Revisional upper eyelid blepharoplasty is often associated with scar-related hyperalgesia and poor tolerance to local anesthesia, which may compromise intraoperative stability and patient experience. This study evaluated whether a multimodal intravenous conscious analgesia protocol based on oliceridine and alfentanil combined with local anesthesia improves perioperative comfort compared with local anesthesia alone. In this prospective randomized clinical trial conducted between January 2023 and January 2025, 132 patients undergoing revisional upper blepharoplasty were assigned to receive either multimodal conscious analgesia (oliceridine plus low-dose alfentanil with local anesthesia, n=72) or local anesthesia alone (n=60). Primary outcomes included intraoperative pain scores and reflex tearing. Secondary outcomes included operative stability, postoperative tissue reactions, patient-reported outcomes, and safety. Patients receiving combined anesthesia reported significantly lower pain scores at all perioperative time points (P < 0.05) and a markedly reduced incidence of reflex tearing compared with controls (6.9% vs 75.0%, P < 0.001). Excessive body movements were also less frequent (14.6% vs 80.0%, P < 0.001). Postoperatively, periorbital swelling and ecchymosis were significantly improved at day 7 (P < 0.05), and FACE-Q intraoperative comfort scores at 3 months were higher in the combined group (88.6 ± 6.2 vs 76.4 ± 9.7, P < 0.001). No severe adverse events occurred in either group. Multimodal opioid-based conscious analgesia combined with local anesthesia provides improved intraoperative comfort and early recovery in revisional blepharoplasty while preserving patient cooperation. Further studies are required to delineate the independent contribution of individual agents and to compare this strategy with established sedation protocols. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Unilateral spinal anesthesia has gained increasing attention in recent years. Emerging evidence suggests that it provides comparable analgesia to conventional bilateral spinal anesthesia while reducing adverse effects, and its efficacy and safety compared to bilateral spinal anesthesia remains controversial. This systematic review and meta-analysis aims to evaluate and compare the efficacy and safety of unilateral versus bilateral spinal anesthesia. Systematic reviews and meta-analysis of randomized controlled trials (RCTs). A systematic search was conducted across PubMed, EMBASE, and Cochrane Library from inception to December 10, 2024. Included studies were randomized controlled trials involving adult patients (≥18 years) undergoing surgery under spinal anesthesia, comparing unilateral versus bilateral spinal anesthesia for efficacy and adverse effects. Studies that focused exclusively on either unilateral or bilateral spinal anesthesia were excluded. The comparator group used the same local anesthetic as the experimental group, with no restrictions on adjuncts (e.g. fentanyl, morphine). Nineteen randomized controlled trials including 1191 patients met the inclusion criteria. Compared with bilateral spinal anesthesia, unilateral spinal anesthesia has a longer onset of sensory blockade (MD = 2.58, 95% CI: 0.93 to 4.22, p = 0.002), a shorter duration of sensory blockade (MD = -27.83, 95% CI: -39.25 to -16.42, p < 0.00001). In addition, unilateral spinal anesthesia significantly reduced the incidence of hypotension (RR = 0.40, 95% CI: 0.31 to 0.52, p < 0.0001), nausea and vomiting (RR = 0.20, 95% CI: 0.07 to 0.56, p = 0.002), and post-dural puncture headache (RR = 0.44, 95% CI: 0.23 to 0.81, p = 0.009). No statistically significant differences were observed in bradycardia and urinary retention. Collectively, these findings support unilateral spinal anesthesia as a strategy that may enhance perioperative safety while maintaining adequate anesthetic efficacy in appropriately selected patients. Unilateral spinal anesthesia may offer a favorable balance between anesthetic efficacy and safety compared with bilateral spinal anesthesia, although its clinical utility may depend on surgical duration and patient characteristics. Unilateral spinal anesthesia is associated with a significantly lower incidence of adverse effects, including hypotension, nausea, vomiting, and headache.Bilateral spinal anesthesia provides faster onset and longer duration of sensory blockade but carries a higher risk of complications.The dose of local anesthetic plays a critical role in the efficacy and duration of unilateral spinal anesthesia.
