Anesthesiology:

CONCLUSIONS: Intravenous paracetamol has 12-fold greater life-cycle carbon emissions than the oral tablet form. Glass vials have higher greenhouse gas emissions than plastic vials. Intravenous administration should be reserved for cases in which oral formulations are not feasible.

Fluid therapy is an integral component of perioperative management. In light of emerging evidence in this area, the Perioperative Quality Initiative (POQI) convened an international multiprofessional expert meeting to generate evidence-based consensus recommendations for fluid management in patients undergoing surgery. This article provides a summary of the recommendations for perioperative fluid management of surgical patients from the preoperative period until hospital discharge and for all types of elective and emergency surgery, apart from burn injuries and head and neck surgery. Where evidence was lacking, recommendations for future research were generated. Specific recommendations are made for fluid management in elective major noncardiac surgery, cardiopulmonary bypass, thoracic surgery, neurosurgery, minor noncardiac surgery under general anaesthesia, and critical illness. There are ongoing gaps in knowledge resulting in variation in practice and some disagreement with our consensus recommendations. Perioperative fluid management should be individualised, taking into account the type of surgery and important patient factors, including intravascular volume status and acute and chronic comorbidities. Recommendations are made for further research in perioperative fluid management to address important gaps.

Prehabilitation aims to reduce the impact of major surgery by improving the physical and psychological resilience of patients. Although exercise represents one component of prehabilitation, nutritional and psychological support are also critical to its effectiveness, and any benefits are only likely to be realised if the different components are implemented together, ideally in a behaviour change framework. Implementation of prehabilitation in cardiac surgery has not been as widespread as in other types of surgery, despite many randomised controlled trials (RCTs) of single interventions in this setting. The late adoption of a prehabilitation programme in cardiac surgery represents an opportunity to ensure that it is both clinically effective and cost-effective before widespread roll-out. This was mostly not done for prehabilitation in noncardiac surgery, where programmes were implemented largely without trials of these combined interventions. The most likely chance of an effective prehabilitation programme for cardiac surgery is to combine all the efficacious and implementable single interventions together in one comprehensive evidence-based programme. This should then be tested in an adequately powered multicentre RCT in a representative cardiac surgery population.

A report on participant views of a two-person check confirming tracheal intubation implemented in their institution found that this check was generally considered feasible and useful, but there was some resistance and some concerns that it would not solve the problem. Social, cultural, and cognitive factors play a role in airway management in the operating theatre, partly because of the pre-eminence of airway management as a cornerstone of the profession of anaesthesia. These factors contribute to loss of situation awareness in airway failure. Although situation awareness might be better maintained by the two-person check, there could be advantages if airway management became the responsibility of the whole operating theatre team. Potential strategies to overcoming the ongoing problem of failed airway management are proposed, including multidisciplinary team training in airway management and a new airway point in the surgical safety checklist time out.

PURPOSE OF REVIEW: To assess current practice in the use of spinal anesthesia in major ambulatory surgery, highlighting its advantages over general anesthesia and identifying potential areas for improvement to facilitate a transition to a sustainable healthcare system.

CONCLUSIONS: Apart from pupillometry, no monitors demonstrated a significant effect on intraoperative opioid consumption. Secondary outcomes indicate limited clinical benefit for patients when using these monitors.

This Recommendation was developed by the Japanese Society of Intravenous Anesthesia Recommendation Making Working Group (JSIVA-WG) to promote the safe and effective practice of total intravenous anesthesia (TIVA), tailored to the current situation in Japan. It presents a policy validated by the members of JSIVA-WG and a review committee for practical anesthesia management. Anesthesiologists should acquire and maintain the necessary knowledge and skills to be able to administer TIVA properly. A secure venous access is critically important for TIVA. To visualize and understand the pharmacokinetics of intravenous anesthetics, use of real-time pharmacokinetic simulations is strongly recommended. Syringe pumps are essential for the infusion of intravenous anesthetics, which should be prepared according to the rules of each individual anesthesia department, particularly with regard to dilution. Syringes should be clearly labeled with content and drug concentration. When managing TIVA, particularly with the use of muscle relaxants, monitoring processed electroencephalogram (EEG) is advisable. However, the depth of sedation/anesthesia must be assessed comprehensively using various parameters, rather than simply relying on a single EEG index. TIVA should be swiftly changed to an alternative method that includes inhalation anesthesia if necessary. Use of antagonists at emergence may be associated with re-sedation risk. Casual administration of antagonists and sending patients back to surgical wards without careful observation are not acceptable.

