Category: Uncategorized

Anesthesia Risk Stratification of Patients with Aortic Stenosis Undergoing Non-Cardiac Surgery

Aortic stenosis is one of the most prevalent valvular heart diseases, particularly in elderly populations, and it presents unique perioperative challenges. The condition involves progressive narrowing of the aortic valve, resulting in fixed left ventricular outflow obstruction ¹. Since cardiac output cannot easily increase in response to physiological stress, patients with aortic stenosis are vulnerable to hypotension, myocardial ischemia, and sudden hemodynamic collapse during anesthesia. Effective anesthesia risk stratification before non-cardiac surgery is therefore essential to minimize complications and guide clinical decision-making.

The first step in risk stratification for anesthesia management is determining the severity of aortic stenosis, typically using transthoracic echocardiography. Key parameters include aortic valve area, mean transvalvular gradient, and peak jet velocity. In addition to valve metrics, left ventricular function and degree of hypertrophy should be evaluated. Higher severity significantly increases perioperative risk, especially when associated with left ventricular dysfunction ^2,3.

Symptomatology plays a critical role in perioperative risk prediction as well. Patients with angina, syncope, or heart failure have markedly higher morbidity and mortality during non-cardiac surgery. Symptomatic status often reflects reduced cardiac reserve and impaired coronary perfusion. In contrast, asymptomatic patients with preserved ventricular function may tolerate surgery better, although they still require careful intraoperative management. Distinguishing between symptomatic and asymptomatic disease is therefore critical to anesthesia planning ^4–6.

The urgency and invasiveness of the non-cardiac surgery significantly influence overall risk, as elective surgeries allow time for patient optimization, including consideration of valve intervention to treat severe aortic stenosis prior to the procedure. High-risk surgeries, such as major vascular operations, impose greater hemodynamic stress compared to minor or intermediate-risk procedures. Emergency surgeries present the highest risk, as there is no opportunity for preoperative cardiac optimization or multidisciplinary planning^7–9.

Guidelines emphasize a team-based approach involving anesthesiologists, cardiologists, and surgeons. Risk stratification places patients with severe symptomatic aortic stenosis in the highest risk category, and elective non-cardiac surgery is typically postponed until valve intervention, such as surgical aortic valve replacement or transcatheter aortic valve implantation (TAVI), is completed. For asymptomatic patients or those undergoing urgent surgery, individualized risk-benefit assessment is essential. Shared decision-making helps balance surgical necessity against cardiovascular risk ^10,11.

From an anesthetic perspective, maintaining hemodynamic stability is paramount. Key goals include preserving sinus rhythm, avoiding tachycardia, maintaining adequate preload, and preventing sudden decreases in systemic vascular resistance. Both general and regional anesthesia can be used, but invasive monitoring is often warranted in moderate-to-severe AS. Arterial line placement and, in selected cases, advanced cardiac monitoring may help guide real-time management^12–14.

Risk stratification of patients with aortic stenosis undergoing non-cardiac surgery requires a comprehensive evaluation of disease severity, symptom status, functional capacity, and surgical urgency. A structured, multidisciplinary approach allows clinicians to identify high-risk patients and optimize perioperative care.

References

1. Aortic Stenosis Overview | American Heart Association. https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/heart-valve-problems-and-causes/problem-aortic-valve-stenosis.

2. Reddy, Y. N. V. & Nishimura, R. A. Evaluating the severity of aortic stenosis: a re-look at our current ‘gold standard’ measurements. Eur Heart J 39, 2656–2658 (2018). DOI: 10.1093/eurheartj/ehy224

3. Berthelot-Richer, M. et al. Discordant Grading of Aortic Stenosis Severity: Echocardiographic Predictors of Survival Benefit Associated With Aortic Valve Replacement. JACC Cardiovasc Imaging 9, 797–805 (2016). DOI: 10.1016/j.jcmg.2015.09.026

4. Pujari, S. H. & Agasthi, P. Aortic Stenosis. in StatPearls (StatPearls Publishing, Treasure Island (FL), 2025).

5. Aortic valve stenosis – Symptoms and causes. Mayo Clinic https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptoms-causes/syc-20353139.

6. What Is Aortic Stenosis? Cleveland Clinic https://my.clevelandclinic.org/health/diseases/23046-aortic-valve-stenosis.

7. Bak, M. et al. Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10‐Year Retrospective Study. Journal of the American Heart Association 13, e032675 (2024). DOI: 10.1161/JAHA.123.032675

8. Herrera, R. A., Smith, M. M., Mauermann, W. J., Nkomo, V. T. & Luis, S. A. Perioperative management of aortic stenosis in patients undergoing non-cardiac surgery. Front Cardiovasc Med 10, 1145290 (2023). DOI: 10.3389/fcvm.2023.1145290

9. Place, A. et al. Peri-operative risk of non-cardiac surgery in patients with aortic stenosis: a systematic review and meta-analysis. Anaesthesia (2025). DOI: 10.1111/anae.70084

10. Kuiper, B. I. et al. Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery? BMC Anesthesiol 24, 9 (2024). DOI: 10.1186/s12871-023-02394-5

11. Arnal-Velasco, D. et al. Multidisciplinary, evidence-based, patient-centred perioperative patient safety recommendations: a European consensus study☆. British Journal of Anaesthesia 135, 723–736 (2025). DOI: 10.1016/j.bja.2025.04.047

12. Cruvinel, C. The Anesthetic Challenges of Managing Patients with Aortic Stenosis for Non-cardiac Surgery. Medical Research Archives 13, (2025). DOI: 10.18103/mra.v13i8.6899

13. Chacko, M. & Weinberg, L. Aortic valve stenosis: perioperative anaesthetic implications of surgical replacement and minimally invasive interventions. Continuing Education in Anaesthesia, Critical Care and Pain 12, 295–301 (2012). DOI: 10.1093/bjaceaccp/mks037

14. Jacobs, D. Aortic stenosis. NYSORA https://www.nysora.com/anesthesia/aortic-stenosis/ (2022).

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The Path Forward for Unmatched Anesthesiology Applicants

Although unmatched anesthesiology applicants—medical students pursuing anesthesiology who do not match into a residency program—face a highly competitive environment, evidence from medical education literature shows that there are multiple structured pathways that can lead to success in the field. Understanding the factors that contribute to match outcomes and the strategies that improve subsequent applications can help applicants navigate the post-match period with clarity and purpose.