Although large language models (LLMs) show potential for patient education, their accuracy, usability, and comprehensibility lack validation in high-risk pediatric anesthesia. Rigorous evaluation is therefore essential prior to widespread clinical use in perioperative parental anesthesia education. This study aims to evaluate the accuracy, reliability, and readability of responses generated by 5 LLMs to parental inquiries regarding pediatric anesthesia, and to assess their suitability for clinical use in perioperative caregiver education. Two expert anesthesiologists identified 33 parental questions on pediatric anesthesia by screening authoritative resources and Google Trends. On December 14, 2025, these questions were submitted to 5 LLMs (DeepSeek-V3.2, ChatGPT-5, Gemini 2.5 Flash, Copilot, and Perplexity) via official web interfaces with default settings and zero-shot prompting, with each query in a separate conversation. Responses were standardized for blinded assessment. Two pediatric anesthesiologists with ≥10 years of clinical experience independently evaluated accuracy and reliability using the 4-point Likert accuracy scale, DISCERN, Ensuring Quality Information for Patients (EQIP), Journal of the American Medical Association (JAMA) benchmark, and Global Quality Score (GQS). After text preprocessing, readability was evaluated using 6 algorithms (Automated Readability Index [ARI], Flesch Reading Ease Score [FRES], Gunning Fog Index [GFI], Flesch-Kincaid Grade Level [FKGL], Coleman-Liau Index [CL], and the Simple Measure of Gobbledygook [SMOG]) via an online calculator. Interrater reliability was analyzed using the intraclass correlation coefficient (ICC); differences across models were assessed with the Kruskal-Wallis H test; and deviations from the sixth-grade benchmark were evaluated using 1-sample Wilcoxon signed-rank tests (P<.05 considered significant). All 5 LLMs demonstrated high clinical accuracy (>90%; P=.12), with Gemini reaching 100%. Nevertheless, safety risks and content hallucinations were still observed. Excluding Gemini and Copilot, the remaining 3 models (ChatGPT, DeepSeek, and Perplexity) each produced unsafe content in 3.03% (n=1) of the 33 queries. Hallucinations were detected in all models except Gemini, with DeepSeek and Perplexity showing the highest hallucination rate (3/33, 9.09%). Furthermore, Perplexity showed superior reliability on DISCERN (median 41; P<.05), yet no model achieved a "good" rating. Gemini achieved the highest EQIP (median 66.67%; P<.05) despite lower GQS (median 3). Transparency was universally poor (JAMA median ≤1), with DeepSeek and ChatGPT showing a "floor effect." ChatGPT had superior readability, but all models exceeded the recommended 6-grade complexity level. In this study, 5 LLMs generally provided clinically accurate information when responding to parental questions about pediatric anesthesia. However, limitations were also identified, including hallucinated content, safety-related deficiencies, limited source transparency, and readability levels exceeding recommended standards. Therefore, LLM-generated information should be interpreted with caution and should not replace clinician guidance.
Painful procedures requiring sedation and analgesia are commonly performed in pediatric emergency departments. However, there is little knowledge about the possible delayed effects of procedural sedation and analgesia on children's behavior. The aim of the current study was to examine children's behavioral changes 4 weeks after procedural sedation and analgesia with intranasal dexmedetomidine and nitrous oxide. Parents of the children who participated in a clinical trial comparing intranasal dexmedetomidine and nitrous oxide for procedural sedation and analgesia during painful procedures were interviewed 4 weeks after procedural sedation and analgesia. The Post Hospitalization Behavior Questionnaire was used for the parental interviews by phone to evaluate changes in children's behavior. Behavioral changes were reported in 13 of 128 (10.2%) children, of which eight experienced negative behavioral changes and five positive changes. Young age was associated with negative behavioral changes; median age was 5.7 years in children with negative behavioral changes and 9.4 years in children with no behavioral changes (p-value 0.0062). Children with negative behavioral changes were less likely to accept the same method for procedural sedation and analgesia in the future (p-value 0.049) as were their parents (p-value 0.012). Parents of children with negative behavioral changes were less satisfied with the general management of procedural sedation and analgesia than parents whose children did not experience negative changes (p-value 0.024). No association with higher pain scores during the procedure and negative behavioral changes was seen. Behavioral changes are uncommon 4 weeks after procedural sedation and analgesia with intranasal dexmedetomidine or nitrous oxide for painful procedures such as fracture reduction.
