The use of prescription opioids has risen dramatically in South Korea in recent years; however, there is no standardized Korean-language instrument to assess opioid withdrawal. The Clinical Opiate Withdrawal Scale (COWS) is a widely used clinician-rated measure for assessing the severity of opioid withdrawal. We aimed to validate the Korean version of the COWS (K-COWS) among patients receiving opioid therapy. We translated and culturally adapted the 11-item COWS into Korean. A total of 66 adult patients with opioid use disorder who were experiencing withdrawal symptoms were assessed. Each patient was evaluated using the K-COWS and completed the Subjective Opiate Withdrawal Scale (SOWS), the brief 3-item Opioid Craving Scale (OCS-3), and the single-item Opioid Craving Visual Analog Scale (OC-VAS). We examined the internal consistency, factor structure [through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA)], and convergent/discriminant validity of the K-COWS. The K-COWS showed good internal consistency (Cronbach's α = 0.79; 95% CI = 0.71-0.86). EFA supported a two-factor structure (physical vs. autonomic clusters) that explained 39% of the variance. In CFA, the two-factor model showed a marginally acceptable fit (χ2  = 47.76, CFI = 0.915, RMSEA = 0.082), whereas the unidimensional alternative showed a poor fit. The K-COWS strongly correlated with the SOWS (r = 0.74, 95% CI = 0.61-0.83, p < 0.001), indicating good convergent validity for withdrawal. In contrast, correlations with the craving measures were weak (OCS-3: r = 0.19, p > 0.05; OC-VAS: r = 0.20, p > 0.05), supporting discriminant validity. The K-COWS is reliable and has demonstrated construct validity for withdrawal severity in Korean clinical settings. Given the preliminary nature of the factor structure, the total score is recommended for clinical decision-making. Future studies should assess inter-rater reliability and confirm the structure in larger, more diverse samples.
Massive transfusion (MT) is critical for trauma patients with severe hemorrhage; however, predicting the need for MT upon hospital arrival remains challenging. Herein, we aimed to identify predictors of MT in adult blunt trauma patients using data from the Korean Trauma Data Bank (KTDB), a nationwide trauma registry in Korea. We retrospectively analyzed data from patients registered in the KTDB from 2017 to 2021. Adult blunt trauma patients who received packed red blood cell (pRBC) transfusion within 24 hours of arrival were included. We divided the patients into the MT and non-MT groups, with MT defined as the administration of ≥ 10 units of pRBCs within 24 hours. We compared the characteristics of the two groups and performed multivariable logistic regression analysis to identify significant predictors of MT, using multiple imputation to address missing data. Among 12,145 patients registered in the KTDB, 2,098 (17.3%) received MT. Compared with the non-MT group, the MT group exhibited lower initial systolic blood pressure, lower Glasgow Coma Scale (GCS) scores, and higher heart rates compared to the non-MT group. Multivariable logistic regression analysis identified systolic blood pressure ≤ 90 mmHg (adjusted odds ratio [aOR], 2.34), heart rate ≥ 120 bpm (aOR, 2.15), respiratory rate < 10 or > 29 breaths per minute (aOR, 2.16), GCS < 13 (aOR, 2.45), and a positive Focused Assessment with Sonography for Trauma (FAST) result (aOR, 2.35) as significant predictors of MT upon arrival. We identified initial systolic blood pressure, heart rate, respiratory rate, GCS, and FAST results as significant predictors of MT in adult blunt trauma patients. These predictors may aid in the development of a Korea-specific MT prediction model, contributing to the timely activation of MT protocols and optimization of blood product utilization.
In the gynecology field, robotic laparoscopic surgery is increasingly being used to enhance the quality of care. The Enhanced Recovery After Surgery (ERAS) program, which improves patient outcomes, is becoming the standard of care, but its impact on gynecological patients remains unclear. We compared the effect of ERAS implementation and conventional care for robotic gynecological surgery. This parallel-group, randomized controlled trial included patients aged 20-70 years undergoing robotic gynecological surgery at a single tertiary medical center in the Republic of Korea. Patients were randomized to conventional care and ERAS groups in a 1:1 ratio. The customized ERAS protocol encompassed minimized fasting, pre-emptive analgesia, transversus abdominis block, and early ambulation. The primary outcome was the Quality of Recovery-15 (QoR-15) score at 24-h and 1-week postoperatively. Secondary outcomes included postoperative pain, ClavienDindo grade ≥ 3 complications, readmission, and length of hospital stay. Of the 66 enrolled patients, data of 65 were analyzed (conventional care, n = 32; ERAS, n = 33). Compared with conventional care, ERAS resulted in a significantly better quality of recovery at 24-h (QoR-15 scores: 93 [71117] vs. 124 [103135], P < 0.001) and 1-week postoperatively (QoR-15 scores: 135 [131142] vs. 142 [136148], P = 0.002). Additionally, the ERAS group had less severe postoperative pain and a shorter length of hospital stay. Complication and readmission rates were comparable between the groups. ERAS implementation in robotic gynecological surgery enhanced the quality of recovery and provided better pain control than conventional care, without affecting patient safety.
