Perineural infiltration is a technique in which local anesthetic is continuously administered through a fixed catheter over nerves at or near the surgical site. Sustained analgesia is achieved when bupivacaine encapsulated in liposomes is slowly released, causing conduction blockade in the peripheral nerve. When used for local infiltration and field blocks, liposomal bupivacaine is predicted to provide prolonged postoperative analgesia up to 72 hours following a variety of surgeries. However, published reports on the quality of extended analgesia with liposomal bupivacaine are mixed. This meta-analysis evaluated the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics. Nine trials (619 patients) were analyzed for the quantitative evidence of pain control 24 to 72 hours postoperatively. The primary outcome was the difference in area under the curve of the pooled 24-hour to 72-hour rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. Perineural liposomal bupivacaine was found to provide a statistically significant but clinically unimportant benefit. Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 hours, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. Thus, high-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.Comment: The introduction of liposomal bupivacaine for perineural administration was initially believed to provide better, more consistent pain control in the postoperative period, as compared with the use of standard (nonliposomal) bupivacaine. Although the use of long-acting local anesthetics for postoperative pain relief remains supported, the difference in cost of providing this service is dramatically different when comparing liposomal versus nonliposomal techniques. The cost of a single dose of Exparel liposomal bupivacaine is about $334 as compared with $3 for a single dose of standard bupivacaine.1Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. Four online bibliographic databases were examined. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. Retrospective studies, case studies, preexisting laryngeal injury/disease, patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, conference abstracts, and patient populations with neurological impairments were excluded. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 6140 patients met eligibility criteria. Edema was the most frequently reported mild injury, with a prevalence of 9 to 84%. Vocal fold hematomas were the most frequently reported moderate injury with a prevalence of 4%. Severe injuries that include subluxation of the arytenoids and vocal fold paralysis were found to be rare (<1%) outcomes. The most prevalent patient complaints were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for postoperative laryngeal assessment after surgery are available, and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocol-guided screening for dysphonia and dysphagia may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.Comment: In the discussion of this paper, the authors state: “the most remarkable finding was that though laryngeal injury and its symptoms are common after intubation, an overwhelming majority of patients will emerge from short-term surgeries (less than 2 hours) without laryngeal injury.” An important limitation of the study was lack of information regarding the size of the endotracheal tubes.It is speculated that opioid-free anesthesia may provide adequate pain control while reducing postoperative opioid consumption; however, published evidence for this speculation is lacking. The authors hypothesized that opioid-free balanced anesthetic with dexmedetomidine would reduce postoperative opioid-related adverse events compared with balanced anesthetic with remifentanil. Patients were randomly assigned to receive a standard balanced anesthetic with either intraoperative remifentanil plus morphine (remifentanil group) or dexmedetomidine (opioid-free group). All patients received intraoperative propofol, desflurane, dexamethasone, lidocaine infusion, ketamine infusion, neuromuscular blockade, and postoperative lidocaine infusion, paracetamol, nefopam, and patient-controlled morphine. The primary outcome was a composite of postoperative opioid-related adverse events (hypoxemia, ileus, or cognitive dysfunction) within the first 48 hours after extubation. The main secondary outcomes were episodes of postoperative pain, opioid consumption, and postoperative nausea and vomiting. The study was stopped prematurely because of 5 cases of severe bradycardia in the dexmedetomidine group. The primary composite outcome occurred in 122 of 156 (78%) dexmedetomidine group patients compared with 105 of 156 (67%) in the remifentanil group (relative risk, 1.16; 95% CI, 1.01–1.33; p = .031). Hypoxemia occurred 110 of 152 (72%) in the dexmedetomidine group and 94 of 155 (61%) in the remifentanil group patients (relative risk, 1.19; 95% CI, 1.02–1.40; p = .030). There were no differences in ileus or cognitive dysfunction. Cumulative 0 to 48 hours' postoperative morphine consumption (11 mg [5–21] vs 6 mg [0–17]) and postoperative nausea and vomiting (58 of 157 [37%] vs 37 of 157 [24%]; relative risk, 0.64; 95% CI, 0.45–0.90) were both less in the dexmedetomidine group, whereas measures of analgesia were similar in both groups. Dexmedetomidine patients had more delayed extubations and prolonged postanesthesia care unit stays.The authors' conclusions refuted their hypothesis that balanced opioid-free anesthesia with dexmedetomidine, compared with remifentanil, would result in fewer postoperative opioid-related adverse events. Conversely, it did result in a greater incidence of serious adverse events, especially hypoxemia and bradycardia.Comment: Although no finite conclusions were drawn from this interrupted study, the report illustrates that avoidance of opioids may pose new risks that might not outweigh the known risks of opioids. It is noteworthy that all patients in this study received 9 other pharmacologic agents as part of their balanced anesthetic. Whether or not profound bradycardia or hypotension would occur with a simpler, streamlined balanced anesthetic technique remains unknown. Several other limitations of the report were described, including the lack of specific monitoring for depth of anesthesia and nociception and the fact that the optimal dosing recommendations for dexmedetomidine for general anesthesia remain unknown.The aim of this study was to estimate the effect of index surgical care setting on perioperative costs and readmission rates across 4 common elective general surgery procedures. Facility fees seem to be a driving force behind rising US healthcare costs, and inpatient-based fees are significantly higher than those associated with ambulatory services. Little is known about factors influencing where patients undergo elective surgery. All-payer claims data from the 2014 New York and Florida Healthcare Cost and Utilization Project were used to identify 73,724 individuals undergoing an index hernia repair, primary total or partial thyroidectomy, laparoscopic cholecystectomy, or laparoscopic appendectomy in either the inpatient or ambulatory care setting. Approximately 87% of index surgical cases were performed in the ambulatory setting. Adjusted mean index surgical costs were significantly lower among ambulatory versus inpatient cases for all 4 procedures (p < .001 for all). Readmission rates among ambulatory versus inpatient-based laparoscopic appendectomy were comparable (odds ratio, 0.63; 95% CI, 0.31–1.26; P = .19). The authors concluded ambulatory surgery offers significant costs savings and generally superior 30-day outcomes relative to inpatient-based care for appropriately selected patients across 4 common elective general surgery procedures.Comment: The authors state that, to their knowledge, this article is the first to directly compare 30-day outcomes and costs among patients undergoing inpatient versus ambulatory surgery across 4 common general surgery operations. It confirms that facility fees seem to be a major source of rising US healthcare costs and that fees associated with inpatient-based care are dramatically higher than those incurred in the ambulatory setting. The study addresses the notion that moderate to major surgery performed outside of the hospital operating room is associated with poorer outcomes, despite the cost advantages. An important limitation of the study is the lack of granularity in the databases used which prevented a detailed comparison of the differences between the patient populations receiving surgery in the hospital and ambulatory venues.Also noteworthy:Comment: It is often hard to know the context in which best clinical practices and current clinical standards and guidelines were developed. This article describes how an early attempt to lower medical malpractice costs in a group of university hospitals became a worldwide effort that resulted in improvements in patient safety. These efforts have evolved into several practices that include among others—the adherence to these patient safety guidelines, simulator training, the promulgation of standards and guidelines by the American Society of Anesthesiologists, and the use of a safety checklist before induction of anesthesia.Summaries and comments provided by