British Journal of Anaesthesia

Background: Perioperative observational studies are increasingly used to evaluate anesthesia practices that are difficult to test in randomized trials, but treatment selection is influenced by surgical procedure type. Scalable and robust methods are needed to adjust for procedure-level confounding across heterogeneous surgical cohorts. Methods: We developed and assessed the utility of a surgical-name embedding framework using free-text procedure names from 627,624 adult perioperative records. Procedure names were embedded using open-source sentence-embedding models, reduced with principal components analysis, and incorporated into entropy-balanced observational analyses. We compared unweighted, clinical covariate adjustment, and clinical covariate plus surgical-name embedding adjustment across three replications of recent perioperative randomized trials: GA-CARES for total intravenous versus volatile anesthesia on cancer mortality, PADDI for dexamethasone and surgical site infection, and GAP for perioperative gabapentin and postoperative length of stay. Results: In the GA-CARES replication, unweighted and clinical covariate adjustment suggested lower two-year mortality with total intravenous anesthesia, whereas adding surgical-name embeddings attenuated the estimate to a nonsignificant association consistent with the randomized trial (OR 0.84 [95% CI, 0.62-1.14]; p=0.274). In the PADDI replication, adding surgical-name adjustment reproduced the trial's overall non-harm finding for 30-day surgical site infection (OR 0.72 [95% CI 0.69-0.76], p<0.001) while preserving the expected protective association with postoperative nausea and/or vomiting. In the GAP replication, the full cohort was null across adjustment strategies, but surgical-name embeddings were required to recover trial-consistent null length-of-stay estimates across cardiac, thoracic, and abdominal subgroups. Department indicators and randomly generated covariates did not reproduce the effect of surgical-name embeddings, supporting the presence and importance of procedure-specific information. Conclusions: Free-text surgical-name embeddings provide a scalable method for representing surgical context in perioperative observational studies. Surgical-name adjustment improved concordance with randomized trial benchmarks while preserving expected treatment effects, supporting its use as an additional layer of confounding adjustment in large perioperative datasets.

Background: Diabetes mellitus (DM) is a common chronic condition among surgical patients. It is associated with increased perioperative morbidity and mortality. Realworld data on the clinical predictors of postoperative complications in diabetic patients undergoing major surgery are limited. This study aimed to characterise perioperative outcomes and identify independent predictors of 28day postoperative complications. Methods: A retrospective cohort study at a single UK tertiary hospital. Adult patients with a known diagnosis of type 1 or type 2 diabetes mellitus who underwent major procedures under general anaesthesia between January 2020 and September 2025 were identified through electronic patient records (EPR). The primary outcome was any postoperative complication within 28 days. We used multivariable logistic regression to identify independent predictors of complications, adjusting for age, sex, ASA grade, surgical category, admission urgency, operative duration, diabetes type, HbA1c, and socioeconomic deprivation (Index of Multiple Deprivation [IMD]). Results: We screened 2623 patients and included 267; we analysed 267 patients (260 with outcome data). The 28day postoperative complication rate was 23.1% (46/199) among those with outcome data. Infection was the most common complication. In multivariate analysis, surgical duration was the only independent predictor of complications (adjusted odds ratio [aOR], 1.71; 95% CI, 1.16 to 2.51; p=0.007). Other variables were not associated with complications. Conclusions: In this study of patients with DM undergoing major surgery, operative duration was the only modifiable independent predictor of 28-day postoperative complications. Socioeconomic deprivation and preoperative HbA1c were not independently associated with outcomes, suggesting that standardised perioperative care pathways may attenuate these effects.

Background: Postoperative delirium is a common syndrome of acute changes in attention, cognition, and consciousness that may result from inflammation and/or neuroinflammation, but few studies have distinguished the relationships of preoperative and 24-hour postoperative systemic inflammation (i.e. in blood) versus neuroinflammation (i.e. in cerebrospinal fluid, or CSF) in postoperative delirium. Methods: We measured CSF and plasma cytokine levels before and 24-hours after non-cardiac/non-neurologic surgery in 199 patients age [&ge;] 60 years who were enrolled in two prospective cohort studies. Delirium was assessed with the confusion assessment method (CAM), 3-minute diagnostic interview for CAM-defined delirium, or the CAM for the Intensive Care Unit (CAM-ICU) in patients who remained intubated postoperatively and validated chart review. Cytokines were measured with immunoassays for IL-6, IL-7, IL-8, IL-10, IL-16, TARC, MCP-1, and IP-10. Associations of CSF and plasma cytokine levels with postoperative delirium were assessed with univariable and multivariable logistic regression analyses with Holm correction for family-wise error. Results: Surgery was associated with significant changes in nearly all measured CSF and plasma cytokines (p < 0.05) except plasma IL-16 and MCP-1. In multivariable analyses adjusted for preoperative Mini-Mental Status Exam (MMSE) score and surgery duration, higher preoperative CSF IL-6 (OR 1.80, 95% CI 1.18-2.75, Holm p=0.049) and CSF IL-8 (OR 1.94, 95% CI 1.22-3.06, Holm p = 0.040) levels were independently associated with postoperative delirium. Higher 24-hour postoperative CSF IL-10 was nominally associated with delirium (OR 1.57, 95% CI 1.06-2.33, p = 0.026) in a multivariable regression controlling MMSE and surgery duration, but this association did not remain significant after multiple-comparison correction (Holm p = 0.21). No other preoperative or 24-hour postoperative CSF or plasma cytokine levels were associated with delirium (p > 0.05). Conclusions: Surgery elicited robust postoperative changes in CSF and plasma cytokines, but 24-hour postoperative cytokine elevations were not significantly associated with postoperative delirium after multiple-comparison correction. In contrast, elevated preoperative CSF IL-6 and IL-8 levels were associated with postoperative delirium independent of baseline cognitive status and surgery duration. Thus, our findings support an important role for preoperative neuroinflammation in postoperative delirium in older elective surgery patients.