A prospective 2024 survey of anesthesiology applicants reported that matched candidates tended to exhibit stronger academic performance, more robust clinical involvement, and earlier engagement with specialty-specific activities compared with unmatched peers (1). These findings suggest that unmatched applicants who pursue targeted academic remediation, optimize exam performance, and seek additional clinical experiences in anesthesiology are well-positioned for a strengthened reapplication.

Match competitiveness is also influenced by broader systemic and demographic factors. A 2024 analysis of diversity, equity, and inclusion in anesthesiology residency matching revealed that over 77% of unmatched anesthesiology applicants ultimately pursued training in other specialties. This illustrates the intense competition within anesthesiology and the importance of early mentorship and guidance (2). Additionally, the study emphasized structural pressures, such as application inflation and increasingly large applicant pools, which can obscure strong candidates. These trends highlight the importance of a strategically crafted application strengthened by longitudinal clinical experiences, research engagement, and mentor advocacy.

For applicants who do not match with an anesthesiology program but wish to reapply, there are several viable pathways that provide meaningful clinical development. For example, transitional year programs have been shown to offer unmatched students valuable clinical exposure, increased autonomy, and improved readiness for subsequent application cycles (3). In addition to transitional programs, preliminary (prelim) year positions in internal medicine or surgery are a well-established route for building foundational clinical skills and demonstrating professionalism, work ethic, and procedural competency. These attributes are highly valued by anesthesiology program directors. Prelim years also provide opportunities to obtain strong, specialty-specific letters of recommendation and maintain close relationships with anesthesiology departments.

A critical but often overlooked barrier for unmatched applicants is the phenomenon of “signal dilution,” in which meaningful indicators of interest become obscured when applicants apply to too many programs. Berger and Cioletti explain that application overload diminishes the impact of authentic engagement, making it more difficult for programs to identify applicants aligned with their mission and training environment (4). This insight offers reapplicants a strategic approach that goes beyond simply “applying more broadly.” Instead, it emphasizes the importance of a curated list of programs strengthened by longitudinal contact, tailored application materials, and mentorship connections. This targeted approach ensures that renewed applications stand out in a crowded field and that program directors recognize genuine specialty commitment and growth.

The path forward for unmatched anesthesiology applicants is challenging but navigable. Success in future match cycles is strongly associated with seeking mentorship early, engaging in structured clinical or academic roles, refining personal statements and interview skills, and obtaining strong, recent evaluations that reflect growth since the prior cycle. Evidence from across medical education supports that unmatched applicants who remain engaged, address identified weaknesses, and leverage available training opportunities frequently match successfully upon reapplication. With thoughtful planning and evidence-informed decision-making, applicants can emerge as more competitive candidates prepared to contribute meaningfully to the field of anesthesiology.

References

1. Pendergrast T, Wolpaw J, Hofkamp MP. Identification of Candidate Characteristics that Predicted a Successful Anesthesiology Residency Program Match in 2024: An Anonymous, Prospective Survey. J Educ Perioper Med. 2025;26(4):E732. Published 2025 Jan 9. doi:10.46374/VolXXVI_Issue4_Hofkamp

2. Sumarli AN, Pineda LS, Vacaru A, et al. Diversity, Equity, and Inclusion in US Anesthesiology Residency Matching. Anesth Analg. 2024;139(5):913-920. doi:10.1213/ANE.0000000000007102

3. Gathright MM, Hankins J, Siddiqui MZ, Thrush CR, Atkinson T. A Transitional Year Residency Program Provides Innovative Solutions for Unmatched Medical Students. J Grad Med Educ. 2021;13(4):561-568. doi:10.4300/JGME-D-20-01231.1

4. Berger JS, Cioletti A. Application overload in the residency match process. J Grad Med Educ. 2016;8(3):317-321.

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What Risks Need to Be Discussed With Surgical Patients?

Informed consent is a foundational ethical and legal requirement in surgical practice. Central to informed consent is a clear discussion of the risks associated with a proposed surgical procedure. The medical literature emphasizes that risk disclosure is not merely a formality, but a process aimed at supporting patient autonomy, shared decision-making, and realistic expectations. Determining which risks must be discussed with surgical patients requires balancing legal standards, clinical relevance, and individual patient factors. This review summarizes key categories of risks that should be communicated to surgical patients based on established ethical guidelines and surgical literature.

A fundamental category includes general surgical and anesthetic risks. Regardless of the specific surgical procedure, common and foreseeable risks should be discussed with patients, such as bleeding, infection, pain, scarring, and delayed wound healing. Significant anesthesia-related risks—including nausea, vomiting, aspiration, allergic reactions, cardiovascular events, and, in rare cases, death—should also be discussed. Although serious anesthetic complications are uncommon, the literature supports disclosure because anesthesia is integral to most surgical interventions and carries independent risk.

A second essential category is procedure-specific risks. These are complications uniquely associated with the operation being performed and often represent the most clinically significant information for patients. Examples include nerve injury during orthopedic or spine surgery, bile duct injury during cholecystectomy, anastomotic leak after bowel surgery, or urinary incontinence and erectile dysfunction following prostate surgery. Even if the probability of these complications is low, they must be disclosed when the potential impact on quality of life is substantial. Courts and professional societies consistently emphasize that severity, not just frequency, determines whether a risk is material to informed consent.

