Emergence Delirium (ED) following general anaesthesia affects up to a third of paediatric patients. Its multifactorial aetiology suggests that the metabolic state derived from preoperative fasting plays a significant role. Ketonemia, a physiological state associated with fasting, has been minimally investigated as an independent risk factor for ED. The KETOMED study aims to determine whether preoperative ketonemia is independently associated with the development of emergence delirium in the paediatric population. Multicentre observational study in paediatric patients under general anaesthesia. Participants will be grouped based on the presence or absence of ED, defined using the Paediatric Anaesthesia Emergence Delirium (PAED) scale. Inclusion and exclusion criteria have been based on age, surgical type, and anaesthesia protocol. Main outcome will be ED and its association with ketone levels. Secondary outcomes include other clinical and sociodemographic risk factors and parental satisfaction. Despite the number of studies showing the beneficial role of ketone bodies in cerebral development, little is known of their potential role in the induction of ED. KETOMED addresses this issue in a robust prospective study using validated tools, including the Spanish translation of the PAED scale. KETOMED is expected to establish evidence supporting the implementation of low-cost preoperative ketonemia screening. The results have the potential to guide clinical practice regarding fasting management and clear fluid administration, ultimately aiming to reduce the incidence of ED and improve the quality and safety of paediatric anaesthetic recovery.
Cardiopulmonary resuscitation (CPR) is a core competency in anesthesiology residency training. In Spain, updated data on how this training is structured and the involvement of anesthesiology departments in in-hospital CPR has been lacking. This study aimed to describe the characteristics of CPR training provided to anesthesiology residents in teaching hospitals, assess whether the training is accredited and by whom, and analyze the role of anesthesiology departments in hospital resuscitation teams. Cross-sectional study based on an online survey distributed in March 2025 to instructors accredited by the European Resuscitation Council (ERC) and, in their absence, to department heads or tutors from the 125 teaching hospitals with Anesthesiology residents in Spain. The survey included 25 items covering demographic data, training, clinical involvement, and technological resources. A total of 123 hospitals responded (98.4%). In 108 of them (87.8%), residents received advanced life support training, and 50 centers (40.7%) offered ERC-accredited programs. Training showed heterogeneity in terms of format, accreditation, and timing. In 60 hospitals (48.8%), anesthesiologists were active members of in-hospital cardiopulmonary resuscitation teams. The availability of mechanical chest compression devices and extracorporeal membrane oxygenation (ECMO) systems was 50.4% and 44.7%, respectively, with regional variability. Although most teaching hospitals provide CPR training, significant disparities exist in accreditation, clinical exposure, and resource availability. Greater standardization is required through accredited, continuous programs incorporating simulation and structured debriefing. Strengthening the role of anesthesiology departments in hospital resuscitation could enhance resident preparedness and ultimately improve patient safety and clinical outcomes.
Preoperative anaemia is a common finding in patients undergoing gastrectomy, and is frequently targeted in optimisation strategies. However, its independent association with postoperative complications remains unclear, and the prognostic value of redefining diagnostic thresholds has not been formally assessed. This prospective substudy of the POWER 4 cohort included 742 patients undergoing elective gastrectomy for cancer. Anaemia was defined by WHO sex-specific thresholds (Hb <13 g/dL in men, <12 g/dL in women) and a universal threshold of <13 g/dL. Four subcohorts were analysed: A1 (WHO, full cohort), A2 (universal, full), B1 (WHO, untreated), B2 (universal, untreated). Multivariable logistic regression was used to assess associations with postoperative complications. Discrimination was evaluated using AUC, AIC/BIC, and Net Reclassification Improvement (NRI). Generalised additive models (GAMs) were used to explore continuous relationships between haemoglobin and risk. Anaemia prevalence was 38.0% with WHO thresholds and 52.4% with the universal threshold. In full-cohort models, anaemia was not independently associated with complications (A1 OR 0.92 [95% CI 0.60-1.41]; A2 OR 0.89 [0.59-1.36]). Model performance was similar (AUC 0.686). In untreated patients (n = 584), discrimination improved (B1 AUC 0.750; B2 AUC 0.743), but anaemia remained non-significant. NRI modestly favoured the universal threshold (A1/A2: 0.048; B1/B2: 0.072), with most reclassification occuring in intermediate risk groups. GAMs showed a smooth monotonic relationship without a clear inflection point. Anaemia was not independently associated with postoperative complications. Redefining thresholds altered prevalence but did not improve prediction. Haemoglobin may be better used as part of an integrated perioperative risk assessment rather than a binary stratifier.