Hypertensive patients tend to have an increased risk of hypotension during anesthesia induction, which can result in adverse outcomes. This study aimed to compare hemodynamic stability with remimazolam versus propofol in hypertensive patients. This meta-analysis analyzed randomized controlled trials investigating the hemodynamic outcomes of remimazolam versus propofol during anesthesia induction in hypertensive adults. A systematic search of electronic databases was conducted in November 2024. Six studies were included in the final analysis. The administration of remimazolam significantly lowered the risk of hypotension (risk ratio [RR] = 0.711, 95% CI [0.545-0.929], I2 = 67.54%) and bradycardia (RR = 0.256, 95% CI [0.101-0.649], I2 = 0.0%). It also resulted in a higher minimum mean arterial pressure (mean difference [MD] = 9.023 mmHg, 95% CI [0.243-17.802], I2 = 97.50%) and higher minimum heart rate (MD = 7.200 beats/min, 95% CI [1.960-12.441], I2 = 86.40%). The trial sequential analysis revealed that none of the outcomes reached the required information size. The administration of remimazolam showed a trend toward superior hemodynamic stability compared with propofol during anesthesia induction in hypertensive patients, especially in minimizing the incidence of hypotension and bradycardia. However, the trial sequential analysis results remain inconclusive, the current evidence is limited by small sample sizes, and larger trials are needed to confirm our findings.
Preoperative comorbidities are associated with postoperative acute kidney injury (AKI). However, whether this association is direct or mediated by intraoperative hypotension (IOH) is unclear. We hypothesized that IOH mediates the relationship between preoperative comorbidities and postoperative AKI. Data from adult patients undergoing non-cardiac surgery under general anesthesia were analyzed. Inverse probability of treatment weighting (IPTW) was applied to achieve a balance between the exposure groups by reducing the baseline differences in the measured covariates. Structural equation modeling (SEM)-based mediation analysis was conducted using the American Society of Anesthesiologists physical status (ASA-PS) classification ≥ 3 as an input and postoperative AKI as an outcome. IOH (duration of mean arterial pressure [MAP] < 60 mmHg), along with albumin and hemoglobin levels, was considered a mediator. We also performed interaction analysis between patient sex and age. After IPTW, 8643.9 (10.8%) patients had an ASA-PS of ≥ 3. AKI occurred more frequently (4.5% vs. 6.9%, P < 0.001) in patients with ASA-PS ≥ 3. ASA-PS ≥ 3 was associated with a total effect estimate of 0.02 on the log-odds of postoperative AKI (P < 0.001). Of the total effect of ASA-PS ≥ 3 on postoperative AKI, 48% was significantly mediated by IOH (26%) and hypoalbuminemia (26%), though anemia showed no significance. The effect of high ASA-PS scores on postoperative AKI was significantly modified by sex, but not by age. High ASA-PS scores increase AKI risk after non-cardiac surgery, a relationship partially mediated by statistically significant pathways involving IOH and hypoalbuminemia.
In this paper, we provide a conceptual introduction to linear mixed-effects models (LMMs), statistical approaches that are used for analysis of longitudinal repeated-measure data, for clinical researchers with a limited statistical background. We begin by contrasting LMMs with repeated-measures analysis of variance, and highlight the limitations of the latter approach, including its restrictive assumption of sphericity and its sensitivity to dropout. We show that LMMs overcome these limitations by providing valid inferences under the missing-at-random assumption, accommodating unbalanced designs, and offering flexible options for modeling covariance structures. Beyond addressing the core assumptions of LMMs, we evaluate the implications of modeling time as a numerical versus as a categorical factor. We discuss approaches for handling baseline values, including longitudinal data analysis, constrained longitudinal data analysis, and analysis of covariance, and describe their relative strengths and limitations in both randomized and observational studies. We explain the roles of random effects and residual covariance structures and provide practical guidance for selecting candidate models by using exploratory plots and information criteria, such as the Akaike and Bayesian information criteria. Overall, by providing a clear and accessible conceptual framework, we hope to enable clinical researchers to understand, evaluate, and apply LMMs effectively.