Risks related to patient-specific factors must also be discussed before the surgical procedure. Comorbid conditions such as diabetes, obesity, cardiovascular disease, pulmonary disease, or immunosuppression can significantly increase perioperative risk. Advanced age, frailty, smoking status, and poor nutritional status are additional modifiers of surgical outcomes. The literature stresses that risk discussions should be individualized, rather than relying on generic consent language, to reflect how a patient’s unique clinical profile alters expected outcomes.

Another important area involves risks of postoperative outcomes and recovery. Patients should be informed about the likelihood of prolonged recovery, functional limitations, need for rehabilitation, chronic pain, or incomplete symptom relief. Unrealistic expectations are a common source of postoperative dissatisfaction and litigation. Discussing the possibility that surgery may not fully resolve symptoms—or may require additional procedures in the future—is therefore a critical component of informed consent.

The literature also highlights the importance of discussing alternatives to surgery and the risks of non-treatment. Informed consent is incomplete without explaining reasonable non-surgical options, such as medical management, watchful waiting, or less invasive procedures, along with

their respective risks and benefits. Patients should also understand the potential consequences of declining surgery, including disease progression, functional decline, or increased future risk.

Finally, rare but catastrophic risks should be explicitly discussed with surgical patients, even if the likelihood of occurrence is low. Although events such as stroke, permanent disability, or death generally occur infrequently, they carry profound consequences. Ethical frameworks and legal standards generally agree that these risks should be disclosed when they are foreseeable, even if statistically uncommon, because a reasonable patient would consider them important when deciding.

In conclusion, effective risk disclosure in surgery encompasses general operative and anesthetic risks, procedure-specific complications, patient-specific risk modifiers, postoperative and recovery-related risks, alternatives to surgery, and rare but serious adverse outcomes. The literature supports a patient-centered, individualized approach that prioritizes clarity, relevance, and shared decision-making. Thorough risk discussions not only fulfill ethical and legal obligations but also enhance trust, improve patient satisfaction, and support better surgical outcomes.

References

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford University Press; 2019.

2. Hall DE, Prochazka AV, Fink AS. Informed consent for clinical treatment. CMAJ. 2012;184(5):533-540. DOI: 10.1503/cmaj.112120

3. American College of Surgeons. Statements on principles: informed consent. Bull Am Coll Surg. 2016;101(1):15-16. https://www.facs.org/about-acs/statements/statements-on-principles/

4. Spatz ES, Krumholz HM, Moulton BW. The new era of informed consent: getting to a reasonable-patient standard through shared decision making. JAMA. 2016;315(19):2063-2064. DOI: 10.1001/jama.2016.3070

5. McKneally MF, Martin DK. An entrustment model of consent for surgical treatment. World J Surg. 2000;24(11):1414-1419. DOI: 10.1067/mtc.2000.106525

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Pressure Support vs Pressure Control

Pressure Support and Pressure Control Ventilation

Pressure-based modes of mechanical ventilation are central to managing patients with acute or chronic respiratory failure. Pressure support ventilation (PSV) and pressure control ventilation (PCV) are two widely used strategies with distinct physiologic features, clinical indications, and potential advantages.

Pressure Support Ventilation is a spontaneous mode in which each breath is initiated by the patient and supported by a clinician-selected level of positive pressure. Because the patient determines respiratory rate, inspiratory time, and much of the flow profile, this mode often produces a more natural breathing pattern. Studies have shown that PSV can reduce patient work of breathing, improve patient–ventilator synchrony, and enhance comfort compared with fully controlled modes. Experimental models of lung injury demonstrate that PSV may lead to improved gas exchange and reductions in inflammatory markers and histologic evidence of ventilator-induced lung injury. These benefits likely stem from the physiological distribution of ventilation and avoidance of forced, time-cycled breaths. During weaning, PSV is frequently preferred due to its ability to support patient effort while encouraging restoration of normal respiratory muscle activity.

However, PSV has limitations. It requires adequate patient respiratory drive, so it is inappropriate in patients who are deeply sedated, apneic, or neurologically impaired. Additionally, PSV allows tidal volumes to fluctuate, which may be problematic in conditions such as acute respiratory distress syndrome (ARDS), where strict tidal-volume limitation is essential. Animal data also suggest that prolonged use of PSV may contribute to diaphragmatic injury due to the varying respiratory load placed on the muscle.

Pressure control ventilation, by contrast, delivers breaths using a preset inspiratory pressure, inspiratory time, and respiratory rate. It provides more consistent support regardless of patient effort, making it suitable for patients who require controlled ventilation due to sedation, paralysis, or severe respiratory muscle weakness. PCV generates a characteristic decelerating flow pattern that may improve recruitment and reduce peak alveolar pressures. Some studies suggest PCV may produce more uniform ventilation in lungs with heterogeneous compliance, potentially reducing regional overdistention.

The limitations of PCV predominantly relate to variable tidal volume. Because delivered volume depends on patient lung mechanics, sudden decreases in compliance or increases in airway

resistance can result in hypoventilation unless settings are adjusted promptly. Conversely, overly high pressure targets may lead to baro-trauma if not carefully titrated. Unlike pressure support ventilation, pressure control ventilation can also contribute to patient–ventilator asynchrony if patients develop spontaneous respiratory effort that conflicts with the set inspiratory timing.

Across clinical studies, no clear superiority of pressure support or pressure control ventilation has been demonstrated for major outcomes such as mortality, duration of mechanical ventilation, or ICU length of stay. Rather, the literature supports choosing the mode based on individual patient physiology and the clinical goals of ventilation. PSV is preferred when supporting spontaneous breathing and during weaning, while PCV provides more reliable ventilation for patients requiring full support. In all cases, lung-protective strategies, close monitoring, and frequent reassessment remain essential regardless of mode selection.