Managing difficult airways in cancer patients remains a significant challenge for anesthetists worldwide due to the risk of serious complications. Therefore, this study aimed to evaluate the feasibility of awake orotracheal intubation using the C-MAC D-Blade in cancer patients with predicted difficult airways undergoing elective surgery under general anesthesia. We enrolled 180 cancer patients with difficult airways, as assessed by the El-Ganzouri Risk Index. Awake orotracheal intubation was performed using the C-MAC D-Blade, with topical local anesthesia and sedation. The primary outcome was the first-attempt intubation success rate. Secondary outcomes included the total intubation time, hemodynamic changes, patient responses, complications, and the ease of the procedure, assessed by both anesthesiologists and patients using a visual analog scale (VAS). First-attempt intubation was successful in 89.4% of patients (n = 161), 8.3% (n = 15) required a second attempt, and 2.2% (n = 4) required a third attempt. No failed intubations were recorded. The mean intubation time with its standard deviation was 40.8 ± 9.01 s. At one and two minutes after intubation, heart rate and mean arterial blood pressure increased significantly from baseline values (P < .001). Tooth damage occurred in three patients, bleeding gums in seven patients, and tissue edema in four patients. The median VAS score for both anesthesiologists and patient satisfaction was 9, indicating high procedural feasibility. Additionally, a statistically significant positive correlation was observed between the number of intubation attempts and cough severity (P = .001). Awake video-laryngoscopic intubation using the C-MAC D-Blade achieved a high first-attempt success rate (89.4%) with minimal complications in cancer patients with predicted difficult airways. These results suggest it is a safe and effective option when careful assessment, adequate topical anesthesia, and appropriate sedation are ensured, although comparative studies are needed to better define its role. Registered at clinicaltrial.gov registry system (clinical trial identifier: PACTR202408730457046).
Aging is a complex process that reduces the body's functional reserve, with cognitive decline being its manifestation at the cerebral level. Cognitive impairment may worsen after surgery and anesthesia. The aim of this study is to describe the incidence of cognitive decline before and after surgery, as well as its associated factors in patients aged ≥65 years. This is a prospective and contextual, study on perioperative cognitive decline, using a convenience sample in a university hospital in Spain. Preoperative cognitive evaluation was performed using the Mini-Mental State Examination (MMSE), the Digit Span Test (both forward and backward), the Free and Cued Selective Reminding Test (FCRST), the Trail Making Test A and B, and the Digit Symbol Substitution Test. Postoperative evaluation was conducted using the abbreviated IQCODE interview. A total of 100 outpatients were studied (mean age 74.46 ± 6.49 yr). Forty-four patients (44%) had preoperative cognitive decline. Variables associated with preoperative cognitive decline included education level (OR 2.11), alcohol consumption (OR 3.37), Barthel Index (OR 2.29), and polypharmacy (OR 2.32), depression (OR 3.48), or COPD (OR 11.5). Following the IQCODE interview, 18% of patients exhibited postoperative cognitive decline. Undiagnosed pre-existing cognitive dysfunction is very common in older patients awaiting surgery, and an important number experience worsening or new onset of cognitive decline following surgery.
The main objective of this study was to create and validate a metric for the correct performance of orotracheal intubation with an angled blade video laryngoscope (GlideScope®). The secondary objectives were to break down the technique into correct phases and steps (competency metrics), define errors and critical errors. Prospective observational study divided into two phases. In phase I, the metric was created: a group of experts deconstructed the procedure, identifying phases and defining the competence metrics and errors with the help of three previous recordings. The metrics were stress-tested for objectivity and consensus was sought in a meeting of 24 experts using the modified Delphi methodology. In phase II, the metric was validated by recording 9 experienced and 9 novice professionals performing the procedure on a mannequin. Subsequently, 2 external evaluators, previously trained in the use of the metric, evaluated the videos independently. A metric was created, defined by 4 phases, 22 competency metrics, and 31 errors, of which 16 were considered critical. Experienced professionals completed more competency metrics than novices (17.05 vs. 13.72 (p = 0.010), had fewer total errors (p = 0.0017) and fewer critical errors 0.55 vs. 2.61 (p < 0.001). Inter-rater agreement for the total score of all videos was >0.80. The metric created is valid and reliably discriminates between operators who are competent and those who are not competent in performing the technique.
