Pub Date : 2025-11-16DOI: 10.1016/j.jclinane.2025.112075
Oya Gumuskaya , Hailey R. Donnelly , Nick Glenn , Julee McDonagh , Anita Skaros , Sophie Liang , Brett G. Mitchell , Luke Bendle , Sarah Aitken , Emile Belramoul , Mitchell Sarkies
Background
Preoperative oral carbohydrate loading is thought to reduce postoperative nausea and vomiting (PONV). However, it is unknown if the benefit of carbohydrate loading is maintained in the presence of total intravenous anaesthesia (TIVA). The aim of this systematic review was to determine whether oral carbohydrate loading reduced PONV compared to overnight fasting between adult elective surgery patients receiving TIVA or inhalational general anaesthesia.
Methods
A search of seven databases was conducted until March 2024. Randomised controlled trials conducted with patient aged 18 years or older were included. Two reviewers independently screened titles, abstracts and full texts, and assessed risk of bias using the Cochrane ROB-2 Tool. Study data was pooled using random effects meta-analyses.
Results
We included 26 studies in this review, and 25 in the meta-analyses (n = 2491). Preoperative oral carbohydrate loading reduced the overall risk (log RR: –0.35, 95 % CI: −0.62 to −0.08, I2 = 51.11 %) and severity (SMD: -0.46, 95 % CI: −0.68 to −0.24, I2 = 62.09 %) of PONV, and pain severity (MD: -0.69, 95 % CI: −1.13 to −0.25, I2 = 83.98 %) compared to prolonged fasting when pooled across both anaesthesia approaches. The risk of PONV was reduced in patients receiving inhalational anaesthesia, but not in those receiving TIVA, while the reduction in severity was more significant in TIVA.
Conclusion
Oral carbohydrate loading reduces the severity of PONV and pain, regardless of the anaesthesia approach, compared to prolonged fasting. These findings support the clinical advantages of oral carbohydrate loading for postoperative outcomes, regardless of anaesthesia approach.
{"title":"The effectiveness of preoperative oral carbohydrate loading on postoperative nausea and vomiting in adults receiving total intravenous anaesthesia compared to inhalational anaesthesia: A systematic review and meta-analysis","authors":"Oya Gumuskaya , Hailey R. Donnelly , Nick Glenn , Julee McDonagh , Anita Skaros , Sophie Liang , Brett G. Mitchell , Luke Bendle , Sarah Aitken , Emile Belramoul , Mitchell Sarkies","doi":"10.1016/j.jclinane.2025.112075","DOIUrl":"10.1016/j.jclinane.2025.112075","url":null,"abstract":"<div><h3>Background</h3><div>Preoperative oral carbohydrate loading is thought to reduce postoperative nausea and vomiting (PONV). However, it is unknown if the benefit of carbohydrate loading is maintained in the presence of total intravenous anaesthesia (TIVA). The aim of this systematic review was to determine whether oral carbohydrate loading reduced PONV compared to overnight fasting between adult elective surgery patients receiving TIVA or inhalational general anaesthesia.</div></div><div><h3>Methods</h3><div>A search of seven databases was conducted until March 2024. Randomised controlled trials conducted with patient aged 18 years or older were included. Two reviewers independently screened titles, abstracts and full texts, and assessed risk of bias using the Cochrane ROB-2 Tool. Study data was pooled using random effects meta-analyses.</div></div><div><h3>Results</h3><div>We included 26 studies in this review, and 25 in the meta-analyses (<em>n</em> = 2491). Preoperative oral carbohydrate loading reduced the overall risk (log RR: –0.35, 95 % CI: −0.62 to −0.08, I<sup>2</sup> = 51.11 %) and severity (SMD: -0.46, 95 % CI: −0.68 to −0.24, I<sup>2</sup> = 62.09 %) of PONV, and pain severity (MD: -0.69, 95 % CI: −1.13 to −0.25, I<sup>2</sup> = 83.98 %) compared to prolonged fasting when pooled across both anaesthesia approaches. The risk of PONV was reduced in patients receiving inhalational anaesthesia, but not in those receiving TIVA, while the reduction in severity was more significant in TIVA.</div></div><div><h3>Conclusion</h3><div>Oral carbohydrate loading reduces the severity of PONV and pain, regardless of the anaesthesia approach, compared to prolonged fasting. These findings support the clinical advantages of oral carbohydrate loading for postoperative outcomes, regardless of anaesthesia approach.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112075"},"PeriodicalIF":5.1,"publicationDate":"2025-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145541026","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-14DOI: 10.1016/j.jclinane.2025.112072
Sangeeta Kumaraswami MD , Shital Patel , James Tom DDS , Rita Agarwal MD, FASA
{"title":"Why Do Deaths and Catastrophic Injury From Anesthesia in the Dental Office-Based Setting Still Occur?","authors":"Sangeeta Kumaraswami MD , Shital Patel , James Tom DDS , Rita Agarwal MD, FASA","doi":"10.1016/j.jclinane.2025.112072","DOIUrl":"10.1016/j.jclinane.2025.112072","url":null,"abstract":"","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112072"},"PeriodicalIF":5.1,"publicationDate":"2025-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145526057","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-10DOI: 10.1016/j.jclinane.2025.112066
J. Ross Renew , Maria Estevez , Mariel Maramba , Michael G. Heckman , Zhihui J. Fang , Sorin J. Brull , Richard H. Epstein
Background
The use of quantitative neuromuscular monitoring during induction of anesthesia to establish a baseline neuromuscular response and ensure paralysis of the vocal cords during laryngoscopy and tracheal intubation has yet to become standard practice. The current study compared intubating conditions based on quantitative measurements (train-of-four count) with intubating conditions based on the time since rocuronium administration.
