This systematic review aims to clarify how combining short- and long-acting local anaesthetics (LA) affects onset time and duration in peripheral nerve blocks. We included randomised controlled trials comparing adults undergoing peripheral nerve blocks with combined short- and long-acting LA with those receiving blocks performed with either a short- or long-acting LA. The primary outcome was the duration of analgesia. Secondary outcomes included the duration of onset time. We conducted meta-analyses, trial sequential analyses (TSA), risk of bias-2 and Grading Recommendations Assessment, Development and Evaluation (GRADE). We included 21 trials with 1539 participants. The combination of short and long-acting LA reduced the duration of analgesia when compared with a long-acting LA (mean difference (MD) = -162 min, 95% CI: -246 to -79, p < 0.01, tau = 181 min, I2 = 96%, TSA-adj. 95% CI: -254 to -71, GRADE = moderate). The combination increased the duration of analgesia when compared with short-acting LA (MD = 216 min, 95% CI: 163-269, p < 0.01, TSA-adj. 95% CI: 150 to 282, GRADE = moderate). Combining short and long-acting LA reduced the duration of onset time (MD = -8.0 min, 95% CI: -11.5 to -4.6, p < 0.01, tau = 7.8 min, I2 = 98%, TSA-adj. 95% CI: -11.8 to -4.3, GRADE = low) when compared with long-acting LA. In contrast, the duration of onset time was increased (MD = 1.7 min, 95% CI: 0.2-3.3, p = 0.03, TSA-adj. 95% CI: 0.1-3.4, GRADE = low) when compared with short-acting LA. Our assessment suggested that combining short and long-acting LA reduced block duration by 2½ h compared with long-acting LA and increased it by 3½ h compared with short-acting LA. The changes in duration of onset time were limited and likely not clinically relevant. Thus, using either long- or short-acting LA alone may generally be sufficient for peri- and postoperative pain management, making the need for combination unclear. This systematic review with meta-analysis presents updated results for different outcomes related to use of combined shorter and longer acting local anaesthetics for anaesthesia nerve blocks. The authors thoughtfully interpret the clinical relevance of the different outcomes in the meta-analysis. PROSPERO identifier: CRD4202346821, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=468211.

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

ABSTRACTIntroductionThis study investigates the impact of active external warming on afterdrop in simulated accidental hypothermia, compared to the effect of passive warming measures.MethodsThis study used data from a randomized crossover field study of experimental hypothermia. Hypothermia was induced in 11 healthy volunteers by pharmacological inhibition of endogenous thermoregulation and exposure to −2°C ambient air in a glacial ice tunnel, wearing wet clothes for a maximum of 2 h, or until their esophageal temperature reached 35°C. Esophageal temperature was measured using a transnasal probe. After cooling, wet clothing was removed and the participants were placed in a hypothermia wrap system for 1 h, with three different sources of active warming applied to the participants in the intervention scenario. After 1 h, the participants were walked with minimal support for balance out of the ice tunnel to a warm tent to recover. The 10 min after the end of the rewarming phase was defined as the afterdrop phase.ResultsMost participants experienced a small drop in temperature during the wrapping phase between the cooling and rewarming phases, followed by a second larger afterdrop while walking out of the ice tunnel. The afterdrop was smaller in the actively rewarmed group, with a mean drop of 0.3°C (min 0.0°C, max 1.2°C) compared to 0.7°C (min 0.0°C, max 1.6°C) in the passively rewarmed group.ConclusionsAdding active external warming reduces afterdrop compared with using only passive external warming measures in non‐shivering individuals. These results may increase understanding of both the afterdrop phenomenon and heat distribution in the body during rewarming.Editorial CommentThis study assessed temperature afterdrop in controlled hypothermia in healthy volunteers who were treated with active external rewarming or passive rewarming. These findings provide detailed insight into how temperature redistribution can occur during rewarming, at least in healthy cases.

