Perioperative Medicine Research Articles

Geriatric surgery centers: the way forward.

Department of Anesthesiology, Perioperative Medicine and Pain, Brigham and Women’s Hospital, Boston, Massachusetts Address Correspondence to: Angela M. Bader, MD, MPH, Department of Anesthesiology, Perioperative Medicine and Pain, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: [email protected]

ЭКСТРЕННОЕ КЕСАРЕВО СЕЧЕНИЕ С РЕПРОТЕЗИРОВАНИЕМ МИТРАЛЬНОГО КЛАПАНА В СВЯЗИ С ЕГО ДИСФУНКЦИЕЙ

Department of Anesthesiology, Perioperative Medicine and Pain Treatment, Shaare Zedek Medical Center, affiliated with Hebrew University, Jerusalem, Israel

Making Regional Anaesthesia Safe

The complexity of current practice in anaesthesiology and perioperative medicine has resulted in employing complex regional anaesthesia techniques to improve patient outcomes in terms of better postoperative pain control and thus facilitate early mobilization and recuperation of patients. However, ensuring patient safety while performing these complex procedures is of paramount importance and all efforts need to be undertaken to minimise the possibility of harm to the patient. Quality improvement and patient safety go hand in hand. Ensuring safe practices in regional anaesthesia is not just an individual task but a collective responsibility of the perioperative team. It thus involves both technical skills as well as non-technical skills and human factors. This article provides a brief discussion of the various measures involving technical and non-technical factors to improve patient safety in modern day regional anaesthesia practice. Keywords: Regional Anaesthesia, Patient safety, Non-technical skills, Human factors

Optimizing neuromuscular blockade management for improving patient safety and peri-operative outcomes: a pilot phase of a quality improvement initiative.

Although quantitative monitoring of neuromuscular blockade (NMB) is recommended, it is not routinely used in daily practice. The optimizing NMB management to improve patient safety and perioperative outcomes (OBISPO) quality improvement (QI) initiative intends to address this issue and change clinicians' behaviors. A pilot phase of the prospective QI intervention was conducted. The primary objective was implement clinical practice change that emphasizes improving NMB monitoring in patients undergoing elective cardiac surgery who are eligible for fast-track extubation between February 2021 and December 2021. The secondary objective was to reduce the train-of-four ratio (TOFR) < 0.9 incidence before tracheal extubation to less than 20%. The intervention included educational sessions for teams. A total of 859 patients underwent elective cardiac surgery, 40% were eligible for fast-track extubation. From our cohort of fast-track cardiac cases, 69% had reported TOFR; 47% of them had residual paralysis (TOFR < 0.9) on arrival to PACU, 22% persisted with residual paralysis after extubation, and 27% were extubated without monitoring. The survey identified cognitive biases, knowledge gaps, unfamiliarity, and lack of trust in quantitative monitoring devices. Workflow disruptions imposed by COVID and changes in NMB monitoring devices have negatively affected our initiative. Our study showed that changes in clinician behavior are among the most challenging issues in perioperative medicine. Continuous teaching and QI initiatives, focused on quantitative NMB monitors and adequate reversal agent use, are mandatory to improve perioperative outcomes. Therefore, new proposals are required to promote changes in current practices.

Artificial Intelligence (AI) in Perioperative Medicine

Artificial Intelligence (AI) in Perioperative Medicine

Cross-sectional study on utilisation of social media by regional anaesthesia and acute pain medicine fellowship programs in the United States.

Social media provides a platform for physicians helping them change the practice in anaesthesiology as it promotes both personal and professional growth. In this cross-sectional study, we identify social media presence and engagement of Accreditation Council for Graduate Medical Education (ACGME)-accredited Regional Anesthesia and Acute Pain Medicine (RAAPM) fellowship programs, specifically on Twitter (Twitter Inc., San Francisco, CA) and Instagram (Meta Platforms Inc., Menlo Park, CA). This article presents current evidence about social media presence and engagement of ACGME-accredited RAAPM fellowship programs on Twitter and Instagram. These findings could potentially help cultivate greater social media engagement in the RAAPM community and improve recruitment of prospective applicants. The list of ACGME-accredited RAAPM fellowship programs for the academic year 2020-2021 was obtained from the ACGME website. Accounts were searched by reviewing each program's website for profile links and by querying for the name of the program directly on Twitter and Instagram. Department of Anesthesiology, Perioperative and Pain Medicine accounts were analysed for posts pertaining to RAAPM elements, and RAAPM fellowship-specific accounts were investigated. Accounts that were solely focused on an anaesthesiology residency were excluded. All posts over the academic year period of 1 July 2020 to 30 June 2021 were analyzed. While many programs had active departmental social media accounts during our study, there was a dearth of RAAPM-related output (3.4% of tweets and 2.7% Instagram posts). Furthermore, only 10% of programs had RAAPM fellowship-specific Twitter accounts, of which only 5% of programs were active. Finally, there were no RAAPM fellowship-specific Instagram accounts. While there is robust use of social media by departmental accounts, there is a paucity of RAAPM-related content and RAAPM fellowship-specific social media accounts. The current gap provides valuable opportunities for future investigations into the cyber footprint and innovative engagement strategies for the RAAPM community.