Background Postoperative nausea and vomiting (PONV) remains a frequent and distressing complication after gynecologic laparoscopic surgery, with residual incidence approaching 30-40% despite contemporary multimodal antiemetic prophylaxis. Transcutaneous auricular vagus nerve stimulation (taVNS) is a noninvasive neuromodulation technique that activates auricular vagal afferents projecting to brainstem nuclei implicated in emetic reflexes. We present the protocol of a randomized trial to evaluate taVNS as an adjunctive, nonpharmacologic strategy to reduce PONV in this high-risk population. Methods This single-center, prospective, randomized, double-blind, sham-controlled, parallel-group superiority trial will enroll 146 adult women undergoing elective gynecologic laparoscopy under general anesthesia. Participants will be randomized 1:1 to active taVNS or sham stimulation, with stratification by Apfel risk score ([&le;]2 vs. [&ge;]3). Two 30-minute sessions will be delivered: one beginning 30 minutes before anesthesia induction and another 30 minutes after arrival in the post-anesthesia care unit. The primary outcome is the incidence of PONV within 48 hours postoperatively. Secondary outcomes include nausea severity (11-point numerical rating scale), time to first PONV episode, number of vomiting/retching episodes, rescue antiemetic use, postoperative pain intensity, cumulative opioid consumption (morphine equivalents), Quality of Recovery-15 scores at 24 and 48 hours, and gastrointestinal recovery indices. Analyses will follow intention-to-treat and per-protocol principles; missing data will be addressed via multiple imputation. Conclusions This trial aims to provide rigorous evidence on the efficacy and safety of perioperative taVNS for PONV prevention in women undergoing gynecologic laparoscopy. If proven effective, taVNS could be integrated into enhanced recovery after surgery (ERAS) pathways as a mechanistically grounded, nonpharmacologic adjunct to standard antiemetic regimens. Trial registration Chinese Clinical Trial Registry ChiCTR2600115965 (prospectively registered).

Background: Perioperative cardiac arrest is associated with high mortality, but population-level estimates of outcomes after perioperative cardiopulmonary resuscitation (CPR) do not account for differences in risk among individual patients. We previously developed the CPR OutcoMes Prediction for Arrest in Surgical Settings (COMPASS) model to estimate 30-day mortality after cardiac arrest requiring CPR on the day of surgery. The model incorporates 33 preoperative predictors and has not been evaluated in a temporally distinct cohort. We therefore sought to temporally validate COMPASS and to develop and temporally validate a simplified point-based mortality score. Methods: We performed a retrospective prognostic study of adults undergoing noncardiac surgery who experienced cardiac arrest requiring CPR on postoperative day 0 in the American College of Surgeons National Surgical Quality Improvement Program. The primary outcome was 30-day mortality. The published COMPASS model, developed using 2012-2023 data, was applied without refitting to the 2024 cohort. A simplified point-based score was developed in the 2012-2023 cohort and temporally validated in 2024. Performance was assessed using discrimination, calibration, and Brier score. Results: The 2024 temporal validation cohort included 429 patients, of whom 274 (63.9%) died within 30 days. The COMPASS model had an area under the receiver operating characteristic curve (AUROC) of 0.82 (95% CI, 0.78-0.86), calibration intercept of 0.24, calibration slope of 1.10, and Brier score of 0.17. The simplified 3-variable score incorporating age, American Society of Anesthesiologists physical status, and case urgency had an AUROC of 0.81 (95% CI, 0.77-0.86), calibration intercept of 0.19, calibration slope of 1.25, and Brier score of 0.17. Conclusions: In a temporally distinct cohort, the published COMPASS model retained predictive performance for 30-day mortality after perioperative CPR. The simplified score showed similar performance. These findings support further evaluation of both approaches as tools for individualized estimation of perioperative CPR mortality.