Despite decades of efforts to optimize procedure-specific pain management, up to 60% of surgical patients still experience moderate to severe pain and opioid-related adverse effects. Current guidelines primarily rely on standardised dosing protocols rather than individual patient characteristics, offering limited support for tailoring opioid therapy to patient-specific needs. This systematic review aimed to identify studies on decision support tools for adjusting perioperative systemic opioid dosing as individualised postoperative pain management and evaluate their effects on postoperative outcomes. We searched EMBASE, MEDLINE and Cochrane Library up to August 2025for studies including adult surgical patients developing, validating or testing decision support tools (prediction models or nociception monitoring systems). Prediction model studies had to include at least two predictors and target the first 24 postoperative hours. Intervention studies had to report pain, opioid use, or opioid-related adverse events within 24 h. Studies on chronic pain, intraoperative-only agents (e.g., remifentanil), or unpublished literature were excluded. Risk of bias was assessed using the Prediction model Risk of Bias Assessment Tool in prediction model studies and Cochrane Risk of Bias and ROBINS-I tool in intervention studies. We conducted meta-analyses for intervention studies (RCTs only) when outcomes were comparable. We included 19 studies on decision support tools for perioperative opioid management: seven development and one impact study on personalised prediction models and 11 intervention studies on nociception monitoring systems. All prediction model studies predicted postoperative opioid requirements, had a high risk of bias, limited external validation and poor overall performance (R2 range: 0.100-0.313). None were clinically tested or provided advice on optimal opioid dosing. For intervention trials evaluating nociception monitoring systems, meta-analyses showed no significant effect on pain, opioid use, or opioid-related adverse events within 24 h after surgery. No studies tested risk stratified/individualised opioid treatment. No prediction model study provided concrete guidance for individualising systemic opioid treatment. Nociception monitor-guided opioid doses did not improve acute postoperative pain, opioid use or opioid-related adverse events. This systematic review assessed if available tested prediction models for individual guiding of opioid analgesic dosing, including monitors designed to assess nociceptive signal influence on clinical status, were of benefit in clinical practice. Findings, for outcomes analgesic effect, opioid dosing, or adverse events related to opioids, none of the models or systems have been demonstrated to have cliear clinical utility for optimizing opioid dosing.

ABSTRACTOptimising pain management during subcutaneous venous port (SVP) implantation is essential for patient‐centred cancer care. However, evidence‐based approaches to minimise intraoperative pain remain underexplored. This trial evaluated the clinical effectiveness and safety of the propofol‐alfentanil patient‐controlled sedation (PCS) technique as an adjunct to local anaesthesia (LA) for pain reduction during SVP implantation. Adult cancer patients at two Swedish anaesthesia departments received either LA + PCS or LA alone for SVP implantation. The primary outcome was the maximum intraoperative pain score on an 11‐point numeric rating scale (NRS). Safety outcomes included respiratory, haemodynamic and insertion‐related complications. Secondary outcomes assessed patient satisfaction and procedural measurements. A total of 340 patients (median age 70 [interquartile range, [IQR] 61–76], 51.8% male) were recruited between January 2023 and November 2024. Median intraoperative NRS pain scores were similar between groups (2 [0–3] vs. 2 [0–3], p = 0.292), with pain scores ≥ 4 reported in 22.9% (LA + PCS) and 22.2% (LA) (OR 0.96; 95% CI 0.57–1.60; p = 0.872). Hypoxia or obstructed airway occurred in 2/166 (1.2%) patients in the LA + PCS group and none in the LA group. Patient satisfaction was high in both groups (10 [10–10], p = 0.102). Optimal procedural conditions were reported more frequently with LA + PCS (96.4% vs. 82.0%; OR 5.84; 95% CI 2.36–14.44; p < 0.001), without affecting perioperative workflow. Propofol‐alfentanil PCS does not significantly reduce intraoperative pain in patients during SVP implantation. Its routine use for pain reduction cannot be recommended. However, PCS may reasonably be offered to patients who prefer procedural sedation.Editorial CommentThis randomised clinical trial found that adding patient‐controlled sedation with propofol‐alfentanil to standard local anaesthesia for subcutaneous venous port implantation does not have an impact on pain scores or patient satisfaction. Additional studies focusing on patients experiences and safety are recommended before implementing propofol‐alfentanil patient‐controlled sedation.Trial Registration: EudraCT number: 2021‐003821‐31; ClinicalTrials.gov identifier: NCT 05688384.