Methods
Consenting adult patients undergoing general anesthesia requiring neuromuscular block were randomized into 2 groups. Following placement of a quantitative electromyographic neuromuscular monitor, general anesthesia was induced with propofol 1–1.5 mg/kg followed by rocuronium 0.6 mg/kg. In one group, intubation commenced 2 min after rocuronium administration (Time Group). In the other, intubation commenced when the first train-of-four (TOF) count was ≤1 (Count Group). Video laryngoscopy was used in both groups and the intubating conditions were noted. A Wilcoxon rank sum test or Fisher's exact test was used to compare intubating conditions between the 2 groups. Spearman's rank correlation test was used to describe the relationship between intubation conditions and the ratio of the amplitude of the first twitch of the TOF sequence, T1, to the control T1 amplitude (T1/Tc).
Results
There were 84 patients in the Count Group and 83 in the Time Group. More patients had ideal intubating conditions (relaxed jaw, abducted vocal cords, and no response to tracheal intubation) in the Count Group (61/84, 73 %) than the Time Group (47/83, 57 %, P = 0.036). The mean composite intubating score was better (lower) in the Count Group than in the Time Group (3.5 vs. 3.9, respectively, P = 0.016). The T1/Tc at intubation correlated with the composite intubating conditions score (Spearman's ρ = 0.34, P < 0.001).
Conclusion
Intubating conditions were better when the timing of intubation was guided by quantitative neuromuscular monitoring to ensure a TOF count ≤1 versus waiting a fixed time interval of 2 min following administration of rocuronium.
{"title":"Intubating conditions based on the time from rocuronium administration versus the train-of-four count: A randomized, prospective, clinical trial","authors":"J. Ross Renew , Maria Estevez , Mariel Maramba , Michael G. Heckman , Zhihui J. Fang , Sorin J. Brull , Richard H. Epstein","doi":"10.1016/j.jclinane.2025.112066","DOIUrl":"10.1016/j.jclinane.2025.112066","url":null,"abstract":"<div><h3>Background</h3><div>The use of quantitative neuromuscular monitoring during induction of anesthesia to establish a baseline neuromuscular response and ensure paralysis of the vocal cords during laryngoscopy and tracheal intubation has yet to become standard practice. The current study compared intubating conditions based on quantitative measurements (train-of-four count) with intubating conditions based on the time since rocuronium administration.</div></div><div><h3>Methods</h3><div>Consenting adult patients undergoing general anesthesia requiring neuromuscular block were randomized into 2 groups. Following placement of a quantitative electromyographic neuromuscular monitor, general anesthesia was induced with propofol 1–1.5 mg/kg followed by rocuronium 0.6 mg/kg. In one group, intubation commenced 2 min after rocuronium administration (Time Group). In the other, intubation commenced when the first train-of-four (TOF) count was ≤1 (Count Group). Video laryngoscopy was used in both groups and the intubating conditions were noted. A Wilcoxon rank sum test or Fisher's exact test was used to compare intubating conditions between the 2 groups. Spearman's rank correlation test was used to describe the relationship between intubation conditions and the ratio of the amplitude of the first twitch of the TOF sequence, T<sub>1</sub>, to the control T<sub>1</sub> amplitude (T<sub>1</sub>/T<sub>c</sub>).</div></div><div><h3>Results</h3><div>There were 84 patients in the Count Group and 83 in the Time Group. More patients had ideal intubating conditions (relaxed jaw, abducted vocal cords, and no response to tracheal intubation) in the Count Group (61/84, 73 %) than the Time Group (47/83, 57 %, <em>P</em> = 0.036). The mean composite intubating score was better (lower) in the Count Group than in the Time Group (3.5 vs. 3.9, respectively, <em>P</em> = 0.016). The T<sub>1</sub>/T<sub>c</sub> at intubation correlated with the composite intubating conditions score (Spearman's <em>ρ</em> = 0.34, <em>P</em> < 0.001).</div></div><div><h3>Conclusion</h3><div>Intubating conditions were better when the timing of intubation was guided by quantitative neuromuscular monitoring to ensure a TOF count ≤1 versus waiting a fixed time interval of 2 min following administration of rocuronium.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112066"},"PeriodicalIF":5.1,"publicationDate":"2025-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145495599","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Aspiration of gastric content is a serious complication of anesthesia, associated with high mortality and morbidity. Recent studies demonstrated that fasting status can be assessed accurately by gastric ultrasound. However, there is still a lack of evidence regarding the application of this technique by inexperienced examiners. We aimed to determine the accuracy of gastric ultrasound performed by medical students after a standardized training sequence.
