Given the concerns regarding maternal and neonatal safety, the application of enhanced recovery after surgery (ERAS) in cesarean delivery remains controversial and has not been adopted in some regions. This study aims to conduct a meta-analysis to compare the ERAS pathway with conventional postoperative care, in order to provide evidence on the safety and efficacy of the ERAS protocols. PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Data, and CBM were searched from their inception until February 2025. Randomized controlled trials (RCTs) published in English or Chinese that compared the ERAS and standard care in cesarean section were eligible for inclusion. Two reviewers independently extracted the data and assessed the risk of bias using the Cochrane risk-of-bias tool. The analyses were conducted using RevMan 5.4 software, and the results were presented as forest plots. Out of 2817 records screened, 10 RCTs comprising 1934 participants met the inclusion criteria. The pooled analyses indicated that ERAS protocols significantly reduced the length of hospital stay (MD -14.13, 95% CI -25.36 to -2.90; p = 0.01), hospitalization costs (MD -447.85, 95% CI -687.04 to -208.66; p = 0.0002), time to first flatus (MD -9.82, 95% CI -13.54 to -6.10; p < 0.00001), time to first stool (MD -15.35, 95% CI -19.10 to -11.60; p < 0.00001), pain sores (MD -1.54, 95% CI -2.10 to -0.99; p < 0.00001), and postpartum hemorrhage (MD -47.75, 95% CI -69.94 to -25.55; p < 0.0001). No statistically significant differences were observed between ERAS and conventional standard recovery in terms of postoperative nausea and vomiting (PONV), urinary retention, postoperative infection, deep venous thrombosis (DVT), 30days readmission rates, and NICU admission rates. The adoption of ERAS protocols in cesarean delivery is associated with accelerated postoperative recovery without compromising maternal or neonatal safety. Nevertheless, these findings should be approached with caution due to the limited number and heterogeneity of the studies included.

Retraction Note: Postoperative Nausea and Vomiting After Metabolic Bariatric Surgery: A Comprehensive Review.

Serotonin-gated 5-HT3 receptors (5-HT3Rs), which belong to the cys-loop superfamily of ligand-gated ion channels, mediate fast excitatory neurotransmission in the central and peripheral nervous system. They are targets for drugs to treat neurological diseases and psychiatric disorders, as well as chemotherapy-induced and postoperative nausea and emesis. The ever-increasing number of resolved 3D structures of the homopentameric form of 5-HT3AR, in combination with new computational approaches allow us to better understand the molecular processes of ligand binding, the subsequent conformational changes, and ion permeation, providing a solid foundation for understanding the biological functions of 5-HT3AR and its heteropentameric 5-HT3R homologs. In this review, we first outline the physiological roles and subunit assembly of heteromeric 5-HT3Rs, which predominate in vivo. We then summarize the latest structural insights into the 5-HT3AR, revealing details of its architecture, ligand-binding sites, and conformational transitions leading to channel activation. Finally, we discuss the evolving pharmacology of 5-HT3R modulators and provide our perspectives on future research directions aimed at resolving the heteropentameric structures of 5-HT3R in their native membrane and developing modern drugs targeting these receptors.

Effect of preoperative ultrasound-guided stellate ganglion block on pain thresholds and postoperative nausea and vomiting in gynecological laparoscopy: a randomised clinical trial.

We compared the incidence of postoperative nausea and vomiting (PONV) in patients undergoing orthognathic surgery under total intravenous anesthesia using propofol with and without ondansetron. Data on PONV within 24 hours after surgery, fentanyl and ondansetron dosing, demographic parameters, smoking history, and prior PONV were retrospectively extracted from the medical records of 291 patients. After propensity score matching, 78 patients were included in the ondansetron and control groups. The incidence of PONV was significantly lower in the ondansetron group (21%) than in the control group (36%; P = .033), whereas the incidence of postoperative headache was comparable. Ondansetron effectively reduced PONV without increasing headaches.

