Our article was a narrative review with the initial aim of synthesising recent trial evidence on the peri-operative management of patients undergoing transcatheter heart valve procedures [1]. Unfortunately, as highlighted by Kawashima et al. [2], there was a paucity of relevant studies, with the literature instead dominated by industry-sponsored randomised non-inferiority trials of new/upgraded devices in specific patient groups using composite complication and mortality outcomes. The use of regional anaesthesia and anti-emetics is indeed a valid option for transfemoral transcatheter aortic valve implantation (TAVI) with or without conscious sedation. However, the focus here is misdirected, because for patients undergoing TAVI there are bigger gains to be made elsewhere. In the UK, a major role of anaesthetists and intensivists is working as part of Heart Teams to apply trial evidence, local expertise and institutional experience to real-world patients to estimate the risks and benefits of TAVI vs. other therapies, including surgery. There is a need for all members of the Heart Team to understand all procedural steps in detail and the procedural planning which aims to reduce the incidence of avoidable complications, such as vascular injury and bleeding. Nothing illustrates this better than the recent news report of a police investigation at an NHS hospital relating to 11 patients who suffered complications following a TAVI procedure [3]. Themes here, as reported, include poor clinical decision-making; poor patient selection; and poor procedural planning. To make a TAVI programme work, all team members, including anaesthetists, require the following: high-level understanding of the procedure; knowledge of what can and might go wrong and the complications which are avoidable; proper governance processes; and expert clinical management. We hope our article helps provide practicing clinicians with the relevant knowledge. However, there remains a real issue with industry-dominated research in this area and the need for patient-focused peri-operative work using patient-reported outcome and experience measures. Hopefully, such work will allow us to further refine and standardise our anaesthetic techniques for these higher-risk, older, and frailer patients undergoing what remains a complex, expensive and life-altering procedure.

We read with interest the systematic review and Bayesian network meta-analysis by Queiroz et al. [1], which compared peri-operative pharmacological interventions to prevent postoperative delirium in patients undergoing cardiac surgery. Their work provides a valuable synthesis of available evidence, and their conclusion is timely and clinically relevant. The real-world feasibility of combining dexmedetomidine and melatonin remains uncertain. While the ranking is compelling, melatonin is not administered routinely in many countries and is unlicensed for clinical use in others. Available formulations vary widely in dose, purity and release characteristics [2]. The authors acknowledge heterogeneity in dosing regimens and intervention timing as key limitations, yet the practical barriers of drug accessibility and standardisation pose substantial challenges to implementation. The haemodynamic profile of dexmedetomidine warrants closer scrutiny. The meta-analysis highlights reductions in postoperative delirium and duration of ICU stay but pays limited attention to the risk of bradycardia and/or hypotension [3]. In patients who are vulnerable and having cardiac surgery, many of whom are older or have impaired ventricular function, haemodynamic instability may outweigh the benefit of delirium prevention. Furthermore, the exclusive focus on pharmacological interventions overlooks the multidimensional nature of postoperative delirium [4]. The authors note that delirium is influenced by factors such as pain, anxiety, stress and peri-operative sleep disruption, yet non-pharmacological strategies such as early mobilisation, optimising the ICU environment, structured sleep promotion and effective analgesia were not considered [5]. A multimodal strategy integrating pharmacological and non-pharmacological measures may provide the most comprehensive protection. Beyond knowing which combination ranks highest, we do not yet know which patient groups stand to benefit the most. The authors' call for standardised protocols and clearly defined outcomes is welcome, yet practical, patient-centred guidance on dosing and timing is still lacking. While this new study advances our understanding of pharmacological prophylaxis for postoperative delirium, the path to clinical translation requires more than drug rankings alone. Consideration of drug accessibility, haemodynamic safety, integration with non-pharmacological care and answers to bedside clinical questions will be essential to guide anaesthetists in balancing efficacy with patient safety.

