In low-resource settings, invasive intracranial pressure (ICP) monitoring is often not available due to its high costs. Therefore, some therapeutic strategies require a different approach than those recommended in the presence of invasive monitoring. In this review, we propose a concise overview on ICP monitoring in low-resource settings, mainly focusing on traumatic brain injury patients. In limited-resource settings, where invasive ICP monitoring is not available, the use of protocols, based on clinical examination and neuroimaging, is associated with improved outcomes and should be adopted in daily clinical practice. In recent years, there has been an increase in interest and use of noninvasive methods for estimating ICP. A recent consensus, requiring validation in future clinical studies, was created with the aim to integrate noninvasive ICP (nICP) methods in the above-mentioned protocols. The creation of protocols that include available/local resources (nICP, neuroimaging, etc.) and the implementation of educational initiatives is a valid strategy for improving care in resource-constrained health systems. Importantly, more research is needed in this area of patient care.
Climate change is already disrupting healthcare delivery with perioperative medicine, particularly pediatric anesthesia, being both highly exposed to climate-related shocks and a major contributor to healthcare-related greenhouse gas emissions (GHG). This review examines how mitigation and resilience strategies can be integrated into pediatric anesthetic practice. Sustainability measures in pediatric anesthesia are currently actionable and clinically beneficial. Reducing the use of volatile anesthetics through low-flow techniques, avoiding N2O or desflurane, and increasing the adoption of total intravenous anesthesia lead to substantial reductions in GHG and are associated with better clinical outcomes. EEG-guided anesthesia further reduces unnecessary exposure to anesthetics and improves recovery profiles. The use of reusable warming drapes or the implementation of 10R policies can markedly reduce our footprint without compromising the quality of care. Sustainable pediatric anesthesia is achievable today and aligns with improved clinical outcomes. Translating evidence into routine practice remains a challenge. Patient safety primacy or entrenched clinical habits continue to slow the adoption of sustainable practices, even when supported by robust data. Success will depend on reframing sustainability as a core component of quality and safety, embedding it within guidelines and audit structures, and supporting clinicians, thereby enabling durable behavior change.
Regional anaesthesia has well established benefits in paediatric perioperative care and acute pain interventions. This article explores current controversies and emerging evidence in paediatric regional anaesthesia. Despite rates of local anaesthetic systemic toxicity (LAST) remaining low, dosing of local anaesthetics in children remains controversial, particularly in neonates, in whom maximum safe doses can easily be exceeded. Local anaesthetic additives, such as dexamethasone, dexmedetomidine, and clonidine, are commonly used to prolong regional anaesthesia and have demonstrated good efficacy and safety, though best route of administration remains debated. Peripheral nerve catheters prolong analgesia and can be safely managed in ambulatory settings. Enhanced recovery after surgery (ERAS) is rapidly expanding in paediatric anaesthesia, and regional anaesthesia forms a key component. Fear of masking compartment syndrome is not supported by current literature and not a contraindication to regional anaesthesia. Studies exploring the utility of awake regional anaesthesia in children have successfully demonstrated the avoidance of general anaesthesia. Anaesthetic training increasingly demands proficiency in ultrasound-guided regional techniques. Regional anaesthesia is a safe and effective analgesic modality in children, including in trauma patients and as part of ERAS protocols, with good evidence for use of additives and low rates of complications, including LAST.
This review examines recent advances in pediatric airway management, including emerging technologies, updated guidelines, and innovative strategies for improving safety across diverse clinical settings. We address the unique challenges faced when managing airways in neonates, infants, and children with complex conditions. The 2024 ESAIC-BJA neonatal and infant airway guidelines provide the first evidence-based recommendations emphasizing preoperative identification of the difficult airway, the use of neuromuscular blockade, videolaryngoscopy, and optimized preoxygenation to mitigate risk in this vulnerable population. Use of videolaryngoscopy continues to increase, with multicenter randomized controlled trials demonstrating 5-10% absolute improvements in first-attempt success rates and significant reduction in severe complications including esophageal intubation and hypoxemia, particularly when combined with supplemental oxygen during laryngoscopy. Registry and meta-analysis data now provide robust evidence that neuromuscular blocking agents improve intubation conditions and reduce complications. Artificial intelligence applications show promise for predicting difficult airways and optimizing endotracheal tube sizing. Front-of-neck access strategies have been refined, acknowledging the limitations of cricothyrotomy in young children. Extracorporeal membrane oxygenation has emerged as a rescue strategy in anticipated cannot-intubate-cannot-oxygenate scenarios. Global disparities in pediatric anesthesia safety persist, with collaborative educational initiatives addressing workforce challenges in low- and middle-income countries. The future of pediatric airway management lies in individualized, technology-enhanced approaches guided by evidence-based algorithms, multidisciplinary collaboration, comprehensive education, and simulation-based training, with a commitment to equitable care delivery worldwide.