Big data in anaesthesia: a narrative, nonsystematic review

Data generation is growing with the use of ‘anaesthesia information management systems’ (AIMS), but the appropriate use of data for scientific purposes is often wasted by a lack of integration. This narrative review aims to describe the use of routinely collected data and its potential usefulness to improve the quality of care, first by defining the six levels of integration of electronic health records as proposed by the National Health Service (NHS) illustrated by examples in anaesthesia practice. Secondly, by explaining what measures can be taken to profit from those data on the micro-system level (for the patient), the meso-system (for the department and the hospital institution) and the macro-system (for healthcare and public health). We will next describe a homemade AIMS solution and the opportunities which result from his integration on the different levels and the research prospects implied. Opportunities outside of high-income countries will also be presented. All lead to the conclusion that a core dataset for peri-operative global research may facilitate a framework for the integration of large volumes of data from electronic health records. It will allow a constant re-evaluation of our practice as anaesthesiologists to offer the best care for patients. In this regard, the training of some anaesthesiologists in data science and artificial intelligence is of paramount importance. We must also take into account the ecological footprint of data centres as these are energy-consuming. It is essential to prepare for these changes and turn the speciality of anaesthesia, collaborating with data scientists, into a more prominent role of peri-operative medicine.

Perioperative medicine for Older People undergoing Surgery (POPS): Comprehensive Geriatric Assessment (CGA) and optimization in the perioperative setting.

Perioperative medicine for Older People undergoing Surgery (POPS): Comprehensive Geriatric Assessment (CGA) and optimization in the perioperative setting.

Simulating high-fidelity emergency front-of-neck access: Training in an obstetric setting.

In a cannot intubate, cannot oxygenate scenario (CICO), emergency front of neck access (eFONA) is the final lifesaving step in airway management to reverse hypoxia and prevent progression to brain injury, cardiac arrest and death. The Difficult Airway Society (DAS) guidelines advise the scalpel cricothyroidotomy method for eFONA. Anatomical and physiological changes in pregnancy exacerbate the already challenging obstetric airway. We aim to assess the impact made by introducing formal eFONA training to the perioperative medicine department of an obstetric hospital. Ethical approval and written informed consent were obtained. 17 anesthetists participated, (two consultants, one senior registrar, four registrars and eight senior house officers). Study design was as follows: Initial participant survey and performance of a timed scalpel cricothyroidotomy on Limbs & Things AirSim Advance X cricothyroidotomy training mannikin. Difficulty of the attempt was rated on a Visual Analogue Scale (VAS). Participants then watched the DAS eFONA training video. They then re-performed a scalpel cricothyroidotomy and completed a repeat survey. The primary endpoint was duration of cricothyroidotomy attempt, measured as time from CICO declaration to lung inflation confirmed visually. After a three-month period, participants were reassessed. Four anesthetists had previous eFONA training with simulation, only one underwent training in the previous year. The mean time-to-lung inflation pre-intervention was 123.6 seconds and post-intervention was 80.8 seconds. This was statistically significant (p = 0.0192). All participants found training beneficial. Mean improvement of VAS was 3. All participants' confidence levels in identifying when to perform eFONA and ability to correctly identify anatomy improved. On repeat assessment, 11/13 participants successfully performed a surgical cricothyroidotomy, mean improvement from first attempt was 12 seconds (p = 0.68) which was not statistically significant. This method of training is an easily reproducible way to teach a rarely performed skill in the obstetric population.

