Hospital Competition in the US

The healthcare landscape in the United States is extremely complex, marked by exchanges and relationships between providers, insurance companies, patients, and hospitals. The competition among hospitals has significant potential to affect both healthcare providers and patients. The dynamics of hospital market competition in the US have changed greatly in the past few decades. The Affordable Care Act, passed in 2010, launched Medicare Value-Based Purchasing, informing the discourse surrounding hospital competition in the United States (Haley et al., 2016). The debate over hospital competition in the US remains an important and continuously evolving issue, especially given the substantial amount of healthcare spending in the United States (National CMS, 2017).

In recent years, hospital markets have become increasingly monopolized, with prominent health systems dominating heavily in many areas. In the United States, each region generally has 3 to 5 consolidated healthcare systems (Cutler and Morton, 2013). For example, between 2007 to 2017, the number of hospitals in the US grew from 2741 to 4597. In this same period, the percentage of hospitals in the U.S. affiliated with a health system increased from 53.4% to 64.3%. Remarkably, the number of health systems underwent little change. While the overall hospital market expanded in terms of beds, admissions, and inpatient days from 2007 to 2017, and the size of the overall hospital market has decreased (Johnson and Frakt, 2020).

Of note, hospitals located in more competitive markets have been associated with lower mortality rates for patients dealing with conditions such as myocardial infarction, heart failure, and pneumonia. This may point to potential benefits of hospital market competition. However, policymakers must strive to develop policies that promote a competitive, yet equitable and transparent healthcare marketplace to enhance patient outcomes (Haley et al., 2016).  Some advantages of consolidated health systems are the ability to coordinate complex care across a variety of providers and sites (Cutler and Morton, 2013).

As hospital competition decreases and markets become more concentrated, healthcare costs tend to increase, according to US data (Cutler and Morton, 2013). Concentrated healthcare networks have the leverage to demand higher insurance premiums and out-of-pocket expenses from patients. Policy interventions must therefore target the pricing strategies that these systems enforce on patients (Johnson and Frakt, 2020). At a local level, governments must propose policies that ensure customer protection in the face of market consolidation and a subsequent increase in healthcare costs (Cutler and Morton, 2013)

In conclusion, the landscape of hospital competition in the US is intricate, multifaceted, and in a constant state of flux. While discussing hospital competition, it is crucial to consider various factors, including the quality of care, patient satisfaction, cost innovation, regulation, as well as partnerships and collaboration. By addressing these dynamics, policymakers and relevant stakeholders can ensure a competitive yet fair and transparent healthcare marketplace that benefits patients.


Cutler, David M, and Fiona Scott Morton. “Hospitals, market share, and consolidation.” JAMA vol. 310,18 (2013): 1964-70. doi:10.1001/jama.2013.281675

Haley, Donald Robert et al. “The Influence of Hospital Market Competition on Patient Mortality and Total Performance Score.” The health care manager vol. 35,3 (2016): 266-76. doi:10.1097/HCM.0000000000000117

Johnson, Garret, and Austin Frakt. “Hospital markets in the United States, 2007-2017.” Healthcare (Amsterdam, Netherlands) vol. 8,3 (2020): 100445. doi:10.1016/j.hjdsi.2020.100445

National CMS. “Health Expenditures Fact Sheet, 2017.” CMS.Gov, Centers for Medicare & Medicaid Services, 2017,


Portable Ultrasound for OR Use 

Ultrasound technology harnesses high-frequency sound waves beyond the hearing abilities of humans. Ultrasonography operates with probes which generate sound waves and capture what is reflected, which is then transformed into an image on a screen (Li et al., 2020). Portable ultrasound devices have been increasingly integrated into the operating room (OR) and have become a vital tool in modern medicine. Often referred to as point-of-care ultrasound (POCUS), this technology offers real-time imaging capabilities. In the operating room, this allows surgeons to make decisions during procedures quickly and with more information.  

Portable ultrasound can decrease the use of invasive procedures, including exploratory surgery, when it is unnecessary. With ultrasound, surgeons can assess the need for invasive measures more accurately (Bollard, et al., 2021). Portable ultrasound devices also provide real-time feedback in the OR. This enables surgeons to monitor changes and adapt their approach during complex surgery.  

Various surgical disciplines benefit from the incorporation of portable ultrasound in the OR. Some surgeries that utilize portable ultrasound include abdominal surgeries. For example, with portable ultrasound in liver or kidney surgeries, surgeons assess blood flow, identify anatomical variations, and detect abnormalities. The POCUS is especially important in detecting free fluid around the abdominal structures, which poses a surgical emergency (Abu-Zidan & Cevik, 2018). Even in plastic surgery, the portable ultrasound has had unique uses (Safran et al., 2018). Ultrasound can be used to visualize anatomy and offer an energy source for procedures. For example, in hand surgeries, POCUS allows surgeons to localize foreign bodies and guide procedures (Bollard, et al., 2021).  

