This study investigates long-term survival in the Cancer and Anaesthesia (CAN) study, focusing on the potential impact of local anaesthetic infiltration during breast cancer surgery. A positive effect from peritumoral infiltration has recently been suggested. We conducted an exploratory data analysis to examine a possible association between uncontrolled exposure to local anaesthetics during breast cancer surgery and long-term survival. Breast cancer patients were recruited to compare long-term survival according to whether anaesthesia was maintained with inhaled sevoflurane or intravenous propofol. Other aspects of anaesthesia, such as the use of local- or regional anaesthesia, were carried out pragmatically according to local institutional guidelines. Kaplan-Meier survival curves were constructed to compare survival between those who received local anaesthetics or not. Among 1670 analysed patients, 803 (48.1%) received local anaesthetic infiltration, 67 (4.0%) received a paravertebral block, 75 (4.5%) received both, and 725 (43.4%) received neither. Over a median follow-up of 76.8 months, no significant differences in overall survival were observed - either between the pooled group of patients who received any local or regional anaesthesia (n = 945) and those who received neither (n = 725; p = 0.54), or among all four groups (p = 0.89). We found no association with local-anaesthetic skin infiltration or regional anaesthesia and long-term survival in this non-preplanned secondary analysis of a randomised controlled trial. In this secondary analysis of an observational follow-up study for anaesthetic exposure and cancer outcomes, regional or localized local anaesthetic treatments were not associated with a survival advantage. How regional anaesthesia or local anaesthetics might interact with clinical cancer natural history in patients is still not clear, though the results here do not support a large effect. EudraCT number: 2013-002380-25; ClinicalTrials.gov Identifier: NCT01975064.

Transperineal (TP) prostate biopsy offers reduced infection risk compared to transrectal (TR) methods, but patient discomfort remains a concern, especially under local anesthesia. This study evaluated the discomfort from a TP prostate biopsy under local anesthesia and strategies to decrease pain. This prospective study included 500 consecutive patients undergoing TP prostate biopsy between June 2023 and November 2024. Pre-biopsy magnetic resonance imaging was used to identify target lesions, followed by TP magnetic resonance imaging/ultrasound (ultrasound) fusion biopsy using the Artemis device. A survey questionnaire was administered immediately following the procedure to assess pain scores related to probe insertion, skin infiltration, deep periprostatic block, and overall discomfort, using the Visual Analog Scale (VAS). A total of 450 consecutive patients underwent TP biopsy with local anesthesia, and 50 patients underwent TP biopsy with sedation. No procedures were aborted, and all patients who underwent the procedure under local anesthesia completed the survey. The median overall VAS score was 2 (interquartile range [IQR] 0-3). Ethyl chloride spray and tactile stimulation reduced skin infiltration pain (p = 0.035), while adding sodium bicarbonate reduced deep block pain (p < 0.001). Combined interventions lowered median overall pain from 3 (IQR 1-5) to 1 (IQR 1-3), p < 0.001. Older patients reported less pain (p < 0.001). No association was found between pain and race, prostate size, number of lesions, lesion location, or grade group. The median duration of hematuria was 5 days (IQR 4-8). Two (0.4%) patients in the local anesthesia group developed urinary retention, and two (0.4%) experienced a vasovagal episode. No patients developed sepsis. TP prostate biopsy with local anesthesia is a well-tolerated outpatient procedure when optimized pain control techniques are implemented. Tactile stimulation, ethyl chloride spray, and the use of NaHCO3-buffered lidocaine significantly enhance patient comfort by reducing pain. These strategies enhance patient experience, making TP biopsy a viable outpatient option.

The Plan A blocks framework was proposed in 2019 with the aim of promoting a small number of versatile, high-value regional anaesthetic techniques to build core competencies among all anaesthetists. Clinical practice, educational curricula and academic understanding have evolved since then. We aimed to provide a pragmatic and clinically focused narrative review on the current understanding of Plan A blocks and to explore their implementation and signpost future directions. We conducted a focused literature search for articles of relevance to Plan A blocks. We also searched online resources, including websites of societies and institutions, for evidence relevant to our primary area of interest. Plan A blocks have influenced the Royal College of Anaesthetists' curriculum and inspired several international consensus projects defining core blocks for adult and paediatric practice. Delphi studies have supported the inclusion of interscalene brachial plexus, axillary brachial plexus, femoral and sciatic nerve blocks as key techniques. Despite wide dissemination, challenges hindering clinical practice change persist, including resource limitations; lack of confidence; and variable access to structured training. Emerging educational technologies such as simulation, artificial intelligence-assisted ultrasound interpretation and augmented reality offer promise, but remain limited by cost and fidelity. The Plan A blocks framework has become an established concept and is accepted widely as a pragmatic, scalable strategy. Although barriers remain to clinical practice change, ensuring widespread competence in Plan A blocks and implementation into clinical pathways should improve patient access to regional anaesthesia globally.