We thank Li et al. [1] for their interest in our survey [2]. We agree that hypoactive delirium in the ICU is difficult to diagnose, often missed and leads to poor outcomes for patients. It would not be appropriate to cross-tabulate results as Li et al. suggest. The survey was designed to capture ICU-level practice and was completed by one individual on behalf of the whole ICU. The training questions reflect ICU-level practice across different healthcare professions, while the confidence questions reflect belief at the individual level from a person already experienced in delirium care. The survey was part of a package of projects funded by the UK National Institute of Health and Care Research. In addition to the survey, we conducted a qualitative study [3], a psychometric review of all instruments to detect delirium and systematic reviews of interventions and implementation methods to prevent and manage it [4, 5]. We are currently triangulating these different strands of evidence, which will then contribute to addressing some of the questions posed by Li et al. Our triangulation of the evidence does not support training in the CAM-ICU as the most important means of improving the detection and treatment of hypoactive delirium. The survey and qualitative study show that the CAM-ICU is implemented variably, and training is only a small part of why this occurs. There are systemic issues which need to be addressed, and these include enhanced training and awareness; protocol-driven care; audit and feedback; computer-generated prompts in clinical information systems; and the inclusion of families in the diagnostic and care processes. The psychometric review answered the question of whether the CAM-ICU (or indeed any other tool or instrument) possessed the necessary characteristics to detect or diagnose ICU delirium. This would answer a question earlier in any logic model, that is, are we using the right tool for the job – not just can we train people in it. These data have not yet been published, but we do not believe that increasing training in the CAM-ICU would improve the detection of any ICU delirium or hypoactive delirium specifically. Little has changed in over 20 years regarding the evidence for interventions to prevent, detect and manage ICU delirium or in the implementation of, or the adherence to, these tools and interventions [3, 6]. A rethink is required to improve patient care and, therefore, clinical outcomes that matter to patients and healthcare providers. Addressing the systemic issues, approached with behavioural science to make it easy for healthcare staff to provide the ‘right’ care that prevents, diagnoses and manages delirium would be the best way to improve care on ICUs.

We thank Jin et al. [1] and Kawashima et al. [2] for their constructive comments on our randomised controlled trial [3]. We like to address these comments and hope to clarify some points. Our study was powered to detect a two-point reduction on the numerical analogue scale, based on previous published data for fascial plane blocks in inguinal hernia surgery [4, 5]. We know that smaller differences may be clinically meaningful especially in day-case surgery and so a type 2 error might have occurred. We will address this topic in our next trial evaluating fascial plane blocks in abdominal surgery. The numerical analogue scale is an easy tool and internationally accepted standard for acute pain research and underpins the sample size calculations of comparable regional anaesthesia trials. Rescue analgesia, satisfaction and 30-day follow-up were also collected to complement this measure. Unfortunately, our cohort consisted exclusively of male patients due to the study period and the randomisation, but this reflects the epidemiology of inguinal hernia overrepresenting male patients with this disease [6]. We agree that there are gender differences in pain perception, and we stated this clearly as a limitation. Regarding the higher-risk population managed in day-case surgery units [1] we think that apart from underrepresented females in this study, the cohort includes patients with comorbidities, higher BMI and a range of ages. Broader studies including female patients are needed to enhance external validity. Randomisation was done after induction of anaesthesia as mentioned by Jin et al. This ensured that patients were blinded. The postoperative assessment was done by a doctor who was not part of the surgical team to handle a double-blinded study design. We agree that this might cause an intra-operative treatment bias, but this should be reduced as the procedure was done by different senior consultants. The randomisation approach will be changed within our next block trial. We agree with Jin et al. that the technique of the rectus sheath block targeted only the anterior branches. The analgesic effect of a transversus abdominis plane block is well studied for inguinal hernia repair and was therefore not the research question in this trial. The aim of this trial was to evaluate the specific effect of a rectus sheath block in inguinal hernia surgery, which we found to not add meaningful analgesia in this context. Even if the pre-emptive anaesthesia as used in this study protocol could mask a potential benefit of the abdominal wall block, it is part of our day-case surgery and was therefore part of the evaluation within this trial. Both groups received this pre-emptive regimen, so it might not influence the postoperative effect of the block. Apart from the numerical analogue scale 3 h after surgery, we agree that opioid-sparing endpoints or patient-reported outcome measurements may improve the research in future projects. Intra-operative analgesia was standardised with remifentanil. We agree that this parameter should have been evaluated in the trial as mentioned by Kawashima et al. [2]. As day-case patients are mostly discharged within 3 h of surgery, we used this as the primary outcome parameter. At all postoperative evaluations, we asked for consumption of pain killers and also evaluated postoperative complications. No patient received opioids after discharge. We apologise that this was not mentioned in the study. Including discharge readiness (for example) would indeed broaden the clinical perspective in our manuscript. Our trial showed that rectus sheath block did not add any anaesthetic benefit but, even so, it is feasible and safe. We agree with the authors of the correspondence that future studies should evaluate larger, more diverse cohorts and report additional clinically relevant data such as opioid consumption and discharge readiness.