Portable ultrasound is not only used on the surgeon’s side in the OR. Anesthesiologists use various forms of ultrasound during surgical procedures to monitor patients. For example, they may use transesophageal echocardiography to manage and watch cardiac and non-cardiac patients in the surgical setting. Cardiac ultrasound can detect pulmonary embolism and cardiac tamponade and guide immediate treatment (Kalagara, et al., 2022). Anesthesiologists may also complete ultrasounds of the lung to diagnose hypoxia, confirm proper placement of an endotracheal tube, or locate the cricothyroid membrane when securing an airway. Anesthesia may also do a gastric ultrasound to help understand the gastric contents of a patient. However, this type of ultrasound is more controversial (De Marchi & Massimiliano, 2017). For patients who have challenging airways, need emergency surgery, or have certain comorbidities, gastric ultrasound may help assess aspiration risk (Li et al., 2020).  

Ultrasound is becoming increasingly integrated in medical education. It is critical that medical students, residents, fellows, and physicians receive proper training on POCUS. An ultrasound’s effectiveness is very dependent on the operator’s skill and their ability to read the image produced by the ultrasound (Li et al., 2020). In anesthesia, where POCUS is of great use in the operating room, there is no standardized education. However, more groups have started organizing education series on this topic and creating frameworks for POCUS education (Li et al., 2020).  

In conclusion, the incorporation of portable ultrasound into the operating room is revolutionizing surgery by enhancing precision, reducing invasiveness, and enabling real-time assessment of anatomical structures and surgical procedures. These devices have become indispensable for surgeons across various medical specialties and for anesthesiologists. As ultrasound technology advances, their prevalence in the operating room is bound to grow. It is vital that research continues to assess best practices for utilizing this transformative technology.   


1) Abu-Zidan, Fikri M, and Arif Alper Cevik. “Diagnostic point-of-care ultrasound (POCUS) for gastrointestinal pathology: state of the art from basics to advanced.” World journal of emergency surgery : WJES vol. 13 47. 15 Oct. 2018, doi:10.1186/s13017-018-0209-y 

2) Bollard, Stephanie Marie et al. “The Use of Point of Care Ultrasound in Hand Surgery.” The Journal of hand surgery vol. 46,7 (2021): 602-607. doi:10.1016/j.jhsa.2021.02.004 

3) De Marchi, Lorenzo, and Massimiliano Meineri. “POCUS in perioperative medicine: a North American perspective.” Critical ultrasound journal vol. 9,1 19. 9 Oct. 2017, doi:10.1186/s13089-017-0075-y 

4) Kalagara, Hari et al. “Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist.” Journal of cardiothoracic and vascular anesthesia vol. 36,4 (2022): 1132-1147. doi:10.1053/j.jvca.2021.01.018 

5) Li, Linda et al. “Perioperative Point of Care Ultrasound (POCUS) for Anesthesiologists: an Overview.” Current pain and headache reports vol. 24,5 20. 21 Mar. 2020, doi:10.1007/s11916-020-0847-0 

6) Safran, Tyler et al. “The role of ultrasound technology in plastic surgery.” Journal of plastic, reconstructive & aesthetic surgery : JPRAS vol. 71,3 (2018): 416-424. doi:10.1016/j.bjps.2017.08.031 


Medications that Slow Gastric Emptying 

Medications that Slow Gastric Emptying

Gastric emptying is a complex physiological process that involves the coordinated movement of ingested food from the stomach to the small intestine, facilitating efficient digestion and nutrient absorption. Numerous factors, such as volume, pH, temperature, and medications, influence the rate of gastric emptying. Medications that slow gastric emptying can alter the rate of orally absorbed drugs and may increase the volume of gastric contents which can lead to significant nausea and vomiting [1,2]. This in turn can increase the risk of pulmonary aspiration, a serious complication in vulnerable patient populations [1,4]. Notably, opioid analgesics have long been recognized as the most common cause of delayed gastric emptying in the realm of anesthesia. However, it is important to note there are other medications with the potential to slow gastric emptying as well.  

Opioid medications, including morphine and codeine, slow gastric emptying by binding to opioid receptors located in the gastrointestinal tract. These medications can impede gastric transit via peripheral or central mechanisms [3]. Following an intramuscular dose of morphine, gastric emptying can be completely inhibited for up to two hours [4]. It is worth noting that drugs necessitating rapid absorption, such as analgesics, antiarrhythmics, and antibiotics, may encounter therapeutic failure when co-administered with opioids. Conversely, drugs with slower absorption profiles tend to be less affected by delayed gastric emptying caused by opioids [4]. 