Perioperative antimicrobial prophylaxis (PAP) is a cornerstone in the prevention of surgical site infection. As an increasing share of procedures shifts to the ambulatory setting, this review examines aspects of PAP that are of particular relevance to ambulatory anesthesiology. Empirical data show suboptimal use of PAP (e.g. unnecessary indication, substance choice, and excessive duration) in many settings, including ambulatory surgery. Focusing on substance choice, penicillin allergy remains a frequent, largely unverified barrier to β-lactam use in PAP. Recent evidence supports structured risk-stratification to safely expand cephalosporin use despite penicillin allergy, in order to reduce adverse effects of second-line antibiotics. Logistically, the widely used 60-min preincision timing rule for PAP was established for intravenous administration and cannot be directly applied to oral prophylaxis, where bioavailability varies substantially between agents and must inform both substance choice and timing. Lastly, the peri-interventional use of endocarditis prophylaxis is part of recent European guidelines on infective endocarditis, including some modifications to previous iterations. Ambulatory anesthesiology presents structurally different conditions from inpatient care - high case turnover, limited time for allergy work-up, variable use of intravenous access, and no postoperative in-house monitoring after discharge. Addressing PAP overuse, allergy label mismanagement, and oral-versus-intravenous administration challenges specifically in this setting offers a concrete pathway toward safer and more evidence-based ambulatory surgical care.
Enhanced recovery after surgery (ERAS) has evolved into a well established, evidence-based framework for perioperative care in numerous surgical disciplines. At the same time, advances in minimally invasive and catheter-based techniques have substantially expanded the number and complexity of procedures performed outside the operating room, leading to a rapid growth of nonoperating room anesthesia (NORA). Despite the clear overlap between ERAS principles and NORA patient needs, comprehensive recovery concepts for interventional procedures remain limited. Current evidence on ERAS-based approaches in NORA is sparse and heterogeneous, mainly originating from gastroenterology, cardiology, and interventional radiology. Existing studies suggest that selected enhanced recovery principles are feasible in interventional care and may improve patient comfort, recovery, safety, and procedural efficiency. However, implementation is often fragmented and lacks standardized, pathway-based peri-interventional management. Enhanced recovery principles hold substantial potential to improve peri-interventional care within the rapidly expanding NORA environment. The critical gap is not the absence of ERAS elements, but the absence of structured peri-interventional recovery governance comparable to established surgical ERAS pathways. Future progress will require holistic, multidisciplinary recovery frameworks, standardized concepts with procedure-specific adaptations, and clinical and economic evidence. Given its central role across the peri-interventional continuum, anesthesiology is well positioned to contribute to and potentially lead the development of structured enhanced recovery pathways beyond the operating room.
Nonoperating room anesthesia (NORA) and continuing education in this setting are both in a state of change. Procedures performed outside the operating room, especially those that require nuanced anesthetic care, are becoming increasingly prevalent. Numerous new innovations are transforming care across NORA settings, especially within gastroenterology, interventional and neurointerventional radiology, and electrophysiology. Concurrently, education for NORA providers is rapidly evolving, influenced by technological advancements and artificial intelligence. Traditional learning, a mode of education in which each learner receives essentially the same content, is now blending with adaptive learning, a field of precision education in which dynamic educational content is curated for individual learners, timed and paced to their preferences and progress, and coupled with artificial intelligence-generated feedback. The mainstays of traditional education for NORA providers remain relevant: content created by professional societies, podcasts, textbooks, and primary literature. Yet new, artificial intelligence-driven approaches for adaptive learning have entered the scene: clinical decision-making tools, literature review and knowledge mapping assistants, online platforms for precision education, virtual reality, and synthetic patients or avatars. This article explores the blending of traditional and adaptive educational modalities in NORA continuing education and discusses the implications and obstacles for the future.
Neuroanesthesia practice in low- and middle-income countries is constrained by workforce shortages, limited infrastructure, and variability in clinical practice. Growing global interest in collaboration makes it timely to evaluate how international partnerships can address these gaps and improve equity in care, education, and research. Recent literature highlights substantial variability in neuroanesthesia practice and limited access to context-appropriate guidelines and advanced technologies. International collaborations, including training partnerships, scholarship programs, and research networks, have improved knowledge exchange, workforce development, and the adoption of standardized practices. Evidence suggests that specialized training is associated with improved clinical outcomes. However, persistent inequities in research participation, authorship, and leadership, as well as concerns regarding sustainability and 'parachute research', remain. International collaboration is a key strategy for advancing neuroanesthesia in resource-constrained settings. Sustainable, equitable partnerships that prioritize local ownership, capacity building, and contextual adaptation are essential to improving clinical practice, strengthening education, and enhancing global research representation.
