United Kingdom. Features of interest included resource protections, staffing, and clinical scope. Sites with availability of both enhanced and critical care facilities, with >10 referrals to enhanced care during the study period, were selected for analysis. Cancelation rates of elective surgery within these facilities were quantified over a 3-month period between September 1, 2023, and November 30, 2023. Rates were defined as the number of elective cases canceled divided by the number of elective referrals to each facility. Multilevel regression was used to explore relationships between structure and process features of enhanced care units and surgical cancelation, using a two-level model with cases nested within hospitals to account for institutional confounding. RESULTS: Complete data were available for 65 sites, of which 28 had an enhanced care facility with sufficient activity for analysis, representing 4112 patients referred to enhanced or critical care. In most institutions, surgical cancelation rates were lower within their enhanced care facility than in critical care. Enhanced care units with beds reserved exclusively for elective cases (odds ratio [OR], 0.54 [0.39–0.76]; P < .001) and clinical care involving multiple specialities (OR, 0.48 [0.33–0.69]; P < .001) were associated with reduced odds of cancelation. On the other hand, enhanced care units that permitted admission of emergency cases (OR, 1.61 [1.06–2.43]; P = .024) were associated with a greater odds of cancelation. CONCLUSIONS: Structure and process features of enhanced care pathways are associated with cancelation rates among high-risk surgical patients in the United Kingdom. These findings may explain why cancelation rates in enhanced care are typically lower than within critical care and may have important policy implications.
BACKGROUND: Postoperative delirium (POD) is a frequent and serious complication, particularly in older adults undergoing major surgery. Pharmacologic prevention remains limited. This study aimed to evaluate whether perioperative ketamine or esketamine reduces POD incidence and to explore optimal administration strategies. METHODS: We systematically searched PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) from inception to January 2025 for randomized controlled trials (RCTs) comparing perioperative ketamine or esketamine with placebo or standard care. The primary outcome was POD incidence (risk ratio [RR]). Subgroup, meta‑regression, and trial sequential analysis (TSA) were performed. Sensitivity analyses addressed active comparators and unit‑of‑analysis issues. RESULTS: Twenty-five RCTs (3344 patients) were included (ketamine: 9; esketamine: 16). Both agents reduced POD risk versus control (ketamine: RR 0.69, 95% CI, 0.49–0.98, P = .04; esketamine: RR 0.58, 95% CI, 0.36–0.95, P = .03). Benefit was more evident with high-dose regimens (single bolus: ketamine >0.5 mg/kg or esketamine >0.25 mg/kg; cumulative dose: ketamine >1.0 mg/kg or esketamine >0.5 mg/kg), bolus-plus-infusion, and in major surgery. The effect was observed when POD was assessed 2 to 7 days postoperatively, but not within 24 hours. TSA indicated that current evidence remains inconclusive due to insufficient information size. Dizziness risk increased (RR 1.45, 95% CI, 1.14–1.84, P = .002), while postoperative depressive symptoms decreased (RR 0.78, 95% CI, 0.63–0.96, P = .02; based on 2 studies, 493 patients). CONCLUSIONS: Perioperative ketamine and esketamine show a potential signal for POD reduction, particularly with optimized dosing in high‑risk patients. However, the evidence is currently inconclusive, and increased dizziness risk precludes routine recommendation. Large, multicenter RCTs are urgently needed.