 Additionally, other medications, such as proton pump inhibitors, anti-Parkinson’s drugs, and GLP-1 receptor agonists commonly used for diabetic patients, have been associated with slow gastric emptying [5]. Furthermore, anticholinergic agents such as atropine and scopolamine can affect gastric motility. These agents’ function by blocking the actions of acetylcholine, a neurotransmitter involved in stimulating gastric motility. Thus, by inhibiting cholinergic receptors in the stomach, they reduce antral contractility and slow gastric emptying [7]. Recent case reports have highlighted diverse causative agents of delayed gastric emptying in patients, emphasizing the importance of identifying the specific drug responsible [6]. In the case of diabetic patients, both diabetes itself and diabetic drugs, particularly GLP-1 agonists, can contribute to gastroparesis through distinct mechanisms [5]. This makes it particularly difficult to distinguish the underlying cause of gastroparesis in these patients.  

In conclusion, understanding the multifaceted factors that influence gastric emptying is important, particularly in the perioperative setting where a variety of pharmaceutical agents are administered. Medications that slow gastric emptying, including opioid analgesics and certain other drugs, can have significant implications for drug absorption and patient outcomes. Knowing which drugs slow gastric emptying and implementing appropriate modifications enables healthcare professionals to make informed decisions regarding drug administration and the management of patients who may be at elevated risk for delayed gastric emptying. 


  1. D. B. Murphy, J. A. Sutton, L. F. Prescott, M. B. Murphy; Opioid-induced Delay in Gastric Emptying: A Peripheral Mechanism in Humans. Anesthesiology 1997; 87:765–770.  
  1. Nimmo WS: Effect of anaesthesia on gastric motility and emptying. Br J Anaesth 1984; 56:29-36. 
  1. Manara L, Bianchetti A: The central and peripheral influences of opioids on gastrointestinal propulsion. Ann Rev Pharmacol Toxicol 1985; 25:249-73. 
  1. Nimmo, W.S. Gastric emptying and anaesthesia. Can J Anaesth 36 (Suppl 1), S45–S47 (1989). 
  1. Little TJ, Pilichiewicz AN, Russo A, et al. Effects of intravenous glucagon-like peptide-1 on gastric emptying and intragastric distribution in healthy subjects: relationships with postprandial glycemic and insulinemic responses. J Clin Endocrinol Metab. 2006;91(5):1916-1923. 
  1. Kalas MA, Galura GM, McCallum RW. Medication-Induced Gastroparesis: A Case Report. Journal of Investigative Medicine High Impact Case Reports. 2021;9. 
  1. Parkman HP, Trate DM, Knight LC, et al. Cholinergic effects on human gastric motility. Gut 1999;45:346-354. 

Subscription-Based Healthcare 

In recent years, subscription-based healthcare has emerged as a revolutionary alternative to the traditional healthcare system. This model, often labeled as “direct primary care” (DPC), involves patients paying a recurring subscription fee to a healthcare provider in exchange for a comprehensive package of medical services (1). Although this model remains relatively new, a 2023 survey showed that 37% of providers offered this form of care, while 80% offered the traditional fee-for-service model (2). Unlike traditional models wherein patients are billed for each individual visit or service, subscription-based healthcare focuses on providing holistic care through a membership-based system (1). With a subscription — typically less than $100 per month (3) — patients can enjoy a range of benefits, including enhanced access to providers and preventative care, while providers can benefit from a reduced clientele and stronger relationships with patients. However, as the system remains in its infancy, several components may render the model impractical for some patients and providers.  

Subscription-based healthcare presents several advantages for subscribers. Primarily, this model offers improved access to providers. Traditional primary care providers see their patients an average of 1.6 times per year with an average of 15 minutes per visit; in contrast, subscription-based providers see their patients an average of 4 times per year with an average of 35 minutes per visit (4). Additionally, subscribers benefit from treatment plans tailored to their specific needs (3). This personalized approach fosters a strong provider-patient relationship, which strengthens understanding, trust, and efficacy (3, 5). Subscriptions include comprehensive care, ranging from prophylactic services, wellness programs, and other crucial measures that can prevent health issues in the future, thereby lowering overall healthcare costs (4). Thus, for many patients, the regular monitoring, routine checkups, and holistic care involved in subscription-based healthcare ensure high-quality, cost-effective health maintenance.  

For specific patient populations, however, this model does not present a viable alternative to traditional healthcare. Subscription-based healthcare does not replace insurance, nor do most participating providers accept insurance, rendering it impractical for chronically ill patients and inaccessible for lower-income patients (4). First, as subscriptions typically exclude visits to the emergency room or urgent care, referrals to other providers, procedures, and specialty care, this method is unlikely to be cost-effective for patients with chronic ailments, who must continue to pay the subscription in addition to insurance costs for specialty or emergency care (3, 6). Second, the recurring cost of subscriptions presents a barrier to lower-income patients, who may be unable to afford the recurring payment, especially when combined with health insurance premiums (6).  

