Anesthesia contributes substantially to healthcare-related greenhouse gas (GHG) emissions especially by inhalational agents such as desflurane, sevoflurane, nitrous oxide, relying on single-use equipment and having high...Anesthesia contributes substantially to healthcare-related greenhouse gas (GHG) emissions especially by inhalational agents such as desflurane, sevoflurane, nitrous oxide, relying on single-use equipment and having high energy demand equipment. Over the past decade, increased awareness of these impacts has led to growing research into sustainable anesthesia, exploring interventions such as low-emission techniques, equipment reuse, waste reduction, and workflow optimization. A scoping review was conducted according to PRISMA and PRESS guidelines. The databases Embase and MEDLINE were searched for studies (2010-2025) reporting on interventions to reduce anesthesia-related carbon footprint equivalents (CO2e). Eligible studies were prospective or retrospective in human patients and reported results in CO2e. Two reviewers independently screened and extracted data. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Of 3309 records identified, 33 studies met the inclusion criteria and were included in the synthesis. Five studies were rated as low quality. The included studies, conducted across ten countries, evaluated diverse sustainability interventions including nitrous oxide restriction, reduction or elimination of desflurane, promotion of total intravenous or regional anesthesia, optimization of fresh gas flows, equipment reuse, waste reduction, telemedicine, and departmental educational programs. Reported outcomes showed CO2e reductions ranging from 50% to over 90%, with some interventions achieving absolute savings of several tonnes CO2e per year. Our analysis shows that various strategies, including low-emission techniques, equipment reuse, waste reduction, and telemedicine, can significantly lower anesthesia-related CO2e without compromising patient safety. The greatest impact comes from combining behavioral, technical, and organizational measures, highlighting the need for a coordinated, system-wide approach.
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT), pulmonary embolism (PE), and post-thrombotic syndrome (PTS), affects up to 900,000 people in the United States each year and as many as 60,000 to 1...Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT), pulmonary embolism (PE), and post-thrombotic syndrome (PTS), affects up to 900,000 people in the United States each year and as many as 60,000 to 100,000 of these patients may die. More than half of the VTE events occurring after hospital discharge are directly linked to a recent hospitalization or surgery. Sudden death is the first symptom in 25% of those who experience a PE, so prevention of VTE is of paramount importance. Several professional organizations have published perioperative guidelines for VTE prevention and accreditation organizations have incorporated VTE risk assessment and prophylaxis in their standards. Ambulatory anesthesiologists, by being part of multidisciplinary teams to establish enhanced recovery pathways at their outpatient facilities, play a pivotal role in identifying patients at risk for developing VTE, customizing risk assessment tools, and establishing thromboprophylaxis protocols for patients at their centers. In addition, anesthesiologists can play a key role in patient education, which is an important component of VTE prevention. With increased migration of complex procedures and patients to the outpatient setting, VTE risk in the high-risk groups of patients approaches inpatient levels. This position statement from the Society for Ambulatory Anesthesia (SAMBA) is tailored toward ambulatory surgery centers and summarizes and synthesizes existing VTE risk assessment and prophylaxis tools into an easy-to-use algorithm.