ABSTRACTBackgroundPrehospital emergency anaesthesia and controlled ventilation are cornerstones in the treatment of traumatic brain injury patients. Currently, there is a lack of consensus regarding the choice of anaesthetic used during the induction of anaesthesia. Esketamine has gained significant popularity, but its use has been limited in patients with traumatic brain injury due to fears of increased intracranial pressure. A protocol for anaesthesia was implemented at a Finnish helicopter emergency medical services (HEMS) unit during 2015 that mandated the use of esketamine over propofol for most patients.MethodsWe performed a retrospective cohort study to evaluate the differences in mortality and physiology in patients with traumatic brain injury, intubated using either propofol or esketamine. We collected data on patients treated by a single HEMS unit in Finland between January 2014 and December 2021. Our primary outcome was mortality before hospital discharge, and our secondary outcome was physiological stability, defined as the frequency of hypotension (systolic blood pressure ≤ 90 mmHg or a decrease of ≥ 10%) after intubation. Controlling for confounders was done through a logistical regression analysis.ResultsWe identified a total of 366 patients, 301 of whom were treated with esketamine and 65 with propofol. There was no significant difference in mortality between the esketamine and propofol groups (odds ratio 0.598, 95% confidence interval 0.281–1.272). The decrease in blood pressure after intubation was greater in the propofol group (absolute change −37.3 vs. −12.4 mmHg, 95% confidence interval −38 to −15 mmHg), but because the initial blood pressure was also higher, both groups had similar postintubation physiology.ConclusionIn this study, we found no significant difference in mortality, but we found significant differences in the haemodynamic responses between esketamine and propofol, with a slightly favourable haemodynamic profile in patients treated with esketamine. The protocol implemented in 2015 heavily shifted the choice of anaesthetics from propofol to esketamine, but there was a distinct resurgence in propofol use during the study period.Editorial CommentPatients with severe head injuries can receive advance intensive care including anaesthetic drugs in the field for intubation, when prehospital teams have this competence. This retrospective analysis presents a comparison of outcomes for traumatic brain injury cases who received either propofol or esketamine in the prehospital setting, as part of a time‐interrupted series where drug choice was changed. While possibly differing in circulatory effects, the two drugs were not associated with a difference in mortality before hospital discharge.

Reliable data on optimal fluid management in the perioperative period for patients with advanced ovarian cancer undergoing cytoreductive surgery is limited. These patients often present with malignant ascites and are prone to significant fluid shifts perioperatively. For this reason, our objective was to define clinical targets for optimal fluid balance and determine whether initial ascites should be included in fluid-loss calculations by examining the association between perioperative fluid balance and major postoperative complications. This prospective, observational study conducted in a centralized and public healthcare system setting in Sweden between 2020 and 2023 included patients with advanced ovarian cancer, > 18 years of age, scheduled for upfront cytoreductive surgery, an ASA physical status I-III with no speech/language issues. The primary outcome was major postoperative complication within 30 days of surgery. The measurements of fluid input and output, cut-offs for fluid balance, perioperative time, and postoperative complications were defined a priori. The association between fluid balance and major postoperative complications was assessed by multivariable regression, adjusted for predefined covariates, yielding odds ratios (OR) with 95% confidence intervals (CI). Of 175 enrolled patients, 162 were included in the final analysis. In the adjusted analysis, there was a significant association between fluid balance of 1750-2700 mL, OR 3.40 (95% CI 1.06-10.9; p = 0.04) and > 2700 mL, OR 3.91 (95% CI 1.33-11.5; p = 0.01) and major postoperative complications. When including initial ascites as fluid loss, a balance of > 2700 mL was associated with major postoperative complications, OR 2.59 (95% CI 1.01-6.66, p = 0.047). An optimal target for perioperative fluid balance to decrease the odds of major postoperative complications is suggested to be < 1750 mL. If initial ascites is included as loss in the calculation of balance, the optimal target of fluid balance is suggested to be < 2700 mL. These results provide practical clinical reference values that may assist anesthesiologists and surgical teams in optimizing perioperative fluid management in advanced ovarian cancer. This secondary analysis of a trial ovarian cancer operative cohort assessed the relation of the estimated fluid balance over the operative day 24 h to major postoperative complications. The findings showed that the groups where the fluid balance was in the categories higher and also most positive had higher odds for having a major complication compared to the group with lowest fluid balance. Ascities fluid was an issue in this cohort, which was managed in the analysis. ClinicalTrials.gov: NCT04065009.