From the providers’ perspective, subscription-based healthcare exhibits the advantages of improved patient-provider relationships and reduced administrative burden. According to a 2018 survey, traditional providers retain an average of 2000 to 2500 patients, while subscription-based providers handle only 300 to 600 (7). With fewer patients, subscription-based providers can devote more time to direct patient care, spend less time completing administrative work, and maintain a smaller staff (2, 3). Moreover, as most subscription-based providers do not accept insurance, the difficulties associated with insurance compliance and management can be avoided altogether, alleviating a significant strain for providers (3, 4). However, with their smaller clientele and absence of fee-for-service payments, subscription-based providers normally generate less income than their traditional peers (3). Additionally, departing from the traditional model and creating a subscription-based practice results in start-up costs and the loss of established patients (8). To deliver quality care, retain subscribers, and still make a profit, providers must find a balance between the costs of care and the subscription fee.  


Subscription-based healthcare has surfaced as an alternative to the traditional fee-for-service model, offering benefits to both patients and providers. However, challenges related to insurance coverage, emergency and specialty care, and affordability may obstruct specific patient populations from subscribing, while difficulties related to income may prevent providers from adopting this model. Patients considering enrolling in subscription-based healthcare — as well as providers considering offering this model — must assess their own needs before shifting from traditional care to this approach.  



1: Wolfson, B. 2021. Can a subscription model fix primary care in the U.S.? The Washington Post. URL:  

2: Couey, C. 2023. What you need to know about the different types of medical practice payment models. Software Advice. URL:  

3: Lamberts, R. 2017. Pros and cons of switching to a subscription practice. Physicians Practice. URL:  

4: Anderman, T. 2018. Pros and cons of concierge medical care. Consumer Reports. URL:  

5: Goforth, A. 2022. Could subscription model be the answer to US health care cost woes? Benefits Pro. URL:  

6: Salter, S. Is subscription model healthcare a real alternative? Daily Leader. URL:  

7: Rajaee, L. 2019.  What is the patient load sweet spot for direct primary care physicians? Elation Health. URL:  

8: Haefner, M. 2020. Physician viewpoint: a subscription model beats fee-for-service. Becker’s Hospital Review. URL:  



Effect of Stress on Surgery Outcomes 

Undergoing surgery places physiological stress on the body, but stress can also have an impact on surgery outcomes. Though there has been increased discussion about this phenomenon and system-based quality improvement efforts, more work is needed to minimize the negative effects of stress on surgery outcomes. Stress in both patients and clinicians must be examined and addressed. 

Research has shown that high psychological and physiological stress responses in patients prior to surgery result in poorer outcomes in otherwise healthy men undergoing simple elective surgical procedures 1. Such psychological stress has been associated with a chronic inflammatory response which tends to hamper postsurgical healing. 

Patient anxiety and depression in patients can also negatively impact surgical outcomes. A recent study which sought to assess this in a large cohort of patients found that preoperative depression and anxiety negatively affect surgical outcomes in female patients undergoing major surgery 2. 

Another recent study sought to further elucidate the link between preoperative psychological variables and interventions and early surgical outcomes. Overall, trait and state anxiety, state anger, active coping, intramarital hostility, and subclinical depression, were found to complicate recovery. In contrast, dispositional optimism, religiousness, anger control, an external locus of control, and low pain expectations were identified as promoting healing. Psychological interventions in the form of guided relaxation, couple support visits, and psychiatric interviews have further been found to promote patient recovery following surgery 3.  

Stress in patients is not the only factor impacting surgery outcomes. Research has demonstrated that acute mental stress in clinicians negatively impacts their surgical performance. In particular, stress-induced negative intraoperative interpersonal dynamics may lead to performance errors and undesirable patient outcomes. A recent research report further confirmed a clear negative relationship between negative responses, both emotional and behavioral, to acute intraoperative stressors and provider performance on surgical outcomes 4. 

Drawing on theory and evidence from reviewed studies, some research has pointed to the utility of the Surgical Stress Effects framework, illustrating how emotional and behavioral responses to stressors can influence individual surgical provider performance, team performance, and patient outcomes. Although coping strategies are not explicitly taught during surgical training, a framework for categorizing surgical stress may help clinicians develop effective coping strategies 5. 

Since stress has been shown to adversely impact multiple aspects critical to optimal performance, advancements in wearable technology have been put forth to reduce barriers to observing and monitoring stress during surgery 6. A number of options are continuously being developed to this end. 

Into the future, an increasingly clear understanding of the impacts of intraoperative stressors may be critical to reducing adverse events and improving outcomes. This will include a better understanding of key surgical stressors, their impact on surgeon performance, and surgeons’ coping strategies. In addition, it will be important to keep quantifying the association of preoperative depression and anxiety symptoms on postoperative complications, length of stay, pain levels, and the incidence of readmission. Future research efforts are certain to continue to minimize the impacts of stress on surgery outcomes. 