Outcome
Accuracy of identifying the fasting status by gastric ultrasound performed by inexperienced examiners.
Methods
In this prospective observational cohort study, five medical students performed 80 gastric ultrasound examinations on healthy, non-obese volunteers. Standardized training consisted of blended online training, one plenary lecture, and 2 h of hands-on-training. Volunteers were randomized in a 2:1:1 ratio to "fasted", "non-fasted, fluid", and "non-fasted, solid" with the examiners being blinded to the fasting status. The examiners determined the fasting status using gastric ultrasound and recorded the gastric cross-sectional area. Beforehand, an expert examiner also conducted all examinations for comparison. Sensitivity, specificity, positive and negative predictive values were calculated from the acquired data. The cross-sectional area was pooled for the expert and non-experts and the results plotted and interrater reliability assessed by the intraclass correlation coefficient (ICC).
Results
Data from 80 individuals were analyzed. The inexperienced examiners correctly identified all non-fasted volunteers (sensitivity 1.00,95 % CI: 0.91–1.00). They wrongly classified 18 out of 40 fasted volunteers as "non-fasted" (specificity 0.55, 95 % CI: 0.40–0.69). Positive predictive value was 0.69 (95 % CI: 0.56–0.79) and negative predictive value 1.00 (95 % CI: 0.85–1.00). The overall ICC was 0.72 (95 % CI 0.57–0.82), and 0.30 (95 % CI -0.32–0.63), 0.66 (95 % CI -0.16–0.87), and 0.27 (95 % CI -0.82–0.71), for the "fasted", "non-fasted, fluid", and "non-fasted, solid" states, respectively.
Conclusions
Examiners with limited experience in ultrasound diagnostics may accurately identify a full stomach in normal-weight volunteers after a standardized training sequence. However, the detected specificity of 0.63 was low, and more focused training on the ultrasound anatomy of an empty stomach may be needed to rule out an empty stomach in a clinical scenario.
背景：胃内容物误吸是麻醉的严重并发症，死亡率和发病率高。最近的研究表明，胃超声可以准确地评估空腹状态。然而，关于没有经验的审查员应用该技术的证据仍然缺乏。我们的目的是确定医学生在标准化训练后进行胃超声检查的准确性。结果：没有经验的检查人员通过胃超声检查确定禁食状态的准确性。方法：在这项前瞻性观察队列研究中，五名医学生对健康的非肥胖志愿者进行了80次胃超声检查。标准化培训包括混合在线培训、一次全体讲座和2小时的实践培训。志愿者按2:1:1的比例随机分为“禁食”、“非禁食、流质”和“非禁食、固体”，审查员对禁食状态不知情。检查人员使用胃超声确定空腹状态并记录胃横截面积。在此之前，一名专家审查员也进行了所有的检查以进行比较。根据获得的数据计算敏感性、特异性、阳性预测值和阴性预测值。将专家和非专家的横截面积汇总，绘制结果，并通过类内相关系数（ICC）评估组间信度。结果：分析了80例个体的数据。没有经验的检查人员正确地识别出所有未禁食的志愿者（灵敏度1.00,95% CI: 0.91-1.00）。他们错误地将40名禁食志愿者中的18人归类为“非禁食”（特异性0.55,95% CI: 0.40-0.69）。阳性预测值为0.69 (95% CI: 0.56 ~ 0.79)，阴性预测值为1.00 （95% CI: 0.85 ~ 1.00）。对于“禁食”、“非禁食、流质”和“非禁食、固体”状态，总体ICC分别为0.72 （95% CI 0.57-0.82）、0.30 （95% CI -0.32-0.63）、0.66 （95% CI -0.16-0.87）和0.27 （95% CI -0.82-0.71）。结论：超声诊断经验有限的检查人员可以在标准化的训练序列后准确地识别正常体重志愿者的饱胃。然而，0.63的检测特异性较低，可能需要对空腹超声解剖进行更集中的培训，以排除临床场景中的空腹。
{"title":"Trust your gut? Evaluating non-expert gastric ultrasound performance – A prospective observational cohort study","authors":"Sarah Baumann , Firmin Kamber MD , Thierry Girard MD , Eckhard Mauermann MD, PhD, M.Sc , Reza Kaviani MD","doi":"10.1016/j.jclinane.2025.112053","DOIUrl":"10.1016/j.jclinane.2025.112053","url":null,"abstract":"<div><h3>Background</h3><div>Aspiration of gastric content is a serious complication of anesthesia, associated with high mortality and morbidity. Recent studies demonstrated that fasting status can be assessed accurately by gastric ultrasound. However, there is still a lack of evidence regarding the application of this technique by inexperienced examiners. We aimed to determine the accuracy of gastric ultrasound performed by medical students after a standardized training sequence.</div></div><div><h3>Outcome</h3><div>Accuracy of identifying the fasting status by gastric ultrasound performed by inexperienced examiners.