Coughing and hemodynamic fluctuations during emergence from anesthesia after a craniotomy can result in serious complications. This study evaluated whether the ultrasound-guided superior laryngeal nerve block (SLNB) attenuates these tracheal tube-related responses. Eighty patients scheduled for elective craniotomy were randomized into the control (Group C, 2 ml 0.9% saline per side) and SLNB (Group S, 2 ml 1% lidocaine per side) group. The primary outcome was the incidence of coughing during the recovery period. Secondary outcomes included the severity of coughing, hemodynamic fluctuations, need for rescue interventions, anesthesia-related parameters, and complications. Compared to controls, the patients in Group S experienced a significantly reduced incidence (78.9% vs. 48.6%; P = 0.006) and severity (P < 0.001) of coughing during emergence. The mean arterial pressure and heart rate were also more stable during and after extubation in Group S than in Group C. Furthermore, Group S required a significantly lower dose of nicardipine during the emergence period (P = 0.032), and both the incidence of and visual analog scale scores for postoperative sore throat at 6 h after extubation were markedly reduced (P = 0.035). No significant differences were noted between the groups in terms of propofol consumption, emergence agitation, extubation time, post-anesthesia care unit stay duration, or complications. The SLNB significantly suppressed extubation-related responses during anesthetic emergence after craniotomy by reducing coughing and attenuating hemodynamic fluctuations, thereby contributing to a smoother emergence profile.
Laparoscopic surgery in the lateral decubitus position can alter pulmonary mechanics and oxygenation. Although positive end-expiratory pressure (PEEP) may alleviate these effects, the optimal level remains unclear. This study evaluated whether electrical impedance tomography (EIT)-guided PEEP titration improves oxygenation compared to a fixed PEEP of 5 cmH2O. In this randomized controlled trial, 74 adult patients undergoing robot-assisted or laparoscopic urologic surgery in the lateral decubitus position were assigned to either the EIT-guided or standard care group. The EIT-guided group underwent decremental PEEP titration to determine and maintain optimal PEEP throughout surgery. The standard care group received a fixed PEEP of 5 cmH2O. The primary outcome was ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) at the end of surgery. Secondary outcomes included intraoperative respiratory mechanics and postoperative pulmonary complications (PPCs) until discharge. Seventy-one patients completed the study (EIT-guided: 35, standard care: 36). The PaO2/FiO2 ratio at the end of surgery was higher in the EIT-guided group than in the standard care group (523.8 ± 82.4 vs. 414.6 ± 96.7 mmHg, P < 0.001). Driving pressure was lower in the EIT-guided group at 30 min after pneumoperitoneum initiation (15.8 [12.5, 17.4] vs. 19.9 [17.2, 22.5] cmH2O, P < 0.001) and at the end of surgery (9.1 [8.0, 10.4] vs. 10.0 [8.8, 12.6] cmH2O, P = 0.033). PPCs did not differ between groups. EIT-guided PEEP titration improved intraoperative oxygenation. Further studies are needed to assess clinical outcomes.
Addressing sparse nationwide data, this study evaluated the 12-month cumulative incidence and clinical predictors of new-onset post-intensive care syndrome (PICS) and its specific domains among in-hospital cardiac arrest (IHCA) survivors. This nationwide population-based cohort study utilized the South Korean National Health Insurance Service database (2013-2023). New-onset PICS was identified through International Classification of Diseases, 10th Revision (ICD-10) coded diagnoses within administrative claims data, representing healthcare utilization-based incidence rather than true symptomatic prevalence. Within the final analytic cohort of 43,331 hospital survivors, the 12-month cumulative incidence of new-onset PICS was 6.7% (95% confidence interval [CI], 6.5-6.9%). These findings reflect healthcare utilization-based incidence, capturing only those impairments that led to formal medical encounters and ICD-10 coding. In a sensitivity analysis of stable one-year survivors (n = 11,862), the incidence significantly rose to 15.9% (95% CI, 15.3-16.6%). Physical impairment was the dominant domain (15.0%), while cognitive (0.5%) and psychiatric (0.8%) domains showed lower rates, suggesting a potential "masking effect" or "floor effect" due to severe neurological injury. Extracorporeal membrane oxygenation support (odds ratio [OR] 1.44, P < 0.001), and increased length of hospitalization were robust predictors. Notably, the odds of PICS diagnosis significantly escalated from 2021 onwards, peaking in 2022 (OR 2.19) and 2023 (OR 2.12). New-onset PICS, driven by physical decline, affects one in six IHCA survivors surviving the first year. Acute care intensity and recent trends highlight the need for early screening and intensive rehabilitation for high-risk survivors.
