BACKGROUND: Compared to standard labor epidurals, placement of a dural puncture epidural (DPE) has been shown to improve labor analgesia efficacy, speed onset of analgesia, and decrease failure rates. However, there is a...BACKGROUND: Compared to standard labor epidurals, placement of a dural puncture epidural (DPE) has been shown to improve labor analgesia efficacy, speed onset of analgesia, and decrease failure rates. However, there is a concern of increased post-dural puncture headache (PDPH) risk. A 25-gauge or larger spinal needle is typically needed for a DPE to have improved efficacy over a standard epidural. A prior meta-analysis comparing combined spinal-epidurals (CSEs) with epidurals did not identify a difference in PDPH rates, but many of the included randomized controlled trials (RCTs) used smaller diameter (27-29 gauge) spinal needles. This systematic review and meta-analysis of RCTs evaluates headache frequency following CSE or DPE labor analgesia techniques with 24- or 25-gauge spinal needles. METHODS: Medline, EMBASE, Scopus, Database of Abstracts of Reviews of Effects, Web of Science Core Collection, and Cochrane databases were searched on May 7, 2024, for RCTs comparing either DPE or CSE techniques using 24- or 25-gauge spinal needles with epidural labor analgesia. The primary outcome was headache. The risk-of-bias 2 tool was used to assess bias. The odds ratio (OR) was the chosen effect size using binomial family Bayesian estimation. The reference category for estimation was the conventional epidural technique group. RESULTS: Encompassing 3278 patients, 1765 (53.8%) received labor epidurals, 971 (29.6%) received DPEs, and 542 (16.5%) received CSEs. The rate of headaches in both groups was low, with headache rates of CSE/DPE and epidural groups (0.59% vs 0.34%), respectively. Headache was a secondary outcome in all the RCTs. In 10 of the 16 RCTs (62.5%), no patients of 1428 (0%; 95% credible interval [CI], 0.00-0.25) reported a headache. A total of nine (0.6%) headaches were reported in the DPE/CSE patients (denominator 1513) and six (0.3%) headaches were reported in the traditional epidural patients (denominator 1765). The posterior distribution of the treatment effect ( θ ) showed that the log OR of 0.35 favored the control group as having fewer events, but the number of events was rare, and the 95% CI was wide (-0.49 to 1.22). CONCLUSIONS: Headache was a rare event in both groups. Although these results are reassuring that either technique is clinically safe, they should be interpreted cautiously. A large RCT examining PDPH as the primary outcome with long-term follow-up is needed to more precisely determine if placement of a DPE or CSE with a 24- or 25-gauge spinal needle increases the risk of PDPH.
BACKGROUND: Cathepsin G (CTSG) is a neutrophil-derived serine protease implicated in inflammatory pain modulation. Genetic variation in CTSG may influence postoperative pain susceptibility. This study evaluated the assoc...BACKGROUND: Cathepsin G (CTSG) is a neutrophil-derived serine protease implicated in inflammatory pain modulation. Genetic variation in CTSG may influence postoperative pain susceptibility. This study evaluated the association between CTSG polymorphisms, CTSG plasma concentration and enzymatic activity, and long-term pain after cardiac surgery. METHODS: We conducted a prospective cohort study including 255 Caucasian adults undergoing elective cardiac surgery via median sternotomy. CTSG single nucleotide polymorphisms (SNPs) rs2070697, rs2236742, and rs45567233 were genotyped. A random subsample of 107 patients underwent measurement of CTSG plasma concentration and enzymatic activity. Pain intensity (visual analogue scale [VAS]) at rest and with movement was assessed at 24 hours, 1 month, 6 months, and 12 months. Ordinal logistic regression was used to analyze associations between CTSG variants and pain. Mendelian randomization evaluated the causal effect of CTSG activity on pain. RESULTS: Overall, 16/250 patients (6.4%) reported moderate to severe postsurgical pain during movement at 6 months, and 6/178 patients (3.3%) at 12 months. At 1 month, pain was associated with higher BMI ( P = .016); at 12 months, it was more frequent in women ( P < .001) and in patients using antidepressants ( P = .022). The rs2070697 AA genotype was associated with reduced pain at 1 month at rest (GA vs AA: OR = 4.329, 95%CI = 1.523-12.310, P = .006), 6 months at rest and in movement (GA vs AA at rest: OR = 4.642, 95%CI = 1.535-14.040, P = .007; GA vs AA in movement: OR = 3.509, 95%CI = 1.169-10.530, P = .025), and 12 months in movement (GA vs AA: OR = 5.754, 95%CI: 1.492-22.200, P = .011). In contrast, the rs2236742 AA genotype was associated with increased pain at all three time points ( P < .05). Carriers of rs2236742 AA also reported greater preoperative informational anxiety (GG vs AA: OR = 0.193, 95%CI: 0.049-0.758, P = .018). CTSG activity was lower in rs2070697 A-allele carriers ( P = .03). CTSG activity and pain showed no causal association. No significant relationships were found for rs45567233. CONCLUSIONS: Variants appear to modulate susceptibility to prolonged post-sternotomy pain. These findings warrant validation in larger multi-ethnic cohorts to clarify mechanisms and potential implications for personalized perioperative pain management.