References

1. Aydogdu M, Gursel G, Yildirim F, et al. Comparison of pressure control and pressure support modes for non-invasive mechanical ventilation in acute hypercapnic respiratory failure. Crit Care. 2010;14(Suppl 1):P237. DOI: 10.1186/cc8469

2. da Silva AL, Bessa CM, Carvalho EB, et al. Pressure-support vs. pressure-controlled ventilation mitigates lung and brain injury in experimental acute ischemic stroke in rats. Intensive Care Med Exp. 2023;11:93. DOI: 10.1186/s40635-023-00580-w

3. Singer BD, Corbridge TC. Pressure modes of invasive mechanical ventilation. South Med J. 2009;102(12):1238-1245. DOI: 10.1097/SMJ.0b013e31822da7fa

4. Melo-Silva CA, et al. Effects of pressure support and pressure-controlled ventilation on diaphragmatic injury in experimental emphysema. Respir Physiol Neurobiol. 2016;228:41-48. DOI: 10.1186/s40635-016-0107-0

5. Spieth PM, et al. Pressure support ventilation attenuates pulmonary inflammatory response compared with pressure-controlled ventilation in experimental lung injury. Crit Care Med. 2011;39(4):770-776. DOI: 10.1097/CCM.0b013e318206bda6

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Government Shutdowns: Impact on Healthcare

Government Shutdowns: Impact on Healthcare

Although they are primarily political and economic events, government shutdowns have profound effects on the U.S. healthcare system. These disruptions can impair federal health agencies, delay research, affect healthcare workers’ pay, slow regulatory approvals, and reduce access to care—especially for vulnerable populations reliant on government programs. Understanding these impacts is critical for healthcare professionals and administrators to anticipate, mitigate, and advocate during periods of fiscal gridlock.

When Congress fails to pass appropriations bills or a continuing resolution, federal agencies operate at reduced capacity. The Department of Health and Human Services (HHS), Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), National Institutes of Health (NIH), and Centers for Medicare & Medicaid Services (CMS) all experience varying degrees of operational slowdown. While critical and life-sustaining services continue, nonessential functions—such as clinical research, regulatory review, and grant administration—often pause. The NIH typically halts the review of new grant applications and delays ongoing research. During the 2018–2019 shutdown, thousands of research proposals were postponed, disrupting timelines for medical innovation. Scientists reported stalled clinical trials and restricted access to federal laboratories, impeding translational work.

Public health surveillance and disease monitoring are also impaired. The CDC curtails routine surveillance activities, delays seasonal influenza tracking updates, and limits outbreak response capacity. Reduced staffing and frozen communication channels can slow the nation’s ability to respond to infectious threats—a vulnerability made starkly evident during past shutdowns coinciding with severe flu seasons. The FDA’s operations are particularly affected. During shutdowns, the agency often suspends routine food safety inspections and slows drug and device approval processes. These delays have downstream consequences for pharmaceutical companies and hospitals awaiting approval of potentially life-saving therapies or devices. Limited oversight during prolonged funding gaps can heighten safety risks for consumers.

Clinical care delivery also faces indirect strain. Although Medicare and Medicaid reimbursements generally continue, claims processing or appeals can face temporary backlogs if support staff are furloughed. Federally Qualified Health Centers (FQHCs), Indian Health Service (IHS) clinics, and community health programs often experience financial uncertainty due to delayed federal grants. The IHS in particular has historically struggled to maintain essential healthcare services during government shutdowns, leaving tribal communities disproportionately vulnerable.

Government shutdowns also harm the healthcare workforce. Federal employees such as CDC epidemiologists, FDA inspectors, NIH researchers, and IHS clinicians may face furloughs or delayed paychecks. In previous shutdowns, medical residents and fellows supported by federal stipends or training grants experienced income disruptions. Morale and retention can suffer when healthcare professionals face uncertainty about their compensation or research continuity. The broader economic consequences can indirectly affect health outcomes as well. Reduced government spending lowers economic activity, increasing unemployment risk and potential loss of private insurance coverage. Mental health burdens can rise as financial instability and uncertainty persist. Studies show that healthcare utilization patterns—particularly preventive and elective services—decline during fiscal disruptions, reflecting both individual financial caution and institutional slowdowns.

In an increasingly complex healthcare landscape, continuity of federal operations is vital for patient safety, research progress, and national health security. Government shutdowns and the pattern of resulting impacts underscore the vulnerability of a system dependent on annual appropriations. Healthcare professionals and leaders play an important role in advocating for legislative reforms that safeguard essential health functions from political impasse.

References

U.S. Department of Health and Human Services. Contingency Staffing Plan for Operations in the Absence of Enacted Annual Appropriations. HHS; 2023.
Taylor L. “Unprecedented” US government shutdown could force mass furlough of health workers. BMJ. 2025 Oct 2;391:r2073. DOI: 10.1136/bmj.r2073
Morabia A, Benjamin GC. When Public Health Gets Shut Down, All Americans Suffer, and the Most Vulnerable Are First. Am J Public Health. 2019 Apr;109(4):530-531. DOI: 10.2105/AJPH.2019.304992
Tobey M, Armstrong K, Warne D. The 2019 Partial Government Shutdown and Its Impact on Health Care for American Indians and Alaska Natives. J Health Care Poor Underserved. 2020;31(1):75-80. DOI: 10.1353/hpu.2020.0009
Filip R, Gheorghita Puscaselu R, Anchidin-Norocel L, Dimian M, Savage WK. Global Challenges to Public Health Care Systems during the COVID-19 Pandemic: A Review of Pandemic Measures and Problems. J Pers Med. 2022 Aug 7;12(8):1295. DOI: 10.3390/jpm12081295

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Medications Associated with Higher Risk of Perioperative Falls

Quantum Computing and EEG: A New Frontier in Anesthesia Monitoring?