Discharge management and workflow efficiency in a postanaesthesia care unit (PACU) can be improved with specific tools assessing discharge readiness. Several authors have found tools to reduce the PACU length of stay (PACU LOS), but results have remained inconsistent. We analysed the effects of the Post-ANaesthesia Discharge Assessment tool (PANDA) on PACU LOS, operating room (OR) holds, PACU nurses' confidence with the discharge decision and their perception of the tools' implementation. This pre-post study with a propensity-matched historical control group evaluated the impact of the semi-automatic PANDA tool in a single primary-level hospital. The tool supports discharge decisions in the PACU. Median PACU LOS pre- and post-implementation was compared using nearest-neighbour propensity score matching and weighted linear regression. OR holds were analysed over 20 consecutive days. A structured nurse survey assessed confidence in discharge decisions and perceptions of the tool's implementation. The study included 8475 patients (pre n = 4509; post n = 3966) and 19 nurses. Median PACU LOS before implementing the PANDA tool was 114 min (IQR 89-144) compared to 103 min (IQR 79-136) after the implementation. The weighted linear model showed an estimated difference in PACU LOS of -16 min (95% CI from -20 to -12 min, p < 0.001). There were too few OR holds for comparison. PACU nurses' confidence in their discharge decision remained unchanged before and after implementation. The PANDA tool received high ratings for acceptability, appropriateness, compatibility and feasibility. Implementing the semi-automated PANDA discharge tool significantly decreased PACU LOS. In addition, PACU nurses reported high acceptance, usefulness and feasibility of the tool. The PANDA discharge tool may optimise routine clinical practice to streamline PACU workflows, support resource allocation and decision-making and promote standardisation. Reducing PACU LOS may also improve patient flow and capacity planning in high-volume settings. The semi-automated PANDA tool was well received by nurses who perceived it as useful and feasible. Given the significant reduction in PACU length of stay, integrating PANDA into clinical practice may enhance post-surgical patient flow and resource allocation, while its main added value lies in improving standardisation, supporting decision-making and PACU workflow.
Deep spinal infection (DSI) is a rare but potentially devastating complication of epidural injections. This study aimed to determine the nationwide incidence and risk factors of DSI after single-shot outpatient epidural injections for pain management. Using customized data from the Korean National Health Insurance Service (Wonju, South Korea) database, all patients who underwent single-shot outpatient epidural injections between 2009 and 2018 were identified. DSI was defined as a new-onset infection within 90 days of the most recent epidural injection that necessitated hospitalization and at least 4 weeks of antibiotic therapy. Multivariable logistic regression was performed to evaluate patient- and procedure-related risk factors. Among 12,049,555 injections in 3,769,014 individuals, 2,422 cases of DSI were identified (0.020% per injection). In multivariable analysis, increased risk was associated with age 65 yr or older (odds ratio [OR], 1.04; 95% CI, 1.04 to 1.05), peripheral vascular disease (OR, 1.38; 95% CI, 1.07 to 1.78), chronic pulmonary disease (OR, 1.33; 95% CI, 1.11 to 1.61), rheumatologic disease (OR, 1.85; 95% CI, 1.41 to 2.43), peptic ulcer disease (OR, 1.42; 95% CI, 1.22 to 1.66), liver disease (OR, 1.57; 95% CI, 1.34 to 1.83), diabetes (OR, 1.44; 95% CI, 1.14 to 1.81), recent immunosuppressant or systemic steroid use (OR, 2.44; 95% CI, 1.73 to 3.45), three or more injections within 90 days (OR, 1.93; 95% CI, 1.47 to 2.55), and lumbosacral-level injections (OR, 1.70; 95% CI, 1.45 to 2.00). In contrast, selective nerve root block was associated with a lower risk of DSI (OR, 0.49; 95% CI, 0.37 to 0.64). Although DSI after single-shot epidural injections is rare, its potential severity underscores the importance of careful patient selection and risk stratification, particularly in older patients, those with comorbidities or immunosuppression, and procedures involving the lumbosacral level.