Obese pregnant women (body mass index ≥ 30 kg/m2) often receive epidural analgesia (EA) during their deliveries. However, there is scarce evidence on the effect of EA on maternal and perinatal outcomes in these women. The goal of this study is to evaluate outcomes in obese women receiving EA during their planned vaginal deliveries. Patient records of obese women undergoing a planned vaginal delivery from January 2018 until December 2023 in a tertiary care center were screened. Women were stratified into two groups depending on whether or not they received EA during their deliveries. EA was provided after shared decision making between provider and mother. Baseline characteristics and perinatal outcomes were collected for both groups. Primary outcomes were conversion to cesarean section (CS) and reduced Apgar scores (<7 at 5 min). Secondary outcomes were mode of delivery, type of anesthesia, estimated blood loss, episiotomies, perineal ruptures, hospital length of stay, fetal umbilical artery pH and base excess. Using inverse probability of treatment weights, primary outcomes per group were adjusted for baseline characteristics in a logistic regression model. 259 women received EA, 144 did not. Women with EA had lower gravidity and parity, more often induction of labor and delivered children with higher birthweights. In total 88 (22%) women in both groups required secondary CS. General anesthesia was avoided for all 64 women with EA. In the non-EA group, general anesthesia was used for seven out of 24 women. After adjustment, conversion to CS (OR 0.984, CI 0.542-1.786, P = 0.957) and reduced Apgar scores (OR 1.138, CI 0.375-3.458, P = 0.820) were not significantly different. Secondary outcomes (unadjusted) showed several differences. EA was associated with more vacuum deliveries (16% vs 2%, P < 0.001), more episiotomies (18% vs 7%, P = 0.003), higher mean blood loss (523 ml vs 351 ml, P < 0.001), and longer mean length of hospital admittance (4.3 days vs 3.5, P < 0.001). Women with a BMI ≥ 30 kg/m2 receiving EA for planned vaginal delivery showed similar conversion to CS and similar Apgar scores, when compared to obese women without EA. Secondary maternal outcomes were less beneficial for the group receiving EA, but fetal outcomes were not. When conversion to surgical delivery was required, general anesthesia was avoided in 100% of women with EA, while 29% of women without EA required general anesthesia, although fetal outcomes were not worse in this group. In conclusion, early epidural placement for intended vaginal delivery in obese women is safe for mother and child and may prevent the need for general anesthesia for conversion to CS.
Wide-awake local anesthesia no tourniquet (WALANT) has increasingly been used as an alternative to brachial plexus block (BPB) for upper extremity surgery; however, comparative evidence regarding analgesic efficacy, recovery outcomes, and patient satisfaction remains inconsistent. This systematic review and meta-analysis aimed to compare WALANT with BPB in upper extremity surgery, with intraoperative pain prespecified as the primary outcome. A systematic search of PubMed, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials was conducted from inception to January 1st, 2026. Comparative randomized and non-randomized studies evaluating WALANT versus BPB in adult patients undergoing upper extremity surgery were included. Risk of bias was assessed using RoB 2 and ROBINS-I tools, and certainty of evidence was evaluated using the GRADE approach. Fifteen studies involving 940 patients met the inclusion criteria. There was no significant difference in intraoperative pain between WALANT and BPB (MD 1.11, 95% CI -2.54 to 4.76). Postoperative pain scores were similar during the early postoperative period (0-2 h) and at 24 h; however, WALANT was associated with lower pain scores between 2 and 8 h postoperatively (MD -1.39, 95% CI -2.58 to -0.19). WALANT was also associated with a shorter length of hospital stay (MD -10.81 h, 95% CI -18.49 to -3.13). No significant differences were observed in complication rates, need for additional anesthesia or analgesia, or patient satisfaction. The certainty of evidence for key outcomes was rated as very low, primarily due to risk of bias, substantial heterogeneity, and imprecision. Based on very low-certainty evidence, WALANT appears to provide analgesic outcomes broadly comparable to BPB in upper extremity surgery and may be associated with shorter hospital stay. These findings should be interpreted cautiously and primarily considered hypothesis-generating, highlighting the need for well-designed randomized trials.
With the advancement of the ERAS (Enhanced Recovery After Surgery) concept, minimally invasive heart valve replacement surgery has become widely performed due to its advantages of smaller trauma and fewer adverse reactions. However, postoperative pain management remains complex and traditional opioid analgesia is often associated with adverse side effects. Oxycodone, an opioid agonist, has strong analgesic effects with relatively few side effects. This study aims to explore the efficacy and safety of oxycodone hydrochloride injection in multimodal pain management following minimally invasive heart valve replacement surgery. This is a prospective, double-blind, randomised controlled clinical trial designed as a non-inferiority study. The schedule of enrolment, interventions and outcome assessments is summarised in figure 2. The study period is from October 2024 to September 2027, and between 30 April 2026 and 31 October 2026, a total of 130 patients undergoing minimally invasive heart valve replacement surgery will be planned to recruit and randomly assign in a 1:1 ratio to receive either oxycodone hydrochloride injection or sufentanil for postoperative patient-controlled analgesia. The primary outcome is the Numerical Rating Scale pain score during coughing at 24 hours postoperatively. Secondary outcomes include measures of postoperative pain control, analgesic consumption, adverse events and recovery-related indicators. To address the risk of type I error due to multiple secondary outcomes, secondary endpoints are prespecified and categorised into key secondary outcomes and exploratory outcomes with corresponding statistical analysis strategies planned. This protocol is V.2.0, dated 29 December 2025. Ethical approval has been obtained from the Ethics Committee of the First Affiliated Hospital of Xi'an Jiaotong University (XJTU1AF2024LSYY-389-04). The study will be conducted in accordance with the Declaration of Helsinki, and informed consent will be obtained from all participants. Study results will be disseminated through peer-reviewed journals, scientific conferences and appropriate public channels. ChiCTR2400094930.