We read with interest the comments by Wang et al. [1] and Çelebioğlu [2] on our article [3]. In both letters, the authors suggest that the control intervention in our study should have been the supra-inguinal fascia iliaca block, which is known to provide more reliable and effective analgesia as compared with the infra-inguinal approach [1, 2]. Our study was initially conceived as a dual-centre trial, involving another emergency department in the UK. The decision to use the infra-inguinal fascia iliaca block as control was dictated by the fact that, in the UK, this technique is the most used across emergency departments, as per national guidance [4]. Therefore, we decided to compare the newer PENG block with the standard care of emergency departments, which is – at least in the UK setting – different from the standard of care delivered in operating theatres by anaesthetists. Future trials, conducted in settings where emergency physicians are familiar with the supra-inguinal fascia iliaca block, should compare this approach with the PENG block. Concerning the choice of outcomes, early pain relief is a key patient-reported outcome as it enables patient comfort during investigations, personal hygiene and transferring between the emergency department and inpatient bed. Similarly, capturing the duration of nerve block analgesia is paramount, especially considering that many patients experience significant delays to surgery due to worsening operating capacity at many centres [5]. Due to the limited resources, we lacked the capacity to reassess pain at time intervals such as at 6-, 12- or 24-h post-block, or at arrival in the operating theatre. Therefore, we decided to focus our efforts on obtaining an accurate measurement of the acute analgesic effect of both interventions. Future adequately funded studies should investigate the effects of blocks in the overall pre-operative time, including important patient-centred outcomes such as the incidence of delirium and the quality of life measured using validated scales. As Wang et al. suggest, the verbal rating scale should be preferred to the visual analogue scale, as the former is a more reliable tool when assessing pain in the older population [1]. Wang et al. also raise concerns about the use of different volumes and concentrations in the two groups of our trial. The choice of the volume is block-specific and based on previous literature. Fascia iliaca block is volume-dependent, requiring an injectate of at least 30 ml, whereas almost all previous trials on the PENG block used 20 ml of injectate, in line with the initial description of the technique. This implies that when comparing these two blocks (or any blocks requiring different volumes), the use of an identical concentration of anaesthetic will result in a different total dose between the two groups. Conversely, the use of an identical dose will result in a different concentration of the anaesthetic. Researchers committed to designing similar trials will inevitably confront themselves with this conundrum. Other investigators opted for an identical local anaesthetic concentration [6], whereas we decided to use an identical dose (75 mg of levobupivacaine) [3]. From a safety perspective, clinicians typically calculate the total dose of local anaesthetic before performing a peripheral nerve block, ensuring it does not exceed the maximum dose allowed for the chosen drug. Therefore, with a pragmatic approach in mind, our trial tried to establish which of the two interventions with a similar risk profile could provide better analgesia. Our findings are not generalisable to a scenario where the PENG block and fascia iliaca block are performed with identical concentrations. When interpreting the results of our trial, clinicians or researchers should expect to replicate the same effect only if the identical methodology is used, including techniques, volumes, doses and concentration of local anaesthetics and use of adjuvants (dexamethasone).