BackgroundFospropofol disodium is a water-soluble prodrug of propofol that avoids a lipid emulsion carrier. It may therefore reduce injection pain, cardiorespiratory depression and lipid exposure. In May 2021 it was approved in China (H20210017) for induction of general anaesthesia in adults. Randomised trials have since tested it for sedation outside the operating room, but this setting has not been systematically reviewed. MethodsWe followed PRISMA 2020 and PRISMA-S and searched Europe PMC, PubMed, Embase, Cochrane CENTRAL, Web of Science and the Chinese databases CNKI, Wanfang and VIP (the last accessed through the XJMU Library database proxy) from inception to 2026. Eligible patients were adults receiving sedation for purposes other than general anaesthesia induction or maintenance, including continuous sedation during ICU mechanical ventilation and procedural sedation. These uses are referred to here as sedation outside the operating room. We included randomised controlled trials with propofol as the comparator and excluded trials of general anaesthesia induction or maintenance to avoid overlap with the published induction meta-analysis. Binary outcomes were pooled with a DerSimonian-Laird random-effects model, and REML plus modified Hartung-Knapp estimates were reported alongside to improve interval coverage when few studies were available. Outcomes with a high proportion of zero cells were also analysed with the Peto method. We stratified by setting and blinding and performed leave-one-out analysis, trial sequential analysis (TSA) and GRADE assessment. Hypotension reached the prespecified threshold of at least 10 studies, so publication bias was assessed with the Harbord test, with the originally specified Eggers test reported alongside. The protocol was prospectively registered and took effect on 16 September 2026. All searches were completed on 21 September 2026, and screening, extraction and analysis were performed after registration. ResultsTwelve randomised controlled trials were included. Event counts for all 12 studies were checked against the full-text original publications. For Liu 2026, a preprint, counts were taken directly from its Tables 2 and 3. Compared with propofol, fospropofol disodium reduced injection pain under the DerSimonian-Laird model (8 studies, OR 0.09, 0.03-0.21) and increased pruritus/paraesthesia (4 studies, OR 32.56, 12.89-82.26; RD +28.5%). During procedural sedation, it was associated with fewer respiratory adverse events (5 studies, OR 0.19, 0.11-0.32). This composite includes respiratory depression, hypoxaemia and related events reported by individual trials and should not be extrapolated to all adult sedation settings. For hypertriglyceridaemia, the DerSimonian-Laird estimate was OR 0.29 (0.13-0.65), but all four studies were conducted in ICU settings and the REML plus modified Hartung-Knapp estimate was 0.29 (0.08-1.08), with a confidence interval crossing 1. Certainty was very low, so this finding remains hypothesisgenerating. Hypotension differed by setting: OR 0.24 (0.13-0.42) for procedural sedation and 0.90 (0.53-1.55) for continuous ICU sedation, with a significant interaction (P < 0.001). The overall estimate (OR 0.51, 0.28-0.93) is reported for summary only. Under REML plus modified HartungKnapp it was 0.51 (0.25-1.03), crossing 1, so it does not support a claim that the drug lowers blood pressure and should not be extrapolated to the ICU. Bradycardia did not differ significantly (9 studies, OR 0.45, 0.17-1.18), and the direction reversed in the only double-blind study. Two studies reported slower onset or loss of consciousness with fospropofol disodium (MD +2.22 and +0.92 min), but these were not pooled because heterogeneity was extreme (I2 = 99.6%). Recovery, discharge and successful extubation showed no clear differences, although heterogeneity was high (I2 = 85%-92%) and the evidence cannot establish equivalence. Sedation efficacy was not pooled because definitions differed. Patient-important outcomes (death, delirium, ICU length of stay and duration of mechanical ventilation) were each reported by only one or two small studies with inconsistent definitions and time points, so no reliable conclusion can be drawn. Setting-specific results should take priority over the overall mean. Certainty ranged from very low to moderate. O_TBL View this table: org.highwire.dtl.DTLVardef@174a615org.highwire.dtl.DTLVardef@143c610org.highwire.dtl.DTLVardef@807653org.highwire.dtl.DTLVardef@1d857eborg.highwire.dtl.DTLVardef@740a59_HPS_FORMAT_FIGEXP M_TBL O_FLOATNOTable 2:C_FLOATNO O_TABLECAPTIONBinary event counts by study and outcome (fospropofol disodium versus propofol). C_TABLECAPTION C_TBL O_TBL View this table: org.highwire.dtl.DTLVardef@538773org.highwire.dtl.DTLVardef@1e1ccbcorg.highwire.dtl.DTLVardef@1486540org.highwire.dtl.DTLVardef@1ef63f9org.highwire.dtl.DTLVardef@18ca7cb_HPS_FORMAT_FIGEXP M_TBL O_FLOATNOTable 3:C_FLOATNO O_TABLECAPTIONThreshold, recording window and intervention requirement for hypotension in each study (10 studies). C_TABLECAPTION C_TBL ConclusionsDuring procedural sedation, fospropofol disodium may reduce injection pain and respiratory adverse events and may lower the risk of hypotension compared with propofol. This hypotension benefit should not be extrapolated to the ICU. During continuous ICU sedation no data were available for injection pain or respiratory adverse events, so the safety evidence in that setting remains limited. Hypertriglyceridaemia was lower only under the DerSimonian-Laird model. Because the result depends on the method and certainty is very low, it cannot be treated as definitive. The main cost is a clear increase in pruritus and abnormal sensations. Onset may be slower, but the evidence comes from two bolus-dosing studies in procedural sedation, and no such disadvantage was seen during continuous ICU infusion. Evidence on sedation efficacy, recovery time, discharge time and successful extubation is limited, and equivalence between the two drugs cannot be asserted. Because most studies were small and open-label and certainty ranged from very low to moderate, these findings support investigational use only and do not justify a routine clinical recommendation. Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWe searched Europe PMC, PubMed, Embase, Cochrane CENTRAL, Web of Science Core Collection and Chinese databases (CNKI, Wanfang, VIP) by crossing drug terms (fospropofol, fospropofol disodium, Lusedra, Aquavan) with sedation setting terms (ICU, mechanical ventilation, endoscopy, gastroscopy, hysteroscopy, bronchoscopy, procedural sedation). Within the retrieved literature, the only relevant meta-analysis addressed general anaesthesia induction; no synthesis of the sedation setting was identified. Added value of this studyThe present synthesis focuses on sedation outside the operating room, includes 12 RCTs, and stratifies by setting. It reports eight safety and efficacy outcomes (recovery time and other continuous outcomes are reported narratively), together with heterogeneity, leave-one-out sensitivity analysis, trial sequential analysis and GRADE certainty, and it quantifies the costs of fospropofol disodium (pruritus/paraesthesia; slower onset after bolus dosing). Clinical implicationsFospropofol disodium may reduce injection pain during sedation. For hypertriglyceridaemia the result depends on the estimator and certainty is very low. During procedural sedation it may reduce hypotension and respiratory adverse events, whereas the evidence for a hypotension benefit during continuous ICU sedation is weak. Because the approved indication in China is adult general anaesthesia induction only, these uses remain investigational; they do not constitute a routine clinical recommendation. Applicability to specific patient groups remains an inference from pharmacological mechanism.