CONCLUSIONS: Our data show a preponderance of spontaneous SEH in all patient populations. SEH developed even though the ASRA guidelines were followed, especially in patients on multiple anticoagulants. Patients with less impairment prior to surgery had a higher likelihood of complete recovery, regardless of the interval between surgery and onset of symptoms.

PURPOSE OF REVIEW: This article explores the unique intersection of the challenges confronting ambulatory anesthesiology education and charts a trajectory forward. The proportion of ambulatory, nonoperating room (NORA), and office-based surgical cases continues to rise; however, the requirements for trainees in these settings have remained static. The rapid evolution of the field combined with a limited workforce also makes continuing education essential, and we discuss the current and future states of ambulatory anesthesia education.

PURPOSE OF REVIEW: Medication administration errors represent a significant yet preventable cause of patient harm in the peripartum period. Implementation of best practices contained in this manuscript can significantly reduce medication errors and associated patient harm.

There were several noteworthy articles published in 2023 affecting the practice of critical care anesthesiology, summarized in this year's "The Year in Cardiothoracic Critical Care: Highlighted Publications From 2023." While many articles published in 2023 were notable and modified practices, the authors have highlighted a broad selection of papers. The selection of papers reviewed for 2023 includes studies demonstrating the noninferiority of organ donation after circulatory death, the immune response to blood administration in lung transplantation recipients, the lack of need for prescribing antiplatelet therapy in Heartmate 3 patients, outcomes following extracorporeal CPR, and evidence contradicting tight glycemic control in the intensive care unit. It is anticipated that all these topics will have further research in 2024 and beyond.

PURPOSE: Impacted fetal head (IFH) can be defined as the deep engagement of the fetal head in the maternal pelvis at the time of cesarean delivery that leads to its difficult or impossible extraction with standard surgical maneuvers. In this narrative review, we aimed to ascertain its incidence, risk factors, management and complications from the perspective of the anesthesiologist as a multidisciplinary team member.

CONCLUSIONS: Multimodal approaches combining pharmacotherapy, surgery and invasive neuromodulation procedures would appear to be the most promising strategy for preventive and treating PLP and RLP. Future efforts should focus on cross-disciplinary education to increase awareness of treatment options exploring best practices for preventing pain at the time of amputation and enhancing treatment of chronic postamputation pain.

PURPOSE OF REVIEW: Although necessary for treatment of acute pain, opioids are associated with significant harm in the perioperative period and further intervention is necessary perioperatively to mitigate opioid-related harm.

INTRODUCTION: Shivering affects 52 % of patients undergoing caesarean delivery under neuraxial anaesthesia. Despite extensive research focused on its prevention, there is still no consensus regarding optimal pharmacological treatment. This systematic review and network meta-analysis aims to compare available intravenous treatments of perioperative shivering in patients undergoing caesarean delivery under neuraxial anaesthesia.

Hallucinogen exposure in patients in the perioperative period presents challenges for anesthesiologists and other anesthesia providers. Acute and chronic exposure to these substances can cause physiological impacts that can affect the function of anesthetic and analgesic medications used during perioperative care. The objective of this narrative review is to educate readers on the wide array of hallucinogens and psychedelics that may influence the perioperative management of patients exposed to these substances. A narrative review of the literature surrounding hallucinogens and psychedelics was completed. Hallucinogens and psychedelics are quite varied in their mechanisms of action and therefore present a variety of perioperative implications and perioperative considerations. Many of these substances increase serotonin levels or act directly at serotonergic receptors. However, there are other relevant actions that may include varied mechanisms from N-methyl-D-aspartate receptor antagonism to stimulation of muscarinic receptors. With hallucinogen exposure rates on the rise, understanding the effects of hallucinogens is important for optimizing management and reducing risks perioperatively for patients with acute or chronic exposure.

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CONCLUSIONS: Aperiodic EEG activity could improve discrimination between consciousness and unconsciousness using spectral analyses.

The first measures to reduce the environmental harm from volatile anaesthetics are implementation of minimal fresh gas flow strategies and avoidance of desflurane. Although anaesthetic waste gas capture systems generally exert high capturing efficiencies, only about half of volatile anaesthetics used in the operating room are accessible for capture. Industry-sponsored reports promise a reduction of the global warming potential by both incineration and recycling of captured volatile anaesthetics. However, independent high-quality peer-reviewed studies are needed to confirm these findings.