</div></div><div><h3>Methods</h3><div>In this prospective observational cohort study, five medical students performed 80 gastric ultrasound examinations on healthy, non-obese volunteers. Standardized training consisted of blended online training, one plenary lecture, and 2 h of hands-on-training. Volunteers were randomized in a 2:1:1 ratio to \"fasted\", \"non-fasted, fluid\", and \"non-fasted, solid\" with the examiners being blinded to the fasting status. The examiners determined the fasting status using gastric ultrasound and recorded the gastric cross-sectional area. Beforehand, an expert examiner also conducted all examinations for comparison. Sensitivity, specificity, positive and negative predictive values were calculated from the acquired data. The cross-sectional area was pooled for the expert and non-experts and the results plotted and interrater reliability assessed by the intraclass correlation coefficient (ICC).</div></div><div><h3>Results</h3><div>Data from 80 individuals were analyzed. The inexperienced examiners correctly identified all non-fasted volunteers (sensitivity 1.00,95 % CI: 0.91–1.00). They wrongly classified 18 out of 40 fasted volunteers as \"non-fasted\" (specificity 0.55, 95 % CI: 0.40–0.69). Positive predictive value was 0.69 (95 % CI: 0.56–0.79) and negative predictive value 1.00 (95 % CI: 0.85–1.00). The overall ICC was 0.72 (95 % CI 0.57–0.82), and 0.30 (95 % CI -0.32–0.63), 0.66 (95 % CI -0.16–0.87), and 0.27 (95 % CI -0.82–0.71), for the \"fasted\", \"non-fasted, fluid\", and \"non-fasted, solid\" states, respectively.</div></div><div><h3>Conclusions</h3><div>Examiners with limited experience in ultrasound diagnostics may accurately identify a full stomach in normal-weight volunteers after a standardized training sequence. However, the detected specificity of 0.63 was low, and more focused training on the ultrasound anatomy of an empty stomach may be needed to rule out an empty stomach in a clinical scenario.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112053"},"PeriodicalIF":5.1,"publicationDate":"2025-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145495632","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Various adjuvants can be added to local anesthetics (LAs) to prolong the duration of regional anesthesia. This network meta-analysis (NMA) aimed to compare the relative efficacy of commonly used adjuvants in transversus abdominis plane (TAP) blocks following cesarean delivery (CD).
Methods
A comprehensive literature search was performed in PubMed, Embase, CENTRAL, web of science, and Wanfang data. Eligible studies were randomized controlled trials comparing the effects of adding an adjuvant to LA versus LA alone or versus another adjuvant in a single-shot TAP block after CD. The primary outcome was time to first analgesia request. Bayesian random-effects NMAs were performed using the LA alone group as the comparator.
Results
Thirty-nine studies involving five adjuvants were included. None of the studies administered intrathecal morphine. Compared to LA alone, time to first analgesic request was significantly prolonged with clonidine (6.9 h, 95 % CrI 4.5–9.4 h), dexamethasone (5.8 h, 95 % CrI 4.2–7.4 h), dexmedetomidine (4.1 h, 95 % CrI 2.7–5.5 h) and magnesium sulfate (3.2 h, 95 % CrI 0.9–5.7 h). Clonidine ranked first, followed by dexamethasone, dexmedetomidine, and magnesium. However, in the outlier analysis and the subgroup analysis of women receiving basic analgesics, dexamethasone ranked first, while magnesium was ineffective. Overall, adjuvants had minimal clinical impact on postoperative opioid consumption or pain scores. Notably, high heterogeneity was observed, and the quality of evidence was rated as low or very low.