Introduction Postoperative analgesic management after minimally invasive cardiac surgery (MICS) should facilitate early recovery while providing adequate pain control. However, direct evidence comparing postoperative remifentanil- and fentanyl-based analgesic strategies after MICS remains limited. We compared these strategies and explored their associations with postoperative recovery, postoperative nausea and vomiting (PONV), and pain management. Methods This retrospective single-center observational cohort study included patients who underwent MICS via a right mini-thoracotomy between January 2023 and June 2026. Patients were categorized according to postoperative remifentanil- or fentanyl-based analgesia in the intensive care unit. Outcomes included time to extubation, PONV, postoperative pain assessed using the numerical rating scale (NRS), additional analgesic use, and intensive care unit length of stay. Multivariable logistic regression examined the association between postoperative opioid strategy and PONV, adjusting for age, sex, and smoking history. Results PONV occurred less frequently in the remifentanil group than in the fentanyl group (20.6% vs 45.0%, P = 0.004), and this association remained significant after adjustment (adjusted odds ratio, 0.23; 95% confidence interval, 0.10-0.56; P = 0.001). Time to extubation was shorter with remifentanil (median, 179 [interquartile range, 134-240.5] vs 247 [190.2-276.5] min; P < 0.001). In contrast, NRS pain scores on postoperative day 0 were higher with remifentanil (3 [1-6] vs 1 [0-2]; P < 0.001), and additional analgesics were used more frequently (80.6% vs 33.3%; P < 0.001). Pain scores on postoperative day 1 did not differ significantly between groups. Conclusion Postoperative remifentanil-based analgesia after MICS was associated with less PONV and earlier extubation but also with greater early postoperative pain and more frequent additional analgesic use than fentanyl-based analgesia. Appropriate transition to longer-acting analgesics with multimodal analgesia may help preserve the potential benefits of remifentanil while maintaining adequate postoperative pain control.

Background: Opioids remain the cornerstone of acute postoperative pain management but are associated with potentially serious adverse effects. We aimed to investigate the effect of oxycodone patient-controlled analgesia with adjunctive S-ketamine on pain after lumbar fusion surgery. Methods: In this secondary analysis, we examined oxycodone and S-ketamine exposure and PCA behaviour during the first 24 h. We assessed current pain versus subsequent PCA activity and whether the association between plasma oxycodone and adequate analgesia changed with postoperative time. Results: Plasma concentrations of administered drugs rose rapidly after PCA initiation, but variation was large. Metabolite concentrations accumulated over time. PCA attempt and delivered-dose rates decreased over postoperative time (RR 0.965 and 0.966 per hour, respectively; both P<0.001). Older age was associated with a lower delivered-dose rate (RR 0.905 per 10 years, 95% CI 0.829-0.987). Each 1-point higher current pain score was associated with more subsequent PCA attempts (RR 1.09, 95% CI 1.04-1.14) and delivered doses (RR 1.07, 95% CI 1.03-1.11). The oxycodone-analgesia association weakened over time [interaction P <0.001; odds ratios (Ors) per 10 ng/mL 1.16, 1.13, and 1.00 at 1, 4, and 24 h, respectively]. In active S-ketamine groups, including S-ketamine, norketamine, and 6-hydroxynorketamine concentrations left the pain-PCA association unchanged (RR 1.09 and 1.07) and preserved the time-dependent oxycodone association (ORs 1.30, 1.26, and 1.02). Conclusions: During PCA, drug exposure develops from patient-generated dosing histories while pain and recovery change. Current pain was associated with subsequent PCA activity, and the oxycodone-analgesia association was time-dependent.