To describe the clinical characteristics of patients over 80 years admitted to the Surgical Intensive Care Unit (SICU) of Hospital de La Princesa, and to identify admission variables associated with mortality and prolonged hospital stay. As a secondary objective, we explored decisions regarding limitation of therapeutic effort (LTE), their predictors, and their impact on survival and length of stay. Retrospective observational study including 100 patients over 80 years admitted to the SICU. Clinical, demographic, and prognostic variables were collected, including age, sex, type of surgery, SOFA and Charlson scores, nutritional status (CONUT), and frailty. Multivariate analysis was performed to identify factors associated with mortality, length of stay, and LTE. Mean age was 85.8 years (SD ± 4.2). Thirty-day mortality was 16%, and mean ICU length of stay was 5.36 days (SD ± 8.2). Mechanical ventilation was the only factor independently associated with mortality (OR 16.6; 95% CI: 1.5-180.6). Development of sepsis and use of vasoactive drugs were associated with longer hospital stays (p < 0.05). LTE decisions were made in 68% of deceased patients, with no significant differences in survival or length of stay between patients with and without LTE. Mechanical ventilation is the main predictor of mortality in patients over 80 years admitted to SICU. Sepsis and vasoactive support prolonged hospital stay. LTE decisions are frequent in this population, although no clear predictors for their application were identified.
Data comparing the effects of caudal epidural anaesthesia and perianal block during anal sphincter sparing procedures under general anaesthesia are limited. We aimed to compare the efficacy and safety of ultrasound-guided caudal block versus perianal block on anal sphincter muscle tone and in reducing postoperative pain among patients undergoing anal sphincter-sparing procedures. This randomized double-blinded study enrolled 46 adult patients, American Society of Anesthesiologists physical status I or II, who underwent anal sphincter sparing procedures under general anaesthesia. Patients were randomly assigned to one of two groups (23 patients each). Group A received an ultrasound-guided caudal block, while Group B received a perianal block. The primary outcome was duration of postoperative analgesia. Secondary outcomes included total postoperative morphine consumption, postoperative pain intensity, time to postoperative ambulation, intraoperative external anal sphincter muscle tone by Digital rectal scoring system (DRESS), patient satisfaction, and incidence of complications. Patients in group A had a statistically significant longer time to first request for analgesia and lower morphine consumption than those in group B (2.50 ± 0.27 vs. 1.57 ± 0.53 h, and 3.30 ± 2.18 mg vs. 5.87 ± 2.05 mg, P < .001). Although these differences are modest in magnitude, they may contribute to improved recovery when combined with multimodal analgesia strategies. Moreover, caudal block resulted in shorter time to ambulation (2.17 ± 0.38 vs 3.48 ± 0.53 h), and low numeric pain scores (1.96 ± 0.56 vs. 3.48 ± 0.66, P < .001). The DRESS and Likert scores were significantly higher in patients in group A than in group B (2.83 ± 0.38 vs. 2.22 ± 0.42, and 3.78 ± 0.42 vs. 2.48 ± 0.66, P < .001). In anal sphincter-sparing operations, ultrasound-guided caudal epidural blocks combined with general anaesthesia may improve pain management, reduce opioid requirements, and thereby reduce the incidence of postoperative nausea and vomiting, while maintaining anal sphincter tone compared to local perianal block.