SummaryIntroductionTherapeutic hypnosis appears to offer psychological and physiological benefits in various medical fields, but despite increasing interest, its value for anaesthesia remains inconclusive.MethodsWe searched for studies of any design in which hypnosis was used for any intervention requiring the presence of an anaesthetist, alone or in combination with any type of anaesthesia, on children and adults. Meta‐analyses using random‐effects models were stratified on hypnosis timing, when three or more randomised controlled trials reported on a similar outcome. Additional analyses were performed adding data derived from non‐randomised controlled studies. The primary outcome was the use of hypnotics and opioids during the intervention. Secondary outcomes included all outcomes related to pain, anxiety or adverse events.ResultsWe identified 142 studies that included 9238 patients (8319 adults, 919 children). Pre‐intervention hypnosis decreased post‐intervention visual analogue scale pain score (mean difference ‐0.88 cm, 95%CI ‐1.72 to ‐0.05) and anxiety (standardised mean difference ‐0.76, 95%CI ‐1.14 to ‐0.38). Per‐intervention hypnosis decreased visual analogue scale pain intensity during the intervention (mean difference ‐1.14 cm, 95%CI ‐1.86 to ‐0.41) without impacting on post‐intervention pain; decreased post‐intervention anxiety (standardised mean difference ‐0.44, 95%CI ‐0.75 to ‐0.13); and lowered the risk of postoperative nausea and vomiting (risk ratio 0.43, 95%CI 0.25–0.74). Adding non‐randomised controlled studies did not alter these results substantially. Evidence of the impact of pre‐ or per‐intervention hypnosis on other outcomes, or of post‐intervention hypnosis on any outcome, was lacking.DiscussionHypnosis may help reduce anxiety, alleviate pain during and after a procedure and lower the incidence of postoperative nausea and vomiting. However, despite the inclusion of more than 9000 patients in studies examining the use of hypnosis for anaesthesia, its impact on most outcomes remains unknown.

Since the very first publication on rapid sequence induction and intubation (RSII) [1], the controversy surrounding the practice has far outpaced the available evidence. This imbalance is one reason the Project for Universal Management of Airways (PUMA) group felt compelled to issue a preview of its forthcoming universal airway guidelines [2]. The Ship of Theseus analogy, cited in the insightful editorial by Lyons and Wiles [3], is an apt metaphor for the evolution of RSII. However, an alternative interpretation, offered by philosopher Thomas Hobbes, might be even more fitting. Hobbes envisioned a scenario in which a custodian reassembles a second ship using all of the original parts discarded by the Athenians, thereby creating a paradox: which of the two is the true Ship of Theseus? This thought experiment raises profound questions about identity, continuity and function. The proposed RSII algorithm from PUMA cited by Lyons and Wiles [3] reflects this paradox. It integrates both the ‘original’ and ‘reassembled’ elements of RSII as conceived by pioneers like Safar and Stept, while also incorporating essential modern updates: continuous oxygen delivery throughout the procedure; strategies to maximise first-pass tracheal intubation success; and the reframing of cricoid force as an optional, operator-dependent manoeuvre. Certain legacy elements of the original RSII have rightly been set aside. Modern anaesthesiology is increasingly data-informed, leveraging audits, observational studies, non-inferiority trials and randomised controlled trials. In the 1970s, the predominant fear during induction in patients with full stomachs was aspiration. Today, the scientific community broadly recognises the concept of the ‘physiologically difficult airway’ [4] and our primary concerns have shifted, recognising the pressing challenges of physiological derangement, including hypoxia and cardiovascular collapse, as emphasised by recent literature [4]. Modern RSII should focus on maximising tracheal intubation first-pass success, most often using videolaryngoscopy paired with the ideal adjunct (yet to be definitively identified). Simultaneously, continuous oxygenation – potentially via high-flow nasal oxygen – should be prioritised, alongside the confirmation of tracheal tube placement using best practice standards [4]. Moreover, RSII should be ‘rapid’ only in the narrow window between the loss of airway reflexes and inflation of the tracheal tube cuff. Every other phase should be deliberate and meticulous: thorough airway management planning; point-of-care gastric ultrasound; tailored drug selection for induction and haemodynamic optimisation (including, at times, the decision to use no induction drugs and proceed with an awake tracheal intubation); and, role and task assignments using a structured checklist-based approach [5]. The absence of conclusive evidence does not imply the absence of value. The RSII may never be wholly evidence-based, but sufficient data now exists to support a consensus-driven, evidence-informed framework. Should future research allow us to systematise RSII fully, clinical judgement will always be essential. A prudent and skilled clinician must still assess the specific risks and benefits for each individual patient. And, as Lyons and Wiles remind us through their editorial and daily practice, this principle applies to all elective, emergency and rapid sequence inductions. This guiding principle must also underlie any medico-legal review or coroner's report. Perhaps the components of RSII have changed and the ships are no longer the same, but the destination of patient safety is unchanged.