BACKGROUND: Postoperative increases in cerebrospinal fluid (CSF) to plasma albumin ratio (CPAR), a blood-brain barrier dysfunction marker, have been associated with postoperative delirium (POD) and prolonged hospital stay. However, the contributions of plasma versus CSF albumin changes remain unclear. AIM: To determine whether 24-hour postoperative changes in plasma and CSF albumin are independently associated with POD and hospital length of stay. METHODS: Plasma and CSF albumin concentrations were measured before and 24-hours postoperatively in older non-cardiac surgery patients. Multivariable logistic and negative binomial regression models evaluated associations between albumin changes and POD or hospital length of stay, adjusting for age, baseline cognition, surgery type, and fluid administration. RESULTS: Of 240 patients, 31 (13.3%) developed POD. From before to 24-hours after surgery, both plasma albumin (median 3.95 to 3.43 g/dL, p<0.001) and CSF albumin decreased (median 22.68 to 20.43 mg/dL, p<0.001). Greater plasma albumin decreases (per 0.43 g/dL) were independently associated with POD (OR 2.14, 95% CI 1.28-3.58; p=0.004) and longer hospital stay (mean ratio 1.44, 95% CI 1.26-1.64; p<0.001). In contrast, CSF albumin changes (per 5.8 mg/dL higher) were not associated with POD (OR 0.97, 95% CI 0.60-1.58; p=0.91) but were modestly associated with longer hospital stay (mean ratio 1.17, 95% CI 1.04-1.32; p=0.01). CONCLUSIONS: Plasma and CSF albumin decreased postoperatively, but only plasma decreases were associated with POD. These results suggest that associations between CPAR increases and POD may be due to postoperative plasma albumin decreases and highlight limitations of CPAR as a standalone marker of postoperative BBB dysfunction.

Introduction. Consistent high-level performance during perioperative critical events is essential for achieving optimal patient outcomes. We sought to better understand factors associated with the performance of anesthesiologists during simulated crisis management. Methods. Sixty clinically active board-certified anesthesiologists (BCAs), 22 junior (6 to 18 mo. training) and 19 senior (24 to 48 mo.) anesthesia trainees participated in standardized, high-fidelity simulated out-of-OR crisis events. Participants completed demographic and practice attributes surveys, and then performed four different 15-minute scenarios. Trained, board-certified raters scored randomly assigned video-recorded performances using checklists and holistic scaled ratings. A principal component analysis summarized survey responses related to participants clinical, simulation, and crisis management experience. Mixed-effects regression was used to examine the relationship of performance ratings to the summarized variables, adjusting for participant attributes, study site, and scenario. Results. The participants were 55% male, 38 (8 SD) years old and had 8.8 (6.7 SD) years of experience (training included). The BCAs were 67% community practitioners. Generally, senior trainees received the highest scores while junior trainees received the lowest. There was a strong association between overall performance and combined years of training and experience (p = 0.008). Experience with prior crises (p=0.040), but not clinical practice attributes (p=0.97) or prior simulation experience (p=0.94), was associated with higher rated performance. High-performing participants were more likely to call for assistance, physically examine the patient, order additional diagnostic tests, escalate therapy (e.g., greater hemodynamic support or antibiotic coverage), broaden the differential, discuss concerns with a colleague, and provide both temporizing and definitive treatment. Discussion. This simulation-based study found differences in performance ratings on perioperative crisis events based on experience and prior exposure to challenging clinical situations. These findings corroborate prior work, validate the use of simulation for assessment, and reinforce the value of ongoing crisis management exposure and training to improve patient care.

Background: Emergency conversion from labor epidural analgesia to Category I cesarean section leaves little time for epidural top-up to produce a surgical block. We examined whether low-dose intravenous esketamine could provide short-term bridging analgesia and sedation while maintaining maternal hemodynamics, oxygenation, and early neonatal safety. Methods: In this randomized study, parturients requiring Category I cesarean section after labor epidural analgesia received either esketamine 0.15 mg/kg or normal saline 1 min before skin incision, together with epidural alkalinized lidocaine. The primary outcome was the longitudinal change in maternal systolic blood pressure during the 20-min observation window. Secondary outcomes included heart rate, SpO2, intraoperative pain, surgeon satisfaction with muscle relaxation, Ramsay sedation score, and neonatal Apgar scores. We analyzed repeated continuous outcomes with linear mixed-effects models and repeated binary outcomes with generalized estimating equations. The single post-administration Ramsay outcome was analyzed using logistic regression. Apgar scores were summarized descriptively using medians, interquartile ranges, and counts.Results: We analyzed 55 parturients, 31 in the esketamine group and 24 in the normal saline group. Esketamine did not meaningfully alter the systolic blood pressure trajectory. Heart rate and SpO2 showed broadly similar patterns between groups, with no signal of esketamine-related respiratory deterioration. The esketamine group had lower odds of intraoperative pain at 5, 15, and 20 min and a higher probability of target Ramsay sedation. Surgeon satisfaction with muscle relaxation showed no clear between-group difference. Apgar scores remained high in both groups. Conclusion: Low-dose intravenous esketamine 0.15 mg/kg may be a practical bridging adjunct during emergency conversion from labor epidural analgesia to Category I cesarean section. It improved early pain control and target sedation without a clear adverse signal in systolic blood pressure, heart rate, oxygenation, or early Apgar scores. Trial Registration: Chinese Clinical Trial Registry, ChiCTR2600121948; retrospectively registered.