Peripheral nerve blocks (PNBs) offer adequate postoperative analgesia in pediatric surgical patients while minimizing systemic opioid use. To enhance block duration and quality, adjuvants such as dexmedetomidine and dexamethasone are frequently added to local anesthetics. However, the comparative efficacy and safety profiles of these treatments in children remain unclear. We performed a systematic review and network meta-analysis of 17 randomized controlled trials comprising 1247 pediatric patients undergoing surgery with PNBs. Interventions included perineural and intravenous dexmedetomidine or dexamethasone versus control. The primary outcome was duration of analgesia (time to first rescue analgesic); secondary outcomes included total opioid consumption, postoperative pain scores at 4, 8, 12, and 24 h, and incidence of adverse events. Perineural dexmedetomidine produced the most extended analgesia duration (mean difference: +6.77 h vs. control), ranking highest in network analysis. However, it did not significantly reduce opioid use. In contrast, dexamethasone-especially via perineural route-significantly reduced postoperative opioid consumption and was associated with lower pain scores at 8 and 12 h postoperatively. Dexamethasone also decreased the incidence of postoperative nausea and vomiting, whereas dexmedetomidine showed no such benefit CONCLUSIONS: Dexmedetomidine offers superior prolongation of block duration but lacks significant opioid-sparing effects. Dexamethasone, despite a shorter block duration, is more effective in reducing opioid consumption and postoperative pain intensity. These differences may be explained by rebound pain or anti-inflammatory mechanisms. Clinical priorities should guide the choice of adjuvant. Further high-quality trials are needed to validate these findings and explore long-term safety.
Intranasal (IN) drug delivery has increasingly considered as an easy, practical and non-invasive alternative to parenteral administration in veterinary medicine, offering rapid systemic and potential nose-to-brain effects. The first part of this review systematically collected and synthesized published evidence on IN administration across animal species, while the second part critically analysed the anatomical, pharmacological and technical factors that determine its success and limitations. Part I consisted a total of 110 eligible studies published between 1991 and 2025, encompassing dogs, cats, rabbits, pigs, ruminants, birds and reptiles. IN delivery has been investigated for a range of purposes and produced clinically meaningful sedation, analgesia and drug reversal, often comparable to intramuscular administration but generally characterized by slower onset and greater variability among species. Despite encouraging and favourable results, IN delivery was not without limitations. Its effectiveness can be strongly influenced by species-specific nasal anatomy and physiology, formulation characteristics and dosing volume. Defensive reactions, poor tolerability, sneezing, nasopharyngeal irritations, hypersalivation or swallowing of the drug are frequently reported. Future progress requires species-specific case selection guidelines and dosing standards, pharmacokinetic validation and developing safe concentrated formulations. Transparent reporting and balanced assessment of both benefits and drawbacks are essential to ensure the safe, effective and ethically responsible integration of IN administration into veterinary anaesthesia and critical care practice.
Depth of anesthesia monitoring has become an important component of modern anesthetic practice. Electroencephalography-based technologies, such as the bispectral index, entropy, and Narcotrend, allow clinicians to assess the level of consciousness more objectively and guide anesthetic titration more precisely. This narrative review summarizes current evidence on the relationship between depth of anesthesia monitoring and major perioperative complications. Available evidence suggests that maintaining an appropriate depth of anesthesia reduces the risk of intraoperative awareness, hypotension associated with excessively deep anesthesia, postoperative delirium, and cognitive dysfunction. Electroencephalography-guided anesthesia appears particularly beneficial in older patients, individuals with cardiovascular disease, and other high-risk populations. Although several limitations remain, including algorithm variability and differential sensitivity to anesthetic agents, the integration of multimodal monitoring, brain network analysis, and artificial intelligence is expected to improve the accuracy and individualization of anesthesia management in the future.