BACKGROUND: There is a paucity of uterine oxytocin receptors during preterm gestation. Whether this affects the requirement of oxytocin dose for uterine contraction in patients with preterm gestation is not researched. W...BACKGROUND: There is a paucity of uterine oxytocin receptors during preterm gestation. Whether this affects the requirement of oxytocin dose for uterine contraction in patients with preterm gestation is not researched. We compared effective dose in 90% of target population (ED90) of oxytocin infusion for satisfactory uterine tone during cesarean delivery in patients with preterm and term pregnancy. METHODS: This biased coin sequential allocation, dose finding study, with triple blinding to dose allocation included nonlaboring women >18 years posted for cesarean delivery under spinal block, into either term or preterm group (n = 30 each; completed or <37-week gestation, respectively). Oxytocin infusion was initiated at 13 IU·h-1 in the first patient in both groups. Dose in subsequent cases was determined by response to oxytocin in previous patient of a particular group (dosing interval = 2 IU·h-1). Uterine tone was assessed using the one-finger palpation method by the surgeon. Myometrial oxytocin receptor expression was also evaluated on tissue obtained during surgery, using immunohistochemistry (IHC). RESULTS: The ED90 of oxytocin infusion to prevent intraoperative uterine atony was 1.5 times greater in the preterm group (25.7 IU·h-1 [95% confidence interval {CI}, 16.4-35.1]) as compared to the term group (16.2 IU·h-1 [95% CI, 14.8-17.7]). Intraoperative oxytocin amount was significantly greater (14.3 [11.7-17.5] vs 12.8 [10.4-14.7] IU; P = .048), and the need of additional uterotonic was clinically higher (16% vs 10%; effect size = 0.5 [95% CI, 0.1-2.5]; P = .448) for the preterm group. IHC showed increased oxytocin receptor expression for term versus preterm group (P = .040). Incidence of oxytocin-associated hypotension was greater for preterm group (50% vs 13%; P = .002). CONCLUSIONS: During cesarean delivery, oxytocin requirement is almost 1.5 times greater for preterm as compared to term pregnancy. This was supported by decreased expression of the myometrial oxytocin receptor upon IHC.
While the field of anesthesiology has a storied history of innovation, especially related to patient safety, contemporary anesthesiologists face growing barriers to innovation from complex regulatory requirements and fin...While the field of anesthesiology has a storied history of innovation, especially related to patient safety, contemporary anesthesiologists face growing barriers to innovation from complex regulatory requirements and financial constraints. The Biodesign framework offers a systematic approach to medical technology development that can be applied to the perioperative space to address these challenges. This process begins with identification and screening of high-value clinical needs, followed by generation and evaluation of potential solutions, and culminates in strategy development, business planning, and fundraising. Each stage is designed to guide clinicians from early observation through translation into viable technologies. By adopting this structured method, anesthesiologists are well-positioned to transform clinical insights into scalable solutions, ensuring the specialty continues to advance patient safety and care in the face of evolving clinical demands.