Premedication is essential in paediatric surgery for smooth induction and anxiety relief. Common agents-ketamine, midazolam, dexmedetomidine, and fentanyl-are administered via intramuscular injection, intravenous infusion, or oral routes, but efficacy varies and no consensus exists on an optimal protocol. Intranasal delivery offers a promising, more comfortable alternative with potential to improve outcomes. This double-blind randomized trial evaluated intranasal dexmedetomidine (1 mcg/kg) (group D) versus midazolam (0.2 mg/kg) as premedication in 90 children (2-12 years) (group M) undergoing corrective surgery for acyanotic congenital heart disease (CHD). Sedation, parental separation anxiety, mask acceptance, and hemodynamic parameters were evaluated. Acceptable sedation was achieved in 62.2% of children in group D and 53.3% in group M. Group D showed superior anxiolysis during separation from parents (93.3% vs. 73.3%) and better mask acceptance during induction (93.3% vs. 53.3%). A statistically significant but clinically mild decrease in diastolic BP occurred in the dexmedetomidine group without adverse effects. Both drugs were effective as intranasal premedication. However, dexmedetomidine showed better results in sedation, less anxiety upon separation from parents, and greater acceptance of the mask, without significant side effects.
Parental accompaniment during anesthesia induction in pediatric patients has become a key strategy in the humanization of surgical care. Various studies have demonstrated its benefits in reducing anxiety in both the pediatric patient and their parents, promoting cooperation and enhancing the perioperative experience. Consequently, there is a need for a clinical practice guideline to guide anesthesiology professionals in the safe and consistent application of this intervention. To develop a clinical practice guideline that establishes evidence-based recommendations, based on expert consensus, for implementing parental accompaniment during anesthesia induction in the pediatric operating room. The Humanization Working Group of the Pediatric Section of the Spanish Society of Anesthesia and Resuscitation (SEDAR) conducted a systematic review of national and international scientific literature, complemented by a multidisciplinary consensus process using the GRADE methodology and the Delphi technique. The guideline defines inclusion and exclusion criteria for patients and companions, proposes a structured action protocol, details safety measures, staff training, and communication strategies with families. Additionally, it offers specific recommendations for different hospital contexts and clinical situations. This guideline serves as a practical tool to facilitate the implementation of parental accompaniment in pediatric operating rooms, in line with policies of humanization and quality of care. Its adoption will help improve the pediatric perioperative experience and strengthen the trust relationship between healthcare professionals and families.
Chronic musculoskeletal pain in older adults is associated with unhealthy lifestyles, possibly influenced by social determinants of health (SDH). To identify the association between SDH and unhealthy lifestyles in older adults with chronic musculoskeletal pain. A cross-sectional study was conducted. A structured survey was administered to assess SDH (gender, educational level, income, availability of green spaces, rurality, multimorbidity, and cohabitation) and lifestyles (physical activity: IPAQ; sleep quality: abbreviated PSQI; perceived stress: PSS-4; adherence to the Mediterranean diet: MedDiet Score). Mann-Whitney U tests and multivariate logistic regression models were applied. One hundred people were included (mean age 69.0 ± 9.8; 83% women). Forty percent were physically inactive, 71% had poor sleep quality, 36% had high perceived stress, and 76% had low adherence to the Mediterranean diet. Female sex was associated with poorer sleep quality (p = 0.023), absence of green areas with less weekly walking time (p = 0.042), multimorbidity with higher perceived stress (p = 0.039), and low educational level with lower adherence to the Mediterranean diet (p = 0.022). These findings were maintained in logistic regression models adjusted for age, body mass index, and pain intensity. Being female, having lower educational attainment, living without access to green areas, and presenting multimorbidity were associated with poorer sleep, decreased dietary adherence, lower physical activity, and higher stress, respectively. These findings correspond to associations observed in a cross-sectional design and do not allow causal relationships to be established.