Postoperative pain management after lumbar spine surgery often involves modest to high doses of opioids, which can contribute to the risk of dependence. Epidural analgesia has emerged as a promising opioid-sparing alternative, but its efficacy compared with conventional opioid-based intravenous patient-controlled analgesia (IV-PCA) in a randomized trial has not been established in these patients. We asked whether an opioid-sparing protocol, compared with conventional opioid-based IV-PCA, (1) provides superior pain control, (2) reduces opioid consumption, and (3) lowers the frequency of opioid-related adverse events. In this multicenter, randomized, double-blind, parallel-group trial, we enrolled 98 patients undergoing single-level lumbar fusion or decompression. Eligible participants were adults age 20 to 80 years diagnosed with lumbar spinal stenosis or spondylolisthesis. Exclusion criteria included history of prior lumbar surgery, coagulation disorders, or opioid dependence. Patients were randomized to either the epidural opioid-free IV-PCA group (intraoperative single-shot epidural ropivacaine injection with opioid-free IV-PCA; epidural group) or the conventional opioid-based IV-PCA group (fentanyl-based IV-PCA; control group). In the epidural opioid-free group, fentanyl was administered solely as a rescue analgesic for breakthrough pain. All patients and outcome assessors were blinded to group allocation. In the fusion arm, 25 patients were randomized to the epidural group and 25 to the control group; data from all randomized patients (n = 25 in each group) were fully analyzed. In the decompression arm, 24 were randomized to the epidural group and 24 to the control group; data from all randomized patients (n = 24 in each group) were fully analyzed. Three patients (one in the fusion arm and two in the decompression arm) discontinued the intervention because of severe postoperative nausea and vomiting but were included in the final analysis based on the intention-to-treat principle, preventing differential loss to follow-up bias. There were no important differences between treatment and control groups in terms of baseline demographic or clinical data in either study arm. The minimum clinically important difference (MCID) for the numeric rating scale (NRS) pain score was defined as 2 points. The sample size was calculated to detect a 15% reduction in NRS scores (0.9 points), ensuring sensitivity to differences smaller than the MCID of 2 points. Secondary outcomes included total fentanyl consumption, rescue analgesic demand, and opioid-related adverse events. There were no clinically important differences between the epidural and control groups in either the decompression or the fusion arms of the study in terms of NRS pain scores at any time point (the largest difference was seen at 24 hours in the fusion group, but it was not clinically important: mean ± SD 2.7 ± 1.5 versus 4.4 ± 1.5 points of 10 total, mean difference -1.8 points [95% confidence interval (CI) -2.6 to -0.9]; p = 0.04). However, despite no important differences in pain control, fentanyl consumption was lower in the epidural groups than the control groups of both the fusion arm (122 ± 140 versus 1467 ± 481 µg, mean difference -1345 µg [95% CI -1550 to -1140]; p < 0.001) and the decompression arm (41 ± 51 versus 1046 ± 451 µg, mean difference -1005 µg [95% CI -1196 to -813]; p < 0.001). In the fusion arm of the study, postoperative urinary retention was less common in the epidural group (4% [1 of 25] versus 32% [8 of 25], relative risk 0.13 [95% CI 0.02 to 0.93]; p = 0.02); there were no differences in complications between the epidural and control groups in the decompression arm of the study. A single epidural ropivacaine injection with opioid-free IV-PCA provided effective pain control, reduced opioid consumption, and decreased urinary retention risk after single-level lumbar spine surgery. This protocol is a viable and effective opioid-sparing strategy. Level I, therapeutic study.

Emergence delirium commonly occurs in pediatric patients after general anesthesia, causing distress and potential harm. Remimazolam, an ultra-short-acting benzodiazepine, has recently been introduced in pediatric anesthesia, but its preventive role against emergence delirium remains unclear. This systematic review with meta-analysis evaluated the effect of remimazolam on the incidence and severity of emergence delirium in children undergoing general anesthesia. PubMed, EMBASE, CENTRAL, Scopus, Web of Science, and Google Scholar were searched for relevant studies. The primary outcome was the incidence of emergence delirium. Secondary outcomes included Pediatric Anesthesia Emergence Delirium score, incidence of hypotension and bradycardia, extubation time, postanesthesia care unit stay, and postoperative nausea and vomiting incidence. Relative risks (RR) or mean difference (MD) with 95% confidence intervals (CI) were calculated using a random-effects model. Ten randomized controlled trials involving 1231 children were included. Remimazolam significantly reduced the incidence of emergence delirium (RR 0.38, 95% CI 0.23-0.63; p = 0.0002) and Pediatric Anesthesia Emergence Delirium score (MD -1.70, 95% CI -2.77 to -0.63; p = 0.0019). It also decreased bradycardia (RR 0.39, 95% CI 0.21-0.70; p = 0.0018). Although the overall incidence of hypotension did not differ significantly (RR 0.35, p = 0.0991), subgroup analysis showed a lower incidence with remimazolam than with propofol (RR 0.14, p = 0.0376). Overall extubation time was comparable (MD -0.75, p = 0.5088), but shorter with remimazolam than propofol (MD -3.36, p < 0.0001). No significant differences were found in postanesthesia care unit stay or postoperative nausea and vomiting. Remimazolam may reduce the incidence and severity of emergence delirium in children after general anesthesia, without affecting hemodynamic stability or recovery time. PROSPERO: CRD420251236789.