Anesth Analg
· 2026 Jul · PMID 42138978
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BACKGROUND: Immersive virtual reality (VR) distraction reduces procedural pain. The current study explores whether immersive VR also reduces how much people can remember about a painful experience: anterograde amnesia fo...BACKGROUND: Immersive virtual reality (VR) distraction reduces procedural pain. The current study explores whether immersive VR also reduces how much people can remember about a painful experience: anterograde amnesia for pain. METHODS: A within-subject, crossover design was used. Sixteen healthy adult volunteers participated. Each participant received 5 thermal stimuli (some hot, some cold) during no-VR and 5 stimuli during immersive VR distraction (treatment order randomized). They were instructed to memorize the order of hot and cold stimuli for a later memory test. After a brief delay after each stimulus set, participants completed a memory recall test for the order of stimuli (the primary measure) and also provided ratings of pain, distraction, anxiety, and nausea using standardized graphic rating scales (GRS; 0-10). RESULTS: Within-subject Wilcoxon signed-rank tests revealed that immersive VR significantly reduced how accurately participants could recall the hot/cold order of thermal stimuli, mean accuracy: 96% correct (standard deviation [SD] = 8.06) in no-VR, versus 59% (SD = 25.79) in VR, Z = 3.09, P = .002, r = 0.77. On a rating scale from 0 to 10, immersive VR was significantly more distracting (mean = 7.60, very distracting, SD =1.72) compared to the control condition (mean = 2.07, mildly distracting, SD = 2.16, Z = 3.42, P < .001, r = 0.86), and on GRS mean pain perception ratings, participants reported significantly lower pain intensity during VR, mean = 4.03 (SD = 1.61) during VR, versus no-VR = 6.30 (SD = 1.81), Z = 3.47, P < .001, r = 0.87. CONCLUSIONS: Results of this study provide preliminary evidence that immersive VR reduces memory for a painful experience. Conscious/episodic memory formation and storage of memories about specific experiences requires attentional resources. VR distraction pain intervention significantly disrupts memory for painful stimuli, leading to what we term "VR amnesia." Our study provides preliminary laboratory evidence that immersive VR during pain induces anterograde amnesia for pain, disrupting the formation of memory for painful events. Further studies exploring the mechanism of how VR reduces memory for painful events are needed. These results suggest the utility of future studies in clinical pain contexts. If VR can reduce the formation of adverse memories associated with painful clinical procedures, VR may serve as an effective nonpharmacological adjunct to reduce postoperative distress and medications and may reduce risk of developing chronic pain.
Intraoperative neuromonitoring (IONM) plays a critical role in assessing neural integrity and guiding surgical decision-making. The effects of traditional anesthetic agents on IONM are well-established, though the impact...Intraoperative neuromonitoring (IONM) plays a critical role in assessing neural integrity and guiding surgical decision-making. The effects of traditional anesthetic agents on IONM are well-established, though the impact of novel anesthetics and adjunct analgesics remains unclear. This scoping review aims to evaluate the effects of novel anesthetic and adjunct analgesic agents on somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) in the intraoperative setting. A comprehensive literature search was conducted using Medline, Cochrane Central, CINAHL, Scopus, LILACS, and Embase, from inception to February 2025. Randomized controlled trials, observational studies, and case series assessing the effects of lidocaine, ketamine, dexmedetomidine, methadone, magnesium, gabapentinoids, xenon, and remimazolam on IONM were included in the review. Backward citation searching was also performed on the included studies. A total of 53 studies met inclusion criteria, comprising 30 randomized and 23 nonrandomized studies. Lidocaine, when administered within analgesic dosing, had minimal impact on SSEPs and MEPs. Ketamine exhibited augmentative, neutral, or suppressive effects on IONM, which appeared to be dependent on the dosing regimen. Dexmedetomidine demonstrated mixed effects on IONM, potentially due to dose-dependent hemodynamic alterations and its unique pharmacokinetic properties. Methadone and magnesium showed minimal impact on IONM, while xenon was associated with clinically relevant suppression of evoked potentials. Remimazolam appeared to maintain neuromonitoring integrity at clinically relevant doses. The effects of novel anesthetic and adjunct analgesic agents on IONM are variable and dose-dependent, necessitating individualized anesthetic strategies. Future research should focus on larger randomized trials with standardized protocols to better define their roles in a neuromonitoring-compatible anesthetic regimen.