Subcutaneous Port Implantation Without Tunneling Site Anesthesia: A Feasible and Efficient Approach?

Surgical safety checklists (SSCs) are widely used tools aimed at reducing postoperative complications and mortality. While compliance is generally high, adherence to individual checklist sections and completeness can vary. This study aimed to assess compliance and completion rates of a locally modified 6-section SSC. We conducted a retrospective analysis of all inpatient and outpatient surgeries performed at a secondary-level hospital in northeastern Switzerland between January 1 and March 31, 2023. The presence and completeness of the scanned SSCs in the electronic medical records were evaluated. Multivariable logistic regression models were used to identify factors associated with missing or incomplete SSCs. A total of 2376 surgeries were analyzed. Overall, SSC compliance was high, with a scanned checklist present in 98% (n=2329) of cases; however, only 73% (n=1734) were fully completed. Missing or incomplete SSCs were more frequent in emergency procedures, outpatient surgeries, cases with local anesthesia, procedures performed on Fridays, certain surgical departments, lower-volume operating rooms, and earlier positions in the surgical schedule. Multivariable analysis confirmed that emergency procedures and the use of local anesthesia were independently associated with lower odds of full SSC completion. No clear associations were found with age, sex, health insurance type, or whether procedures were performed during regular operating hours. The "Sign-In" and "Team Time-Out" sections had the highest completion rates, whereas "Patient Ready for Operating Room" and "Sign-Out" were most frequently omitted. This study demonstrated a high overall rate of SSC compliance, though variation among checklist sections was observed. Specific contexts-particularly emergency and outpatient settings-were associated with reduced completeness, indicating opportunities for targeted quality improvement.

Dexmedetomidine for procedural sedation during ophthalmic surgery is popular, in part due to high levels of patient satisfaction and analgesia, and low intraocular pressure and respiratory depression, compared to alternative medications. However, longer recovery times were reported when dexmedetomidine was used for cataract or vitreoretinal surgery. Because of these reports, a concern was raised by our hospital's retinal surgeons and administrators that dexmedetomidine might be delaying discharge home from the postanesthesia care unit. Therefore, we performed a retrospective analysis of discharge times of all patients undergoing vitreoretinal surgery under regional anesthesia and sedation at our high-volume ophthalmology specialty hospital. Data from all cases involving vitreoretinal surgery in adults performed with sedation were extracted from the hospital's electronic health record system. Discharge times were calculated from the end of surgery (eye dressings applied) until discharge home from the phase II postanesthesia care unit. Using general linear models, discharge times were compared between patients who received dexmedetomidine or other medications for sedation between fiscal year (July 1 to June 30) 2020 and fiscal year 2024. The modeling controlled for interactions between sedation group and year, and included the anesthesia clinician administering the sedation as a fixed effect. The fraction of cases during which dexmedetomidine was used for sedation during vitreoretinal surgery increased progressively from <0.7% in 2019 to 91.3% by 2023. Among the 6180 cases with dexmedetomidine, the mean (standard deviation ) dose of dexmedetomidine, normalized for body weight and the interval from entering the operating room to the end of surgery, was 0.24 (0.20) µg/kg/h. Intermittent bolus doses were administered without infusion in 96.3% of cases. The mean discharge time among the dexmedetomidine cases did not differ significantly from the 2274 cases without dexmedetomidine (-2.04 minutes; 95% confidence interval, -5.71 to 1.65 minutes; P = .28). A low-dose, bolus dexmedetomidine technique did not prolong the time to home discharge when administered for sedation during vitreoretinal surgery. Managerial concerns about such use prolonging discharge times following vitreoretinal surgery are unwarranted.