Interoception is described as the sensitivity to internal bodily stimuli, and plays an important role in pain perception. Heightened interoceptive sensibility (i.e. self-reported interoceptive abilities) may reinforce misinterpretation of stimuli, enhancing pain perception. This study aimed to investigate the relationship between interoceptive sensibility and acute postoperative pain. Interoceptive sensibility was measured using the Private Body Consciousness Scale in two prospective observational surgical cohorts: a Caesarean delivery cohort (C-section cohort) of 146 patients, and a lower extremity orthopaedic surgery cohort (Ortho cohort) of 70 patients. One day after surgery, patients rated pain (primary outcome) and other postoperative symptoms (secondary outcomes) on a 0-10 scale. Bonferroni corrections were applied to secondary outcomes. Interoception positively correlated with pain (C-section cohort: Spearmans rho = 0.182, P = 0.028; Ortho cohort: rho = 0.259, P = 0.031), and with dizziness (C-section cohort: rho = 0.309, P = 0.002; Ortho cohort: rho = 0.348 P = 0.041) in both cohorts. In the C-section cohort, interoception correlated with shivering (rho = 0.321, P < 0.001). In the Ortho cohort, interoception correlated with nausea (rho = 0.366, P = 0.023) and helplessness (rho = 0.363, P = 0.026); whereas no correlation with pain catastrophising was found (rho = 0.240, P = 0.539). In pooled multiple linear regression analysis (n = 216), interoception predicted pain after controlling for age, sex and anaesthetic technique (B = 0.119, 95% CI [0.027-0.210], P = 0.011). These findings highlight the potential role of interoception in identifying patients at risk for acute postsurgical pain.

Background: Depth of anesthesia is routinely monitored using electroencephalographic (EEG) indices such as the Bispectral Index (BIS), which reduce cortical activity to a single numerical real-time series. However, these scalar descriptors fail to capture inter-individual variability, drug-specific EEG signatures, and transitions between brain states. Methods: We analyzed transient EEG patterns during general anesthesia induced by propofol and sevoflurane in 89 patients. Iso-electric suppressions (IES), $\alpha$-suppressions, and spectral power in the $\alpha$ and $\delta$ bands were quantified across controlled concentration plateaus. We compared conventional BIS monitoring with a novel State-Chart representation mapping EEG activity into discrete depth states. Results: Increasing hypnotic concentration produced a consistent shift from $\alpha$-dominant to $\delta$-dominant activity and a reduction in maximal $\alpha$ frequency. IES occurred predominantly at high propofol concentrations and remained infrequent under sevoflurane. Compared with BIS, the State-Chart showed a marked reduction in temporal variability (0.5 $\pm$ 0.6 vs 4.0 $\pm$ 2.9; $p<10^{-90}$). Importantly, our State-Chart separates stable from transition regimes and discriminates identical concentration levels. Statistics computed over prior dosing (ascending vs descending), reveals refined clustering not captured by BIS. Conclusions: Anesthesia depth drugs concentrations vs EEG effects is more accurately described by structured EEG state transitions than by a single numerical index. The State-Chart provides a stable, physiologically interpretable representation of brain activity and reveals transition states preceding deep cortical suppression, supporting individualized and predictive monitoring of anesthesia.

Background. Videolaryngoscopy still requires adjuncts or hyperangulated rescue in a clinically important minority, and bedside screening discriminates modestly. Point-of-care ultrasound (POCUS) of the anterior airway is a promising alternative, but existing prediction models are opaque or assume a pre-specified functional form. We developed and internally validated a parsimonious, fully disclosed POCUS risk equation whose form is recovered from data and whose structural properties are machine-checked by formal proof - to our knowledge the first formally verified clinical risk predictor - following TRIPOD+AI 2024. Methods. In a prospective single-centre, single-operator cohort of 259 adults undergoing elective videolaryngoscopy (no-Easy airway 68/259, 26.3%), Sequentially Thresholded Least Squares with bootstrap stability selection (B=300) screened a 71-term library of nine POCUS features and retained a seven-term logistic equation; a two-term bootstrap-stable model was pre-specified as robustness analysis. Internal validation used 5x10 repeated cross-validation plus temporal and device hold-outs, with pre-specified overfitting and optimism assessments. Five behavioural properties of the deployed equation were machine-checked in Lean 4. Results. Two interactions met the |c|/sigma_c>2 stability criterion: skin-to-epiglottis x skin-to-hyoid-bone distance and tongue volume x sagittal tongue area. The seven-term equation reached a 5x10 cross-validated C-statistic of 0.966 (optimism-corrected 0.968) and held across temporal and device hold-outs (0.94-0.97). Calibration-in-the-large matched prevalence, with cross-validated slope 0.90 attenuating to 0.625 out-of-time; standard recalibration restored 0.92 without loss of discrimination. The pre-specified two-term robustness model reproduced this performance (C-statistic 0.964-0.968; events-per-parameter 34; shrinkage 0.99), confirming the result is not an artefact of the screening stage. Net benefit over a clinical baseline was positive across 10-50% thresholds. All five Lean 4 theorems compiled without sorry. Conclusions. A sparse, formally verified POCUS equation predicts difficult videolaryngoscopy with high internally validated discrimination and quantified, modest overfitting. Because the equation was developed in a single-operator cohort and its inputs are operator-dependent, external validation requires prior harmonisation of the measurement protocol and operator credentialing.