ANALYSIS OF THE EFFECT OF ARNICA MONTANA ON EDEMA AND ECCHYMOSIS IN RHINOPLASTY

Introduction: Edema and ecchymosis are the two most common complications that occur in the immediate postoperative period after rhinoplasties. Arnica montana is a homeopathic medicine used in wound healing and to improve edema and ecchymosis. The purpose of this study is to compare the benefit of Arnica montana used topically with the oral route after rhinoplasty. Methods: In this clinical trial, study subjects were divided into three groups. The first group received topical Arnica montana gel, the second group received it orally, and the third was the control group. Patients had photographs taken to analyze the edema and ecchymosis on the 1st and 7th postoperative days. The photographs were analyzed by two peer reviewers, who classified the edema and ecchymosis in degrees. Results: The mean age was 27.08 years, ranging from 16 to 53 years old. Female individuals predominated. For the two variables analyzed (edema and ecchymosis), results indicate there is no significant difference between the groups at both assessment times. Conclusion: In our prospective study, we found no significant differences between patients who underwent rhinoplasty who received the perioperative homeopathic medicine Arnica montana orally and topically from those in the control group.

Perioperative outcomes in intermediate and high-risk patients after major surgery following introduction of a dedicated perioperative medicine team: A single centre cohort study.

Intermediate and high-risk patients undergoing surgery are often managed on a surgical ward in the absence of haemodynamic or ventilatory support requirements necessitating intensive care unit or high dependency unit admission. We describe a model of care for the multidisciplinary management of selected postoperative patients and the epidemiology of patients managed using this model at a tertiary Australian hospital.Of 25,139 patients undergoing inpatient surgery at our institution over a two-year period, 506 (2%) were referred to the Perioperative Medicine team. The median age of patients referred was 74 years; 85% had an American Society of Anesthesiologists physical status ≥3, and 44% underwent emergency surgery. Major complication or death within 30 days was 44.2% (213/482). The most common complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program were transfusion within 72 h (17.4%), pneumonia/aspiration pneumonitis (11.3%), and acute renal failure (10.6%); median time to Medical Emergency Team call was 146 (interquartile range 77-279) h.Sixty-six percent of referred patients (280/423) required an intervention during their time under the service. This high incidence indicates that this population of patients merits closer attention, including routine measurement and reporting of postoperative outcomes to monitor and improve quality of care at our institution as part of an integrated perioperative service. We believe that with so much current focus on perioperative medicine, it is important we translate this to clinical care by evolving traditional models of management into more innovative strategies to meet the complex demands of today's surgical patients.

Attendance at anaesthetic or perioperative medicine preadmission clinic and the relationship with unplanned ICU and/or HDU admission Postoperatively

Quality perioperative care not only involves careful preoperative assessment but also identifying the appropriate level of postoperative care. For some patients this involves planned admission to ICU or High Dependency Unit (HDU) postoperatively. With the limited resources and existent bed pressures it is important this postoperative destination is identified in advance. In this study we aimed to assess whether attendance in specialist preadmission clinic, involving an assessment by either an anaesthetic consultant or perioperative medicine physician, was related to unplanned ICU/HDU admissions postoperatively.All patient surgeries conducted at St Vincent's Hospital Melbourne between July-December 2019 were retrospectively collected. Patients were excluded if they were emergency cases, hospital transfers or cardiac cases. Patients were grouped as either being seen in preadmission clinic by an anaesthetist/perioperative medicine physician or not and whether they were later admitted to ICU. Patients were counted as planned ICU admissions if there was a preoperative bed request or a noted plan for ICU ahead of surgery. Of 7712 surgeries conducted, 160 were admitted to ICU (2.07%). Of the ICU admissions, 73 were unplanned (0.9% of all surgeries) and 87 were planned (1.1%). Of the unplanned admissions, 19 were seen in preadmission clinic and 54 were not. This suggests that a preoperative review by a specialist anaesthetic consultant or perioperative medicine physician was associated with a reduction in unplanned ICU/HDU admission at our hospital.

Editorial introductions.