Conclusions
With the high heterogeneity and the low or very low quality of the evidence, clonidine, dexamethasone, and dexmedetomidine may prolong analgesia after CD without intrathecal morphine when used as adjuvants in TAP blocks. Furthermore, dexamethasone and dexmedetomidine appear preferable when basic analgesics are administered. Nevertheless, these results should be interpreted with caution.
{"title":"Adjuvants in transversus abdominis plane blocks to prolong analgesia duration following cesarean delivery: A systematic review and network meta-analysis","authors":"Li-Zhong Wang, Jia-Yue Huang, Xiang-Yang Chang, Feng Xia","doi":"10.1016/j.jclinane.2025.112067","DOIUrl":"10.1016/j.jclinane.2025.112067","url":null,"abstract":"<div><h3>Background</h3><div>Various adjuvants can be added to local anesthetics (LAs) to prolong the duration of regional anesthesia. This network meta-analysis (NMA) aimed to compare the relative efficacy of commonly used adjuvants in transversus abdominis plane (TAP) blocks following cesarean delivery (CD).</div></div><div><h3>Methods</h3><div>A comprehensive literature search was performed in PubMed, Embase, CENTRAL, web of science, and Wanfang data. Eligible studies were randomized controlled trials comparing the effects of adding an adjuvant to LA versus LA alone or versus another adjuvant in a single-shot TAP block after CD. The primary outcome was time to first analgesia request. Bayesian random-effects NMAs were performed using the LA alone group as the comparator.</div></div><div><h3>Results</h3><div>Thirty-nine studies involving five adjuvants were included. None of the studies administered intrathecal morphine. Compared to LA alone, time to first analgesic request was significantly prolonged with clonidine (6.9 h, 95 % CrI 4.5–9.4 h), dexamethasone (5.8 h, 95 % CrI 4.2–7.4 h), dexmedetomidine (4.1 h, 95 % CrI 2.7–5.5 h) and magnesium sulfate (3.2 h, 95 % CrI 0.9–5.7 h). Clonidine ranked first, followed by dexamethasone, dexmedetomidine, and magnesium. However, in the outlier analysis and the subgroup analysis of women receiving basic analgesics, dexamethasone ranked first, while magnesium was ineffective. Overall, adjuvants had minimal clinical impact on postoperative opioid consumption or pain scores. Notably, high heterogeneity was observed, and the quality of evidence was rated as low or very low.</div></div><div><h3>Conclusions</h3><div>With the high heterogeneity and the low or very low quality of the evidence, clonidine, dexamethasone, and dexmedetomidine may prolong analgesia after CD without intrathecal morphine when used as adjuvants in TAP blocks. Furthermore, dexamethasone and dexmedetomidine appear preferable when basic analgesics are administered. Nevertheless, these results should be interpreted with caution.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112067"},"PeriodicalIF":5.1,"publicationDate":"2025-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145495573","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Sanming First Hospital affiliated to Fujian Medical University in China.
Patients
120 adults with American Society of Anesthesiologists physical status I–II scheduled for elective unilateral PCNL.
Interventions
Patients were randomized 1:1:1 to receive ESPB, TPVB, or placebo to test ESPB superiority over placebo and non-inferiority to TPVB.
Measurements
The primary outcome was Quality of Recovery-15 (QoR-15) score at 24 h. We tested ESPB superiority over placebo (8-point clinically important difference) and non-inferiority to TPVB (6-point margin). Secondary outcomes included pain scores, morphine consumption, time to first rescue analgesia, patient satisfaction, and adverse events.
Main results
ESPB demonstrated significantly higher QoR-15 scores than placebo (median difference 11.0 points, 95% CI 7.0–14.0, P < 0.001) and met non-inferiority criteria versus TPVB (median difference 1.0 point, 95% CI −5.0 to 2.0). Both blocks reduced pain scores and morphine consumption by approximately 40% compared with placebo (P < 0.001), with no differences between techniques. Time to first rescue analgesia was prolonged with both blocks compared with placebo (P < 0.001). Patient satisfaction was higher with both blocks than with placebo (P < 0.001). No block-related complications occurred; postoperative adverse events were similar across groups.
Conclusions
ESPB significantly improved recovery quality after PCNL, demonstrating superiority to placebo and non-inferiority to TPVB. ESPB represents an effective alternative to TPVB for PCNL analgesia, with comparable efficacy and safety.
