The growing number of older adults undergoing surgery necessitates that we address the adverse effects of overt and covert perioperative stroke. Preclinical studies have suggested that anesthesia-induced preconditioning may provide neuroprotection by preserving mitochondrial function, activating cytosolic signaling pathways, and reducing neuroinflammation. However, these promising findings from animal studies have not yet translated into improved clinical outcomes. The discordance between preclinical and clinical outcomes may be due to age-related mitochondrial dysfunction and other comorbidities in older human populations, which reduce the effectiveness of anesthetic preconditioning. Mitochondria, which are central to the effectiveness of preconditioning, may be therapeutic targets to restore the neuroprotective effects of anesthetic preconditioning in the aging brain. Emerging evidence suggests that physical prehabilitation, a key component of Enhanced Recovery After Surgery programs, may influence mitochondrial function and could thus, restore anesthesia-induced preconditioning. Although further research is needed to determine the impact of physical prehabilitation on mitochondrial function and anesthetic preconditioning, incorporating physical prehabilitation into perioperative care might enhance neurological outcomes for older patients undergoing surgery.

The growing number of older adults undergoing surgery necessitates that we address the adverse effects of overt and covert perioperative stroke. Preclinical studies have suggested that anesthesia-induced preconditioning may provide neuroprotection by preserving mitochondrial function, activating cytosolic signaling pathways, and reducing neuroinflammation. However, these promising findings from animal studies have not yet translated into improved clinical outcomes. The discordance between preclinical and clinical outcomes may be due to age-related mitochondrial dysfunction and other comorbidities in older human populations, which reduce the effectiveness of anesthetic preconditioning. Mitochondria, which are central to the effectiveness of preconditioning, may be therapeutic targets to restore the neuroprotective effects of anesthetic preconditioning in the aging brain. Emerging evidence suggests that physical prehabilitation, a key component of Enhanced Recovery After Surgery programs, may influence mitochondrial function and could thus, restore anesthesia-induced preconditioning. Although further research is needed to determine the impact of physical prehabilitation on mitochondrial function and anesthetic preconditioning, incorporating physical prehabilitation into perioperative care might enhance neurological outcomes for older patients undergoing surgery.

The growing number of older adults undergoing surgery necessitates that we address the adverse effects of overt and covert perioperative stroke. Preclinical studies have suggested that anesthesia-induced preconditioning may provide neuroprotection by preserving mitochondrial function, activating cytosolic signaling pathways, and reducing neuroinflammation. However, these promising findings from animal studies have not yet translated into improved clinical outcomes. The discordance between preclinical and clinical outcomes may be due to age-related mitochondrial dysfunction and other comorbidities in older human populations, which reduce the effectiveness of anesthetic preconditioning. Mitochondria, which are central to the effectiveness of preconditioning, may be therapeutic targets to restore the neuroprotective effects of anesthetic preconditioning in the aging brain. Emerging evidence suggests that physical prehabilitation, a key component of Enhanced Recovery After Surgery programs, may influence mitochondrial function and could thus, restore anesthesia-induced preconditioning. Although further research is needed to determine the impact of physical prehabilitation on mitochondrial function and anesthetic preconditioning, incorporating physical prehabilitation into perioperative care might enhance neurological outcomes for older patients undergoing surgery.

The growing number of older adults undergoing surgery necessitates that we address the adverse effects of overt and covert perioperative stroke. Preclinical studies have suggested that anesthesia-induced preconditioning may provide neuroprotection by preserving mitochondrial function, activating cytosolic signaling pathways, and reducing neuroinflammation. However, these promising findings from animal studies have not yet translated into improved clinical outcomes. The discordance between preclinical and clinical outcomes may be due to age-related mitochondrial dysfunction and other comorbidities in older human populations, which reduce the effectiveness of anesthetic preconditioning. Mitochondria, which are central to the effectiveness of preconditioning, may be therapeutic targets to restore the neuroprotective effects of anesthetic preconditioning in the aging brain. Emerging evidence suggests that physical prehabilitation, a key component of Enhanced Recovery After Surgery programs, may influence mitochondrial function and could thus, restore anesthesia-induced preconditioning. Although further research is needed to determine the impact of physical prehabilitation on mitochondrial function and anesthetic preconditioning, incorporating physical prehabilitation into perioperative care might enhance neurological outcomes for older patients undergoing surgery.