Objective To evaluate outcomes of different doses of esketamine in postoperative patient-controlled intravenous analgesia (PCIA) combined with preoperative intercostal nerve block (ICNB) analgesia protocol for acute postoperative pain (APP) relief in patients undergoing thoracoscopic lobectomy. Materials and methods A total of 360 patients scheduled for thoracoscopic lobectomy at Xuzhou Central Hospital between October 2021 and July 2023 were enrolled and randomly assigned into three groups using the random envelope method. Before anesthesia induction, all patients received ICNB, followed by general anesthesia. Group C received PCIA using sufentanil at 0.03 μg/kg/h, Group K1 received a low dose of esketamine at 0.015 mg/kg/h in PCIA, and Group K2 received a moderate dose of esketamine at 0.03 mg/kg/h in PCIA. Numerical Rating Scale (NRS) pain scores were recorded at 2, 4, 24, 48, and 72 h postoperatively. The incidence of APP within 72 h post-surgery, the requirement for rescue analgesia and the occurrence of adverse reactions, were assessed and recorded for the three groups. Results There were significantly lower NRS scores in Group K2 at 2, 4, 24, 48, and 72 h postoperatively, compared to Groups C and K1 (P &amp;lt; 0.01). However, there were no statistically significant differences in NRS scores between Group C and Group K1 (P &amp;gt; 0.05). The incidence of APP within 72 h postoperatively was significantly lower in Group K2, compared to Group C and Group K1 (P &amp;lt; 0.05). Additionally, Group C exhibited a significantly higher the incidence of postoperative nausea and vomiting (PONV) than the other two groups (P &amp;lt; 0.05). Group K2 demonstrated superior postoperative analgesic efficacy, including reduced rescue analgesia needs and lower opioid consumption, without affecting hospital stay length compared to Groups C and K1. Conclusion A dose of 0.03 mg/kg/h esketamine in PCIA combined with preoperative ICNB significantly alleviates APP in patients undergoing thoracoscopic lobectomy, reducing resting pain scores by approximately 30% at 24 h compared to sufentanil-based analgesia. Clinical Trial Registration https://www.chictr.org.cn/ , Identifier ChiCTR2100051000.

Remimazolam is a novel benzodiazepine, but its comparative efficacy against midazolam in elderly patients undergoing laparoscopic cholecystectomy (LC) remains understudied. Objective To compare the efficacy and safety of remimazolam and midazolam in elderly patients with moderate surgical risk (ASA II-III) undergoing LC. A retrospective analysis was conducted on 184 patients who underwent LC under general anesthesia between January 2022 and January 2024. Patients were divided into remimazolam (n = 81) and midazolam (n = 103) groups. The primary outcome was extubation time, defined as the time from the end of anesthesia to successful extubation. Secondary outcomes included post-anesthesia care unit (PACU) stay duration, hemodynamic and respiratory parameters, and adverse events. The remimazolam group exhibited significantly shorter extubation times (33min [IQR 24.0-44.5] vs. 42min [IQR 30.0-61.0], p = 0.0003) and PACU stays (55min [IQR 45-65] vs. 65min [IQR 55-80], p = 0.0001) compared to the midazolam group. Hemodynamic profiles and the incidence of adverse events, including hypotension and bradycardia, were comparable between the two groups (p > 0.05). No respiratory depression or postoperative nausea and vomiting were observed in either group. An association between remimazolam use and clear clinical advantages over midazolam in LC was observed, including faster recovery and shorter PACU stays, with comparable hemodynamic stability and safety profiles. These findings suggest that remimazolam is a promising alternative for anesthesia in minimally invasive surgeries. Further multicenter studies are warranted to confirm these results and explore its utility in diverse surgical settings.

