Background: Patient-controlled intravenous analgesia with remifentanil (RPCA) is increasingly considered as an alternative to epidural analgesia during labor. Its pharmacological profile—ultrashort half-life, rapid metabolism, and ease of titration—offers theoretical advantages in terms of speed, autonomy, and clearance. Nevertheless, questions remain regarding its pharmacodynamic profiles, especially related to its analgesic potential and safety. Objective: To evaluate whether RPCA is an effective and safe method for intrapartum analgesia. Methods: A structured PubMed search (2000–2025) yielded 130 articles. After applying predefined selection criteria, 74 studies were included. These comprised randomized controlled trials, systematic reviews, guidelines, and both prospective and retrospective observational studies. Due to heterogeneity in protocols and outcomes, no meta-analysis was performed. Results: RPCA was more effective than systemic opioids like pethidine in terms of pain relief and maternal satisfaction. Compared to epidural analgesia, RPCA provided less potent pain relief but similar satisfaction in selected patients. Conversion rates to neuraxial techniques ranged from 19% to 41%. Respiratory depression—mostly mild desaturation—was common. Severe maternal complications have been reported, particularly in association with inadequate monitoring or concurrent sedatives. Neonatal outcomes, including Apgar scores and umbilical cord pH, were generally comparable to other analgesic methods. Conclusion: RPCA provides superior pain relief to systemic opioids and may offer a valuable alternative when neuraxial techniques are not feasible. While less effective than epidural analgesia, it can yield high maternal satisfaction. Respiratory events are common and sometimes severe, requiring strict safety measures including uninterrupted midwifery care, continuous saturation and respiratory monitoring, written protocols, a dedicated IV line, and staff trained in cardiorespiratory resuscitation.

Background: Thromboembolic complications are the most frequent risk in endovascular treatment of intracranial pathology. To prevent this, unfractionated heparin (UFH) is used. The effect of heparin is difficult to predict. Therefore, bedside monitoring is necessary by measuring activated clotting time (ACT). Objectives: The aim of this study is to explore which factors are contributing to the variability in ACT values and to assess if a more individualized approach is potentially beneficial. Design: A retrospective, single-center study at Ghent University Hospital. Methods: All patients who underwent an elective interventional neuroradiologic procedure with the administration of heparin between January 2018 and December 2023 were enrolled. A baseline measurement of ACT was done before heparin administration. A second measurement was taken five minutes after administration. A retrospective analysis was conducted to identify potential predictors of ACT levels and their association with heparin dosing. Results: 285 patients (193 males, age 55 ± 12 years) were included. Patients with higher weight (p < 0.001), higher body mass index (BMI) (p < 0.001) and patients already taking acetylsalicylic acid (p < 0.001) and thienopyridines (p < 0.001) received higher doses of heparin. In univariate analysis gender, height, weight, BMI, use of acetylsalicylic acid or thienopyridines, creatinine, AST, aPTT, baseline ACT and heparin dose (p: <0.001, 0.004, <0.001, 0.004, <0.001, <0.001, 0.019, 0.038, 0.003, <0.001, <0.001 resp.) were associated with ACT values. In multivariate analysis baseline ACT, heparin dose, weight and use of thienopyridine (p: <0.001, <0.001, <0.001, <0.001 resp.) were retained as significant independent predictors. Conclusion: Significant interindividual variability exists in ACT response after a loading dose of heparin. A more accurate estimation of the appropriate dose may be possible by considering other influencing factors, such as weight, baseline ACT and preoperative use of antiplatelet therapy. Nevertheless, some level of unpredictability is likely to persist.