Falls are among the most frequent and costly complications following surgery, often leading to prolonged hospitalizations, loss of independence, and higher morbidity. For anesthesiologists, who directly influence perioperative prescribing practices, it is essential to recognize medications that elevate fall risk. The perioperative period creates a unique vulnerability: patients often receive sedatives, analgesics, and sleep aids while recovering from anesthesia, all of which can impair balance, attention, and orthostatic regulation. Careful medication stewardship can reduce fall risk without compromising pain control or patient comfort.

Sedative–hypnotics, especially the non-benzodiazepine “Z-drugs” such as zolpidem, are common medications in the perioperative period and may contribute to the risk of falls. In a large case–control study of hospitalized adults, zolpidem was independently associated with increased odds of inpatient falls, even after accounting for comorbidity and concomitant medication use. Mechanistically, sedative-hypnotics impair balance, increase amnesia, and contribute to nocturnal confusion, all of which can impact mobility, particularly in the first postoperative night. For anesthesiologists, avoiding routine initiation of zolpidem postoperatively and instead prioritizing nonpharmacologic sleep strategies represents an actionable and evidence-based step.

Benzodiazepines, traditionally viewed as strong contributors to delirium and falls, have a more nuanced profile in recent literature. A 2023 systematic review and meta-analysis found that perioperative benzodiazepines did not significantly increase delirium risk overall and were effective in preventing intraoperative awareness. However, in older, frail, or cognitively impaired patients, benzodiazepines remain problematic due to sedation, impaired motor coordination, and potentiation of other CNS depressants. In practice, this means reserving benzodiazepines for well-justified indications, tailoring dosing, and avoiding them in high-risk patients.

Gabapentinoids, such as gabapentin and pregabalin, are increasingly scrutinized for their role in perioperative safety. Once widely prescribed for opioid-sparing analgesia, they are now associated with significant adverse events. A nationwide cohort study of older surgical patients demonstrated that perioperative gabapentin use was linked to increased risk of delirium, new antipsychotic prescriptions, and pneumonia. Separately, a 2024 analysis found gabapentinoid exposure to be associated with a higher risk of hip fractures, particularly among frail patients and those with kidney disease. For anesthesiologists, this means gabapentinoids should be reserved for clear neuropathic indications, prescribed at the lowest effective dose, and carefully adjusted for renal function. They should also be avoided in combination with other sedatives whenever possible.

Opioid medications remain a cornerstone of perioperative pain management but are also significant contributors to fall risk. Their sedative and cognitive effects impair reaction time and balance, while their potential to induce orthostatic hypotension increases instability during early ambulation. When combined with benzodiazepines, gabapentinoids, or hypnotics, opioids can have synergistic effects that magnify fall risk. Effective strategies to mitigate this include the use of multimodal analgesia, regional techniques, and early de-escalation of opioid therapy. Opioid stewardship not only reduces fall risk but also enhances recovery and patient satisfaction.

Practical interventions can be embedded throughout the perioperative pathway. Preoperatively, anesthesiologists should identify high-risk patients—those who are aged 65 or older, frail, cognitively impaired, or with renal insufficiency—and reconcile home sedatives. Intraoperatively and in the PACU, minimizing sedative burden, avoiding routine benzodiazepines, and carefully reviewing postoperative sleep orders are key steps. On the ward, nonpharmacologic sleep hygiene strategies should be prioritized, and if hypnotics are absolutely required, the lowest effective dose should be chosen and not combined with opioids or gabapentinoids. Nursing fall-prevention protocols should also be coordinated with prescribing practices to ensure safe mobilization.

Anesthesiologists play a central role in mitigating perioperative fall risk through medication choices. The most concerning agents are sedative–hypnotics, benzodiazepines in vulnerable populations, gabapentinoids in older or renally impaired adults, and opioids, especially when used in combination. Reducing unnecessary sedative load, tailoring prescriptions to individual risk profiles, and embedding fall-prevention strategies into perioperative care pathways can meaningfully improve patient safety.

References

Kronzer VL, Wildes TS, Avidan MS. Review of perioperative falls. Br J Anaesth. 2016;117(6):720-732. doi: 10.1093/bja/aew377.
Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med. 2013;8(1):1-6. doi: 10.1002/jhm.1985.
Park CM, Inouye SK, Marcantonio ER, et al. Perioperative gabapentin use and in-hospital adverse clinical events among older adults after major surgery. JAMA Intern Med. 2022;182(11):1117-1127. doi: 10.1001/jamainternmed.2022.3680.
Leung MTY, Turner JP, Marquina C, Ilomäki J, Tran T, Bykov K, Bell JS. Gabapentinoids and risk of hip fracture. JAMA Netw Open. 2024;7(11):e2444488. doi: 10.1001/jamanetworkopen.2024.44488.
Wang E, Belley-Côté EP, Young J, et al. Effect of perioperative benzodiazepine use on intraoperative awareness and postoperative delirium: a systematic review and meta-analysis. Br J Anaesth. 2023;131(3):302-313. doi: 10.1016/j.bja.2022.12.001.

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Anesthesia Considerations for Patients with History of Neck Fracture

Anesthesia Considerations for Patients with Past Neck Fracture

Administering anesthesia to patients with a history of neck fracture presents unique challenges and requires thorough preoperative planning. The cervical spine plays a crucial role in airway management and positioning during anesthesia, and any previous injury to this area may complicate standard protocols. While a healed neck fracture may not present active symptoms, the long-term structural or neurological changes can significantly affect anesthetic risk and technique.

Safe airway management is a core concern during anesthesia for patients with a history of neck fracture. Neck mobility may be limited due to pain, surgical fusion, hardware placement, or residual instability. Limited extension or flexion of the cervical spine can make direct laryngoscopy difficult, increasing the risk of failed intubation or airway trauma. In such cases, alternative airway strategies must be considered. These include the use of video laryngoscopy, fiberoptic bronchoscopy, or even awake intubation if necessary. The objective is to minimize neck movement while securing the airway, reducing the risk of spinal cord injury or exacerbation of an existing condition.