Background: Among the various diaphragm-sparing alternatives to interscalene block, costoclavicular block (CCB) demonstrated a low hemidiaphragmatic paresis (HDP) occurrence but an inconsistent analgesic effect in arthroscopic shoulder surgery. We hypothesized that a larger volume of local anesthetic for CCB could provide sufficient analgesia by achieving sufficient supraclavicular spreading. Methods: Sixty patients scheduled for arthroscopic rotator cuff repair were randomly assigned to receive CCB using one of two volumes of local anesthetic (CCB20, 0.75% ropivacaine 20 ml; CCB40, 0.375% ropivacaine 40 ml). The primary outcome was the rate of complete analgesia (0 on the numeric rating scale of pain) at 1 h postoperatively. The secondary outcomes included a sonographic assessment of local anesthetic spread, diaphragmatic function, pulmonary function, postoperative opioid use, and other pain-related experiences within 24 h postoperatively. Results: The rates of complete analgesia were not significantly different (23.3% [7/30] and 33.3% [10/30] in the CCB20 and CCB40 groups, respectively; risk difference 10%, 95% CI [–13, 32], P = 0.567). There were no significant differences in other pain-related outcomes. Among the clinical factors considered, the only factor significantly associated with postoperative pain was the sonographic observation of supraclavicular spreading. There were no significant differences in the incidence of HDP and the change in pulmonary function between the two groups. Conclusions Using 40 ml of local anesthetic does not guarantee supraclavicular spread during CCB. Moreover, it does not result in a higher rate of complete analgesia compared to using 20 ml of local anesthetic in arthroscopic shoulder surgery.

Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.

Sugammadex, the first noncompetitive antagonist developed for the reversal of neuromuscular blockade (NMB), is one of the few drugs that has revolutionized anesthetic practice. However, the use of sugammadex for children between the ages of 2 and 17 years has only recently been approved and is currently not approved for children under the age of 2 years. Although the precision and reliability of reversal of NMB with sugammadex are of great benefit in pediatric anesthesia, several important questions remain regarding its use in our youngest patients. In this brief narrative review, we aim to provide an overview of the key considerations and potential challenges that anesthesiologists often face when using sugammadex in pediatric patients.

Intravenous patient-controlled analgesia (PCA) is valuable for delivering opioids in a flexible and timely manner. Although it is designed to offer personalized analgesia driven by the patients themselves, users often report insufficient pain relief, which can be addressed by optimizing its settings and multimodal analgesia. We adopted a systematic approach to modify PCA protocols by utilizing a serial audit process based on institutional PCA data. This review retrospectively examined the process, encompassing data from 13,230 patients who had used PCA devices. The two modifications to the fentanyl-based PCA protocols resulted in three distinct phases. In the first phase, high opioid consumption and unintended PCA withdrawal were the common issues. These were addressed in the second phase by omitting the routine use of basal infusion. However, this led to increased delivery-to-demand ratios, mitigated in the third phase by increasing the bolus dose from 15 μg to 20 μg. These serial protocol changes have produced varied outcomes across different surgical departments, underscoring the need for careful and gradual adjustments and thorough impact assessments. Drawing insights from this audit process, we incorporated findings from the literature on PCA settings and multimodal analgesic approaches. This review underscores the significance of iterative feedback and refinement of analgesic protocols to achieve optimal postoperative pain management. Additionally, it discusses critical considerations regarding the postoperative audit processes.

Sugammadex, the first noncompetitive antagonist developed for the reversal of neuromuscular blockade (NMB), is one of the few drugs that has revolutionized anesthetic practice. However, the use of sugammadex for children between the ages of 2 and 17 years has only recently been approved and is currently not approved for children under the age of 2 years. Although the precision and reliability of reversal of NMB with sugammadex are of great benefit in pediatric anesthesia, several important questions remain regarding its use in our youngest patients. In this brief narrative review, we aim to provide an overview of the key considerations and potential challenges that anesthesiologists often face when using sugammadex in pediatric patients.