Background and Objective: Postoperative delirium (POD) is a common complication of surgery, associated with significant morbidity and additional health care costs. Postoperative cognitive dysfunction (POCD) overlaps with postoperative delirium, but is considered to occur in the months following hospital discharge. The primary aim of this narrative review was to assess the effect of the use of depth of anesthesia (DoA) monitoring on the incidence of postoperative delirium. Secondary aims were to examine the effect of using DoA monitoring on postoperative cognitive dysfunction and the total dosage of anesthetics used. Methods: An extensive search of PubMed and Embase databases was conducted until April 2025. Inclusion criteria were randomized controlled trials and articles published in English, and studies including adult patients under general anesthesia, where anesthetics were titrated using a depth of anesthesia monitor, to determine the incidence of POD or POCD. The quality of relevant articles was assessed using the Cochrane risk-of-bias tool. Results: After full-text evaluation and quality assessment, ten articles were included in this narrative review. Six out of eight articles found a significant decline in POD when using a depth of anesthesia monitor. In comparison, only one of five studies found a significant decline in POCD. Seven study groups concluded that using a DoA monitoring system led to a decrease in the total dose of anesthetic administered. Conclusion: Based on the reviewed literature, there may be a beneficial effect on the incidence of POD when a DoA monitor is used during general anesthesia. The effect on POCD seems to be much less significant. DoA monitoring also seems to be useful in lowering anesthetic dosages. However, this subject needs further study in large-scale prospective studies.

Cardiovascular disease (CVD) has become an increasingly prevalent cause of maternal morbidity and mortality during pregnancy over the past decade. This trend emerges due to rising survival rates in patients with congenital heart disease, but also due to an increased prevalence of acquired conditions such as arterial hypertension. The physiological changes of pregnancy, such as the 40–50% increase in cardiac output and a reduction in systemic vascular resistance in particular, pose significant risks to women with impaired cardiac function. Effective management requires an interdisciplinary Pregnancy Heart Team (PHT), of which anaesthetists are an integral part. Preconception and antenatal anaesthetic assessments are crucial for planning labour analgesia or surgical deliveries, particularly in high-risk cases. The use of regional anaesthetic techniques is generally preferred, although general anaesthesia may be required in emergency situations or when neuraxial blocks are contraindicated. Specialist anaesthetists should be involved in caring for women at risk of acute decompensation or requiring advanced support. It is vital to carefully select anaesthetic agents, as drugs such as methylergometrine, oxytocine and carboprost can exacerbate cardiac stress. Postpartum monitoring is also crucial due to ongoing haemodynamic shifts. Incorporating anaesthesia expertise into coordinated, risk- stratified antenatal and postpartum care improves safety and outcomes for both mother and newborn.

Background: Methoxyflurane (C3H4Cl2F2O, Penthrox), introduced initially as a volatile anesthetic in the 1960s, was later discontinued as a general anesthetic due to nephrotoxicity. However, recent studies have highlighted its significant analgesic properties at subanesthetic doses. This literature review explores the evolution of methoxyflurane from a general anesthetic to a widely used analgesic, focusing on its current applications, safety profile, environmental impact and regulatory aspects. Methods: PubMed, Embase, and Cochrane Library were searched in July 2024 for articles related to methoxyflurane. Results: Effectiveness: Methoxyflurane offers rapid and effective pain relief. Its self-administration feature by inhalation provides significant advantages in situations where time-sensitive pain management is critical. Safety: The safety profile of methoxyflurane is favorable, with only mild, transient side effects such as dizziness and nausea. No significant long-term renal or cardiovascular complications have been observed at subanesthetic doses. Environmental Impact: Compared to other volatile anesthetics, methoxyflurane has a low global warming potential, due to its short atmospheric lifetime and low radiative efficiency. Conclusion: Methoxyflurane has proven to be a potent and effective analgesic, particularly in emergency and trauma care. Furthermore, its lower environmental impact compared to other anesthetics aligns with growing sustainability goals in healthcare. Despite its benefits, further research is necessary to address gaps in its use for vulnerable populations, such as children and pregnant women, and to explore its broader clinical applications and ecological footprint.