A detailed preoperative assessment is essential. This includes a thorough review of the patient’s medical history, imaging studies such as cervical spine X-rays or MRI, and any prior neurosurgical interventions like fusion or hardware placement. The anesthesiologist should evaluate current neck mobility and neurological status. A history of weakness, numbness, or gait disturbances may indicate underlying instability or chronic spinal cord involvement, which must be factored into the anesthesia plan ^1–5.

Proper positioning during anesthesia and surgery is critical for patients with a history of neck fracture, especially when manipulating the neck. Patients with a past cervical fracture may require additional support to keep the spine aligned during procedures: Foam pads, cervical collars, or custom headrests may be used to prevent unintended movement. Even minor mispositioning can lead to nerve injury or compromise blood flow to the brain and spinal cord in at-risk patients. Extra care may be required during transfers and changes in positioning on the operating table, with close collaboration between surgical and anesthesia teams being essential ^4,5.

The choice between general, regional, or monitored anesthesia care in the context of a history of neck fracture should also be carried out carefully. In many cases, general anesthesia is still appropriate, but modifications may be necessary. Induction agents should be selected to allow for smooth, controlled airway management. If regional anesthesia is considered, such as a nerve block or spinal anesthesia, the patient’s spinal anatomy and neurological status must be carefully evaluated to avoid complications. In some cases, regional techniques may be safer and help avoid airway manipulation altogether, particularly for procedures not involving the head or neck ^6,7.

Patients with a history of neck fracture may be at increased risk for delayed neurological complications. Postoperative monitoring should include neurological status and respiratory function assessments, particularly if the patient’s history includes spinal cord injury. If the procedure involves prolonged neck manipulation or positioning, observation in a recovery unit or intensive care setting may be warranted to ensure no new deficits develop ^7,8.

In summary, anesthesia for patients with a history of neck fracture requires individualized planning, careful airway and positioning strategies, and a thorough understanding of the patient’s cervical spine condition. With appropriate precautions, these patients can safely undergo anesthesia and surgery with minimized risk.

References

1. Ramkumar, V. Preparation of the patient and the airway for awake intubation. Indian J Anaesth 55, 442–447 (2011). DOI: 10.4103/0019-5049.89863

2. Fiberoptic bronchoscopy: Technique, risks, what to expect. https://www.medicalnewstoday.com/articles/fiberoptic-bronchoscopy (2024).

3. Chemsian, R., Bhananker, S. & Ramaiah, R. Videolaryngoscopy. Int J Crit Illn Inj Sci 4, 35–41 (2014). DOI: 10.4103/2229-5151.128011

4. Wiles, M. D. et al. Airway management in patients with suspected or confirmed cervical spine injury. Anaesthesia 79, 856–868 (2024). DOI: 10.1111/anae.16290

5. Austin, N., Krishnamoorthy, V. & Dagal, A. Airway management in cervical spine injury. Int J Crit Illn Inj Sci 4, 50–56 (2014). DOI: 10.4103/2229-5151.128013

6. Folino, T. B. & Mahboobi, S. K. Regional Anesthetic Blocks. in StatPearls (StatPearls Publishing, Treasure Island (FL), 2025).

7. Bao, F., Zhang, H. & Zhu, S. Anesthetic considerations for patients with acute cervical spinal cord injury. Neural Regen Res 12, 499–504 (2017). DOI: 10.4103/1673-5374.202916

8. Dooney, N. & Dagal, A. Anesthetic considerations in acute spinal cord trauma. Int J Crit Illn Inj Sci 1, 36–43 (2011). DOI: 10.4103/2229-5151.79280

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Lidocaine and Tinnitus

Lidocaine is a local anesthetic commonly used across a variety of clinical settings. It can be given intravenously to facilitate tracheal intubation, applied to the gums in dentistry to numb an area prior to a procedure, and administered during surgery to reduce pain and improve outcomes after the operation.¹ Like other local anesthetics, lidocaine binds to sodium channels in nerve cells, preventing nerve depolarization and the transmission of a nerve impulse. Less commonly, lidocaine can be used to manage tinnitus.

Patients with tinnitus hear ringing or other noises without external sources. Often caused by hearing loss or an ear injury, tinnitus can be treated with sound therapies, cognitive behavior therapies, and medications that aid in sleep.² However, there is no FDA-approved drug or treatment specifically for the condition. The need, however, is considerable: according to the American Tinnitus Foundation, 25 million Americans experience some form of the condition, with 2 million, or 8%, finding it debilitating.³

For decades, lidocaine has been observed to temporarily alleviate or dissipate the symptoms of tinnitus. In a 1978 study, the intravenous injection of lidocaine in 78 patients with tinnitus led to the complete disappearance of symptoms in 27 (35%), partial improvement in 22 (28%), and no observed change in 21 (26%).⁴ More recent studies have also demonstrated lidocaine’s positive impact. A 2018 study evaluated an injection of lidocaine with the steroid dexamethasone administered directly into the middle ear through the ear drum (known as an intratympanic injection). Compared to patients who received only dexamethasone, those who received the lidocaine-containing injection experienced improvements in their tinnitus symptoms, as measured by the loudness matching test, in which the volume of an external noise is adjusted to match that of the tinnitus, and the tinnitus handicap index, in which a patient quantifies the difficulties they are experiencing due to tinnitus.⁵

The mechanism by which lidocaine reduces tinnitus symptoms is not entirely clear, but it is thought to relate to the anesthetic’s ability to lower spontaneous hyperactivity in the central nervous system, which can itself be implicated in tinnitus.⁶ Furthermore, lidocaine can improve blood flow to the inner ear and reduce the cochlear microphonic, the electric potential generated by cochlear hair cells in response to sound.⁷

Despite its successes, using lidocaine to treat tinnitus remains imperfect. In fact, it may even have a worsening effect: in one randomized controlled trial, over 30% of patients with tinnitus had worsened symptoms.⁷ Lidocaine can also lead to other side effects, including prolonged numbness, tingling, and slurred speech.

