Anesthesiology, September 28 edition

This multicenter interrupted time-series study analyzed 148,762 general anesthetic cases across 11 public hospitals from 2022 to 2025. Deactivation of central nitrous oxide pipelines was associated with the largest reduction in nitrous oxide-related emissions, while a clinical decision-support advisory produced smaller but significant reductions in fresh gas flow and total hourly carbon dioxide-equivalent emissions. At one hospital, 94.6% of centrally supplied nitrous oxide was lost before reaching patients.

Impact: The study translates anesthetic sustainability from individual clinician behavior to system-level infrastructure, identifying pipeline deactivation as a high-leverage intervention. Its large multicenter dataset and quantified emissions estimates provide actionable evidence for hospital policy and align with current professional recommendations.

Clinical Implications: Hospitals should audit central nitrous oxide pipeline losses and consider deactivation where clinically appropriate, alongside fresh gas flow reduction and avoidance of high-impact volatile anesthetics. Implementation should include safety review, staff communication, and monitoring for unintended effects on clinical care.

Future Directions: Future studies should use multicenter pragmatic implementation designs to evaluate safety, cost, equity, and sustained environmental effects of nitrous oxide pipeline deactivation. Standardized reporting of anesthetic gas use and life-cycle emissions would improve cross-institutional comparisons.

This observational BioCog cohort study included 618 patients aged 65 years or older undergoing elective surgery. Preoperative dysnatremia was associated with higher rates of postoperative delirium, complications, in-hospital mortality, and 90-day mortality, but adding dysnatremia to established models produced only minimal improvement in prediction of delirium and complications. Predictive discrimination improved modestly for mortality outcomes.

Impact: The study distinguishes statistical association from clinically useful prediction, an important methodological point for perioperative risk stratification. Its negative finding cautions against treating dysnatremia as a broadly useful standalone predictor for postoperative delirium or complications.

Clinical Implications: Preoperative sodium abnormalities should prompt clinical evaluation and optimization, but sodium status alone should not be expected to substantially improve delirium or complication risk prediction beyond established clinical factors. Its possible contribution to mortality risk models requires external validation.

Future Directions: Future research should assess whether correction of dysnatremia improves outcomes or whether sodium abnormalities primarily function as markers of frailty and systemic disease. Larger multicenter cohorts should test dynamic sodium trajectories and evaluate whether dysnatremia adds value within procedure-specific or geriatric risk models.

This updated systematic review and meta-analysis evaluated randomized trials of caudal, interlaminar, and transforaminal epidural injections for lumbar disc herniation and radiculitis. It found Level I evidence supporting local anesthetic plus corticosteroids for transforaminal and interlaminar injections, Level II evidence for local anesthetic alone in those approaches, and Level II evidence for both injectate strategies with caudal injections. The evidence base remained limited for long-term outcomes and direct between-approach comparisons.

Impact: The review addresses a common but controversial intervention and explicitly grades evidence certainty across approaches and injectates. Its main contribution is to clarify where evidence is strongest while acknowledging that the apparent certainty is constrained by sparse high-quality randomized and long-term data.

Clinical Implications: For appropriately selected patients with lumbar disc herniation or radiculitis, fluoroscopic transforaminal or interlaminar epidural injection using local anesthetic plus corticosteroid has the strongest reported evidence base. Clinicians should avoid interpreting this as proof that one approach is universally superior, because direct comparative evidence and long-term studies remain limited.

Future Directions: Future trials should directly compare caudal, interlaminar, and transforaminal approaches using standardized patient-centered outcomes, prespecified clinically important response thresholds, and follow-up beyond 6 months. Studies should also clarify the incremental benefit and safety of corticosteroids over local anesthetic alone.