Background. The optimal anesthetic strategy for mechanical thrombectomy remains contested; clinical trials and meta-analyses yield conflicting results. Emerging evidence has shown stress hyperglycemia ratio (SHR) to be among the strongest independent predictors of poor thrombectomy outcomes. General anesthesia (GA) is known to provoke a more pronounced neuroendocrine stress response than procedural sedation, yet no prior study has investigated perioperative glucose dynamics between GA and sedation in thrombectomy patients. Methods. Using the TriNetX federated research network, we conducted a retrospective propensity score-matched cohort study of non-diabetic adults undergoing mechanical thrombectomy for anterior circulation acute ischemic stroke under GA versus sedation. After propensity score matching 2,556 matched pairs remained. Results. At the population level, mean glucose divergence was modest in absolute terms (Day 0: 110.90 vs 106.77 mg/dL; ? = 4.13 mg/dL; p = 7.82 x 10-11; Day 1: 107.69 vs 103.25 mg/dL; ? = 4.44 mg/dL; p = 8.16 x 10-14). GA conferred an 83.2% relative risk increase to severe-range hyperglycemia, defined as blood glucose > 181 mg/dL on the day of the index procedure (Day 0: RR = 1.832, 95% CI 1.457 ? 2.303; NNH: 29), with effects persisting on day 1 following the thrombectomy (Day 1: RR = 1.66, 95% CI 1.228 ? 2.249). GA patients received significantly more exogenous insulin on both days 0 (GA: 21.24%, Sedation: 17.23%, RR = 1.231, p = 2.96 x 10-4) and day 1 (GA: 11.3%, Sedation: 8.69%, RR = 1.30, p = 0.00178). All primary outcomes survived Bonferroni correction. Conclusion. General anesthesia is strongly associated with persistent hyperglycemia following mechanical thrombectomy in non-diabetic patients. These findings identify anesthesia-modality as a potential modifiable risk and provides a mechanistic hypothesis in the ongoing GA versus CS debate for thrombectomy. Future glucose management protocols may need to be tailored to anesthetic strategy.

Background: In Denmark, perioperative high-dose glucocorticoid treatment were step-wisely implemented for total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). We aimed to estimate the effect of a single high dose of glucocorticoids on opioid consumption following primary THA, TKA, and UKA. Methods: This was a prespecified analysis of a multicenter natural experiment using electronic health record data. We included elective THA, TKA, or UKA surgeries performed in Eastern Denmark from 2017-2025. At each center, surgeries before implementation of high-dose glucocorticoids served as controls, whereas surgeries after implementation comprised the intervention group. The primary outcome was the between-group difference in cumulative 0-24h opioid consumption, which included preemptive end-of-surgery doses. The predefined minimal important difference was set at 5 mg IV morphine equivalents. Secondary outcomes were maximum 0-10 numerical rating scale (NRS) pain score and incidence of opioid-related adverse events within 24 hours, hospital length of stay, and days alive and out of hospital at 30 days. Results: A total of 47,317 surgeries performed at nine centers were analyzed: 13,010 controls and 34,307 in the intervention group. During the study period, five centers implemented high-dose glucocorticoids for THA patients, two for TKA/UKA patients. High-dose glucocorticoids were administered to 6% of patients before implementation versus 92% after. High-dose glucocorticoids resulted in a mean reduction of 3.8 mg intravenous (IV) morphine equivalents (95% CI 3.3;4.3). The intervention also reduced the maximum 0-24h NRS pain score by 0.8 points (99% CI 0.7;0.9), but there was no difference in adverse events, length of stay, or days alive and out of hospital. Conclusions: Implementation of high-dose glucocorticoids reduced 0-24-hour opioid consumption by 3.8 mg IV morphine equivalents after elective hip and knee arthroplasty. This difference was below the prespecified minimal important difference threshold. Online registration: https://doi.org/10.1101/2025.11.11.25339982

Abstract Background: Mean arterial pressure (MAP) is pharmacologically augmented in selected perioperative and critical care settings, including acute neurological conditions and after cardiac arrest, with the aim of improving cerebral perfusion, although it remains uncertain whether higher arterial pressure translates into increased cerebral blood flow (CBF). We investigated the CBF response to MAP augmentation with norepinephrine (NE), a commonly used vasopressor in perioperative and critical care settings, during propofol-based general anesthesia. Methods: In this prospective within-subject interventional study, 16 neurologically intact patients with ASA physical status I-II undergoing elective surgery were studied using phase-contrast magnetic resonance imaging. CBF was quantified in the awake state and during propofol-based general anesthesia before and after NE-induced MAP augmentation. During general anesthesia, NE was titrated to increase MAP by approximately 25% from baseline. Concurrent systemic hemodynamics were assessed. Results: General anesthesia was associated with a 50.1% (interquartile range, 42.1?55.7%) reduction in CBF and a 24.2% (20.3-29.2%) reduction in MAP compared with the awake state (both P<0.001). During general anesthesia, NE-induced MAP augmentation increased MAP by 25.7% (21.9-32.0%; P<0.001), whereas CBF remained unchanged (P=1.000). Cardiac output remained unchanged (P=0.163), whereas systemic vascular resistance index and cerebrovascular resistance increased by 40.0% (28.7-45.2%) and 36.2% (17.7-42.8%), respectively (both P<0.001). Changes in CBF during MAP augmentation were not associated with concurrent changes in MAP, cardiac output, or systemic vascular resistance index. Conclusions: In neurologically intact patients undergoing propofol-based general anesthesia, clinically relevant NE-induced MAP augmentation did not increase CBF despite an approximately 50% lower CBF than in the awake state. These findings challenge the assumption that pharmacological elevation of an otherwise adequate MAP improves cerebral perfusion in this setting. While maintaining adequate arterial pressure remains essential, further MAP augmentation should not be assumed to increase CBF. Clinical Trial Registration: https://clinicaltrials.gov/study/NCT06855407; NCT06855407.