Preoperative assessment is a central but increasingly complex component of pediatric anesthetic care. While perioperative safety in children has improved substantially, preventable complications remain prevalent. This review examines current concepts of pediatric preoperative evaluation, highlights emerging trends and controversies, and proposes the concept of anesthesia as a perioperative "navigator", whose guiding function begins with preoperative assessment. Contemporary practice of preoperative assessment increasingly includes structured risk stratification, procedure-specific planning, optimization of modifiable risk factors, and family centered communication. Advances highlight shorter fasting regimens, growing implementation of methods to optimize preexisting or chronic conditions such as pediatric patient blood management, refined strategies to manage upper respiratory tract infections and individualized approaches to manage preoperative anxiety. At the same time, digitalization, remote preassessment models, and delegation of assessment tasks are shaping clinical workflows. Shared decision-making and proactive communication have emerged as key determinants of cooperation for children and their families. Modern pediatric preoperative evaluation should be viewed less as a static medical checkpoint and more as starting for the dynamic process of perioperative "navigation". Integrating medical risk assessment with structured planning and effective communication remains essential to reduce complications and improve both safety and experience in pediatric anesthesia.
Chronic preoperative pain is increasingly recognized as a major determinant of perioperative complexity and postoperative outcomes. This review summarizes current evidence on the role of regional anaesthesia and analgesia (RAA) in adult surgical patients with pre-existing chronic pain, focusing on mechanistic rationale, short-term benefits, and potential long-term effects on persistent postoperative opioid use (PPOU) and chronic postsurgical pain (CPSP). Pre-existing chronic pain is common across surgical populations and is consistently associated with higher postoperative pain intensity, increased opioid requirements, delayed recovery, and poorer clinical outcomes. Psychological vulnerability, including anxiety, depression, and pain catastrophizing, further increases the risk of adverse pain trajectories and persistent opioid use. RAA provides effective opioid-sparing analgesia and may attenuate nociceptive transmission, central sensitization, and neuroinflammatory activation. Evidence strongly supports short-term analgesic benefits, whereas effects on PPOU and CPSP remain heterogeneous. RAA is a key component of individualized perioperative care in patients with chronic preoperative pain. Its greatest value lies in improving acute pain control, reducing opioid exposure, and supporting recovery. Long-term benefits are plausible but inconsistent, and are most likely when RAA is embedded within multimodal, phenotype-driven, and transitional pain care pathways.
With advances in technology, 30-50% of anesthesia cases have moved to nonoperating room anesthesia (NORA) sites. NORA challenges include patient and ergonomic complexity, which can complicate anesthesia care during routine and emergency situations. This review aimed to summarize current evidence on NORA crisis resource management (CRM). CRM in NORA is characterized by working with unfamiliar teams in locations not primarily designed for delivering anesthesia care. Equipment and personnel resources may be limited or different from what is available in the operating room. While few studies directly evaluate the effect of CRM in NORA settings, there is widespread consensus about the utility of crisis simulation training to improve team behaviors, role clarity, and timeliness of care. In addition, team building, process improvement, and the development of cognitive aids can be byproducts of well-executed CRM training programs. CRM can address several of the key challenges in NORA, including working in unfamiliar teams and in locations not primarily designed for anesthesia care. The paucity of studies may reflect the difficulty of implementing interprofessional CRM training in production-driven settings. Future research efforts should explore barriers to CRM training and successful implementation strategies in NORA.
Artificial intelligence in health is evolving rapidly, and there is a lot of hope that it may improve patient outcomes. The perioperative management of patients with major trauma is a challenge, as it requires rapid decision-making in complex and evolving clinical situations. Anesthesiologists are central to the early resuscitation, operative management, and postoperative supervision of these patients. Advances in artificial intelligence, together with the increasing availability of large trauma databases and real-time monitoring systems, have highlighted the potential role of artificial intelligence in trauma anesthesia. Artificial intelligence models may improve triage accuracy or assist clinicians in anticipating complications such as hemorrhagic shock, secondary brain injury, or prolonged stay in the hospital. Moreover, artificial intelligence-driven tools offer opportunities to individualize anesthetic and postoperative strategies by integrating patient characteristics, injury severity, or physiological responses. Yet, implementing these tools still faces important limitations, while it will require the training and their cultural adoption by a generation of physicians. This review aimed to report the current applications and future perspectives of artificial intelligence in the anesthetic management of severely injured patients. It also emphasizes its potential to enhance decision-making, personalize care, and ultimately improve patients' outcomes in trauma anesthesia.