BACKGROUND: Older cardiac surgery patients have a higher prevalence of cognitive dysfunction and elevated risk of perioperative neurocognitive disorders (PND), both independently related to adverse postoperative outcomes...BACKGROUND: Older cardiac surgery patients have a higher prevalence of cognitive dysfunction and elevated risk of perioperative neurocognitive disorders (PND), both independently related to adverse postoperative outcomes. Neuromonitoring using electroencephalogram (EEG) and cerebral oximetry (CO) may predict PND. However, preoperative factors influencing intraoperative neurophysiological characteristics are not well understood. We conducted a study in a cardiac surgery cohort to better understand the relationship of preoperative cognitive dysfunction to intraoperative burst suppression (BS), spectral edge frequency (SEF), cerebral hypoxia/desaturation, and dual cerebral events involving both BS and cerebral desaturation to potentially link preoperative cognitive dysfunction to intraoperative neuromonitoring variables associated with PND. METHODS: This is a secondary analysis of a triple-blinded, ongoing, multi-center randomized trial assessing the efficacy of postoperative intravenous acetaminophen to reduce postoperative delirium (POD) in older cardiac surgery patients. We studied 110 patients ≥60 years who underwent CABG and/or valve surgery under general (inhalational) anesthesia at a single academic center. Preoperative cognitive status was assessed using the Montreal Cognitive Assessment (MoCA) and classified as normal (MoCA score≥26) or impaired (MoCA <26). Intraoperative frontal electroencephalogram data were recorded using the EEG monitor (SedLine, Masimo Inc). BS was detected using a recursive variance estimation algorithm, quantifying burst suppression duration (BSD). SEFs were derived through multi-taper spectral analysis. Intraoperative cerebral oxygenation was measured via cerebral oximetry (O3, Masimo), identifying cerebral desaturations (CO values <60%). Univariate analyses assessed associations between preoperative cognitive dysfunction and BSD, SEF, cerebral desaturation, and dual cerebral events of BS and cerebral desaturation. Multivariable regression analyses for these variables controlled for demographics and intraoperative confounders. RESULTS: Baseline characteristics were comparable between the groups. There was no statistically significant correlation between preoperative cognition and BSD in cognitively impaired individuals (Cohen's d = 0.33; P = .09; remaining insignificant on adjustment, P = .8). Adjusted analyses showed those with abnormal MoCA scores had an average of 1.4 Hz lower SEF values (95% confidence interval [CI], 0.07-2.6; P = .03). Cognitively impaired patients demonstrated no significant increase in time spent in cerebral desaturations (55.4 [12.4-119] vs 46.3 [19.2-81.9] minutes; P = .6). No disparities were observed between the groups regarding concurrent and nonconcurrent abnormal EEG and CO values. CONCLUSIONS: Preoperative cognitive dysfunction was associated with significantly lower SEFs, indicating increased isoflurane sensitivity without affecting BS or correlating with CO. SEF shows potential as a marker for cognitive vulnerabilities, but further studies are needed to validate its clinical utility and establish thresholds to optimize perioperative care.
BACKGROUND: Labor epidural analgesia (LEA) catheter failure and replacement is a common problem in obstetrical anesthesia. The relationship between LEA catheter replacement and labor analgesia maintenance regimen is not...BACKGROUND: Labor epidural analgesia (LEA) catheter failure and replacement is a common problem in obstetrical anesthesia. The relationship between LEA catheter replacement and labor analgesia maintenance regimen is not well defined. The primary study objective was to investigate whether maintenance with programmed intermittent epidural boluses (PIEB) is associated with fewer epidural catheter replacements than continuous epidural infusions (CEI). A secondary study objective was to investigate whether initiation of LEA by the combined spinal epidural (CSE) technique was associated with fewer catheter replacements than the common epidural (EPID) technique. METHODS: A combined pre-post and historical cohort study was conducted with data retrieved between July 1, 2013, and December 31, 2019, to compare patients who received labor LEA initiated by either EPID or CSE (cohort study) and maintained with either PIEB or CEI (pre-post comparison), each in combination with patient-controlled epidural analgesia. The a priori primary outcome was catheter replacement. Secondary outcomes consisted of time until catheter replacement, incidence of catheter top-ups, incidence of catheter withdrawal, a collapsed composite index of catheter intervention, and time until catheter top-up. Data were analyzed using confounder-adjusted logistic regression and Cox proportional hazards regression, and primary factors were assessed for 2-way interactions. RESULTS: A total of 11,277 EPIDs and 4082 CSEs were included. A total of 13,177 were maintained with PIEB and 2182 with CEI. When considering the primary outcome, EPID was associated with a 1.28× increase in the odds of replacement of the LEA catheter compared to CSE (95% confidence interval [CI], 1.01-1.65; P = .049). However, CEI was not significantly related to the primary outcome of LEA catheter replacement (odds ratio [OR] = 1.19; 95% CI, 0.90-1.56; P = .21). Among secondary outcomes, CEI was associated with a 1.34× increase in the odds of at least 1 catheter top-up (95% CI, 1.17-1.55; P < .001), a 1.34× increase in the odds of catheter intervention (95% CI, 1.10-1.64; P = .004), and had a greater hazard ratio (HR) for shorter time until catheter top-up (HR = 1.29; 95% CI, 1.14-1.46; P < .001) compared to PIEB. CONCLUSIONS: LEA catheter replacement was more common with EPID than CSE, but not markedly different between CEI and PIEB. Clinician interventions to optimize analgesia were more common with CEI than with PIEB.