Different adjuvants are used in combination with intrathecal local anesthesia to improve the quality of spinal anesthesia. Opioids are most used for this purpose, but these are associated with side effects such as pruritus and postoperative nausea and vomiting. Various medications have been utilized for prophylaxis or treatment of these side effects especially pruritus. Although mu-receptor antagonists are generally used intravenously or subcutaneously for the treatment of pruritus, few studies have investigated the role of intrathecal mu-receptor antagonists. So, this systematic review aimed to evaluate the effect of using intrathecal mu-receptor antagonists when used with local anesthetics like bupivacaine, and opioids for the prevention of opioid-related side effects. This meta-analysis was conducted while following PRISMA guidelines. We registered this review with the PROSPERO database in February 2025. Two authors performed the literature searches in February 2025 and then repeated after one month to ensure accuracy. Two authors independently appraised the individual studies according to the Consolidated Standards of Reporting Trials checklist. Literature search was done using online databases including PubMed, Google Scholar, Science Direct and Cochrane library. Potential bias was evaluated using the risk of bias-2 (RoB-2) tool. We included randomized controlled trials that compared intrathecal mu-receptor antagonists with control for patients undergoing surgery under spinal anesthesia. The primary outcome of the study was the incidence of pruritus. We utilized the Review manager software, RevMan for MAC 5.4, to conduct the meta-analysis. Mean difference (MD), standard mean difference (SMD) and odds ratios (OR) were calculated for different outcomes. Using random effect models, Peto odd ratios were used for weighing models. Funnel plots and Egger's test were utilized to assess the risks for publication bias across studies. A total of 9 randomised controlled trials (n = 653) were included in this systematic review and meta-analysis. The incidence of pruritus in mu-receptor antagonist group was 19.3 vs 58.8 in the control group with an OR of 0.15 [P < .00001, (CI 0.11-0.21)]. Mu-receptor antagonists significantly reduced the incidence of PONV with an OR of 0.26 [P < .00001, (CI 0.18-0.36)]. I2 value for pruritus was 32% while it was 72% for PONV. There was no significant difference in VAS pain scores between two groups during the first 24 h except at 2 h postoperatively. Furthermore, the use of intrathecal mu-receptor antagonists did not significantly affect the time to first analgesic request. The use of intrathecal mu-receptor antagonists significantly reduces the occurrence of opioid-related side effects such as pruritus and PONV.
Chronic post-surgical pain (CPSP) affects 17% of patients undergoing surgery, and identifying those at risk is essential. In this analysis, we used the GENDOLCAT scale to evaluate the risk of CPSP (rCPSP) in patients scheduled for surgery and characterise those with rDCPQ ≥ 30%. We included patients scheduled for surgery in whom the rCPSP was calculated during the preoperative assessment using the GENDOLCAT scale, which includes the following variables: age, type of surgery, preoperative pain at the surgical site, preoperative pain in other areas of the body, and the physical and mental dimensions of the SF-12. We calculated the rCPSP of 589 patients who were divided into 4 groups according to the aggressiveness of their surgery. Four risk groups were defined: ≤10%; >10%-20%; >20%-30%; and ≥30%; the latter being high risk. A total of 22.8% (n = 134) had an rDCPQ ≥ 30%; the mean age was 48.9 ± 12.9; preoperative pain at the surgical site was 4.8 ± 3.5 (VNS) and 5.3 ± 2.9 (VNS) beyond the surgical site; the SF-12 physical and mental dimension scores were 34.7 ± 10.6 and 41.6 ± 12.4, respectively. Of this group, 34% (n = 46) underwent minimally aggressive procedures. A high proportion of patients scheduled for surgery have a high risk of DCPQ, although many undergo minimally aggressive procedures. This shows the importance of using a systematic method to determine the risk of DCPQ in all surgical patients.
Opioid-free anesthesia (OFA) aims to achieve effective perioperative pain control while avoiding the adverse effects associated with opioid use. Its usefulness in breast surgery remains poorly studied. The primary objective of this study was to compare morphine consumption in the post-anesthesia care unit (PACU) between patients undergoing opioid-free anesthesia and those receiving conventional opioid-based anesthesia. A retrospective, observational, single-center study was conducted at the University Hospital of A Coruña. A total of 87 patients who underwent breast surgery between January and July 2022 were included. Two groups were compared: opioid-free anesthesia (OFA, n = 41) and conventional opioid-based anesthesia (non-OFA, n = 46). The need for morphine rescue at PACU discharge, at 24 h, and at 48 h postoperatively (if patients remained hospitalized) was recorded. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), oral tolerance, night rest, and length of stay in the PACU and hospital. The OFA group showed significantly lower morphine consumption in the recovery unit (9.8% vs. 47.8%; P < .001), with an absolute risk reduction of 38.1%. No PONV events were observed in the OFA group compared with 21.7% in the non-OFA group (P = .001). Delayed oral tolerance was more frequent in the non-OFA group (0% vs. 15.2%; P = .013), and night rest was also better in the OFA group (94.4% vs. 65.7%; P < .05). No differences were found in PACU or hospital length of stay. The OFA technique provided adequate analgesic control with a significant reduction in postoperative adverse effects. Opioid-free anesthesia in breast surgery is a safe and effective technique that improves postoperative recovery.