Although lidocaine is not currently recommended for the treatment of tinnitus, recent new approaches in leveraging the anesthetic may help change this. In one study, participants with chronic tinnitus wore a lidocaine patch and had improved symptoms after several months of treatment.⁸ Though the sample size was small, this approach may help represent a new avenue of care for the millions struggling with tinnitus.

References

1. Beecham, G. B., Nessel, T. A. & Goyal, A. Lidocaine. in StatPearls (StatPearls Publishing, Treasure Island (FL), 2025).

2. What Is Tinnitus? — Causes and Treatment | NIDCD. https://www.nidcd.nih.gov/health/tinnitus (2023).

3. What is Tinnitus? | American Tinnitus Association. https://www.ata.org/about-tinnitus/why-are-my-ears-ringing/ (2023).

4. Melding, P. S., Goodey, R. J. & Thorne, P. R. The use of intravenous lignocaine in the diagnosis and treatment of tinnitus. J. Laryngol. Otol. 92, 115–121 (1978), DOI: 10.1017/s002221510008511x

5. Elzayat, S. et al. Evaluation of Adding Lidocaine to Dexamethasone in the Intra-tympanic Injection for Management of Tinnitus: A Prospective, Randomized, Controlled Double-blinded Trial. Int. Tinnitus J. 22, 54–59 (2018), DOI: 10.5935/0946-5448.20180009

6. Kim, S. H. et al. Review of Pharmacotherapy for Tinnitus. Healthcare 9, 779 (2021), DOI: 10.3390/healthcare9060779

7. Duckert, L. G. & Rees, T. S. Treatment of tinnitus with intravenous lidocaine: A double-blind randomized trial. Otolaryngol. Neck Surg. 91, 550–555 (1983), DOI: 10.1177/019459988309100514

8. O’Brien, D. C., Robinson, A. D., Wang, N. & Diaz, R. Transdermal lidocaine as treatment for chronic subjective tinnitus: A Pilot Study. Am. J. Otolaryngol. 40, 413–417 (2019), DOI: 10.1016/j.amjoto.2019.03.009

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Anesthesiology Residency Rotations: A Comprehensive Overview

Anesthesiology residency programs are meticulously structured to provide residents with a broad and in-depth clinical experience. The training typically spans four years: it begins with a Clinical Base Year (PGY-1) and is followed by three years of Clinical Anesthesia (CA-1 to CA-3). Each phase is designed to build upon the previous, ensuring a progressive acquisition of knowledge and skills necessary for competent anesthetic practice. During anesthesiology residency, anesthesiologists-in-training gain experience in diverse clinical settings through rotations and extensive hands-on practice that aim to prepare them for independent practice.

Anesthesiology residency programs are primarily dedicated to cultivating compassionate, knowledgeable, and highly skilled anesthesiologists who can safely and effectively care for patients across a wide range of clinical settings. The mission is to provide comprehensive, progressive training that emphasizes excellence in perioperative medicine, pain management, and critical care ^1,2.

The PGY-1 year serves as the foundation for anesthesiology training, emphasizing the development of general medical knowledge and patient care skills. PGY-1 rotations intersect with various specialties, including internal medicine, surgery, emergency medicine, and critical care, to provide a comprehensive understanding of patient management across various medical disciplines at the start of residency ^3,4.

The CA-1 year marks residents’ immersion into the field of anesthesiology. During this period, residents focus on mastering basic anesthetic techniques and perioperative patient management. This year is pivotal in developing the residents’ proficiency in administering anesthesia and managing patients in the perioperative setting ^5,6.

In the CA-2 year, residents delve into anesthesiology subspecialties, gaining exposure to complex surgical cases and advanced anesthetic techniques. Rotations during anesthesiology residency typically include pediatric anesthesia, obstetric anesthesia, cardiothoracic anesthesia, neuroanesthesia, regional anesthesia, and critical care. This diverse clinical exposure equips residents with the skills necessary to manage a wide array of anesthetic challenges ^7,8.

The final year of residency, CA-3, focuses on refining clinical skills, fostering leadership abilities, and preparing residents for independent practice. Residents often have the opportunity to tailor their rotations based on career interests, engaging in advanced subspecialty rotations, elective experiences, or in-depth research projects. This flexibility allows residents to align their training with future career goals and interests ^9,10.

Anesthesiology residency rotations are thoughtfully designed to provide a comprehensive and progressive training experience. From establishing foundational medical knowledge in the PGY-1 year to refining advanced clinical skills and leadership in the CA-3 year, each phase plays a crucial role in developing competent and confident anesthesiologists. The structured yet flexible nature of these programs ensures that residents are well prepared to meet the diverse challenges of anesthetic practice and to contribute meaningfully to patient care and the broader medical community.

References

1. Miller, J. Mission & Vision – Anesthesiology and Perioperative Medicine. https://www.uab.edu/medicine/anesthesiology/about/mission-vision.

2. Program Mission & Aims » Department of Anesthesiology » College of Medicine » University of Florida. https://anest.ufl.edu/education/residency/program-aims/.

3. Staszak, J. et al. Changing of an anesthesiology clinical base year to create an integrated 48-month curriculum: experience of one program. J Clin Anesth 17, 225–228 (2005). DOI: 10.1016/j.jclinane.2004.08.005

4. Clinical Base Year (PGY-1). Anesthesiology https://www.anesthesiology.cuimc.columbia.edu/education/residency/clinical-anesthesia-rotations/clinical-base-year-pgy-1 (2017).

5. Curriculum | Anesthesia Residency | IU School of Medicine. https://medicine.iu.edu/anesthesia/education/residency/curriculum.