​Introduction A critical service gap was identified at a secondary military hospital in Taif City, characterized by periods of zero utilization of epidural analgesia (EA) and an elevated baseline cesarean section (CS) rate. This quality improvement (QI) project was initiated to recover EA services, reduce maternal operative morbidity, and improve clinical outcomes through a standardized multidisciplinary practice change. ​Materials and methods Using a quasi-experimental (retrospective-prospective) design, clinical metrics from the baseline period (January-September 2024) were compared with the post-intervention period (January-September 2025). A multidisciplinary team (anesthesia, obstetrics, nursing, and administration) implemented a three-cycle Plan-Do-Study-Act (PDSA) framework. Interventions included root cause analysis, resource optimization, and data-driven monthly performance huddles. Patient satisfaction was assessed via a prospective cross-sectional comparative study. ​Results Following the intervention, EA utilization significantly increased from 4.9% (n = 30/610) in 2024 to 13.5% (n = 85/628) in 2025 (χ² (1, N = 1,238) = 26.24, p < .001; Cramer's V = 0.15). The CS rate decreased from 40.2% (n = 410/1,020) to 32.5% (n = 302/930) (χ² (1, N = 1,950) = 12.19, p < .001; Cramer's V = 0.08), while spontaneous vaginal deliveries (SVD) increased from 55.9% (n = 570/1,020) to 63.8% (n = 593/930) (χ² (1, N = 1,950) = 13.06, p < .001; Cramer's V = 0.08). Instrumental delivery rates remained stable at 3.9% (n = 40/1,020) and 3.8% (n = 35/930), respectively (χ² (1, N = 1,950) = 0.15, p = .698). In 2025, patients receiving EA reported significantly higher satisfaction (93.6%; n = 80/85) compared to the non-EA group (76.5%; n = 415/543) (t (626) = 35.15, p < .001). Mean staff satisfaction during implementation was 74.6% (n = 47/63). Conclusions This standardized, consultant-led model successfully optimized labor analgesia and delivery outcomes, providing a resilient and reproducible framework for enhancing maternal safety and institutional resource stewardship at a national scale.
Postoperative nausea and vomiting (PONV) is a prevalent adverse event following bimaxillary orthognathic surgery, with opioids being a significant contributing factor. Oliceridine, a G protein-biased μ-opioid receptor agonist, reduces activation of the β-arrestin pathway and may decrease gastrointestinal adverse events relative to traditional opioids. This study aimed to evaluate the efficacy and safety of oliceridine relative to sufentanil for postoperative patient-controlled intravenous analgesia (PCIA) in this population, with a particular emphasis on PONV. This prospective, double-blind, randomized controlled exploratory trial was conducted at the Peking University School and Hospital of Stomatology from March to August 2025. A total of 100 eligible patients (ASAI-II, BMI 18-24 kg/m2, aged 18-60 years) were randomly assigned in a 1:1 ratio to receive either oliceridine (0.25 mg/kg combined with tropisetron 10 mg, designated as Group O) or sufentanil (1.25 μg/kg combined with tropisetron 10 mg, designated as Group S) via patient-controlled intravenous analgesia (PCIA), which included a 2 mL/h background infusion, 0.5 mL bolus, 15-min lockout interval. All participants were administered multimodal antiemetic prophylaxis and standardized general anesthesia. The primary outcome measure was the incidence of PONV within 72 h. Secondary outcome measures included the severity of PONV, the use of rescue antiemetics, postoperative pain scores assessed using an 11-point numerical rating scale (NRS), and the occurrence of adverse events. Statistical analyses were conducted using SPSS version 26.0, with a significance threshold set at p < 0.05. The baseline characteristics were comparable between the groups. The incidence of PONV within 72 h was lower in Group O compared to Group S (40.0% vs. 50.0%; odds ratio [OR] = 0.67, 95% confidence interval [CI]: 0.30-1.47; p = 0.315). Similarly, the incidences of moderate-to-severe PONV (26.0% vs. 36.0%; OR = 0.59, 95% CI: 0.28-1.25; p = 0.108) and the requirement for rescue antiemetics (20.0% vs. 34.0%; OR = 0.49, 95% CI: 0.20-1.20; p = 0.115) were lower in Group O. However, none of these differences reached statistically significance. A repeated-measures analysis of variance (ANOVA) for moderate-to-severe postoperative pain revealed a significant effect of time (F = 17.189, p < 0.001) but no significant group-time interaction (p = 0.142). No serious adverse events, such as respiratory depression or hypotension, were reported in either group, and the incidence of dizziness was similar between the groups (22% vs. 24%, p > 0.05). Oliceridine demonstrated comparable analgesic efficacy and safety to sufentanil, exhibiting numerically lower, albeit not statistically significant, differences in postoperative nausea and vomiting (PONV) and the use of rescue antiemetics. Considering the exploratory nature of this study and the determination of the sample size based primarily on clinical feasibility rather than statistical power, these findings should be regarded as preliminary. Further validation in larger, adequately powered trials incorporating dose-optimization designs is necessary. https://www.chictr.org.cn/showproj.html?proj=257554, Identifier: ChiCTR2500096345.