  1. Linn, B. S., Linn, M. W. & Klimas, N. G. Effects of psychophysical stress on surgical outcome. Psychosom. Med. (1988). doi:10.1097/00006842-198805000-00002
  2. Geoffrion, R. et al. Preoperative Depression and Anxiety Impact on Inpatient Surgery Outcomes: A Prospective Cohort Study. Ann. Surg. (2021). doi:10.1097/AS9.0000000000000049
  3. Mavros, M. N. et al. Do psychological variables affect early surgical recovery? PLoS One (2011). doi:10.1371/journal.pone.0020306
  4. Chrouser, K. L., Xu, J., Hallbeck, S., Weinger, M. B. & Partin, M. R. The influence of stress responses on surgical performance and outcomes: Literature review and the development of the surgical stress effects (SSE) framework. American Journal of Surgery (2018). doi:10.1016/j.amjsurg.2018.02.017
  5. Wetzel, C. M. et al. The effects of stress on surgical performance. Am. J. Surg. (2006). doi:10.1016/j.amjsurg.2005.08.034
  6. Grantcharov, P. D., Boillat, T., Elkabany, S., Wac, K. & Rivas, H. Acute mental stress and surgical performance. BJS open (2019). doi:10.1002/bjs5.104

Anesthesia Considerations for Patients Taking Blood Thinners 

Perioperative and regional anesthesia management for patients on anticoagulation can pose a major problem. Typically, anticoagulants, i.e. blood thinners, are prescribed for patients who are at risk for clotting or thromboses. Common indications for this medication include atrial fibrillation, deep venous thromboses, and mechanical heart valves1. When stopping anticoagulation abruptly, such as for a surgery, rebound hypercoagulability can occur. Meanwhile, keeping a patient on anticoagulation during surgery or neuraxial anesthesia increases the risk of bleeding and hematoma formation. As a result, there are special considerations needed when administering anesthesia to patients on blood thinners. 

One area of anesthesia where these considerations about bleeding risk on blood thinners are especially important is epidurals placed in the spinal cord. Bleeding risk increases with age, presence of a coagulopathy, abnormalities of the spinal cord, or a prolonged indwelling neuraxial catheter while on anticoagulation2. Interestingly, the anesthesia management of patients differs depending on what anticoagulant a patient is taking2. This is due to the differing pharmacokinetic and pharmacodynamic profile of each anticoagulant class. Further, patient and surgery specific factors must be taken into account when managing an anticoagulant with anesthesia.  

The American Society of Regional Anesthesia and Pain Medicine (ASRA) has summarized practice guidelines and recommendations regarding management of anticoagulant agents for regional anesthesia. This can apply to neuraxial blockades and the removal of catheters including epidurals to reduce risk of hematomas3. However, for patients prior to surgery, the evaluation is different. Bleeding risk is assessed with the HAS-BLED score which represents hypertension, abnormal liver or kidney function, stroke, bleeding history or predisposition, labile International Normalized Ratio [INR], elderly, drugs and alcohol. Each variable is one point, and a score greater than three indicates a high bleeding risk4. The HAS-BLED score has been found to be a reliable predictor for perioperative bleeding risk and can be used as a guideline for stratifying patients into low and high risk5.  

For patients with recent venous thromboembolism (VTE) or an ischemic stroke, the risk of recurrence or a major cardiovascular event is high. Thus, for these patients, recommendations are to defer surgery up to 3 months for those with a VTE and 9 months for those with a recent ischemic stroke6. Further, for patients at particularly high risk for thromboembolism, bridging therapy may be required according to traditional recommendations. This involves replacing a long-acting anticoagulant, such warfarin, with a short-acting one, such as low-molecular weight heparin, prior to surgery. Of note, current data has disputed the efficacy of bridging therapy and thus its use remains in question4

Overall, while there are guidelines in place from the ASRA for regional anesthesia, perioperative management of anticoagulation requires a different approach. Along with using valid scores like HAS-BLED, using clinical judgement while considering patient factors and the timing of surgery is important.  Both for regional anesthesia and perioperatively, balancing risks and benefits in patients is key. With the development of new oral anticoagulation agents and the decreased need for monitoring, such as with apixaban and dabigatran, considerations for anesthesia for patients on blood thinners may be able to be simplified and streamlined to optimize benefits of surgery while minimizing patient risk of either bleeding or thromboses.   


1. Shaikh SI, Kumari RV, Hegade G et al. Perioperative Considerations and Management of Patients Receiving Anticoagulants. Anesth Essays Res 2017; 11 (1): 10-16. 

2. Horlocker TT. Regional anaesthesia in the patient receiving antithrombotic and antiplatelet therapy. Br J Anaesth 2011; 107 Suppl 1: i96-106. 