We congratulate Buffoli et al. on the comparison of the combination of pericapsular nerve group (PENG) and lateral femoral cutaneous nerve blocks with erector spinae plane (ESP) block for analgesia after primary elective total hip arthroplasty [1]. We suggest two points for future clinical research. First, the temporal match between block duration and the early mobilisation window warrants closer scrutiny. Sensory block from single-shot ropivacaine 0.5% regresses typically within 8–12 h, yet patients are encouraged to ambulate 6–10 h after surgery. A potential analgesic gap between 12 h and 24 h could obscure any real difference between the two techniques. Future trials could incorporate dexamethasone as an adjuvant or employ liposomal bupivacaine to prolong analgesia [2], while objective gait analysis with accelerometers would provide a more sensitive assessment of motor power. Second, the influence of obesity and skeletal morphometry on block success deserves more detailed evaluation. The reported mean BMI was 26–27 kg.m-2, effectively excluding patients with severe obesity in whom an enlarged iliopsoas fat pad and deeper osseous landmarks reduce sonographic clarity. Similarly, hypertrophic lumbar transverse processes or advanced spondylosis may limit cranio-caudal spread after ESP block [3]. Stratifying by BMI and pre-procedural ultrasound measurement of iliopsoas thickness and transverse process depth would clarify the generalisability of each technique. Looking forward, we advocate the creation of a prospective registry dedicated to regional anaesthesia in joint arthroplasty, capturing real-time metrics such as block success rates, falls, duration of stay and 30-day readmission. Integration of an electronic health record-based decision support tool would allow anaesthetists, orthopaedic surgeons and rehabilitation specialists to select between PENG and ESP techniques according to BMI, lumbar morphology and surgical approach. Regulatory bodies should consider incorporating ‘zero motor block’ as a quality indicator and support standardised ultrasound-guided training to reduce operator-dependent variability. Once again, we commend Buffoli et al. for this important contribution and hope that these perspectives will stimulate further refinement of precision, safety and patient-centred peri-operative analgesia.

We read with interest the article by Godet et al. [1] and commend the authors for presenting a well-structured and timely investigation into tracheal extubation practices. Their study contributes meaningful evidence to the ongoing discussion on how tracheal extubation location may influence peri-operative efficiency. The primary outcome of the study, a quantifiable gain in operating theatre efficiency when tracheal extubation occurs in the post-anaesthesia care unit (PACU), is notable. However, the associated finding of a 30-min increase in PACU stay offsets any efficiency gained intra-operatively. This challenges the assumption that tracheal extubation in the PACU translates automatically to improved system-wide throughput. We agree that any practice change must be viewed in the context of both safety and overall workflow implications. Crucially, it also raises the issue of whether the infrastructure and staffing of PACUs are adequately prepared to absorb this role shift. We commend the authors for highlighting the important topic of complications following tracheal extubation in the PACU. However, we urge caution in interpreting some of the reported findings, particularly regarding the definition of desaturation used. Defining desaturation as any drop in oxygen saturation below 96% may be overly sensitive and could overestimate clinically significant events. In otherwise healthy adults, brief, self-resolving desaturations or those rapidly corrected with simple interventions often carry limited clinical consequences. This conservative threshold may, therefore, skew complication rates unfavourably. A more pragmatic cutoff, such as SpO2 < 92%, coupled with enhanced PACU staff training and standardised tracheal extubation protocols, might provide a clearer and more balanced assessment of risks and benefits. Supporting this approach, a large retrospective study at Massachusetts General Hospital used a stricter definition of desaturation (SpO2 < 90% for > 10 s) to better correlate hypoxaemia with adverse outcomes, including escalation of care [2]. Previous research similarly favours lower thresholds as they better reflect clinically meaningful hypoxaemia, avoid overdiagnosis and help reduce unnecessary oxygen administration and its associated risks [3]. We suggest future investigations adopt these more evidence-based parameters to gauge more accurately the safety and efficiency of tracheal