Wide-awake local anesthesia no tourniquet (WALANT) is increasingly used for flexor tendon repair, but comparative data versus general/regional anesthesia(GA/RA) are limited. The aims of the WAFER trial were to generate high quality comparative data on WALANT versus GA/RA for flexor tendon repair and assess the feasibility of performing a large multicenter trial of this nature. WAFER was a multicenter, assessor-blinded, parallel-group RCT with embedded qualitative and health economic components across four major hand units. Patients were randomized on a 1:1 basis to have flexor tendon repair under GA/RA or WALANT. The primary feasibility outcomes were recruitment, retention and trial acceptability in addition to clinical outcomes which included range of motion (Total-active-motion score), grip/pinch strength, finger circumference, complications and patient reported outcome measures(PROMS) (Michigan-Hand-Questionnaire, EQ-5D-5L). Qualitative interviews were conducted with clinicians and participants to assess acceptability and equipoise. Economic analyses summarized intra-operative costs and impact on productivity. The primary analysis set was per-protocol. Sixty participants were randomized across all sites (30 WALANT; 30 GA/RA); 56 were analyzed per-protocol. At 6 months, mean TAM score(SE) for GA/RA was 67.6(5.6) vs 60.3(6.3) in the WALANT group. Tendon rupture was reported in two patients in the GA/RA group and three in the WALANT group. PROMs improved over time in both groups, patients in the WALANT arm reported consistently higher MHQ scores across domains. Participants in WALANT arm returned to work earlier than participants in GA/RA arm (mean 3.0 vs 6.7weeks). Intra-operative costs were lower with WALANT by 54% (-£398, 95% CI -£509 to -£287). A pragmatic comparison of WALANT versus GA/RA with tourniquet for primary flexor tendon repair is deliverable and safe. Inter-arm clinical differences were small; however, WALANT showed lower intra-operative costs and a signal for earlier return to work.

Inguinal hernia repair is one of the most common surgical procedures worldwide and is frequently performed as day-case surgery. Postoperative pain may delay recovery and occasionally necessitate unplanned hospital admission. Regional anesthesia techniques, including transversus abdominis plane (TAP) and rectus sheath (RS) blocks, have shown promise in improving analgesia. However, their combined efficacy in open inguinal hernia repair has not been established in randomized trials. The PRO-RSTAP trial is a prospective, double-blind, four-arm randomized controlled trial conducted at three hospitals in Finland. The study evaluates the individual and combined effects of TAP and RS blocks in adults undergoing elective open inguinal hernia repair. Two hundred patients are randomized equally into four groups: (1) placebo TAP + placebo RS, (2) active TAP + placebo RS, (3) active RS + placebo TAP, and (4) active TAP + active RS. All patients receive standardized sedation and multimodal analgesia, including paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), and rescue opioids. The primary outcome is cumulative perioperative opioid consumption from block administration until hospital discharge, expressed as intravenous morphine equivalents. Secondary outcomes include pain scores, conversion to general anesthesia, postoperative nausea and vomiting, time to discharge, and unplanned admissions or emergency visits within 7 days. The planned sample size provides 80% power to detect a clinically meaningful reduction in opioid use (two-sided α = 0.05). Analyses follow the intention-to-treat principle. The first participant was enrolled in September 2025, and the trial is ongoing. No interim efficacy analysis is planned. Safety is monitored continuously throughout the study. This randomized controlled trial is designed to determine whether combining TAP and RS blocks improves postoperative analgesia and recovery after open inguinal hernia repair. The results will contribute to evidence-based optimization of regional anesthesia strategies in ambulatory surgery. EU Clinical Trials Information System (CTIS): 2024-513406-59-00; ClinicalTrials.gov identifier: NCT07423910.

Perioperative anxiety plays a key role in patients, particularly for postoperative recovery. Immersive virtual reality (VR), which has been developed in recent years for use in regional anesthesia, may help reduce this anxiety and limit intraoperative sedative consumption. The aim of this study was to objectively assess the impact of VR distraction on perioperative anxiety by evaluating sedative use during total knee arthroplasty (TKA) under spinal anesthesia (SA). A retrospective, single-center cohort study was conducted in patients receiving SA with a VR headset (group 1), compared to those receiving SA alone (group 2). The primary outcome measure was intraoperative sedative consumption. Secondary outcomes included perioperative complications (oxygen administration, hypotension) and analgesic consumption within five postoperative days (nefopam and oral morphine equivalent). Pearson's Chi-square and Wilcoxon-Mann-Whitney tests were used to assess categorical and continuous variables, respectively. There were 30 patients (group 1) who used a VR headset during the procedure, while 30 patients (group 2) received SA alone. The mean age was 71 years. There was a significant reduction in intraoperative sedative consumption in patients undergoing TKA under SA with VR (95% confidence interval [0.13 to 0.87], P = 0.018). A reduction in nefopam consumption within the five postoperative days was also observed (95% confidence interval [-0.1 to 33.7], P = 0.005). There were no significant differences found regarding oxygen administration, intraoperative hypotension, and length of hospital stay or oral morphine equivalent consumption within five postoperative days. The use of VR is an innovative approach that appears effective in reducing sedative consumption without increasing perioperative complications in patients undergoing TKA under SA. This promising study encourages further large-scale research to better assess the impact of VR in surgeries performed under SA. IV.