Background: Meta-analyses and randomized controlled trials (RCTs) play pivotal roles in evidence-based medicine. However, meta-analyses are increasingly criticized for overestimating treatment effects and lacking agreement with large RCTs, potentially resulting in misleading or premature conclusions that influence clinical guidelines. Small, early-phase trials and publication bias contribute to type I and type II errors, raising concerns about the strength of meta-analytic findings. Trial Sequential Analysis (TSA) is a statistical tool designed to assess the robustness of cumulative evidence by adjusting for random errors and required information size. Objective: This study evaluates the agreement between meta-analyses and subsequent large RCTs in perioperative medicine published between 2015 and 2022. Additionally, it investigates whether TSA alters the interpretation of meta-analytic findings. Methods: A systematic search identified large RCTs (≥1,000 participants, with at least one major dichotomous clinical outcome) and their corresponding preceding meta-analysis. TSA was applied to each outcome to determine whether the meta-analysis had reached a reliable conclusion and to classify results into distinct evidence zones. Results: Of the 23 outcome comparisons assessed, 78.3% of meta-analyses correctly predicted the results of the corresponding large RCTs. However, TSA reclassified several initially ‘accurate’ predictions as inconclusive or potentially false positive, particularly under assumptions of higher relative risk reductions. Conclusion: Although meta-analyses often align with subsequent RCTs, they carry a substantial risk of false positives, especially when based on small studies. TSA adds important nuance by identifying when cumulative evidence is insufficient for firm conclusions. These findings support a cautious interpretation of meta-analyses in clinical decision-making and emphasize the need for large, well-powered RCTs before changing clinical practice.

Objective: The aim of this study is to assess the incidence of postoperative delirium (POD) in patients over 60 years undergoing neurosurgery at our institution. The secondary objectives are to identify risk factors for POD, focusing on preoperative, intraoperative, and postoperative data. Background: POD is one of the most common postoperative complications. Recent meta-analyses indicate that the incidence of POD following neurosurgery is highly variable, particularly for spinal procedures. Accurate risk estimation and the identification of key risk factors are crucial for implementing preventive measures for patients who are most at risk of this complication. Methods: This prospective observational study included 113 patients over 60 years of age undergoing spinal and cranial neurosurgery between May 2023 and September 2023. The incidence of postoperative delirium was assessed using the Nursing Delirium Screening scale (Nu-DESC). Data was collected from preoperative, intraoperative, and postoperative assessments. Results: The incidence of postoperative delirium was approximately 1.8%, which was insufficient to identify significant predictors of delirium. Consequently, post hoc exploratory analyses were conducted. Focusing specifically on lumbar surgery, the findings indicated that psychological factors related to pain, particularly high scores on the Pain Catastrophizing Scale, were strongly associated with postoperative pain (NRS >7). Additionally, longer surgery durations were correlated with a prolonged hospital stay, and redo surgery was a predictor of delayed first mobilization. Conclusions: POD seems to be underrecognized at our institution. Raising awareness among patients and healthcare professionals about the importance of identifying and addressing this complication is essential to improve patient outcomes. Future research should focus on exploring interventions, to further enhance patient outcomes, particularly for those undergoing high-risk surgeries like intracranial procedures.

Background: Studies comparing the effect of different doses of tranexamic acid (TXA) in pancreaticobiliary surgeries are lacking. We conducted this randomized controlled trial to compare the effect of two different doses of TXA on intraoperative blood loss during pancreaticobiliary surgeries. Methods: 62 adult patients undergoing pancreaticobiliary surgeries were randomized to receive either 15mg/kg bolus of TXA before incision (group A) or 15 mg/kg TXA bolus before incision followed by 1/mg/kg/hr TXA infusion for the length of surgery (group B). The primary objective was to compare intraoperative blood loss between the two groups. Secondary objectives were to compare intraoperative blood transfusion, change in hematocrit, length of hospital stay (LOS), incidence of deep vein thrombosis (DVT) and 28-day mortality. Results: There was no significant difference in blood loss between the two groups {553.0 ml (257.5-728.0) in group A and 423.0 ml (313.5-499.0) in group B, p=0.17}. The change in hematocrit (2.2% and 0.4% in groups A and B respectively, p=0.35) and LOS (25 ± 8 days in group A vs. 20 ± 6 days in group B, p =0.80) were comparable between the groups. Both groups had a 0% 28-day mortality and no DVT was observed in any patient. Conclusion: We found that there was no difference in intraoperative blood loss in pancreaticobiliary surgeries when a bolus only or a bolus plus infusion regimen of TXA was used. No patient in either group had thrombotic complications.