Anesthesiology, October 16 edition

In this randomized trial of 80 patients, surgeon-performed shoulder field anesthesia was noninferior to interscalene block for cumulative 48-hour postoperative pain. Interscalene block provided better analgesia at 4–8 hours, but shoulder field anesthesia had similar opioid use and satisfaction, shorter hospital stay, and no observed Horner syndrome or respiratory events.

Impact: This study provides clinically relevant Level I evidence for a lung-sparing alternative to interscalene block, directly addressing a major safety limitation of a standard shoulder analgesic technique. Its noninferiority design supports individualized selection of regional anesthesia according to respiratory risk.

Clinical Implications: Shoulder field anesthesia can be considered when avoiding phrenic nerve dysfunction is important, particularly in patients with limited pulmonary reserve or elevated risk from hemidiaphragmatic paralysis. Clinicians should recognize that interscalene block may provide superior analgesia during the first several postoperative hours.

Future Directions: Larger, multicenter trials should confirm respiratory safety using systematic diaphragmatic ultrasound and pulmonary function testing, and should evaluate procedure-specific outcomes across diverse populations and surgical settings.

This meta-analysis included 25 randomized controlled trials involving 3344 patients. Ketamine and esketamine were associated with lower postoperative delirium risk, particularly with higher-dose or bolus-plus-infusion regimens and in major surgery, but trial sequential analysis indicated that the cumulative evidence remains inconclusive; dizziness was increased.

Impact: The study synthesizes the largest evidence base in the provided set for a clinically important and unresolved perioperative question. Its explicit dose-response exploration and trial sequential analysis appropriately temper enthusiasm and argue against routine adoption before adequately powered multicenter trials.

Clinical Implications: Ketamine or esketamine may be considered investigational options for selected high-risk patients, especially during major surgery, but the current evidence does not support routine prophylactic use. Clinicians should weigh possible delirium benefit against increased dizziness and the uncertainty of the evidence.

Future Directions: Large, multicenter, prospectively registered randomized trials should standardize delirium definitions, timing of assessment, dosing strategies, active comparators, and adverse-event reporting, with particular attention to older adults undergoing major surgery.

In this prospective open-label randomized trial of 180 patients, both TAP block strategies reduced early postoperative pain and rescue tramadol use compared with port-site infiltration. The combination of low-pressure pneumoperitoneum and laparoscopic-guided TAP block produced lower coughing and resting pain at 6 hours and less shoulder-tip pain, although differences in local anesthetic dose, volume, and timing limit attribution to individual components.

Impact: The study tests a pragmatic, readily implementable combination of regional anesthesia and surgical technique that may improve recovery while reducing opioid rescue medication. Its value is primarily clinical and operational, although the multifactorial intervention limits mechanistic attribution.

Clinical Implications: TAP block may be preferred over port-site infiltration when reducing early pain and rescue opioid use is a priority after laparoscopic cholecystectomy. Low-pressure pneumoperitoneum may offer additional benefit, but the choice should consider surgical exposure and the lack of component-specific attribution.

Future Directions: Future trials should use factorial or otherwise component-controlled designs with standardized local anesthetic dosing, a prespecified primary endpoint, blinded outcome assessment where feasible, and patient-centered recovery outcomes such as quality of recovery and opioid-related adverse effects.