3. Gogarten W, Vandermeulen E, Van Aken H et al. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol 2010; 27 (12): 999-1015. 

4. Polania Gutierrez JJ RK. Perioperative Anticoagulation Management. Treasure Island (FL): StatPearls Publishing. 2021. 

5. Omran H, Bauersachs R, Rubenacker S et al. The HAS-BLED score predicts bleedings during bridging of chronic oral anticoagulation. Results from the national multicentre BNK Online bRiDging REgistRy (BORDER). Thromb Haemost 2012; 108 (1): 65-73. 

6. Hornor MA, Duane TM, Ehlers AP et al. American College of Surgeons’ Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg 2018; 227 (5): 521-536 e521. 


Safety of Non-Operating Room Anesthesia 

Non-operating room anesthesia, also known as NORA, refers to the use of anesthesia in settings outside of a traditional operating room. Non-operating room anesthesia is used in intensive care, gastroenterology, cardiology, and other areas of medicine for various diagnostic and interventional procedures (2). While NORA offers several benefits, non-operating room anesthesia has been documented to have a higher incidence of malpractice resulting in preventable deaths compared to traditional anesthesia delivered in operating rooms (5). Implementing precautionary measures to ensure patient safety when delivering non-operating room anesthesia can improve patient outcomes as the use of NORA continues to grow. 

Despite some of its associated safety concerns, non-operating room anesthesia offers a number of benefits to patients. For example, NORA allows for procedures to be performed in settings that are more convenient and comfortable for patients compared to an operating room, such as a doctor’s office or a clinic. This can reduce the need for hospitalization and result in cost savings for patients. Additionally, NORA can improve patient outcomes by allowing patients to undergo less invasive procedures that can be performed more quickly and efficiently (1). 

One of the most common issues with non-operating room anesthesia is that procedures performed outside of the operating room may not have the same safety protocols in place as those in a traditional setting (1). The locations where NORA is performed may not have the proper anesthesia equipment necessary to safely deliver anesthesia and monitor patients. Additionally, the location may lack proper lighting or have restricted mobility that limits access to patients (2). There may also be fewer staff with anesthesia training on site compared to a hospital setting (4). A single anesthesiologist may be responsible for providing all aspects of anesthesia care. Malpractice claims for non-operating room anesthesia have a higher rate of death compared to traditional anesthesia (5). Inadequate oxygenation and ventilation are the most common cause of death in NORA settings, accounting for a third of NORA malpractice claims (5). That being said, with proper safety protocols, non-operating room anesthesia is a valuable part of modern medicine. 

Improving the safety of non-operating room anesthesia requires diligence on the part of providers and appropriate work environments and safety procedures (2). Providers should take care to assess patient risk prior to administering anesthesia, monitor patients’ vitals during the procedure, and provide proper postoperative care. In particular, intraoperative monitoring needs to be held to the same high standards in place in a traditional operating room to ensure proper oxygenation and circulatory function (4). 

Moreover, collaboration between anesthesiologists and staff who are present during non-operating room anesthesia is necessary to develop safety plans when delivering NORA. Conducting comprehensive patient assessments prior to the procedure and offering adequate pain control and postoperative monitoring is essential to improving patient outcomes (4). As technologic advancements in medicine continue to increase, the menu of less invasive procedures suitable for NORA will grow in number. As a result, improved safety measures for non-operating room anesthesia can contribute to higher standards of healthcare for older and high-risk patients (1). 


  1. Bonovia et al. “Non-operating room anesthesia in the intensive care unit.” Journal of Clinical Anesthesia, vol. 78, June 2022, doi: 10.1016/j.jclinane.2022.110668 
  1. Herman et al. “Morbidity, mortality, and systems safety in non-operating room anesthesia: a narrative review.” British Journal of Anesthesia, vol. 127, no. 5, pp. 729-744, Nov 2021, doi: 10.1016/j.bja.2021.07.007 
  1. Maddirala, Subrahmanyam, and Annu Theagrajan. “Non-operating room anaesthesia in children.” Indian journal of anaesthesia vol. 63,9 (2019): 754-762. doi:10.4103/ija.IJA_486_19 
  1. Wong, Timothy et al. “Non-Operating Room Anesthesia: Patient Selection and Special Considerations.” Local and regional anesthesia vol. 13 1-9. 8 Jan. 2020, doi:10.2147/LRA.S181458 
  1. Woodward, Zachary G et al. “Safety of Non-Operating Room Anesthesia: A Closed Claims Update.” Anesthesiology clinics vol. 35,4 (2017): 569-581. doi:10.1016/j.anclin.2017.07.003 

The Importance of Sleep Before Surgery 

Getting a good night’s rest before undergoing surgery can help reduce the levels of postoperative pain that you experience and even protect you from developing chronic postoperative pain (1). Sleep and pain have a bidirectional relationship that has been well-established in the medical literature. A decline in sleep quality correlates with an increase in the risk of developing new pain and experiencing an increase in existing pain, while existing pain can also diminish sleep quality (4). Discerning the various factors that can exacerbate acute and chronic pain after surgery is essential for improving the quality of life for patients and developing better methods of pain management. One potential step toward the ongoing goal of reducing pain and improving patient comfort postoperatively is emphasizing the importance of sleep before surgery. 