Patients with chronic pain face elevated risks of inadequate postoperative analgesia, prolonged opioid use, and chronic postsurgical pain. Digital health technologies have expanded rapidly into perioperative care, yet their implications for chronic pain populations and for health equity remain insufficiently examined. This review synthesises recent evidence on digital health interventions for perioperative pain management while critically appraising how these technologies engage with, or exclude, people living with chronic pain. Five categories of digital intervention are identifiable, ranging from transitional pain services delivered via telehealth that actively target high-risk patients to general remote monitoring platforms that exclude chronic pain nuances and systematically marginalise digitally disadvantaged populations. Multicomponent platforms combining education, monitoring, and communication produce larger effect sizes than single-component interventions, yet most studies omit psychological dimensions and do not stratify for baseline chronic pain. Digital perioperative interventions risk reinforcing structural inequities unless guided by precision biopsychosocial models, multidimensional outcome measurement, equity-informed design, and hybrid care preserving in-person contact for those who need it most. Future trials must adopt core outcome sets measuring functional recovery, psychological distress, and chronic postsurgical pain transition.
Chronic pain management increasingly requires a patient-centered, adaptive approach. This review examines how shared decision-making (SDM) and individualized strategies develop and function in chronic pain care, emphasizing their relevance in practice. Recent literature highlights that SDM improves patient satisfaction, engagement, and psychological outcomes across various chronic pain conditions. However, SDM is most effective when viewed as an ongoing, iterative process rather than a one-time decision. Studies show that alignment between patient and clinician expectations, effective communication, and recognition of patient preferences are key determinants of success. In opioid management, SDM may unintentionally sustain prescribing patterns, underscoring the need for balanced communication and clinician training. Decision aids and structured tools can support SDM by improving patient knowledge and involvement, although barriers such as health literacy and access to technology remain. Persistent discrepancies between patient and clinician perspectives, as well as contextual and socioeconomic factors, can challenge implementation. SDM is an essential component of chronic pain management but is insufficient as a standalone strategy. Effective care requires continuous support, education, and adaptation within a strong therapeutic relationship. Future approaches should focus on flexible, context-sensitive interventions that integrate biopsychosocial principles and address individual patient needs.
ICU procedures are increasingly complex, often requiring deeper sedation or general anesthesia, and are increasingly performed at the bedside to avoid transport risk. This trend has expanded the role of anesthesiologists in ICU nonoperating room anesthesia (NORA). This review summarizes practical anesthetic considerations for these procedures, focusing on optimization, monitoring, and systems issues. ICU patients frequently have shock, hypoxemia, right ventricular failure, metabolic acidosis, organ dysfunction, and neurologic injury that change anesthetic pharmacokinetics and hemodynamic responses. Bedside tracheostomy, percutaneous endoscopic gastrostomy, extracorporeal membrane oxygenation cannulation, bronchoscopy, thoracic interventions, and selected neurosurgical and interventional radiology procedures are feasible in the ICU but carry higher rates of cardiorespiratory events than operating room cases, largely because of illness severity and environmental constraints. Short-acting sedatives, noninvasive respiratory support, point-of-care ultrasound, and structured checklists, simulation, and dedicated ICU NORA pathways can reduce complications. Emerging artificial intelligence and machine learning tools that process physiologic and waveform data may further improve risk stratification, early detection of instability, and decision support. Bedside ICU procedures blur the boundaries between sedation, monitored anesthesia care, and general anesthesia. Effective practice requires individualized plans, clear rescue pathways, and coordination between anesthesia, ICU, and procedural teams, supported by advanced monitoring and data-driven decision support.
Retention is increasingly recognized as a critical determinant of both trial validity and long-term therapeutic success in patients with implanted medical devices. This review is timely because neuromodulation research continues to expand, while concerns remain regarding attrition, incomplete follow-up, and the limited generalizability of available evidence. Recent literature indicates that dropout in chronic pain and neuromodulation research is driven by a combination of demographic, psychological, clinical, and structural factors. Pain catastrophizing, low self-efficacy, unrealistic treatment expectations, logistical burden, and dissatisfaction with treatment allocation all contribute to nonretention. Contemporary neuromodulation trials also face additional challenges related to staged treatment pathways, crossover, implantation procedures, and prolonged follow-up, which complicate the definition, reporting, and analysis of attrition. Recent reporting initiatives further highlight persistent inconsistency in participant-flow reporting and missing-data handling in neuromodulation research. Retention should be viewed not as a secondary logistical issue, but as a shared clinical and research responsibility. Greater emphasis on patient-centered retention strategies, transparent attrition reporting, and rigorous management of missing data is essential to strengthen trial integrity, improve interpretability of neuromodulation evidence, and support durable engagement with implanted device therapy in routine care.