BACKGROUND: Both medication shortages and hospital waste are important challenges in contemporary medicine. These challenges must be balanced to favor patient safety, which remains a fundamental goal of anesthesiology. M...BACKGROUND: Both medication shortages and hospital waste are important challenges in contemporary medicine. These challenges must be balanced to favor patient safety, which remains a fundamental goal of anesthesiology. METHODS: This retrospective study, based on material delivery and provider-reported major adverse intraoperative cardiovascular events, evaluates the impact of a fluid conservation strategy in the operating room, implemented on October 10, 2024, after the 2024 nationwide IV fluid shortage caused by Hurricane Milton. RESULTS: A total of 46,893 patients were cared for in the included operating rooms from October 2023 to January, 2025. The fluid conservation strategy successfully decreased weekly delivery requirements for fluids (median [IQR]: 1936 [1668-2055] vs 862 [740-1155] mL per case, P < .01; mean difference -1050 mL; 95% CI -665 to -1435 mL). This decrease was paralleled with a decrease in weekly costs for both fluids and fluid tubing (19,618 [13,991-21,930] vs 12,578 [9391-13,424] $, P < .01; mean difference -6784; 95% CI -1737 to -11,831 $) as well as weight of weekly plastic waste created 221.2 [205.6-246.5] vs 138.6 [105.7-155.2] kg, P < .01; mean difference -77 kg; 95% CI -25.7 to -128.8 kg). The incidence of major adverse events and case cancelations did not change after the implementation of the fluid reduction strategy. CONCLUSION: Our mitigation strategy decreased fluid usage per case, related costs, and plastic waste generated from fluids and infusion tubing. Further research focused on patient outcomes is needed before implementing such a strategy into standard care practice.
BACKGROUND: Despite evidence supporting methadone analgesic efficacy, perioperative methadone use remains limited due to concerns regarding respiratory depression. The aim of this systematic review and meta-analysis is t...BACKGROUND: Despite evidence supporting methadone analgesic efficacy, perioperative methadone use remains limited due to concerns regarding respiratory depression. The aim of this systematic review and meta-analysis is to objectively evaluate the current evidence on the association between perioperative intravenous methadone administration and postoperative respiratory depression, compared with other opioids.1. METHODS: Ovid MEDLINE, Ovid Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus were searched from January 1, 1970 to April 5, 2025. Eligible studies were randomized clinical trials (RCT) and retrospective studies comparing perioperative intravenous methadone administration with other opioids in adult or pediatric surgical patients and reporting postoperative respiratory depression events. Summary estimates were calculated as relative risks with a 95% confidence interval for the main analysis. The primary outcome was postoperative respiratory depression, defined as naloxone use, respiratory rate <8 breaths per minute, or SpO2 <90%. RESULTS: Twenty-five studies comprising 116,815 surgical patients were included. Twelve RCTs (n = 845) contributed data to the primary analysis. Respiratory depression occurred in 7.7% of methadone-treated patients and 6.6% of controls. Methadone was not associated with a significant greater risk of respiratory depression (relative risk [RR] 1.22, 95% confidence interval [CI], 0.76-1.95). Bayesian meta-analysis, subgroup analyses stratified by methadone dose, timing of events, and surgical population, and analyses of retrospective studies did not reveal greater risk of respiratory depression. Certainty of evidence was rated very low due to risk of bias and lack of continuous monitoring strategies in most of the included studies. CONCLUSION: Perioperative intravenous methadone was not associated with a higher risk of respiratory depression, compared to other opioids. The available evidence is predominantly derived from retrospective datasets, emphasizing the need for prospective studies with rigorous respiratory monitoring to further validate the safety of perioperative intravenous (i.v.) methadone administration.
Sevoflurane is a widely used inhaled anesthetic for adult and pediatric surgeries. In both populations, sevoflurane has been reported to have neurotoxic long-term effects such as cognitive impairment. One of the most imp...Sevoflurane is a widely used inhaled anesthetic for adult and pediatric surgeries. In both populations, sevoflurane has been reported to have neurotoxic long-term effects such as cognitive impairment. One of the most important mechanisms for neurotoxicity mediated by sevoflurane is neuronal cell death. In this review, we analyze published data from animal and clinical studies that investigate the potential neurotoxic effects of sevoflurane in both the developing and aged brains. We briefly introduce the characteristics of the major cell death modalities described on exposure to sevoflurane anesthesia (apoptosis, ferroptosis, necroptosis, pyroptosis) as well as mitochondrial dysfunction, oxidative stress, and their involvement in altering neurological functions. We briefly discuss how sevoflurane limits cell death on distinct cells such as cardiomyocytes and under certain conditions such as anesthesia preconditioning. Here, we highlight the importance of distinct cell death modalities in sevoflurane-induced neurotoxicity in populations at risk and propose several strategies for minimizing these effects.