研究目的：比较ESPB、TPVB和安慰剂治疗PCNL后的恢复质量。设计：随机、双盲、安慰剂对照试验。单位：福建医科大学附属三明第一医院。患者：120名具有美国麻醉医师协会身体状态I-II的成人，计划进行选择性单侧PCNL。干预措施：患者以1:1:1的比例随机接受ESPB、TPVB或安慰剂，以检验ESPB优于安慰剂和TPVB的非劣效性。测量：主要终点是24小时的恢复质量-15 （QoR-15）评分。我们测试了ESPB优于安慰剂（8分临床重要差异）和TPVB非劣效性（6分差）。次要结局包括疼痛评分、吗啡用量、首次抢救镇痛时间、患者满意度和不良事件。主要结果：ESPB的QoR-15评分明显高于安慰剂（中位差11.0分，95% CI 7.0-14.0， P）。结论：ESPB显著提高PCNL术后的恢复质量，优于安慰剂，不逊于TPVB。ESPB是一种有效的替代TPVB的PCNL镇痛方法，具有相当的疗效和安全性。
{"title":"Erector spinae plane block versus paravertebral block and placebo for recovery quality after percutaneous nephrolithotomy: A randomized controlled trial","authors":"Yanting Xiao , Huifen Lin , Yifen Zhuo , Jiahan Yang , Weidong Pan , Weitao Gao , Guisheng Ding , Yusheng Yao","doi":"10.1016/j.jclinane.2025.112056","DOIUrl":"10.1016/j.jclinane.2025.112056","url":null,"abstract":"<div><h3>Study objective</h3><div>To compare recovery quality after PCNL using ESPB, TPVB, and placebo.</div></div><div><h3>Design</h3><div>Randomized, double-blind, placebo-controlled trial.</div></div><div><h3>Setting</h3><div>Sanming First Hospital affiliated to Fujian Medical University in China.</div></div><div><h3>Patients</h3><div>120 adults with American Society of Anesthesiologists physical status I–II scheduled for elective unilateral PCNL.</div></div><div><h3>Interventions</h3><div>Patients were randomized 1:1:1 to receive ESPB, TPVB, or placebo to test ESPB superiority over placebo and non-inferiority to TPVB.</div></div><div><h3>Measurements</h3><div>The primary outcome was Quality of Recovery-15 (QoR-15) score at 24 h. We tested ESPB superiority over placebo (8-point clinically important difference) and non-inferiority to TPVB (6-point margin). Secondary outcomes included pain scores, morphine consumption, time to first rescue analgesia, patient satisfaction, and adverse events.</div></div><div><h3>Main results</h3><div>ESPB demonstrated significantly higher QoR-15 scores than placebo (median difference 11.0 points, 95% CI 7.0–14.0, <em>P</em> < 0.001) and met non-inferiority criteria versus TPVB (median difference 1.0 point, 95% CI −5.0 to 2.0). Both blocks reduced pain scores and morphine consumption by approximately 40% compared with placebo (<em>P</em> < 0.001), with no differences between techniques. Time to first rescue analgesia was prolonged with both blocks compared with placebo (<em>P</em> < 0.001). Patient satisfaction was higher with both blocks than with placebo (<em>P</em> < 0.001). No block-related complications occurred; postoperative adverse events were similar across groups.</div></div><div><h3>Conclusions</h3><div>ESPB significantly improved recovery quality after PCNL, demonstrating superiority to placebo and non-inferiority to TPVB. ESPB represents an effective alternative to TPVB for PCNL analgesia, with comparable efficacy and safety.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112056"},"PeriodicalIF":5.1,"publicationDate":"2025-11-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145458440","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-04DOI: 10.1016/j.jclinane.2025.112063
Zhen-Zhen Xu , Dong-Liang Mu
{"title":"Unmasking the silent threat: Navigating the myocardial injury in oncological surgery","authors":"Zhen-Zhen Xu , Dong-Liang Mu","doi":"10.1016/j.jclinane.2025.112063","DOIUrl":"10.1016/j.jclinane.2025.112063","url":null,"abstract":"","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112063"},"PeriodicalIF":5.1,"publicationDate":"2025-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145450560","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-04DOI: 10.1016/j.jclinane.2025.112054
Terry J. Biel MD MBA , Cristina L. Wood MD MS , Rachel M. Kacmar MD
Background
Previous studies have suggested that increased morbidity, mortality, and lapses in supervision are associated with anesthesiologist supervision ratios, yet estimates of anesthesia activity in obstetric settings have been limited to estimates based on annual delivery volumes. One single-center estimate found that hourly weekday activity was 89 % higher than hourly weeknight and weekend activity.
Methods
We utilized electronic anesthetic records and personnel schedules from a single tertiary care center to determine concurrent obstetric anesthesia activity, service capacity, and utilization for every minute of the year.
Results
Average activity per minute was 0.546, 0.448, 0.415, and 0.383 and average activity divided by service capacity (utilization) was 0.253, 0.253, 0.247, and 0.222, for weekday days, weekday nights, weekend/holiday days, and weekend/holiday nights, respectively. All differences were statistically significant, except weekday days and weekday nights were not significantly different.