The post anesthesia recovery phase following bariatric surgery is a high-risk period characterized by increased susceptibility to respiratory and hemodynamic complications, warranting prolonged monitoring and targeted interventions. Despite advancements in perioperative care, the identification of risk factors for extended recovery remains a critical unmet need in obese populations. This single-center retrospective study analyzed 169 consecutive patients undergoing laparoscopic sleeve gastrectomy for metabolic syndrome and extubated in post anesthesia care unit (PACU) at Peking University Third Hospital (2015-2025). Patients were stratified by PACU length of stay (LOS) into extended (≥ 42min, 75th percentile) and control (< 42min) groups. Comprehensive perioperative variables were evaluated, including ‌preoperative data of demographic profiles, American Society of Anesthesiologists (ASA) physical status, higher body mass index (BMI), obesity surgery mortality risk score (OS-MRS), and obstructive sleep apnea syndrome (OSAS) comorbidity; ‌Intraoperative and postoperative‌ data including procedure duration, hypoxemia incidence, pain scores, rate of postoperative nausea and vomiting, number of rescue antiemetic administered, postoperative complications, reoperation rates, length of hospital stay, 30-day readmission rates and mortality. Univariate analysis and binary Logistic regression analysis were performed to find the risk factors of prolonged LOS. The extended PACU-LOS group (n = 45, 26.6%) demonstrated significantly higher BMI (40.6 [38.1, 47.2] vs. 38.7 [34.9, 44.0] kg/m², p = 0.007), ASA III prevalence (66.7%% vs. 25.8%, p < 0.001), existence of OSAS (71.1% vs. 33.1%, p < 0.001), intraoperative peak end-tidal carbon dioxide partial pressure (41 [39, 46] vs.39 [36, 42] p < 0.001) and post-extubation hypoxemia incidence (62.2% vs. 9.7%, p < 0.001). Logistic regression analysis identified three independent predictors: post-extubation hypoxemia (OR = 14.771, 95%CI: 5.557 ~ 39.268), ASA III (OR = 3.924, 95%CI: 1.362 ~ 11.304), and OSAS (OR = 3.122, 95%CI:1.091 ~ 8.934). ASA III classification, preexisting OSAS, and post-extubation hypoxemia independently predict extended PACU-LOS in patients undergone laparoscopic sleeve gastrectomy. These findings underscore the imperative for preoperative risk stratification using standardized scoring systems, protocolized post-extubation oxygenation strategies, and resource allocation for high-dependency monitoring in at-risk patients. While this study establishes predictors of extended PACU-LOS, its correlation with postoperative complications warrants dedicated future investigation.

Total Intravenous Anesthesia Versus Volatile Anesthesia in Bariatric Surgery:A Balanced Comparison of Patient-reported Pain, Postoperative Nausea and Vomiting, and Opioid Use in a Randomized Controlled Trial.

Effect of Amisulpride Inclusion in a Postoperative Nausea and Vomiting Protocol: A Retrospective Pre-Post Analysis.

Impact of intraoperative hypotension on postoperative nausea and vomiting in patients undergoing orthognathic surgery.

To evaluate the effects and morbidities associated with perioperatively administered analgesics in paediatric patients undergoing tonsillectomy. Systematic review and network meta-analysis (NMA) of randomised controlled trials. Paediatric patients undergoing tonsillectomy. The treatment networks included five interventions (paracetamol, paracetamol with opioids, ibuprofen, ketorolac or opioids) and a control group (placebo or saline). The outcomes measured were the incidence of postoperative bleeding (any event and those requiring surgical intervention), postoperative nausea and vomiting (PONV) and the frequency of analgesic intake. Both pairwise analysis and NMA were utilised to assess the data. No treatments induced significant postoperative bleeding compared with the control. Paracetamol, ibuprofen and ketorolac tended to decrease the incidence of PONV. Only ibuprofen significantly reduced the need for analgesics (odds ratio = 0.32, 95% confidence interval = 0.11-0.91, p < 0.05). All other comparisons showed trends but lacked statistical significance, as their confidence intervals included 1.0. The ranking hierarchy revealed that ketorolac ranked the lowest in postoperative bleeding but first in the incidence of PONV. Paracetamol ranked second in postoperative bleeding, PONV, and need for analgesics. While ibuprofen appeared to be the most effective in managing postoperative pain, paracetamol showed favourable trends in reducing postoperative bleeding, PONV, and the need for additional analgesics. Ketorolac tended to be associated with a lower incidence of PONV but showed a tendency toward a higher incidence of postoperative bleeding. However, further well-designed, standardised studies would be needed to confirm these conclusions.