Maternal hypotension is common during spinal anesthesia for cesarean delivery and is influenced by patient position. Positioning also affects sensory block height, which determines visceral analgesia. This study compared immediate supine, sitting, and semi-sitting positions to identify the optimal balance between cardiovascular stability and surgical anesthesia. In this randomized controlled trial, 216 ASA II term parturients scheduled for cesarean delivery under spinal anesthesia were assigned to three groups (n = 72). Group A received immediate supine positioning, Group B sat for three minutes, and Group C assumed semi-sitting for three minutes. All received 2.5 mL of 0.5% hyperbaric bupivacaine. The primary outcome was maternal hypotension; secondary outcomes included block height, intraoperative discomfort, vasopressor use, and neonatal Apgar scores. Hypotension occurred most in Group A (65.3%), followed by Group C (47.2%) and Group B (33.3%) (P < .001). The supine group had 3.79 times higher odds of hypotension compared with sitting. Ephedrine use was greatest in Group A (14.5 ± 3.2 mg) and least in Group B (8.1 ± 2.3 mg). Median block height was T3 in Group A, T5 in Group C, and T6 in Group B. Intraoperative discomfort was highest in Group B (22.2%) compared with Group C (12.5%) and Group A (5.6%) (P = .009). Hypotension correlated with nausea, most frequent in Group A (19.4%). Neonatal Apgar scores were ≥8 at 1 and 5 min in all groups. Maternal position after spinal anesthesia significantly influences hemodynamics and block height. Sitting reduces hypotension but risks lower block and discomfort, while semi-sitting provides a favorable compromise. [NCT06857162].
Lumbar plexus block (LPB) can be used with different techniques for anaesthesia and postoperative analgesia during femoral surgery. This study aimed to compare in-plane and out-of-plane methods using the Shamrock technique. Forty-two patients scheduled for surgery due to femoral neck fractures were included in this randomized controlled study. The Shamrock technique was used to visualise the lumbar plexus. Patients were randomized to 2 groups: one group received LPB using the in-plane technique (IP group, n = 20), and the other received LPB using the out-of-plane technique (OOP group, n = 20). The primary outcome measure was block procedure time. Secondary outcomes included the number of needle insertions and redirections, needle depth (cm), minimal nerve stimulation (mA), sensory and motor block levels, and epidural spread. No statistically significant difference was found between the groups in block procedure times (p > 0.05).The number of insertions and the number of needle redirections were significantly lower in the OOP group compared to the IP group (p = 0.005). The needle depth was significantly greater in the IP group compared to the OOP group (6.5 ± 1.1 cm vs 5.1 ± 0.8 cm, p = 0.001). No difference was found in sensory and motor block times (p > 0.05). No differences were observed in the number of patients with epidural spread or in the incidence of complications (p > 0.05). The OOP technique demonstrated similar efficacy to the IP method using the Shamrock technique. The OOP technique can be used as an alternative for elderly patients in whom the IP technique can be difficult.