extubation in the PACU. There are also encouraging real-world examples of PACU-based tracheal extubation protocols being implemented successfully with nurse-led models. A hospital in Ireland describes a Lean approach to nurse-led tracheal extubation in adult PACU, reporting good outcomes and safety under defined protocols [4]. Similarly, Chillingworth et al. reported on safe tracheal extubation in the PACU, highlighting the potential for such models to be both effective and safe when supported appropriately [5]. These examples suggest that, rather than dismissing tracheal extubation in the PACU based solely on complication rates, we should explore the conditions under which it can succeed, particularly with enhanced training, adequate staffing and refined protocols. In summary, Godet et al. have contributed valuable insight into the potential trade-offs between operating theatre efficiency and PACU resource demands. We propose that a nuanced interpretation of their findings is warranted and advocate for further prospective work that builds on these results, incorporating adjustments to complication definitions and structured implementation strategies. This would allow us to better understand whether the benefits of tracheal extubation in the PACU can be realised safely and sustainably.

We thank Professor Sethuraman for his comments [1] on our article [2]. Regarding the concern that the assumption of non-inferiority lacked justification, we believe it is important to consider the evidence available at the time the study was designed, rather than applying current standards retrospectively. Our trial was registered in December 2021, at which time there were no published studies directly comparing the incidence of delirium between remimazolam and propofol. Furthermore, since there had been reports suggesting that benzodiazepines could increase the risk of delirium in patients who are critically ill [3, 4], adopting a non-inferiority design was a reasonable choice at the time. When the study was completed and the article was written, several relevant studies had been published, and we considered it appropriate to reflect their findings in the introduction [5]. The second point concerns whether our study adhered to the principles of non-inferiority trial design and reporting. We believe this may reflect a misunderstanding. The study was, in fact, conducted within a non-inferiority framework. The absence of an explicit statement of non-inferiority in the Clinical Research Information Service registry reflects a limitation of the platform itself, which classifies studies only as interventional or observational and does not include an item to indicate non-inferiority designs. At the time of planning, no previous trials had compared remimazolam and propofol directly in this specific context. Consequently, sample size estimation had to rely on pilot data. Figure 1 supports our conclusion of non-inferiority. Forest plot showing the difference in the incidence of postoperative delirium between remimazolam and propofol. The black circle represents the point estimate of the absolute difference in delirium incidence (remimazolam–propofol), and the horizontal black line indicates the 95%CI. The vertical dashed line denotes the line of no difference (i.e. 0), and the vertical red line represents the non-inferiority margin (set at 10%). The plot shows that the upper bound of the CI does not exceed the non-inferiority margin, supporting the conclusion that remimazolam is non-inferior to propofol in terms of postoperative delirium incidence. The 95%CI for the difference in proportions (remimazolam–propofol) was calculated using the standard formula: The third point relates to the clinical interpretation of the non-inferiority design, specifically the omission of pharmaco-economic considerations. We acknowledge that this aspect was not addressed. However, we believe that while cost is an important factor, it is not a required component in the interpretation of every non-inferiority trial. As mentioned in the introduction, remimazolam offers several clinical advantages over propofol, including no injection pain, greater haemodynamic stability, and more rapid recovery [2]. For clinicians who place greater value on these features, the higher cost of remimazolam may be acceptable. We believe that our findings may serve as a meaningful reference when selecting anaesthetic drugs for older patients. Non-inferiority trials are generally more complex and methodologically demanding than conventional randomised trials, but they are feasible within clinical research. Our study adhered to the principles of non-inferiority trial design, and we consider the interpretation of the results to be appropriate in showing non-inferiority.