Multi-omics and transcriptomic profiling of anesthetic response reveals RNA regulatory networks in postoperative nausea and vomiting.

Acute postoperative pain is typically managed with titration of opioids, balancing pain intensity and opioid-related adverse events (ORADEs). Often, the dosing strategy is individualised based on the clinician's intuition or expertise. The influence of broader patient-related predictors remains insufficiently synthesised. This systematic review aimed to synthesise evidence on associations between patient-related predictors and opioid use, pain intensity and ORADEs within 24 h after surgery. In this systematic review, we searched MEDLINE, Embase and CENTRAL for studies examining associations between patient-related predictors and opioid use, pain, or ORADEs within 0-24 h postoperatively. We used Quality in Prognosis Studies (QUIPS) for risk of bias and conducted meta-analyses. We included 39 studies (294,221 patients) investigating 31 patient-related predictors. Meta-analyses showed that young age and chronic pain were associated with moderate-severe pain risk and large opioid consumption. Smoking, non-normal BMI, anxiety and preoperatively opioid use or pain were associated with moderate-severe pain. Female sex and lower ASA-scores were associated with postoperative nausea and vomiting. No other ORADEs were assessed. All but two studies were high risk of bias. The certainty of evidence was low due to high risk of bias and substantial heterogeneity in designs, populations and exposure/outcome definitions. Within 24 h after surgery, younger age, female sex, lower ASA score, smoking, abnormal BMI, anxiety, chronic pain and chronic opioid use were associated with greater postoperative complexity in terms of increased pain intensity, opioid use, or risk of nausea and vomiting. This comprehensive review provides important understanding of patient-related predictors, which can contribute to a more individualised perioperative pain management, including dosing of preventive analgesia at the end of surgery and in adjusting as-needed opioid doses postoperatively. CRD42024559821.

Previous studies have demonstrated that perioperative use of lidocaine effectively reduces opioid requirements in various surgical procedures. Our objective was to evaluate the effect of postoperative intravenous lidocaine infusion on opioid consumption following pelvic bone tumor surgery. This single center randomized controlled trial in a tertiary teaching hospital containing a total of 70 patients, aged 18 to 65 years, with American Society of Anesthesiologists(ASA) physical status classifications of I to III, who were scheduled to undergo pelvic bone tumor surgery. Participants were randomly assigned in a 1:1 ratio to either the lidocaine group(L Group) or the control group(C Group). The L Group received lidocaine for postoperative analgesia, whereas the C Group was administered a placebo saline infusion.The primary outcome was postoperative opioid consumption. Secondary outcomes included the time to first bowel movement, the incidence of postoperative nausea and vomiting(PONV), and pain scores at rest and during movement on postoperative days. A significant difference was observed in the cumulative 72-h morphine equivalent consumption between the L Group (n = 33) and the C Group (n = 33). Patients in the L Group required significantly less morphine equivalent consumption compared to the C Group (13 (0-52) mg vs. 25 (14-85) mg, P = 0.043). Additionally, the proportion of patients experiencing breakthrough pain was significantly lower in the L Group compared to the C Group (33.33% vs. 75.76%, P = 0.001). No significant differences were noted between the groups in secondary outcomes, including the incidence of PONV, numerical pain scores at rest or during movement, time to first bowel evacuation, or time to first oral intake. Postoperative intravenous lidocaine infusion is effective in reducing opioid consumption and the incidence of breakthrough pain following pelvic bone tumor surgery. This single-center, prospective RCT was registered with the Chinese Clinical Trial Registry (ChiCTR2100051207, 15/09/2021). The first research participant was enrolled in September 20, 2021.