Interscalene brachial plexus block (ISB) remains the gold standard nerve block in shoulder arthroscopic surgery. However, some anatomical variations exist in addition to several reported complications and technical challenges. Upper trunk block (UTB) may be a feasible alternative. The primary outcome was the success rate of UTB and ISB. Secondary outcomes included: duration of block performance, guidance interventions, visualization of anatomic structures, postoperative pain and opioid consumption, and diaphragmatic function. One hundred and twenty patients were divided randomly into 2 groups; 60 patients received ISB before general anaesthesia (GA) and 60 patients received UTB before GA. All blocks were performed by anaesthesia trainees under supervision of an attending consultant. Age, sex, BMI, and duration of surgery were not different statistically. The duration of block performance was significantly longer in the ISB group (P = 0.002). Guidance interventions in the ISB group were higher than the UTB group (P < 0.001). There were no significant differences regarding the worst postoperative pain score (P = 0.574), postoperative nalbuphine consumption (P = 0.813) or success rate (P = 0.31) between groups. Visualization of the anatomic structures in the 2 groups was not statistically significant (P = 0.183). Diaphragmatic function was significantly affected in the ISB group (45% complete paralysis and 35% paresis) versus (8.3% complete paralysis and 30% paresis) in the UTB group. UTB may be considered a safer and a technically easier approach than ISB for providing equivalent intra and postoperative regional analgesia in arthroscopic shoulder surgery by anaesthesia trainees.
The widespread adoption of ultrasound in regional anaesthesia has profoundly changed both clinical practice and the way this field should be taught. The current challenge is not merely the availability of more blocks or approaches, but preventing the growing number of variants and terms from leading to fragmented learning and inconsistent clinical decision-making. From this standpoint, competence should be viewed as the integration of clinical judgement, evidence-informed selection, pharmacological knowledge, safe technical performance, proper documentation, patient communication, and follow-up. Within such a framework, simulation should occupy a central place in training pathways not only during residency, but also in the continuing education of professionals involved in regional anaesthesia, because it supports competency-based progression and allows more objective assessment of learning outcomes. Accreditation processes promoted by scientific societies may help standardise practice, provided that adequate educational resources and teaching capacity are available for real implementation. In high-pressure clinical settings with frequent staff turnover, standardisation of training and care processes does not oppose clinical individualisation, but rather makes it safer, more reproducible, and better adapted to each patient's characteristics.
The cornerstone of vasopressor treatment for distributive shock is norepinephrine; however, the administration of high doses is associated with significant adrenergic toxicity and increased morbidity and mortality. Angiotensin II, a recently approved physiological alternative to norepinephrine within a multimodal vasopressor strategy, has the advantage of rebalancing the renin-angiotensin-aldosterone system and reducing catecholamine doses. This review analyses the role of angiotensin II in distributive shock, exploring its pharmacodynamic characteristics and its impact on haemodynamic stability. The evidence collected to date has identified specific groups that derive clinical benefit, particularly patients with acute kidney injury, acute respiratory distress syndrome, or prior exposure to renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors). Dynamic assessment tools, such as the AIMRITE (Angiotensin-II Initial MAP Response Index of Treatment Effect) index, may be useful for assessing early response to angiotensin II and supporting therapeutic decisions at an early stage. Ultimately, angiotensin II allows clinicians to implement personalised, safe therapeutic measures that are tailored to the complexity of the critically ill patient.
Total knee arthroplasty (TKA) is associated with significant postoperative pain. Regional analgesic techniques targeting femoral nerve (FN) and adductor canal (AC) are commonly employed; however, uncertainty persists regarding optimal injection site within the AC. Cadaveric investigations provide anatomical insights into injectate spread patterns, but their interpretation requires caution when extrapolating to clinical practice. Twelve thighs from six embalmed human cadavers underwent ultrasound-guided injections of different-colored dyes, with equal volumes administered at three predefined locations: FN, proximal AC, and distal AC. Subsequent anatomical dissections were performed to assess nerve staining patterns. Injection sites and volumes were standardized to allow for comparative anatomical evaluation. Femoral-level injections stained the femoral nerve and its major branches. Proximal AC injections consistently stained both the saphenous nerve and nerve to vastus medialis, whereas distal canal injections predominantly stained the saphenous nerve with only variable distal obturator involvement. The vaso-adductor membrane stained consistently after proximal canal injection. No sciatic nerve staining was observed. Equal-volume dye injections at the FN, proximal AC, and distal AC demonstrate distinct patterns of neural staining. Proximal AC injections resulted in consistent staining of both SN and NVM, whereas distal injections predominantly involved SN. These findings provide anatomical relevance regarding adductor canal block techniques but do not imply clinical superiority of any technique. Clinical correlation is required before extrapolating these observations to clinical practice.