6. Residency Curriculum Overview. https://medicine.yale.edu/anesthesiology/education/resident-life/curriculum/.

7. Program Structure & Rotations – UW Anesthesiology & Pain Medicine. https://anesthesiology.uw.edu/education/residency-program/program-structure-rotations/.

8. Rotations. Dept. of Anesthesiology | GW School of Medicine and Health Sciences https://anesthesiology.smhs.gwu.edu/rotations.

9. Keck School of Medicine of USC Anesthesiology Residency Program. Department of Anesthesiology https://keck.usc.edu/anesthesiology/training-education/keck-school-of-medicine-residency-program/.

10. Curriculum Anesthesiology Residency | Icahn School of Medicine. Icahn School of Medicine at Mount Sinai https://icahn.mssm.edu/education/residencies-fellowships/list/msh-anesthesiology-residency/curriculum.

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Sodium Bicarbonate Adjuvant in Anesthesia

Sodium Bicarbonate Adjuvant in Anesthesia

Sodium bicarbonate, also known as baking soda, is most commonly used in cooking and cleaning, but it has a wide range of medical applications. It’s a basic compound and can therefore neutralize acid indigestion; in this context, it’s known as an antacid. It can also be used to treat acidosis, an excessive buildup of acid in the body’s fluids and tissues. The same principle makes sodium bicarbonate an effective adjuvant in anesthesia.

An adjuvant is a medication given together with a peripheral nerve block, which blocks pain signaling in nerves near the site of surgery and has fewer side effects compared with general anesthesia. An adjuvant can help shorten the time required for onset of analgesia (the inability to feel pain), while also prolonging its duration and depth. Sodium bicarbonate increases the pH of the anesthetic drug, which allows it to more readily exist in its un-ionized, or uncharged, form.¹ In this form, the anesthetic can more easily cross the lipid membrane of peripheral nerves, allowing for a greater analgesic effect and a faster onset.

Sodium bicarbonate has been shown to serve as an effective adjuvant to regional anesthesia in a variety of clinical settings. In one study, investigators added sodium bicarbonate to the anesthetic drugs dexamethasone and ropivacaine for a block of the supraclavicular brachial plexus nerves (which control movement in the upper limb) for upper limb orthopedic surgery.² Patients who received this treatment regimen had quicker onset and longer duration of nerve block compared with the control group. Another trial found that adding sodium bicarbonate to the local anesthetic lignocaine injected into the palate for extraction of the maxillary bilateral premolar teeth reduced pain and shortened the onset of anesthesia, while also increasing its duration.³ The American Society of Anesthesiologists lists a sodium bicarbonate adjuvant as part of its recommendations for the use of adjuvant medications during cesarean delivery (C-section).⁴

However, other studies indicate that sodium bicarbonate may add little to no benefit when used as an adjuvant to anesthesia. One group of investigators found that while sodium bicarbonate leads to a greater reduction of pain in patients undergoing wisdom tooth removal, it made no significant difference in the duration of anesthesia.⁵ Another study in patients undergoing lower extremity surgery observed that sodium bicarbonate did not impact the onset or duration of anesthesia from bupivacaine.⁶

The apparent inconsistencies in when sodium bicarbonate has a significant effect on anesthesia might be a function of which anesthetic is used and where it is administered. One analysis found that it worked best with lidocaine and bupivacaine for epidural block, with lidocaine for brachial plexus block, and with mepivacaine for sciatic and femoral nerve blocks.⁶

Further research into the use of sodium bicarbonate as an adjuvant can not only help guide care providers in providing it to the patients who stand to benefit the most, but it can also help them move away from opioids and the tremendous risk of addiction and overdose they carry. Opioids have traditionally been used as an adjuvant for nerve block,⁷ and they are sometimes used to manage post-operative pain, which sodium carbonate can help alleviate. Thus, sodium bicarbonate may play an important role in reducing the use of opioids in the surgical setting.

References

1. Edinoff, A. N. et al. Adjuvant Drugs for Peripheral Nerve Blocks: The Role of NMDA Antagonists, Neostigmine, Epinephrine, and Sodium Bicarbonate. Anesthesiol. Pain Med. 11, e117146 (2021), DOI: 10.5812/aapm.117146

2. Kour, L., Sharma, G. & Tantray, S. H. Evaluation of Addition of Sodium Bicarbonate to Dexamethasone and Ropivacaine in Supraclavicular Brachial Plexus Block for Upper Limb Orthopedic Procedures. Anesth. Essays Res. 15, 26 (2021), DOI: 10.4103/aer.aer_45_21

3. Gupta, S., Kumar, A., Sharma, A. K., Purohit, J. & Narula, J. S. ‘Sodium bicarbonate’: an adjunct to painless palatal anesthesia. Oral Maxillofac. Surg. 22, 451–455 (2018), DOI: 10.1007/s10006-018-0730-x

4. Statement on the Use of Adjuvant Medications and Management of Intraoperative Pain During Cesarean Delivery. https://www.asahq.org/standards-and-practice-parameters/statement-on-the-use-of-adjuvant-medications-and-management-of-intraoperative-pain-during-cesarean-delivery

5. Shyamala, M. et al. A Comparative Study Between Bupivacaine with Adrenaline and Carbonated Bupivacaine with Adrenaline for Surgical Removal of Impacted Mandibular Third Molar. J. Maxillofac. Oral Surg. 15, 99–105 (2016), DOI: 10.1007/s12663-015-0791-4

6. Candido, K. D. et al. Addition of bicarbonate to plain bupivacaine does not significantly alter the onset or duration of plexus anesthesia. Reg. Anesth. 20, 133–138 (1995).

7. Krishna Prasad, G. V., Khanna, S. & Jaishree, S. V. Review of adjuvants to local anesthetics in peripheral nerve blocks: Current and future trends. Saudi J. Anaesth. 14, 77–84 (2020), DOI: 10.4103/sja.SJA_423_19