Conrad D, Schneider SO, Beller S
… +4 more, Wagenpfeil G, Volk T, Müller-Wirtz LM, Meiser A
Anesth Analg
· 2026 May · PMID 41980265
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BACKGROUND: Central venous catheterization (CVC) of the subclavian vein is a standard procedure in medicine. Ultrasound guidance is increasingly recommended to improve the success rates and reduce complications. This stu...BACKGROUND: Central venous catheterization (CVC) of the subclavian vein is a standard procedure in medicine. Ultrasound guidance is increasingly recommended to improve the success rates and reduce complications. This study compared the success rates and complications of ultrasound-guided microconvex in-plane subclavian puncture (MISP) with those of the landmark technique. METHODS: In this randomized controlled trial, 101 patients scheduled for elective surgery were enrolled and randomly assigned to either the group MISP or the control group using the landmark technique after ultrasound prescan. The primary end point was an a priori defined composite risk score including puncture attempts, required time, posterior venous wall injury, arterial punctures, hematoma formation, hemo-, pneumothorax, and catheter mispositioning. The secondary and exploratory end points included success rates, complication rates, and procedural times. Comparisons between groups were performed using Student t test, χ2 test, and Mann-Whitney U test with a significance level of 0.05. Data are mean ± standard deviation [SD], frequencies (%) or 95% confidence interval [CI] [lower limit-upper limit]). RESULTS: The mean ± SD composite risk score was significantly lower in the MISP group compared to control (6.4 ± 5.9 vs 11.6 ± 10.8; mean diff 5.21 [95% CI, 1.71-8.71], P = .028). The MISP technique demonstrated significantly higher as-treated overall success rates (86% [95% CI, 74.6%-93.9%] vs 71% [95% CI, 56.2%-82.5%], P = .046) and significantly reduced the risk of arterial punctures (1.9% [95% CI, 0.05%-10.45%] vs 12% [4.5%-24.3%], number needed to harm: 10 punctures, P = .047). One pneumothorax was noted in both groups (2% each). The mean procedural time was 5 minutes longer in the MISP group (P < .001). CONCLUSIONS: Compared with the landmark technique, the ultrasound-guided MISP technique significantly reduced the risk of complications. The extended procedural time may be justified by lower complication rates. Further studies should evaluate the implementation of the MISP technique as a standard approach for subclavian vein catheterization.
BACKGROUND: Intraoperative hypotension (IOH) in pediatric patients is associated with multiple adverse outcomes. This study aims to delineate the incidence of IOH, the risk factors associated with its occurrence, and the...BACKGROUND: Intraoperative hypotension (IOH) in pediatric patients is associated with multiple adverse outcomes. This study aims to delineate the incidence of IOH, the risk factors associated with its occurrence, and the association of IOH with outcomes in pediatric patients undergoing noncardiac procedures. METHODS: Data from 6748 pediatric patients undergoing noncardiac surgical procedures between January 2015 and August 2022 at a single center were extracted from the American College of Surgery National Surgical Quality Improvement Program pediatric database. Blood pressure data yielded the incidence of IOH, defined as a decrease in systolic blood pressure to below -2 standard deviations for the age- and sex-specific preparation and surgical phase reference values as established by de Graaff et al, for a minimum duration of 5 minutes. This threshold was chosen based on its clinical relevance and its ability to capture significant hypotensive events that may impact patient outcomes. Exploratory multivariable analysis was performed to identify independent risk factors for IOH and associated outcomes, including cardiac arrest, mortality, length of stay, and postoperative ventilation. RESULTS: The institution-specific incidence of IOH was 7.8% (529/6748, 95% CI, 7.2%-8.5%)). The majority of patients with IOH, 58.4% (309/529), had only one 5-minute epoch below the threshold. Preoperative factors including respiratory disease (aOR 1.5 [95% CI, 1.1-2.05]; P = .01), ASA ≥ 3 (aOR 1.9 [95% CI, 1.29-2.82]; P = .001), previous CPR (aOR 8.7 [95% CI, 1.09-69.2]; P = .041), malignancy (aOR 2.4 [95% CI, 1.24-4.62]; P = .009), age 2 to 5 years (aOR 4 [95% CI, 1.18-13.5]; P = .026), age 6 to 8 years (aOR 4.86 [95% CI, 1.36-17.3]; P = .015), age 9 to 11 years (aOR 6.46 [95% CI, 1.68-24.7]; P = .007), and age ≥ 12 years (aOR 7.49 [95% CI, 1.92-29.3]; P = .004) were found to be associated with IOH. Also, patients with IOH had higher rates of postoperative ventilation (aOR 2.25 [95% CI, 1.07-4.73]; P < .001). DISCUSSION: Although brief intervals of IOH among children undergoing noncardiac procedures can occur, recognizing risk factors for IOH can identify high-risk patients preoperatively. This enables the tailoring of perioperative care with preventive measures and management strategies such as adjusting anesthetic agents, fluid management, and intraoperative monitoring, to mitigate the occurrence and impact of IOH, thereby optimizing postoperative outcomes.