Placement of an intraoperative urinary catheter frequently leads to catheter-related bladder discomfort (CRBD) in the immediate postoperative period. We assessed the efficacy of a fixed-dose combination (FDC) of acetaminophen/ibuprofen in alleviating CRBD. In this double-blinded, active-controlled, randomized trial, adults aged 20-79 years undergoing elective robot-assisted laparoscopic radical prostatectomy were randomly assigned to one of three groups: intravenous acetaminophen 1 g/ ibuprofen 300 mg (FDC), 1 g acetaminophen alone, or 100 mL normal saline (placebo). The intervention was administered when fascial closure was initiated. The primary outcome was moderate-to-severe grade CRBD (grade ≥3) incidence in the post-anesthesia care unit (PACU). Secondary outcomes included moderate-to-severe CRBD incidence at 1, 2, and 6 h; CRBD grade distribution; pain scores; 24-h opioid requirements; postoperative nausea and vomiting (PONV); medication-related complications; patient satisfaction; and Quality of Recovery-15K (QoR-15K) scores. Overall, 172 patients were analyzed (FDC, n = 58; acetaminophen, n = 57; and placebo, n = 57). Moderate-to-severe CRBD incidence at PACU was 46.6% in the FDC group and 59.6% in both the acetaminophen and placebo groups (P = 0.3). In repeated-measures analysis, CRBD incidence decreased significantly over time across all groups. Between-group differences at individual postoperative time points were limited and not consistently reproduced across assessments. No significant differences were observed in pain score, PONV, opioid consumption, medication-related complications, patient satisfaction, or QoR-15K. Perioperative acetaminophen/ibuprofen FDC administration was well tolerated but did not significantly reduce moderate-to-severe CRBD incidence in the immediate postoperative period. Further studies with scheduled-dosing and investigations in other surgeries are warranted for applicability.
This study aims to evaluate the global burden of adverse effects of medical treatment (AEMT) using data from the Global Burden of Disease Study (GBD) 2021. Data were extracted from the GBD 2021, covering 204 countries/territories from 1990 to 2021. AEMT was defined using ICD-9 and ICD-10 codes, encompassing complications from medical procedures, treatments, or healthcare exposures. Estimates were categorized into fatal and non-fatal outcomes and stratified by age, sex, year, and covariates, including the Socio-demographic Index (SDI). Mortality-incidence ratios (MIRs), defined as the ratio of mortality calculated by dividing the number of deaths by the total incident cases, were analyzed. In 2021, the global age-standardized prevalence, incidence, disability-adjusted life years (DALYs), and mortality rates of AEMT were 11.48 (95% uncertainty interval [UI], 8.86-14.13), 150.44 (131.19-171.81), 64.19 (51.06-73.11), and 1.53 (1.29-1.68) per 100,000 population, respectively. DALY rates were highest in the early neonatal group (4,789.47 per 100,000 population [95% UI, 3,682.00-5,963.30]), while mortality rates followed a U-shaped pattern across age groups. In 2021, MIRs were highest at both ends of the age range: the early neonatal group (0.58 [95% UI, 0.55-0.58]) and the 95+ age group (0.05 [0.04-0.06]). This pattern was consistent across all SDI quintiles, with higher MIRs observed in lower SDI quintiles. The significantly higher prevalence and incidence rates of AEMT among the older population in high SDI quintiles, compared to lower SDI quintiles, could be attributed to the healthcare overutilization, highlighting the need for policy adjustments.