Eighty percent of surgery patients experience moderate to severe pain immediately after undergoing an operation, and the majority of these patients are still experiencing pain when they are discharged from the hospital (1). As many as ten to fifty percent of patients, furthermore, can develop chronic pain as a result of surgery (1). Research suggests that disrupted sleep the night before surgery plays a major role in exacerbating the severity of postoperative pain. 

In one study, patients with lower sleep efficiency the night before breast-conserving surgery had significantly higher levels of postoperative pain in the weeks following the operation compared to those that did not experience sleep disturbances (5). Accordingly, sleep continuity (having fewer disruptions) appears to have a greater impact on the level of pain a patient experiences after surgery compared to sleep duration (5). This may be because sleep disruption affects the acute stress response that takes place in the body in response to a surgical operation, involving complex interactions between the neuroendocrine, immune, and metabolic systems (5). 

While the reciprocal relationship between sleep and pain and the importance of sleep continuity has been well-established, the mechanisms behind the effect that sleep has on postoperative pain are less clear. In another study, the preemptive administration of caffeine to lab rats who had been deprived of sleep prior to a surgical incision prevented the increase in levels of mechanical hypersensitivity and time to recovery that were seen in the control group, who didn’t receive caffeine (1). The results suggest that the neurotransmission of adenosine—a sleep-promoting neuromodulator that affects sleepiness—may play a role in the relationship between sleep and pain. Since caffeine acts as an adenosine receptor antagonist, it may help reduce postoperative pain in rats who were sleep deprived prior to surgery by affecting adenosine-dependent mechanisms. 

Improving the quality of sleep for patients before surgery is critical to improving surgical outcomes and quality of life for patients. Non-pharmacological and pharmacological methods can be combined to encourage healthier sleep habits in patients, both before, during, and after their time at the hospital. Practicing good sleep hygiene, relaxation techniques, and CBT and ACT-based therapies for treating insomnia can help combat sleep disturbances and improve sleep quality (4). In the case of patients who need pharmacological treatments for sleep, medications like benzodiazepines or supplements like melatonin may help improve sleep in the short-term (4). 

Ultimately, multiple factors affect the severity of postoperative pain, including sociological, demographic, psychological, and biological elements (1). Those who experience surgery-related anxiety due to fear of death, pain, or financial reasons are especially vulnerable to poor sleep the night before surgery. Promoting high-quality sleep through good sleep habits and addressing the sociodemographic factors that may play into poor sleep for a patient can help improve surgical outcomes and prevent patients from developing chronic postoperative pain. 


  1. Hambrecht-Wiedbusch, Viviane S et al. “Preemptive Caffeine Administration Blocks the Increase in Postoperative Pain Caused by Previous Sleep Loss in the Rat: A Potential Role for Preoptic Adenosine A2A Receptors in Sleep-Pain Interactions.” Sleep, vol. 40, 9 (2017), zsx116, doi: 10.1093/sleep/zsx116 
  1. Luo, ZY., Li, LL., Wang, D. et al. Preoperative sleep quality affects postoperative pain and function after total joint arthroplasty: a prospective cohort study. J Orthop Surg Res14, 378 (2019). 
  1. Mohammad, Hamid et al. “Sleeping pattern before thoracic surgery: A comparison of baseline and night before surgery.” Heliyon vol. 5,3 e01318. 12 Mar. 2019, doi:10.1016/j.heliyon.2019.e01318] 
  1. Sipila, Reetta M. and Eija A. Kalso. “Sleep Well and Recover Faster with Less Pain—A Narrative Review on Sleep in the Perioperative Period.” Journal of Clinical Medicine, vol. 10, 9 (2021). doi: 10.3390/jcm10092000 
  1. Wright, Caroline E et al. “Disrupted sleep the night before breast surgery is associated with increased postoperative pain.” Journal of pain and symptom management, vol. 37, 3 (2009): 352-62. doi:10.1016/j.jpainsymman.2008.03.010 

Uses of Cameras in Surgery 

Minimally invasive surgery using a camera has arguably been the most important surgical advancement in the last three decades. It revolutionized surgical practice with well-demonstrated advantages over conventional open surgery, including decreased surgical trauma and incision-related complications such as surgical site infections, postoperative discomfort, and hernia, as well as a shorter hospital stay and better aesthetic result.4 Cameras allow surgeons to visualize and navigate the body during procedures without creating a large incision. Several different types of cameras are used in surgery, each with its unique features and advantages that have contributed to patient outcomes. 