BACKGROUND: Burnout remains prevalent among anesthesiology residents. Contributing workplace factors include limited control over scheduling, unpredictable hours, critical patient care needs, and other residency challeng...BACKGROUND: Burnout remains prevalent among anesthesiology residents. Contributing workplace factors include limited control over scheduling, unpredictable hours, critical patient care needs, and other residency challenges. The Family Anesthesia Experience (FAX) is a program designed to educate residents and their support persons on wellness and residency demands. The focus of this multisite study was to evaluate the impact of FAX on first year clinical anesthesiology (CA1, ie, PGY2s) residents' wellness. METHODS: This was a prospective evaluation study involving 15 US anesthesiology residency programs, 13 of which completed FAX. CA1 wellness was evaluated through surveys assessing perceived stress as the primary outcome, with exploratory outcomes including burnout, depression, psychological wellness, and social support. Additionally, changes in support persons' understanding and knowledge of residency demands were tracked over time. The study included a historical control group of 302 CA1s (2019-2021) who did not participate in FAX, and an intervention group of 88 CA1s that participated in FAX (2021-2022). Statistical analyses compared changes in metrics between groups using linear mixed models and generalized linear models. RESULTS: Significant reductions in perceived stress were observed in the intervention group at 6 months post-FAX (mean change = -2.14, 95% CI, -3.95 to -0.34; P =.021, effect size = 0.58) relative to the control group, but there was no sustained difference at 12 months. Compared to the control support persons, intervention support persons reported increased understanding of residency demands, with significant improvements at 6 (mean change = 2.80, 95% CI, 1.12-4.48; P =.001, effect size = 0.77) and 12 (mean change = 2.59, 95% CI, 0.12-5.05; P =.039, effect size = 0.71) months. Improvement in support persons' understanding did not predict changes in CA1 wellness outcomes. First generation physician residents reported lower family support at baseline but showed significant improvements in family support at 6 months (mean change = 3.05 points; 95% CI, 0.25-5.84; P =.033; effect size = 1.23) compared to their non first generation peers. CONCLUSIONS: FAX participation was associated with reduced perceived stress in residents up to 6 months post-intervention. First generation physicians experienced greater improvements in perceived family support compared to their non first generation peers. Our findings suggest that resident wellness may be enhanced by engaging both residents and their support persons in an educational wellness program that outlines the professional expectations and demands of anesthesiology residency training.