Extracorporeal membrane oxygenation (ECMO) has become a vital life-support tool in critical care, particularly during the COVID-19 pandemic. The rapid growth of ECMO research necessitates bibliometric analysis to identify trends, key contributors, and obstacles, including concerns regarding scientific integrity, such as retractions. A bibliometric analysis was conducted using the Scopus database (search date: August 25, 2025), with the phrase "extracorporeal membrane oxygenation" searched in the title, abstract, or keywords. All English-language publications from 1958 and 2025 were covered. Data on publication trends, prominent countries, institutions, journals, authors, keywords, and citation/Altmetric Attention Scores were obtained. Retractions were detected using standardized queries on PubMed, and data on publication year, retraction year, country, and reasons were obtained. A total of 26,786 ECMO-related publications were examined. The number of publications showed a significant upward trend (P < 0.001), peaking in 2022 with 240 articles. The United States was the leading country (n = 11,261), followed by Germany (n = 2,349), Italy (n = 1,756), China (n = 1,660), and the United Kingdom (n = 1,642). The ASAIO Journal was the most prolific source (n = 1,204). Harvard Medical School (n = 585) ranked first among institutions. Coronavirus disease 2019 (COVID-19)-related papers dominated citation and altmetric impact, with the 2020 JAMA Wuhan cohort publication receiving the most citations (n = 17,423). Between 2012 and 2024, nine ECMO-related articles were retracted. This analysis highlights the significant global growth of ECMO research, demonstrating considerable academic and social impact, particularly during the COVID-19 pandemic. The results offer valuable insights into publication trends, major contributors, and research visibility, potentially informing future research and partnerships in this field.
Spinal anesthesia in older patients can be technically challenging due to degenerative spinal disease. The L5-S1 interspace often remains accessible and is a useful fallback; however, it has been associated with higher rates of therapeutic failure due to inadequate block height. Injection of hypobaric local anesthetic may promote cranial intrathecal spread and address this limitation. We investigated this by evaluating the efficacy and block characteristics of low-dose hypobaric bupivacaine injected at the L5-S1 level in a prospective observational study. Fifty-four patients undergoing elective total hip or knee arthroplasty received ultrasound-assisted spinal anesthesia at L5-S1 with 10 mg of 0.33% hypobaric bupivacaine. The primary outcome was surgical completion without conversion to general anesthesia, supplemental opioids, or local anesthetic infiltration. Secondary outcomes included adequate anesthesia for surgical incision, block pharmacodynamics, hemodynamic stability, adverse effects, patient satisfaction, and surgeon-perceived quality of anesthesia. Surgical completion without anesthetic supplementation was successful in 50 patients (92.6%, 95% CI 82.1-97.8%). Adequate anesthesia for surgical incision was achieved in 53 patients (98.2%, 95% CI 90.1-100%). Four patients required supplemental opioids: one for surgical incision, and three for surgical completion following prolonged injection-to-incision intervals (47-59 minutes) due to unanticipated delays in operating room readiness. No patients required conversion to general anesthesia. Full motor recovery occurred within 198 ± 53 minutes. Patient and surgeon satisfaction with quality of anesthesia was high. Hypobaric 0.33% bupivacaine injected at L5-S1 may be a useful fallback option in lower-extremity arthroplasty if challenging spinal anatomy renders other interspaces inaccessible.
Continuous variables are often dichotomized or categorized in clinical research to improve interpretability or to align with clinical thresholds. However, arbitrary or poorly justified cut-off points can cause substantial information loss, reduced statistical power, and potentially misleading conclusions. In this article, we describe commonly used approaches for determining cut-off points, including guideline-based thresholds, median, or quantile splits, and statistically derived methods, such as receiver operating characteristic (ROC) curve-based approaches (e.g., Youden Index and related criteria). We also discuss the clinical and methodological implications of these approaches using illustrative examples and offer practical recommendations to support the transparent and appropriate use of cut-offs in anesthesia and perioperative research.
Despite various available methods for monitoring a patient's respiratory system, conventional monitors provide limited ventilatory function information. This study explored the feasibility of intraoperative lung sound patterns to discriminate preoperatively diagnosed ventilatory dysfunction. Forty-five patients who had undergone preoperative pulmonary function testing were enrolled for analysis, comprising 15 patients per normal, obstructive, and restrictive group. High-fidelity lung sounds were recorded intraoperatively using esophageal stethoscopes equipped with digital microphone devices. After signal processing, morphological features of the acoustic data, including the inhale/exhale peak ratio (I/Ep), were extracted. Their discriminative abilities for obstructive and restrictive types were assessed and compared with conventional monitoring parameters. I/Ep showed strong discriminative performance, with an area under the receiver operating characteristic curve of 0.950 (95% CI: 0.887-0.991) for obstructive and 0.950 (95% CI: 0.867-0.995) for restrictive types. The median values of I/Ep were 2.9 in the restrictive, 2.2 in the normal, and 1.5 in the obstructive group (P < 0.001). Conventional ventilatory parameters (compliance, peak inspiratory pressure, and slope of end-tidal CO2) did not significantly differ among the groups. Our study demonstrated that the I/Ep derived from intraoperative acoustic data differed according to preoperatively diagnosed ventilatory dysfunction. Hence, acoustic inhale and exhale patterns contain clinically useful information not captured by conventional ventilator parameters. Further studies are warranted to explore the clinical application of acoustic feature analysis for real-time intraoperative monitoring.