Temporomandibular joint (TMJ) disorders are prevalent musculoskeletal conditions. Common therapies include TMJ manual therapy, TMJ exercise, and modalities such as low-level laser, therapeutic ultrasound, and transcutaneous electrical nerve stimulation (TENS). This study ranked TMJ manual therapy, TMJ exercise, low-level laser therapy, therapeutic ultrasound, and TENS for pain relief and improved maximal mouth opening (MMO) to strengthen evidence for clinical practice. PubMed, Scopus and Ovid MEDLINE were systematically searched from inception to March 2026 for randomized controlled trials evaluating TMJ manual therapy, TMJ exercise, low-level laser therapy, therapeutic ultrasound, and TENS for TMJ disorder. A frequentist network meta-analysis with a random-effects model was performed to compare treatment effects across interventions, with standardized mean differences calculated as the effect size. Treatment rankings were estimated using the surface under the cumulative ranking curve. Publication bias was assessed using funnel plots and Egger test. This network meta-analysis demonstrated significant pain reduction with therapeutic ultrasound, TMJ manual therapy, TMJ exercise, and low-level laser therapy, and TENS. Therapeutic ultrasound showed the highest probability of providing pain relief, followed by TMJ manual therapy, low-level laser therapy, TMJ exercise, and TENS. For MMO, TMJ manual therapy, low-level laser therapy, therapeutic ultrasound, and TENS showed significant improvements, while TMJ exercise demonstrated a borderline effect. Based on the surface under the cumulative ranking curve rankings, TMJ manual therapy had the highest probability ranking, followed by therapeutic ultrasound. This network meta-analysis suggests that TMJ manual therapy had a higher probability ranking than TMJ exercise for reducing pain and improving MMO. Among physical modalities, therapeutic ultrasound and low-level laser therapy tended to rank higher than TENS. These findings may help inform clinical decision-making in the management of TMJ disorder. Future studies should further investigate the influence of treatment duration and TMJ disorder diagnostic subtypes.
Women with endometriosis are at increased risk of severe postoperative pain due to nociceptive sensitization. While multimodal analgesia reduces opioid use, the added value of objective nociception monitoring remains unclear. This study evaluated whether NOL®-guided opioid titration improves perioperative outcomes within a standardized multimodal regimen. In this prospective, randomized, single-blinded trial, premenopausal women undergoing laparoscopic surgery for suspected endometriosis or adenomyosis were assigned to NOL®-guided analgesia or standard care based on clinical assessment. All patients received a standardized multimodal protocol. The primary outcome was total perioperative opioid consumption. Secondary outcomes included postoperative pain scores (NRS) and PACU length of stay. Exploratory analyses assessed the association between preoperative pain (Mankoski Pain Scale, MPS) and postoperative outcomes. A total of 111 patients were analyzed (NOL®: n = 54; control: n = 57). Total perioperative opioid consumption did not differ significantly between groups (adjusted mean difference = 14 μg for Fentanyl and 52 μg for Remifentanil; p = 0.8). Surgery duration was an independent predictor of opioid use (p < 0.001) and PACU length of stay (p = 0.01), whereas treatment group had no significant effect. Postoperative pain scores were comparable between groups at all time points. NOL®-derived metrics were not associated with opioid consumption or pain. Higher preoperative MPS scores independently predicted higher pain scores in the late PACU phase. NOL®-guided opioid titration did not reduce perioperative opioid consumption or improve early postoperative outcomes compared with standard multimodal analgesia in women undergoing laparoscopic surgery for endometriosis.
Intrathecal adjuvants are frequently used in spinal anaesthesia for lower-limb surgery to enhance block quality and prolong postoperative analgesia. However, evidence remains fragmented across individual agents. This systematic review with frequentist network meta-analysis aimed to compare the efficacy and safety of intrathecal adjuvants in patients undergoing lower limb orthopaedic surgery to evaluate the effectiveness and safety of intrathecal adjuvants combined with long-acting local anaesthetics for lower limb orthopaedic surgery. A systematic search of PubMed, CENTRAL, and Embase was conducted to retrieve English-language RCTs involving adult patients undergoing lower limb orthopaedic surgery under single-shot spinal anaesthesia. We included trials evaluating any intrathecal drug or placebo added to a long-acting local anaesthetic. Our primary outcome was the duration of effective analgesia, defined as the time to the first analgesic requirement, in hours. We selected randomised controlled trials (RCTs) reported in English. We included 183 RCTs, for a total of 14,431 patients and 27 interventions. Morphine combined with ketorolac, morphine alone followed by diamorphine, clonidine combined with morphine and ketamine combined with midazolam provided the greatest prolongation of effective analgesia. Morphine also significantly reduced pain at 12 h and postoperative opioid consumption with no impact on motor block duration. Dexmedetomidine reduced pain intensity at 12 h but substantially prolonged motor block duration and increased the incidence of bradycardia. Morphine and neostigmine showed an increased risk of postoperative nausea and vomiting, while several interventions increased the risk of pruritus. The certainty of evidence ranged from low to very low due to within-study bias, reporting bias, high heterogeneity, imprecision and incoherence. Considering the body of evidence in an NMA framework, intrathecal morphine appears to offer a potentially favourable efficacy-safety balance. Dexmedetomidine may prolong motor block and increase the risk of bradycardia. The certainty of the evidence was low to very low and needs caution interpretation. PROSPERO CRD42024557751.