BACKGROUND: Whether heating local anesthetic solutions to core body temperature (37°C) for epidural labor analgesia reduces intrapartum fever incidence remains undefined in the current literature. METHODS: This double-bl...BACKGROUND: Whether heating local anesthetic solutions to core body temperature (37°C) for epidural labor analgesia reduces intrapartum fever incidence remains undefined in the current literature. METHODS: This double-blind randomized controlled trial (RCT) enrolled 220 nulliparous parturients (18-35 years, American Society of Anesthesiologists [ASA] physical status II, term singleton pregnancy). Participants were randomized to receive epidural labor analgesia with 0.075% ropivacaine + 0.5 µg/mL sufentanil at 37°C (warmed group) or 22°C (room-temperature group). Epidurals were placed at L3-L4 with a test dose of 3 mL of 1.5% lidocaine at room temperature, followed by programmed bolus epidural analgesia (initial 10 mL, 10 mL/h) and patient-controlled epidural analgesia (PCEA) 5 mL (30-minute lockout). Tympanic temperature was measured every 30 minutes from epidural initiation to delivery, defining intrapartum fever as ≥38°C. The primary outcome was fever incidence, on which the power analysis was based, and also maximum temperature and shivering. Secondary outcomes comprised analgesia onset, block level, labor durations, neonatal Apgar scores, umbilical cord blood pH and BE, and maternal adverse events. RESULTS: A total of 220 parturients were included (warmed group, n = 110; room-temperature group, n = 110). The warmed group had a lower intrapartum fever incidence (15.5% [17/110] vs 30.9% [34/110], relative risk [RR] 0.5 [95% confidence interval {CI}, 0.298-0.840]; P = .007); however, the reduction of 49.8% did not reach the preset clinically meaningful difference of 60% reduction proposed in the power analysis. The maximum body temperature was also lower in the warmed group: median (interquartile range [IQR]) 37.4 (IQR, 37.2-37.7) °C vs 37.6 (IQR, 37.3-38.0) °C, median difference -0.2 (95% CI, -0.3 to -0.1) °C (P = .006). Shivering incidence was not different between groups (10.9% [12/110] vs 14.5% [16/110]; P = .418). No statistically significant differences were observed between groups in any of the secondary outcomes assessed, including block characteristics, local anesthetic consumption, labor duration, neonatal outcomes, and maternal adverse events. CONCLUSION: Although we found a 50% reduction in the incidence of temperature rise using warmed (37°C) local anesthetics for epidural labor analgesia, this did not reach our preset threshold of 60% reduction.
BACKGROUND: Minimally invasive pulse wave analysis devices are widely used for perioperative hemodynamic monitoring, but their accuracy and ability to track changes in cardiac output remain controversial. Previous review...BACKGROUND: Minimally invasive pulse wave analysis devices are widely used for perioperative hemodynamic monitoring, but their accuracy and ability to track changes in cardiac output remain controversial. Previous reviews mainly addressed accuracy, whereas trending ability has been reported inconsistently. METHODS: We conducted a systematic review and meta-analysis of studies comparing minimally invasive pulse wave analysis devices with reference techniques. Methodological quality was assessed through a predefined fitness appraisal (simultaneity, homoscedasticity, absence of systematic trend, independence). Random-effects models (metafor, R 4.3.2) were used with log and logit transformations as appropriate. We included 50 studies; 49 provided accuracy/precision data and all 50 provided trending ability data, yielding 69 and 70 lines of analysis, respectively. Subgroup analyses were performed by device, clinical setting, and conflict of interest. RESULTS: Across all devices and settings, pooled bias was 0.09 L/min (95% confidence interval [CI], -0.05 to 0.23) and pooled percentage error was 48.3% (unweighted mean 49.0%, 95% CI, 45.8-52.2). Global trending analyses showed pooled four-quadrant concordance of 72.6% (95% CI, 67.9-77.4) and polar plot ±30° agreement of 63.2% (95% CI, 54.9-71.5). Heterogeneity was extreme (I2 >95% throughout). Subgroup analyses showed lower percentage error in intensive care unit (ICU) (≈42%) than in noncardiac surgery (≈55%) and more favorable results in studies with declared conflict of interest (≈44% vs 51%, P < .05). MostCare and Argos achieved four-quadrant concordance >90% and polar agreement close to accepted thresholds, but these estimates were based on few studies. Sensitivity analyses restricted to high-quality datasets yielded results very similar to the overall estimates. CONCLUSIONS: Minimally invasive pulse wave analysis devices do not achieve sufficient accuracy or trending ability to be interchangeable with reference techniques. Extreme heterogeneity persists across devices, clinical settings, and methodological quality. Differences associated with conflicts of interest and between ICU and noncardiac surgery populations suggest that performance is context-dependent and influenced by study sponsorship. Taken together with recent evidence and new methodological standards for cardiac output validation, our findings underscore the need for more transparent algorithms, rigorous reporting of trending ability, and standardized validation frameworks before these technologies can be considered reliable for guiding hemodynamic management.