Conclusions
Our findings do not support the previously reported 89 % greater hourly workload differential for weekday activity versus weeknight and weekend activity; our largest difference was about 43 % more activity per minute for weekday days vs weekend/holiday nights.
{"title":"From “how busy we are” to “how we are busy”: Pragmatic, minute-by-minute analysis of obstetric anesthesia activity, service capacity, and utilization","authors":"Terry J. Biel MD MBA , Cristina L. Wood MD MS , Rachel M. Kacmar MD","doi":"10.1016/j.jclinane.2025.112054","DOIUrl":"10.1016/j.jclinane.2025.112054","url":null,"abstract":"<div><h3>Background</h3><div>Previous studies have suggested that increased morbidity, mortality, and lapses in supervision are associated with anesthesiologist supervision ratios, yet estimates of anesthesia activity in obstetric settings have been limited to estimates based on annual delivery volumes. One single-center estimate found that hourly weekday activity was 89 % higher than hourly weeknight and weekend activity.</div></div><div><h3>Methods</h3><div>We utilized electronic anesthetic records and personnel schedules from a single tertiary care center to determine concurrent obstetric anesthesia activity, service capacity, and utilization for every minute of the year.</div></div><div><h3>Results</h3><div>Average activity per minute was 0.546, 0.448, 0.415, and 0.383 and average activity divided by service capacity (utilization) was 0.253, 0.253, 0.247, and 0.222, for weekday days, weekday nights, weekend/holiday days, and weekend/holiday nights, respectively. All differences were statistically significant, except weekday days and weekday nights were not significantly different.</div></div><div><h3>Conclusions</h3><div>Our findings do not support the previously reported 89 % greater hourly workload differential for weekday activity versus weeknight and weekend activity; our largest difference was about 43 % more activity per minute for weekday days vs weekend/holiday nights.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112054"},"PeriodicalIF":5.1,"publicationDate":"2025-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145451495","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-11-04DOI: 10.1016/j.jclinane.2025.112059
Krister Mogianos , Josefine Holgersson , Johan Undén , Anna K.M. Persson
Objective
To evaluate if adding esketamine and clonidine has positive effects on postoperative pain, postoperative nausea and vomiting, and quality of recovery in patients who are at high risk for postoperative pain.
Design
Patient- and assessor-blinded, superiority, randomised controlled trial.
Setting
Single centre between 2022 and 2024.
Patients
125 adult patients, ASA I – II, planned for elective laparoscopic surgery and risk-classified as high risk of pain, based on perceived pain associated with venous cannulation.
Intervention
Patients were randomised to either an anaesthesia protocol, including an intravenous bolus of esketamine (0.25 mg.kg−1) after induction and clonidine (1 μg.kg−1) during maintenance phase (EC), or standard of care (SOC) no esketamine or clonidine included.
Measurements
Primary outcome: worst pain intensity in the PACU. Secondary outcomes: worst pain, and proportion having NRS ≥ 4, at 24 h (during rest and movement), worst pain and proportion having NRS ≥ 1, at 3- and 6-months (during rest and movement), postoperative recovery at 24 h, PONV in the PACU and at 24 h. Rescue dose opioids in the PACU was an exploratory outcome.
Results
Worst pain scores in the PACU were 5.7 in the EC group and 5.5 in SOC group (P = 0.78). After 24 h, no difference in postoperative pain (rest; 5.8 vs 6.1, P = 0.35, movement; 6.1 vs 6.2, P = 0.68), postoperative recovery (P = 0.92) or PONV (P = 0.80) was found. Proportion of patients with NRS ≥ 4 in the PACU was 50 % vs 48 % (P = 0.55) and at 24 h 73 % vs 81 % at rest (P = 0.27) and 76 % vs 81 % during movement (P = 0.50). Rescue opioids in the PACU were similar (5.9 mg vs 6.6 mg, P = 0.47). There were no differences in persistent pain at 3 or 6 months at rest (P = 0.72, P = 0.12) or movement (P = 0.48, P = 0.18).
Conclusion
Adding esketamine and clonidine, as an individualised multimodal anaesthesia strategy, did not influence acute or persistent postoperative pain, early recovery, need of rescue opioids or PONV in patients, who were assessed as high risk for APOP.