Due to multiple factors, patients will experience significant postoperative pain following laparoscopic total hysterectomy (TLH), predominantly manifesting as visceral pain. For the first time, we compared the analgesic effects of intertransverse process block (ITPB) and erector spinae plane block (ESPB) in patients undergoing TLH. We hypothesized that ITPB would further reduce the perioperative opioid dosage and improve visceral pain in TLH patients when compared with ESPB. This research included 66 patients (18-65 years-of-age) undergoing TLH under general anesthesia. Patients were assigned by randomization to either an ITPB or ESPB group. Ultrasound-guided bilateral intertransverse process blocks at T10-11 were performed for patients in the ITPB group, with 0.375% (20 mL) ropivacaine per side. For the ESPB group, we performed bilateral ultrasound-guided ESPB at the T10 level with 0.375% ropivacaine (20 mL) per side. All patients received total intravenous anesthesia guided by the bi-spectral index (BIS). The primary outcome included total opioid use, expressed as morphine equivalents, within the first 24 h following surgery. Patients in the ITPB group required significantly lower intraoperative remifentanil doses (mean difference: -328.0 μg, 95% CI: -395.2 to -260.9, p < 0.001) and exhibited reduced cumulative opioid consumption within 24 h postoperatively (mean difference: -2.5 mg morphine equivalents, 95% CI: -3.85 to -1.15, p < 0.001) when compared to the ESPB group. The ITPB group also exhibited significantly lower Numerical Rating Scale (NRS) scores for visceral pain upon awakening and at 2, 4, 6, 8, and 24 h after surgery when compared to the ESPB group (p < 0.001). Similarly, NRS scores for incisional pain were significantly lower in the ITPB group immediately after awakening and at 4, 6, and 8 h postoperatively (p < 0.05). Compared with ESPB, ITPB more effectively reduced perioperative opioid consumption and provided superior and sustained postoperative visceral analgesia for patients undergoing total laparoscopic hysterectomy. In addition, ITPB was associated with improved short-term postoperative recovery quality. In future, studies need to elucidate the underlying mechanisms of ITPB and optimize the volume and concentration of local anesthesia for administration.
Postoperative hypoxemia, a critical complication after surgery, has garnered increasing attention in perioperative research. This study aimed to explore global trends, research hotspots, and collaboration networks in postoperative hypoxemia from 1998 to 2024 through bibliometric analysis. A bibliometric analysis. Publications related to postoperative hypoxemia from 1998 to 2024 were retrieved from the Web of Science Core Collection. A bibliometric analysis was conducted using VOSviewer (version 1.6.20), CiteSpace (version 6.3.R1), and R package "bibliometrix" (version 4.3.3) to analyze publication trends, co-authorship networks, and keyword co-occurrence patterns. A total of 248 publications were identified, with an annual growth rate of 1.35%. Key journals were Anesthesia and Analgesia and British Journal of Anaesthesia. The United States led in citations, followed by China and Denmark. Leading institutions included the Cleveland Clinic Foundation and the University of Copenhagen. In total, 1380 authors were involved in these publications, with Jean-Michel Constantin, Samir Jaber, and Daniel I. Sessler emerging as leading contributors. Keyword analysis revealed that "surgery" was the most frequently occurring term, reflecting the central theme of research. The keyword burst analysis indicated an early emphasis on oxygen monitoring and atelectasis, while recent trends highlight a shift toward precision ventilation strategies and positive airway pressure. This bibliometric analysis highlights the increasing global interest and collaboration in postoperative hypoxemia research. Emerging trends such as noninvasive ventilation and optimization of end-expiratory pressure offer valuable insights for future clinical applications and research in perioperative care.