Regional anaesthesia in Video or Robot assisted thoracic surgery: A French multicentre prospective observational cohort study (ARTIST study).

Periacetabular osteotomy, commonly performed for prearthritic hip dysplasia, was identified as a procedure that could benefit from an enhanced recovery after surgery pathway due to wide variation in multimodal pain management and regional anesthesia practices at our institution. The global aim of this project was to implement an enhanced recovery after surgery pathway for patients undergoing periacetabular osteotomy. Our SMART aim was to achieve greater than 70% compliance for the intraoperative medication bundle elements during the first PDSA cycle. A multidisciplinary pathway was designed and implemented with key stakeholders from the Departments of Evidence Based Practice, Anesthesiology, Orthopedic Surgery, and Perioperative Nursing. Patient data from all patients undergoing periacetabular osteotomy from 2018 to the present were analyzed, which included the baseline cohort as well as outcomes from two Plan-Do-Study-Act cycles. After ERAS implementation and two subsequent Plan-Do-Study-Act cycles, we observed a decrease in hospital length of stay from 3.34 days (95% CI [2.95, 3.72]) to 2.37 days (95% CI [2.00, 2.74]) and an intraoperative medication bundle compliance of 90%. These gains occurred with minimal change in average postoperative pain scores and no hospital readmissions within 30 days of surgery. Multidisciplinary enhanced recovery after surgery pathways continue to play a critical role in standardizing perioperative care, reducing unwarranted variation, and promoting faster recovery across paediatric populations.

For total knee arthroplasty (TKA) performed in an ambulatory setting, reliable analgesia is essential for same-day discharge (SDD). Although adductor canal blocks (ACBs) are effective, access to anesthesiologist-performed ACBs (aACBs) may be limited by regional anesthesia availability in resource-constrained centers. Even when expertise exists, lack of perioperative workflow integration can reduce efficiency, prolong procedural time, and increase costs. The objective of this study was to evaluate whether surgeon-performed ACBs (sACBs) are non-inferior to aACBs regarding time to discharge, perioperative outcomes, and patient-reported outcome measures. A prospective randomized controlled trial of 200 SDD TKA patients was conducted. Participants were randomized to receive preoperative aACB or intraoperative sACB. The primary outcome was time from spinal anesthetic reversal to discharge. The secondary outcomes included Numeric Pain Rating Scale (NPRS), 24-hour morphine milligram equivalent use, SDD failure, 24-hour readmission, and patient-reported outcome measures at baseline and two weeks postoperatively. Power analysis used a representative SDD TKA sample detecting a 15% difference in the primary outcome (power 80%, α = 0.05). Time to discharge was not different in sACB compared to aACB: 209.5 minutes (range, 10 to 510) compared to 231.1 (range, 59 to 455), P = 0.06. Secondary outcomes showed no significant differences: NPRS at baseline, 4.3 (aACB) versus 4.3 (sACB), P = 0.87; and NPRS at discharge, 2.4 (aACB) versus 2.9 (sACB), P = 0.07. The 24-hour opioid consumption was 35.8 morphine milligram equivalent (aACB) versus 43.6 (sACB), P = 0.31. There were no 24-hour readmissions. There were 13 patients who failed SDD: eight (aACB) versus five (sACB), P = 0.42. The sACBs were non-inferior to aACBs for outpatient TKA. An sACB represents a safe alternative that may reduce reliance on limited anesthesia resources. With standardized perioperative integration, sACB may improve operating room efficiency and reduce costs.

Regional Anesthesia for Hip Fracture Surgery in Frail Adults: Primary Anesthetic and Perioperative Analgesic Approaches.