目的：评价艾氯胺酮联合可乐定对术后疼痛高危患者术后疼痛、恶心呕吐及恢复质量的积极影响。设计：患者和评估者双盲，优势，随机对照试验。设定：2022年至2024年之间的单一中心。患者：125例成人患者，ASA I - II，计划进行选择性腹腔镜手术，根据感知到的与静脉插管相关的疼痛，风险分类为高风险疼痛。干预：患者被随机分配到麻醉方案，包括诱导后静脉注射艾氯胺酮（0.25 mg.kg-1）和维持期（EC）的可乐定（1 μg.kg-1），或不包括艾氯胺酮或可乐定的标准护理（SOC）。测量：主要结果：PACU中疼痛强度最大。次要结局：24小时（休息和运动期间）疼痛最严重，NRS≥4的比例最大，3个月和6个月（休息和运动期间）疼痛最严重，NRS≥1的比例最大，24小时术后恢复，PACU和24小时的PONV。PACU的救援剂量阿片类药物是一个探索性结局。结果：PACU最差疼痛评分EC组为5.7分，SOC组为5.5分（P = 0.78）。24 h后，术后疼痛（休息；5.8 vs 6.1, P = 0.35；运动；6.1 vs 6.2, P = 0.68）、术后恢复（P = 0.92）或PONV （P = 0.80）均无差异。PACU中NRS≥4的患者比例为50%对48% (P = 0.55)， 24 h时73%对81% (P = 0.27)，运动时76%对81% （P = 0.50）。PACU的救援阿片类药物相似（5.9 mg vs 6.6 mg, P = 0.47）。3、6个月休息时（P = 0.72, P = 0.12）或运动时（P = 0.48, P = 0.18）持续疼痛无差异。结论：作为一种个体化的多模式麻醉策略，加入艾氯胺酮和氯定对被评估为APOP高风险的患者的急性或持续性术后疼痛、早期恢复、救援阿片类药物或PONV的需求没有影响。
{"title":"The additive effect of esketamine and clonidine in patients at high risk for acute postoperative pain undergoing laparoscopic surgery: A randomised controlled trial","authors":"Krister Mogianos , Josefine Holgersson , Johan Undén , Anna K.M. Persson","doi":"10.1016/j.jclinane.2025.112059","DOIUrl":"10.1016/j.jclinane.2025.112059","url":null,"abstract":"<div><h3>Objective</h3><div>To evaluate if adding esketamine and clonidine has positive effects on postoperative pain, postoperative nausea and vomiting, and quality of recovery in patients who are at high risk for postoperative pain.</div></div><div><h3>Design</h3><div>Patient- and assessor-blinded, superiority, randomised controlled trial.</div></div><div><h3>Setting</h3><div>Single centre between 2022 and 2024.</div></div><div><h3>Patients</h3><div>125 adult patients, ASA I – II, planned for elective laparoscopic surgery and risk-classified as high risk of pain, based on perceived pain associated with venous cannulation.</div></div><div><h3>Intervention</h3><div>Patients were randomised to either an anaesthesia protocol, including an intravenous bolus of esketamine (0.25 mg.kg<sup>−1</sup>) after induction and clonidine (1 μg.kg<sup>−1</sup>) during maintenance phase (EC), or standard of care (SOC) no esketamine or clonidine included.</div></div><div><h3>Measurements</h3><div>Primary outcome: worst pain intensity in the PACU. Secondary outcomes: worst pain, and proportion having NRS ≥ 4, at 24 h (during rest and movement), worst pain and proportion having NRS ≥ 1, at 3- and 6-months (during rest and movement), postoperative recovery at 24 h, PONV in the PACU and at 24 h. Rescue dose opioids in the PACU was an exploratory outcome.</div></div><div><h3>Results</h3><div>Worst pain scores in the PACU were 5.7 in the EC group and 5.5 in SOC group (<em>P</em> = 0.78). After 24 h, no difference in postoperative pain (rest; 5.8 vs 6.1, <em>P</em> = 0.35, movement; 6.1 vs 6.2, <em>P</em> = 0.68), postoperative recovery (<em>P</em> = 0.92) or PONV (<em>P</em> = 0.80) was found. Proportion of patients with NRS ≥ 4 in the PACU was 50 % vs 48 % <em>(P</em> = 0.55) and at 24 h 73 % vs 81 % at rest (<em>P</em> = 0.27) and 76 % vs 81 % during movement (<em>P</em> = 0.50). Rescue opioids in the PACU were similar (5.9 mg vs 6.6 mg, <em>P</em> = 0.47). There were no differences in persistent pain at 3 or 6 months at rest (<em>P</em> = 0.72, <em>P</em> = 0.12) or movement (<em>P</em> = 0.48, <em>P</em> = 0.18).</div></div><div><h3>Conclusion</h3><div>Adding esketamine and clonidine, as an individualised multimodal anaesthesia strategy, did not influence acute or persistent postoperative pain, early recovery, need of rescue opioids or PONV in patients, who were assessed as high risk for APOP.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"108 ","pages":"Article 112059"},"PeriodicalIF":5.1,"publicationDate":"2025-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145445063","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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