Current Opinion in Anesthesiology was launched in 1988. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of anesthesiology is divided into 15 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Editors of the journal and the Section Editors for this issue. EDITORS Peter KrankePeter KrankePeter Kranke is Consultant Anaesthesiologist and Professor of Anaesthesia at the Department of Anaesthesia and Critical Care, University Hospitals of Würzburg, Germany and the Würzburg Medical School. He is Head of Clinical Research and since 2007 Section Head for Obstetrics and Gynaecology within the Department of Anaesthesia at the University of Würzburg. He holds a Medical degree from the University of Heidelberg and earned an MBA and a PhD from the University of Würzburg. Prof. Kranke was appointed a Fellow of the European Society of Anaesthesiology and Intensive Care (FESAIC) at Euroanaesthesia 2022. He has been editor of the European Journal of Anaesthesiology and other national and international journals. As a member of the committee on Regional Anaesthesia and Obstetric Anaesthesia within the German Society of Anaesthesiology and member of the European Society of Anaesthesiology and Intensive Care (ESAIC) he contributes to various guidelines and consensus statements in the field of obstetric anaesthesia perioperative medicine on a national, European as well as international level. Currently, he is chairman of the guideline committee of the ESAIC. He is co-author of the international consensus guidelines on the management of post-operative nausea & vomiting (PONV) under the auspice of the Society of Ambulatory Anesthesia and ASER. Besides PONV, his current interests include healthcare economics, patient blood management, evidence-based medicine and clinical research in the perioperative setting, ambulatory anaesthesia, fast-track recovery, simulation and safety in medicine and outcomes research in perioperative medicine. Leopold EberhartLeopold EberhartLeopold Eberhart is a Professor of Anesthesiology and Intensive Care at the Philipps-University of Marburg and also works in a newly-opened Clinic for Day-Surgery as the head of Anesthesiology and Perioperative Care. He studied medicine at the University of Ulm, where he graduated in 1995 and also trained to be a specialist for Anesthesiology until 1999. In 2001, he transferred to the Philipps-University of Marburg and became a senior physician for Anesthesiology. Prof. Eberhart habilitated in 2003. In the early 2000 s he earned additional qualifications for Emergency Medicine, Intensive Care Medicine and Pain Medicine. He also studied the management of health and social care organisations at the Universities of Kaiserslautern and Witten-Herdecke and earned the title “Master of Arts” in 2007. Prof. Eberhart's main scientific topics are the improvement of the patients’ perioperative well-being by reducing common postoperative side-effects, like nausea, vomiting, shivering and pain. He also developed the PPP33-questionnaire for assessing quality of life in the perioperative period, which was awarded with the Lilly Quality of Life-Award in 2004. In total, he published over 200 scientific papers in peer-reviewed journals since 1994. Prof. Eberhart is a member of national and international anesthesia communities and a founding member of the Cochrane Anesthesia-Review Group. Daniel ArnalDaniel ArnalDr Daniel Arnal is anaesthesiologist, Head of the Surgical Process, at the Hospital Universitario Fundacion Alcorcon, Spain, and is the European Society of Anaesthesiology and Intensive Care (ESAIC) Patient Safety and Quality Committee Chair. Dr Arnal is cofounder and immediate past president of the Spanish Anaesthesia Incident Reporting System (SENSAR), and Latin America and Vice-president of the Quality, Patient Safety and Ethics of the Spanish Society of Anaesthesiology and Reanimation (SEDAR). His publications and scientific interests focus on Patient Safety and is Co-editor of the Spanish Anaesthesia and Critical Patient Crisis Manual. As clinical simulator instructor participates as faculty in IDEhA Simulation Centre (Alcorcon), SENSAR and ESAIC patient safety continuous education programs.

ADDING OBJECTIVITY TO SUBMAXIMAL EXERCISE TESTING BY ASSESSMENT OF HEART RATE RECOVERY – A HEALTHY VOLUNTEER STUDY III (SEARCH-III)