To evaluate the clinical feasibility and anaesthetic efficacy of a combined Bier block and brachial plexus block administered with xylazine sedation (seda-block) for metacarpal and radioulnar osteosynthesis in neonatal calves, and to compare this technique with conventional xylazine-ketamine anaesthesia. Prospective controlled pilot study. Fourteen client-owned neonatal calves undergoing unilateral forelimb osteosynthesis. Calves were randomly allocated to two groups: seda-block (SB; n=7), receiving intravenous xylazine combined with brachial plexus block and intravenous regional anaesthesia, and xylazine-ketamine (XK; n=7), receiving intravenous xylazine followed by ketamine. Sedation quality, desensitization, surgeon satisfaction, xylazine consumption and need for supplemental dosing were evaluated intraoperatively. Sedation scores, desensitization scores and surgeon satisfaction did not differ significantly between groups. Total xylazine consumption and surgery duration were comparable. Repeated xylazine administration was required in both groups to maintain immobility; however, adequate surgical conditions were achieved without conversion to general anaesthesia in the seda-block group. The combined use of Bier block and brachial plexus block with xylazine sedation may provide clinically acceptable surgical conditions under the specific conditions of this study, and could represent a practical alternative to general anaesthesia in selected neonatal calves.

Rebound pain, a sudden increase in pain intensity after resolution of regional anesthesia, remains a major challenge in postoperative patient care. Intravenous (IV) dexamethasone has been proposed as a preventive strategy, but whether its effectiveness varies across patient characteristics remains unclear. This retrospective study included patients who underwent upper extremity orthopedic surgery under brachial plexus block (BPB). Rebound pain was defined as the occurrence of both severe pain (numeric rating scale ≥ 7) and rescue analgesic administration between 4 and 24 hours after BPB. The association between IV dexamethasone and rebound pain was evaluated using multivariable logistic and generalized random forest (GRF) models. Among the 1,171 patients, 651 (55.6%) received IV dexamethasone. The dexamethasone group had a significantly lower incidence of rebound pain (7.1% vs. 16.9%, P < 0.001) with delayed onset (median 14 vs. 11 hours). IV dexamethasone was an independent protective factor (odds ratio, 0.42; 95% confidence interval [CI], 0.27 to 0.64; P < 0.001). GRF analysis estimated an average treatment effect of -0.09 (95% CI -0.13 to -0.05), corresponding to a 9% absolute risk reduction. Calibration testing demonstrated accurate model (GRF) estimation (mean coefficient, 0.98; P < 0.001) and no statistically detectable heterogeneity in treatment effect (differential coefficient, -0.30; P = 0.713). IV dexamethasone was associated with reduced rebound pain without evidence of meaningful heterogeneity in treatment effect in patients undergoing upper extremity surgery under BPB. These findings suggest a potential preventive role for dexamethasone as an adjunct to perioperative pain management in this population.

Beyond the OR: Continuous Ambulatory Regional Analgesia Feasibility and Early Signal for Improved Maturation