Tegileridine is a novel selective μ-opioid receptor agonist. This exploratory dose‑finding study aimed to estimate the 50% effective dose (ED50) and secondarily the 95% effective dose (ED95) of tegileridine for suppressing the cervical dilation reflex during hysteroscopic surgery under propofol anesthesia, compare it with fentanyl, and evaluate perioperative safety in an exploratory manner. This prospective, randomized, single‑center trial enrolled 54 patients (ASA I‑II). Patients received tegileridine (initial dose 16.67 μg/kg) or fentanyl (initial dose 2 μg/kg) with propofol. Doses were adjusted using the Dixon sequential method. The primary endpoint was ED50 with its 95% confidence interval (CI), estimated using the percentile bootstrap method (2,000 replicates) as the primary inferential framework. ED95 was calculated secondarily via probit regression. Safety data are reported descriptively. Twenty‑seven patients per group completed the study. The bootstrap‑based ED50 for tegileridine was 23.22 μg/kg (95% CI: 22.39‑24.19); for fentanyl, 1.51 μg/kg (95% CI: 0.97‑4.07). The ED50 potency ratio (tegileridine:fentanyl) was approximately 1:15 (95% uncertainty range derived from bootstrap CIs: 1:5.5 to 1:24.9). The ED95 values from probit regression were 23.89 μg/kg (95% CI: 23.68‑24.12) for tegileridine and 1.97 μg/kg (95% CI: 1.87‑2.07) for fentanyl. Respiratory depression/hypoxemia was observed in 14.8% of the tegileridine group and 59.3% of the fentanyl group; these exploratory findings should be interpreted with caution given the small sample and open‑label design. This exploratory study estimated the ED50 of tegileridine and fentanyl for hysteroscopic surgery. The ED50-based potency ratio and the observed differences in safety outcomes require confirmation in larger, adequately powered, blinded trials. The ED95 estimates are model‑based and carry substantial uncertainty. Chinese Clinical Trial Registry, ChiCTR2500107995.
Central sensitization may contribute to persistent postpartum pain, but the factors associated with the pain outcome are poorly understood. We identified independent associated factors with elevated CSI scores at 6-10 weeks postpartum. Pregnant women admitted for delivery were asked to complete pre-delivery questionnaires evaluating pain and psychological vulnerabilities. Data on labor pain intensity, obstetric interventions, and neonatal outcomes were collected. An online survey was conducted at 6-10 weeks postpartum to assess elevated CSI scores, defined a priori as a Central Sensitization Inventory (CSI) score of ≥50. Of the 816 women, 401 (49.1%) had levated CSI scores at 6-10 weeks postpartum. Multivariable analysis identified six independent associated factors of elevated CSI scores: Pre-delivery factors including higher Edinburgh Postnatal Depression Scale (EPDS) score (adjusted odds ratio (aOR) 1.42, 95%CI 1.15-1.74, p = 0.001); a higher pre-delivery CSI score (aOR 2.50, 95%CI 2.01-3.10, p < 0.0001); higher Angle Labor Pain Questionnaire (A-LPQ) Enormity of pain subscale score (aOR 1.24, 95%CI 1.05-1.47, p = 0.01), and higher Fear-Avoidance Components Scale (FACS) pain-related anxiety subscale score (aOR 1.26, 95%CI 1.04-1.51, p = 0.02); and obstetric complications including manual removal of the placenta (aOR 4.06, 95%CI 1.11-14.82, p = 0.03) and intrauterine growth restriction (aOR 8.90, 95%CI 1.12-70.74, p = 0.04) (AUC: 0.79 (95%CI 0.76-0.82)). Increased pre-delivery pain and psychological vulnerabilities, and obstetric complications were independently associated with the development of elevated postpartum CSI scores. Recognition of these associated factors may help identify women at risk and inform targeted strategies to mitigate central sensitization and persistent pain. Clinicaltrials.govNCT03167905.
This large-sample, randomized, double-blind controlled trial directly compared the analgesic efficacy and impact on respiratory function of ultrasound-guided erector spinae plane block (ESPB) versus serratus anterior plane block (SAPB) in patients with unilateral multiple rib fractures. A total of 158 eligible patients were randomized to receive either ESPB (n = 73) or SAPB (n = 85), performed with 0.375% ropivacaine. The primary outcome was the time-weighted area under the curve (AUC) of resting pain Numerical Rating Scale (NRS) scores over 24 h post-intervention. Secondary outcomes included dynamic pain scores, opioid consumption, respiratory function (diaphragmatic excursion, FVC, FEV1), recovery quality (QoR-15), and clinical outcomes. The ESPB group demonstrated a significantly lower 24-h pain AUC compared to the SAPB group (mean difference -17.78, 95% CI: -21.00 to -14.56, p < 0.001), indicating superior comprehensive analgesia. ESPB also significantly reduced 24-h opioid consumption and improved QoR-15 scores (both p < 0.01). While both groups showed significant within-group improvement in respiratory function parameters, no significant between-group differences were found. Subgroup analysis revealed that the analgesic superiority of ESPB was consistent across different fracture locations but was more pronounced in patients with ≤5 fractures (interaction p = 0.023). Safety profiles and complication rates were comparable. For patients with unilateral multiple rib fractures, ESPB provides significantly better early comprehensive analgesia and reduces opioid requirements compared to SAPB, without compromising safety. ESPB may be considered as a preferred first-line regional analgesic technique, especially for patients with a lower fracture burden. Chinese Clinical Trial Registry (ChiCTR), Registration No. ChiCTR2300067544.