<h3>Objective</h3> Risk prediction is a fundamental component of perioperative medicine. Submaximal exercise tests (SET) are a better-tolerated modality for functional capacity estimation versus maximal tests; but their results are easily influenced by patient motivation and effort. Heart rate recovery (HRR) may be an alternative, objective, modality for cardiopulmonary fitness determination. HRR1 and HRR2 (difference between HR at peak exercise and one/two minutes after exercise cessation) are validated methods for quantifying HRR after maximal testing. Previous work suggests however that HRR1/2 after submaximal exercise may be effort dependent.[1,2] Our group has devised two novel HRR quantification parameters, area under the curve (AUC) and effort correction, both demonstrating good reproducibility in the submaximal setting;[3,4] however, the minimum effort required for reliable HRR quantification during SET remains unknown. We therefore assessed the reproducibility of both existing and novel HRR quantification techniques across different submaximal effort levels. <h3>Design and methods</h3> Following R&D approval and with informed consent, 36 healthy adult volunteers underwent two SETs using a modified Astrand-Rhyming cycle ergometer protocol in a randomised order. Participants exercised briefly to 60% of predicted maximum heart rate (HRmax) and 70% HRmax, with one hour rest between SETs. HR was recorded at 30-second intervals during the recovery period for six minutes. HRR was quantified using HRR1, HRR2, and AUC. Effort-corrected (EC) equivalents of HRR1, HRR2 and AUC were computed by dividing absolute parameters by the effort ratio (HR on exercise cessation divided by HRmax). Intra-individual reproducibility was assessed between SETs using intraclass correlation coefficient (ICC), Spearman's correlation (rs) and Bland-Altman analysis. <h3>Results</h3> Effort-corrected HRR1 proved the best parameter displaying moderate reproducibility (ICC=0.58, 95%CI 0.32-0.76), moderate positive correlation (rs=0.64, p<0.001) and smallest bias (5.2bpm, LoA=-27.0-37.3) between SETs (fig. 1). Similarly, AUC reproducibility improved from poor (ICC=0.46) to moderate (ICC=0.56) after effort-correction. ICC remained poor in HRR2 after effort correction (HRR2 ICC=0.32 vs. EC-HRR2 ICC=0.44). Despite improvement in all parameters following effort correction, reproducibility and correlation were poor-moderate and Bland-Altman analysis demonstrated marked variability of differences across mean values with wide limits of agreement. <h3>Conclusion</h3> Unsatisfactory reproducibility was demonstrated across all HRR parameters at 60% HRmax versus the previously used target of 70% HRmax. Sensitivity analyses revealed a proportion of participants with elevated baseline HR such that minimal effort was required to reach the less demanding 60% HRmax target, producing no HRR as a result. Excluding these "non-responders" improved reproducibility of parameters between SETs. Using "personalised" HR targets based on each participant's resting HR may therefore better standardise effort exerted during testing. Further work should explore the applicability of submaximal HRR in the surgical population.

Looking inward to improve pediatric chronic pain outcomes: a call for team science research.

aDepartment of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, United States bDepartment of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States *Corresponding author. Address: Stanford University School of Medicine, 1070 Arastradero Rd, Suite 300, MC5581, Palo Alto, CA 94304, United States. Tel.: +1 650-497-6896. E-mail address: [email protected] (C. W. Hess). Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Trends in research on the perioperative use of acupuncture in the last 20 years: A CiteSpace-based bibliometric analysis and literature review

ObjectiveResearch on acupuncture-related techniques in the perioperative period has been increasing in the last 20 years. In this research, a bibliometric analysis was performed to review the application of acupuncture for perioperative medicine and to evaluate the trends in research on the perioperative use of acupuncture.MethodsCiteSpace was used to analyze published papers on the perioperative use of acupuncture in the Web of Science database from 2001 to 2021. The research trends were evaluated based on the number of publications, keywords, journals, countries, institutions, and authors. Moreover, collaborative networks and reference co-citation network maps were analyzed.ResultsA total of 719 related studies were included in the analyses. The number of annual publications has gradually been increasing. Evidence-Based Complementary and Alternative Medicine published the most (49 articles). Regarding the cited journals, Anesthesia &amp;amp; Analgesia ranked first in terms of frequency (361), while Pain ranked first in terms of centrality (0.71). China (284) and the China Medical University (26) published the most. Wang Yu (21 articles) was the most active author, while Lee A (116) was the most co-cited author. The most co-cited reference was a meta-analysis of acupuncture for post-operative pain (212). The “post-operative cognitive dysfunction” cluster was new research directions that had recently emerged. Pain-related keywords had the highest frequency in keywords about indications.ConclusionResearch on perioperative acupuncture is a promising field, and more cooperation in global scientific research is needed. Our results may help researchers in identifying potential collaborators, research frontiers, and hot topics.

Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial

Tracheal intubation in neonates and infants is a potentially life-saving procedure. Video laryngoscopy has been found to improve first-attempt tracheal intubation success and reduce complications compared with direct laryngoscopy in children younger than 12 months. Supplemental periprocedural oxygen might increase the likelihood of successful first-attempt intubation because of an increase in safe apnoea time. We tested the hypothesis that direct laryngoscopy is not inferior to video laryngoscopy when using standard blades and supplemental oxygen is provided. We did a non-inferiority, international, multicentre, single-blinded, randomised controlled trial, in which we randomly assigned neonates and infants aged up to 52 weeks postmenstrual age scheduled for elective tracheal intubation to either direct laryngoscopy or video laryngoscopy (1:1 ratio, randomly assigned using a secure online service) at seven tertiary paediatric hospitals across Australia, Canada, Italy, Switzerland, and the USA. An expected difficult intubation was the main exclusion criteria. Parents and patients were masked to the assigned group of treatment. All infants received supplemental oxygen (1 L/Kg per min) during laryngoscopy until the correct tracheal tube position was confirmed. The primary outcome was the proportion of first-attempt tracheal intubation success, defined as appearance of end-tidal CO2 curve at the anaesthesia monitor, between the two groups in the modified intention-to-treat analysis. A 10% non-inferiority margin between direct laryngoscopy or video laryngoscopy was applied. The trial is registered with ClinicalTrials.gov (NCT04295902) and is now concluded. Of 599 patients assessed, 250 patients were included between Oct 26, 2020, and March 11, 2022. 244 patients were included in the final modified intention-to-treat analysis. The median postmenstrual age on the day of intubation was 44·0 weeks (IQR 41·0-48·0) in the direct laryngoscopy group and 46·0 weeks (42·0-49·0) in the video laryngoscopy group, 34 (28%) were female in the direct laryngoscopy group and 38 (31%) were female in the video laryngoscopy group. First-attempt tracheal intubation success rate with no desaturation was higher with video laryngoscopy (89·3% [95% CI 83·7 to 94·8]; n=108/121) compared with direct laryngoscopy (78·9% [71·6 to 86·1]; n=97/123), with an adjusted absolute risk difference of 9·5% (0·8 to 18·1; p=0·033). The incidence of adverse events between the two groups was similar (-2·5% [95% CI -9·6 to 4·6]; p=0·490). Post-anaesthesia complications occurred seven times in six patients with no difference between the groups. Video laryngoscopy with standard blades in combination with supplemental oxygen in neonates and infants might increase the success rate of first-attempt tracheal intubation, when compared with direct laryngoscopy with supplemental oxygen. The incidence of hypoxaemia increased with the number of attempts, but was similar between video laryngoscopy and direct laryngoscopy. Video laryngoscopy with oxygen should be considered as the technique of choice when neonates and infants are intubated. Swiss Pediatric Anaesthesia Society, Swiss Society for Anaesthesia and Perioperative Medicine, Foundation for Research in Anaesthesiology and Intensive Care Medicine, Channel 7 Telethon Trust, Stan Perron Charitable Foundation, National Health and Medical Research Council.

Brief History of Opioids in Perioperative and Periprocedural Medicine to Inform the Future.

Background: Opioids and derivatives of opium had been used as analgesics for thousands of years before the introduction of inhalational anesthetic agents. Once these early volatile agents were in widespread use, opioids were used as part of anesthetic care for premedication, as intraoperative adjuncts to general anesthesia, and for the management of postoperative pain. Evidence of growing dependence on opioids in the perioperative and periprocedural patient is supported by the ongoing research to develop synthetic opioids and to customize the pharmacokinetics and pharmacodynamics to achieve specific therapeutic goals. Methods: We explore the history of opioid use in perioperative care as a means of future management in light of new persistent opioid abuse. Results: As the opium chemical structure has been modified, newer nonopioid analgesics have been approved and brought into clinical practice. Opioid-sparing and opioid-free anesthetic techniques are not only a possibility, but a reality. Conclusion: Continuing research in neurobiology and addiction genetics will ultimately lead to a pharmacogenetic approach to patients at risk for new persistent opioid abuse.

Fentanyl Patch Overdose-Case Report

Fentanyl was introduced more than 50 years ago. It has become the most often used opioid for intraoperative analgesia. Since the early 1990s the fentanyl patch has been available for management of chronic pain of all forms of cancer as well as the persistent, intense pain from many noncancerous maladies. Fentanyl is inexpensive to synthesize and prepare for the marketplace and is now familiar to clinicians working in pain and perioperative medicine throughout the world. Fentanyl has also become popular for illicit use and commonly being combined with other drugs and many overdose cases have been reported.

Prediction Algorithms: Is Peer Review Enough?

Prediction Algorithms: Is Peer Review Enough?