Facial aesthetic surgery is increasingly performed under local anesthesia, with or without sedation, in office-based settings. This systematic review and meta-analysis aimed to determine the safety profile of such procedures by measuring the incidence of complications following facial cosmetic surgery under local anesthesia, with or without sedation. A systematic review of the literature was performed in line with the PRISMA guidelines. The databases PubMed, Embase, Scopus, CINAHL, and Web of Science were searched. Studies reporting on complications following facial cosmetic surgery performed in outpatient settings under local anesthesia, with or without sedation, were included. The pooled weighted incidence of complications was calculated using a random-effects inverse variance model with Freeman-Tukey transformation. Twelve studies were included, with a procedure pool of 3283. The incidence of total complications was 5.6%, 95% CI [2.8, 9.3]. The incidence of major complications was 1.6%, 95% CI [0.1, 4.3], while minor complications occurred in 3.7%, 95% CI [2.0, 5.7], of cases. Combined facial aesthetic procedures were uncommon, with 9% of patients undergoing multiple procedures in the same operative setting. Facial cosmetic surgery under local anesthesia, with or without sedation, appears to be associated with a low incidence of complications. Combined procedures were uncommon, indicating that operative scope in these settings is generally limited. Substantial heterogeneity among studies underscores the need for standardized definitions of complications, anesthetic protocols, and evidence-based patient selection criteria. Future research should focus on developing these frameworks and incorporating validated outcome measures to further optimize safety and patient satisfaction. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Syringe liposuction is widely used for submental contouring in office-based practice because it requires simple equipment and can be performed under local anesthesia. However, there is little quantitative guidance for setting target aspirated volume based on universally obtainable preoperative findings. This study aimed to develop and internally evaluate a regression equation to preoperatively predict aspirated volume using only outpatient-accessible measures. In this single-center prospective observational study, we analyzed 63 consecutive patients who underwent submental liposuction with the syringe technique between January and August 2025, all operated on by a single surgeon. Preoperative variables included vertical length, transverse width, caliper-based skinfold thickness at the neck base, palpation-based subcutaneous firmness (score 1-3), and body mass index (BMI). The primary outcome was aspirated volume (mL) measured in the syringe at the end of the procedure. Pearson correlations were calculated, followed by multiple linear regression using the least squares method. For clinical practicality, skinfold thickness, vertical length, BMI, and firmness were selected as explanatory variables for the final prediction model. Model performance was summarized using MAE and RMSE, and internal validation was performed using bootstrap optimism correction. The cohort comprised 53 women (84.1%) and 10 men, with a median age of 26.0 years. Mean skinfold thickness was 12.3±3.6 mm, mean vertical length 3.7±0.6 cm, median BMI 21.4, and median aspirated volume 19.0 mL. Aspirated volume correlated positively with skinfold thickness (r=0.639), vertical length (r=0.587), and BMI (r=0.466), and negatively with firmness (r=-0.386). The multiple regression model showed good fit (R2=0.610, adjusted R2=0.569, F=14.63, p=5.80×10-10). The resulting equation was: aspirated volume (mL) = -7.3587 + 0.7904×skinfold thickness (mm) + 0.3084×vertical length (cm) + 0.8934×BMI - 4.3066×firmness (1-3). Overall prediction error was MAE 3.51 mL and RMSE 4.77 mL; 50/63 cases (79.37%) were within ±5 mL absolute error. A practical regression equation based solely on simple outpatient measurements predicts submental liposuction volume with moderate accuracy. This model may support standardized planning of target aspirated volume and provide a quantitative basis for education and patient counseling in office-based aesthetic practice. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The rapid rise in intravitreal injections (IVIs) for vitreoretinal disorders underscores the need to optimize the procedure and support long-term patient compliance. Patient-reported pain and discomfort remain significant barriers to adherence. This systematic review evaluates the efficacy and safety of various local anesthetic methods for mitigating pain during IVIs. Conducted in accordance with PRISMA guidelines, a comprehensive search of PubMed and Google Scholar was performed to identify English-language randomized controlled trials (RCTs). Eligible studies included patients aged 18 years and older receiving local anesthesia for IVIs, where pain was quantified using standard visual or oral analog scales (0-10 or 0-100). Our systematic review and meta-analysis included 14 RCTs comprising 1,300 patients. Analysis of topical lidocaine, tetracaine, and proparacaine formulations showed comparable analgesic efficacy, with all agents consistently achieving mild mean Visual Analog Scale (VAS) pain scores. No clinically meaningful superiority was identified among these primary agents (p = 0.62). Adjunctive therapies, particularly physical cooling (e.g., ice patches), demonstrated significant pain-reducing potential. While oxybuprocaine alone was less effective, its combination with physical cooling achieved the lowest mean pain scores. Meanwhile, topical NSAIDs showed limited additional benefit. Regarding safety, subconjunctival anesthetic injections were associated with a significantly higher incidence of subconjunctival hemorrhage and chemosis compared to topical applications, suggesting that topical strategies provide a favorable safety and efficacy profile for routine intravitreal injections. In conclusion, this systematic review and meta-analysis confirms that no single topical anesthetic is superior for intravitreal injections; all primary agents provide comparable, effective pain control. Topical application is safer than subconjunctival injection, which is associated with higher rates of hemorrhage and chemosis. Consequently, clinical protocols should standardize low-risk topical methods and incorporate simple non-pharmacological adjuncts, such as physical cooling, to optimize patient comfort.

Pain is one of the most common reasons for presentation to the emergency department, yet it remains frequently undertreated despite effective therapies. Emergency physicians must provide timely analgesia while accounting for diagnostic uncertainty, patient heterogeneity, and safety concerns, particularly related to opioid use. This narrative review synthesizes contemporary evidence on multimodal pain management in emergency medicine. A focused literature search of PubMed and Scopus was conducted to identify studies published between 2015 and 2025, as well as selected landmark studies and major clinical guidelines. Multimodal analgesia, combining pharmacological and non-pharmacological strategies targeting different pain pathways, is associated with improved pain control and reduced opioid use in emergency settings. Key elements include early pain assessment, timely initiation of therapy, opioid-sparing approaches, and use of non-opioid analgesics, low-dose ketamine, and regional anesthesia. Implementation remains inconsistent due to operational constraints such as overcrowding, workflow pressures, and variability in clinician experience. A structured, patient-centered multimodal approach may improve pain control and support safer, more consistent analgesic care in emergency medicine.