Thoracic spinal anaesthesia (TSA) is gaining increasing recognition as a valuable regional anaesthetic technique in modern surgical practice, particularly for patients who are at high risk for complications associated with general anaesthesia. With the growing volume and complexity of surgical procedures worldwide, the demand for safer, targeted anaesthetic approaches has expanded. TSA involves intrathecal injection of local anaesthetic agents at thoracic vertebral levels, producing segmental sensory, motor, and sympathetic blockade suitable for a range of surgical interventions. Advances in anatomical knowledge and imaging modalities, especially MRI and ultrasound guidance, have improved the safety profile of this technique. Studies demonstrate a relatively wider posterior cerebrospinal fluid space in the thoracic region, offering a protective margin during needle placement. Although technical challenges exist due to narrow interlaminar spaces and angulated spinous processes, refined approaches such as paramedian insertion and optimal patient positioning enhance procedural success. Compared with general and lumbar spinal anaesthesia, TSA offers several advantages, including reduced cardiopulmonary complications, improved perioperative analgesia, attenuated surgical stress response, earlier return of gastrointestinal function, decreased postoperative nausea and vomiting, and shorter hospital stay. The use of lower doses of local anaesthetic also contributes to greater haemodynamic stability. TSA has been successfully employed in breast surgery, abdominal cancer procedures, laparoscopic cholecystectomy, nephrectomy, and selected thoracic surgeries, particularly in elderly and high-risk patients with compromised pulmonary function. Despite its benefits, potential complications such as hypotension, bradycardia, post-dural puncture headache, neurological injury, and infection must be considered. Careful patient selection, adherence to contraindications, and informed consent remain essential. Overall, TSA represents a safe and effective alternative anaesthetic modality with expanding clinical applications.

Over the last few years, nanocrystal technology has expanded to improve the bioavailability of poorly water-soluble drugs, which is challenging. Nanocrystals (NCs) exhibit many properties, such as enhancing drug solubility, dissolution, oral absorption, and high drug loading. Ondansetron hydrochloride (ONH) is an antiemetic drug that antagonizes a serotonin 5-HT3 receptor in the peripheral and central nervous system and is widely prescribed for the management of chemotherapy and radiotherapy-induced vomiting and nausea, as well as for postoperative nausea. ONH exhibits approximately 60% bioavailability due to its poor solubility and first-pass metabolism in the liver. Its solubility is pH-dependent, its precipitates above pH 6. Preparation of ONH-NCs to increase its dissolution rate as a preliminary study to be prepared as a sublingual film to avoid first-pass metabolism. NCs were prepared using the nanoprecipitation method and optimized via a D-optimal surface design considering drug to stabilizer ratio, solvent to anti-solvent ratio, stirring rate, and stabilizer type. The process yielded particle sizes (PS) ranging from 99-409 nm and a polydispersity index (PDI) range of 0.08-0.44 using stabilizers such as Soluplus®, Brij 35®, and Kollidon VA 64® (Koli 64). Differential scanning calorimetry (DSC) and X-ray diffraction (XRD) demonstrated showed reduced crystallinity, while Fourier transform infrared (FTIR) spectroscopy confirmed drug-stabilizer compatibility, and Field Emission Scanning Electron Microscopy (FESEM) depicted its morphological characterization. The results revealed that nanocrystallization of ONH may enable faster drug release at pH 6.8.

Postoperative nausea and vomiting can be a serious issue in reducing caloric intake for patients in the early stage after surgery. In Japan, ondansetron injection is now approved by insurance as a countermeasure against postoperative nausea and vomiting, but the number of reports on its effects regarding caloric intake is limited in the early stage following surgery, and opinions about the effects are divided. Thus, we examined how the effects of ondansetron administration during surgery influence caloric intake starting the day after surgery. We examined 65 patients who received a 4mg injection of ondansetron during gynecological surgery under epidural anesthesia, in comparison to 51 patients who did not receive any antiemetic. Our study was to compare the amount of caloric intake the day after surgery. The patient group who received an ondansetron injection showed higher caloric intake (1364.1 ± 55.9 vs 1188.3 ± 63.1 kcal; ANCOVA, p = 0.045). A significant increase in caloric intake was observed in patients with an Apfel Score of 3 (807 ± 62 vs 593 ± 76 kcal; p = 0.031). Our study indicated that ondansetron administration during gynecological surgery may have a positive effect on increasing postoperative caloric intake one day after surgery.