Objective: To develop a typology of recurrent clinical and decisional trajectories preceding early postprocedural death among patients with preexisting code-status limitations. Background: Patients with do-not-resuscitate orders experience higher postoperative mortality, but the clinical and decisional processes underlying early deaths are poorly understood. Mortality and code status alone cannot determine whether these deaths reflect constrained rescue, unsuccessful treatment, progression of terminal illness, or reassessment-driven redirection of care. Methods: We conducted a retrospective qualitative trajectory analysis of electronic health record documentation across five academic and community hospitals from March 2024 through June 2025. Eligible adults had an active preprocedural code-status limitation and died within 3 calendar days of a procedure requiring anesthesia, before hospital discharge. Using an adapted sequence-based composite approach, 2 reviewers independently reconstructed cases as ordered clinical and decisional sequences and reached consensus on recurrent trajectory families; illustrative composites were then generated. A third reviewer independently classified cases while blinded to the consensus assignments; agreement was assessed using unweighted Cohen kappa. Results: Among 2,833 patients with preexisting code-status limitations who underwent a procedure, 44 (1.6%) died within 3 days; the 42 who died before hospital discharge were included. Four trajectory families were identified: established terminal trajectory (5 [12%]), abrupt terminal event (5 [12%]), comfort-focused redirection after reassessment (29 [69%]), and sustained rescue attempt (3 [7%]). Redirection followed progressive deterioration or persistent critical illness despite treatment in 20 cases and a discrete event or finding in 9; rescue-oriented treatment frequently continued or escalated before reassessment and redirection. In sustained-rescue trajectories, intensive treatment continued through death, including in 2 patients whose limitations on CPR remained in effect. The independent reviewer agreed with the consensus classification for 39 of 42 cases (92.9%; {kappa}, 0.86; 95% CI, 0.70-1.00). Conclusions: Early postprocedural deaths among patients with preexisting code-status limitations followed distinct clinical and decisional trajectories. Mortality and code status alone could not distinguish an established terminal trajectory, abrupt death, reassessment-driven redirection, or sustained but unsuccessful rescue. A longitudinal approach that considers procedural intent, evolving prognosis, treatment, and reassessment provides a more clinically meaningful basis for interpreting mortality and structuring perioperative decision making.

Lines, drains, and airway devices are commonly used in surgical and inpatient care to support treatment and patient monitoring. While these devices are essential, prolonged device retention is associated with complications such as infection, tissue injury, thrombosis, and extended hospital stay. Understanding how long devices remain in place and how duration varies across device types is important for improving patient safety and guiding device management practices. This study analyzes device duration patterns using Patient Lines, Drains, and Airways (LDA) data containing information on device type, placement time, and removal time across multiple patient encounters. Exploratory data analysis and machine learning approaches are used to examine duration distributions, distinguish short and prolonged device retention, and identify structural patterns across device categories. The findings indicate notable variation in device duration patterns across categories, with identifiable differences in device retention behavior across device groups. This study highlights the value of observational electronic health record data for characterizing device exposure patterns and provides a foundation for future data-driven device management and risk assessment.

Introduction: The incidence of postoperative delirium (POD) is high in frail elderly patients who have undergone gastrointestinal surgery, and POD significantly increases the risk of complications and medical burden. Opioid-free anaesthesia (OFA) involves a multimodal analgesic strategy, which may help to reduce the risk of POD. However, relevant studies focusing on frail elderly patients are still limited. This study aims to investigate the effect of OFA on the occurrence of POD in frail elderly patients after gastrointestinal surgery. Methods: This single-centre, prospective, randomized controlled trial (RCT) will be conducted at the First Affiliated Hospital of Shandong First Medical University, China. A total of 44 frail elderly patients aged 65 years or older who plan to undergo elective gastrointestinal surgery (modified frailty index (mFI > 0.27) will be randomly assigned to either the OFA group (receiving dexmedetomidine, esmolol, and ketamine) or the opioid-based anaesthesia (OBA) group. The primary outcome is the incidence of POD within 7 days after surgery or at discharge. Secondary outcome measures include the perioperative stress response, inflammation, intraoperative haemodynamics, postoperative 30-day all-cause mortality, intraoperative haemodynamic changes, 15-item quality of recovery (QoR-15), and postoperative complications during hospitalization. This study focuses on frail elderly individuals (a high-risk population) and aims to investigate the potential benefits of the OFA strategy in reducing the incidence of POD by reducing exposure to opioids through multimodal analgesia. If positive results are obtained in this study, they may provide new evidence for optimizing the perioperative management of such patients. This study is a single-centre, prospective RCT, and the results can provide preliminary evidence for subsequent studies to be performed on a larger scale. Discussion: This study focuses on frail elderly individuals (a high-risk population) and aims to investigate the potential benefits of the OFA strategy in reducing the incidence of POD by reducing exposure to opioids through multimodal analgesia. If positive results are obtained in this study, they may provide new evidence for optimizing the perioperative management of such patients. This study is a single-centre, prospective RCT, and the results can provide preliminary evidence for subsequent studies to be performed on a larger scale. Trial registration: NCT07603596.