The purpose of this review is to present the most updated literature on care considerations for lactating patients in nonoperating room anesthesia (NORA) locations, including interventional radiology and gastroenterology. NORA procedures with anesthesia have been markedly increasing in volume with projections that it will comprise over 50% of anesthetics. Compared to surgery, NORA can be more complex for lactating patients, as it frequently involves additional procedural agents with varying degrees of breastfeeding compatibility because of medication transfer or physiologic challenges. While clinicians may be concerned about infant exposure to medications after patients receive anesthesia, it is important to support the breastfeeding dyad in the perioperative period and only interrupt breastfeeding if indicated. A 'sleep and keep' principle should be employed to minimize unnecessary interruption of breastfeeding. Lactating patients require perioperative support and collaboration between the anesthesiologist and proceduralist to maintain breastfeeding during an already stressful time. Evidence-based resources should be referenced to determine NORA-based medication compatibility and aid patient and physician decision making regarding lactation management perioperatively.
Postoperative follow-up after regional anesthesia is essential for identifying complications, distinguishing expected block effects from pathologic findings, and guiding clinical decision-making. As regional techniques expand into ambulatory settings, scalable and reliable follow-up strategies have become increasingly important, making this a timely area of review. Recent literature highlights the use of mobile applications, automated messaging systems, and telemedicine encounters to improve accessibility and patient engagement in follow-up care. However, these approaches rely heavily on subjective patient-reported data and lack structured, objective assessment, limiting their utility for accurate neurologic evaluation. In-person follow-up remains the gold standard because of its ability to integrate objective examination with clinical judgment. Emerging strategies incorporating structured video-based assessments and artificial intelligence-assisted guidance aim to enhance the quality and consistency of remote evaluations. While digital and remote follow-up models improve scalability, their current limitations necessitate cautious implementation. Hybrid approaches that integrate objective assessment into remote platforms may bridge the gap between accessibility and diagnostic accuracy. Further research is needed to validate these models and define their role in optimizing postoperative care after regional anesthesia.
The growing incidence of acute neurological disorders, has underscored the increasing global need for dedicated neurocritical care (NCC) services. The organization and delivery of NCC services in low- and middle-income countries (LMICs) continue to evolve from a fragmented care system toward a comprehensive care model. This article reviews the available literature on the delivery of NCC services in LMICs and examines key domains, including infrastructure requirements, education and training frameworks, and research capacity, to support organizational models of care. Earlier publications from LMICs highlight the state of NCC services and the persistent rural versus urban disparities in access to specialized care. Authors have also discussed the organization of existing NCC units and have proposed minimum standards for establishing NCC units. In an effort toward standardized care for NCC patients, researchers have focused on strategies to increase education, training, and research capacity. They discuss pragmatic strategies and future directions aimed at strengthening and expanding NCC services across LMICs. There is an urgent need to strengthen NCC facilities across LMICs to mitigate the ongoing variability in clinical practice and service delivery. Addressing NCC infrastructure together with disparities experienced by critically ill patients requires targeted, context-sensitive interventions.
This review aims to address the unique challenges in nonoperating room anesthesia (NORA) locations, emphasizing the importance of patient selection, risk stratification, and comprehensive preoperative evaluation to ensure safe anesthetic care for increasingly complex patients. The volume of NORA procedures has risen significantly, with patients often presenting higher comorbidity burdens and advanced age. Standardized protocols and validated assessment tools, such as the STOP-Bang questionnaire and a simple frailty questionnaire (e.g., FRAIL), can aid anesthesiologists in effectively stratifying risk and tailoring anesthesia plans. Challenges in NORA include logistical constraints, personnel dynamics, and environmental factors that can compromise patient safety. The integration of telemedicine and artificial intelligence into preoperative assessments shows promise in improving efficiency and safety by allowing for remote evaluations and tailored care. Adequate patient selection and preoperative optimization are essential for enhancing outcomes in NORA locations. Adherence to national safety guidelines and multidisciplinary collaboration is crucial for navigating the complexities of remote anesthesia care. Future research should focus on refining preoperative screening methods and utilizing artificial intelligence to better address the unique needs of patients undergoing procedures outside traditional operating rooms.