Research on the impact of ergonomic risk factors on neuropathic pain is limited. Accordingly, this study investigated the relationship between ergonomic risk exposure and neuropathic pain in a population of South Korean workers. Data were obtained from the third and fourth rounds of the Korean Work, Sleep, and Health Study. Neuropathic pain was identified using the Douleur Neuropathique 4 (DN4) screening tool. The association between ergonomic risk factors and neuropathic pain was analyzed using multiple logistic regression analysis. Odds ratios (ORs) with 95% CIs were estimated after adjusting for relevant confounding factors. Two-wheeled vehicle operation (OR = 3.66; 95% CI, 1.26-10.58), manual material handling (OR = 2.81; 95% CI, 1.63-4.85), kneeling or squatting (OR = 2.47; 95% CI, 1.35-4.53), repetitive hand or finger motions (OR = 2.10; 95% CI, 1.38-3.19), trunk flexion, extension, or lateral bending (OR = 2.13; 95% CI, 1.25-3.63), and wrist twisting, pushing or pulling with upper limbs (OR = 1.90; 95% CI, 1.08-3.34) were significantly associated with neuropathic pain in the fully-adjusted model. This study supports a link between ergonomic risk factors and neuropathic pain among South Korean workers.
Multimodal analgesia has become a foundational principle of acute perioperative pain management and enhanced recovery and involves the application of nonpharmacologic, pharmacologic, and/or interventional techniques. The overall goal of this approach is to apply a combination of different modalities that target discrete points along the pain pathway and thereby avoid the overreliance on opioids and associated side effects. Since our review in 2018, there have been significant developments that have prompted an updated review of multimodal analgesia. In this article, we identify and summarize important trends that influence the current approach to acute perioperative pain management as well as provide an updated clinical guide on multimodal analgesia with an emphasis on novel therapies. While a continued emphasis on multimodal opioid-sparing analgesia remains, additional evidence, newer regional techniques, and novel agents such as suzetrigine have emerged since our last review and have expanded options for perioperative pain management. In addition, special situations require specific recommendations, such as when designing a perioperative pain management plan for surgical patients who have opioid tolerance or live with opioid use disorder. These complex patients are at a higher risk for poor postoperative pain control and other adverse outcomes. This review includes suggested guidance on tailoring multimodal analgesia in this population with patient-specific therapies that can be added for appropriate indications and are supported by available evidence and guidelines.
Postoperative pain may impair recovery; however, its association with postoperative complications remains unclear. We investigated this association in patients undergoing minimally invasive colorectal cancer surgery. This retrospective multicenter study analyzed data from the Korean Enhanced Recovery After Surgery (ERAS) registry collected between October 2023 and December 2025. Adult patients who underwent colorectal cancer resection at six tertiary institutions were included. Pain intensity on postoperative day one was assessed using the pain/discomfort dimension of the EuroQol 5-Dimension 5-Level questionnaire and categorized as mild, moderate, or severe. The primary outcome was overall postoperative complications, defined as a Comprehensive Complication Index (CCI) score ≥ 8.7. The secondary outcomes were major complications (CCI ≥ 26.2) and length of postoperative hospital stay (LOS). Associations between pain severity and outcomes were evaluated using multivariable binary logistic regression for overall complications, Firth's penalized likelihood logistic regression for major complications, and multivariable linear regression for LOS. A total of 985 patients were included. Compared with mild pain, severe pain was associated with higher odds of overall complications (odds ratio, 1.76; 95% CI, 1.11-2.81), whereas neither moderate nor severe pain was associated with major complications. Moderate and severe pain were both associated with longer LOS (LOS ratios, 1.07 [95% CI, 1.01-1.13] and 1.08 [95% CI, 1.02-1.15], respectively). Severe early postoperative pain was independently associated with a higher complication burden and longer LOS. As causality remains unproven, prospective studies are needed to determine whether optimized pain control can directly reduce complications.