Laparoscopic surgery uses cutting-edge technology to reduce tissue damage in which thin tubes called trocars are inserted in small “ports.” 2 A small camera (typically a laparoscope or endoscope) is then inserted into the trocars to view the procedures as a magnified image is projected to video monitors in the operating room.2 Depending on the operation, specialized equipment can also be introduced through the trocars. Not only do these techniques often provide the same results as traditional “open” surgery (which sometimes requires a big incision), but minimally invasive surgery (using tiny incisions) with cameras may also offer substantial advantages: (I) a quicker recovery; (II) a shorter length of hospitalization; (III) less scarring and tissue damage; and (IV) less discomfort.2 While laparoscopic surgical procedures has several advantages over traditional open surgery, acquiring the necessary skills, such as depth perception and video-hand-eye coordination, to move instruments within the operative field safely and effectively can be challenging.1 

Robotic surgery, which also uses cameras, has emerged as a new technique that is overcoming some difficulties of the standard laparoscopic approach in the field of hepatic, pancreatic, and esophageal surgery. It offers magnified three-dimensional optics, surgeon-controlled camera vision, working arms allowing very stable retraction, and unmatched ergonomics of instrument motion, with significantly less fatigue for the surgeon. 3 One of the major concerns regarding robotic technology is the high cost of equipment purchase and maintenance.3 Robotic surgery is more costly than laparoscopic or open surgery for various reasons, including equipment, higher operating time, and replacing materials as they wear out. Furthermore, the da Vinci surgical system is the only surgical robot in use.3 A lack of competition may be one of the factors keeping prices stable and high today.3 

With hundreds of millions of minimally invasive surgeries procedures performed globally, fiber optic cameras and robots have become indispensable tools and have revolutionized the field of surgery and surgeons’ capacity to capture information during surgery. 5 They have also helped to improve patient outcomes by reducing the risk of complications and the need for follow-up surgeries. However, it is important to note that using cameras in surgery does not eliminate the need for skilled surgeons. Cameras can only provide the surgeon with a visual aid; the surgeon’s skill and judgment ultimately determine the procedure’s success. 


  1. Alaker, M., Wynn, G. R., & Arulampalam, T. (2016). Virtual reality training in laparoscopic surgery: A systematic review & meta-analysis. International journal of surgery (London, England), 29, 85–94. 
  1. Baltayiannis, N., Michail, C., Lazaridis, G., Anagnostopoulos, D., Baka, S., Mpoukovinas, I., Karavasilis, V., Lampaki, S., Papaiwannou, A., Karavergou, A., Kioumis, I., Pitsiou, G., Katsikogiannis, N., Tsakiridis, K., Rapti, A., Trakada, G., Zissimopoulos, A., Zarogoulidis, K., & Zarogoulidis, P. (2015). Minimally invasive procedures. Annals of translational medicine, 3(4), 55. 
  1. Biffi, R., Luca, F., Bianchi, P. P., Cenciarelli, S., Petz, W., Monsellato, I., Valvo, M., Cossu, M. L., Ghezzi, T. L., & Shmaissany, K. (2016). Dealing with robot-assisted surgery for rectal cancer: Current status and perspectives. World journal of gastroenterology, 22(2), 546–556. 
  1. Bouquet de Joliniere, J., Librino, A., Dubuisson, J. B., Khomsi, F., Ben Ali, N., Fadhlaoui, A., Ayoubi, J. M., & Feki, A. (2016). Robotic Surgery in Gynecology. Frontiers in surgery, 3, 26. 
  1. Mascagni, P., Alapatt, D., Sestini, L., Altieri, M. S., Madani, A., Watanabe, Y., Alseidi, A., Redan, J. A., Alfieri, S., Costamagna, G., Boškoski, I., Padoy, N., & Hashimoto, D. A. (2022). Computer vision in surgery: from potential to clinical value. NPJ digital medicine, 5(1), 163. 
  1. Scognamiglio, P., Stüben, B. O., Heumann, A., Li, J., Izbicki, J. R., Perez, D., & Reeh, M. (2021). Advanced Robotic Surgery: Liver, Pancreas, and Esophagus – The State of the Art?. Visceral medicine, 37(6), 505–510. 

Post-Anesthesia Induction Hypotension 

Hypotension, also known as low blood pressure, can occur during or after anesthesia and must be watched closely by anesthesia providers. The post-anesthesia induction period may see increased risk for hypotension 1. Post-anesthesia induction hypotension (PAIH) can significantly impact surgical outcomes and remains one of the factors most closely associated with anesthesia-related morbidity 2. It is therefore critical to understand, predict and treat it as best as possible.  

Hypotension is roughly defined as a > 30% decrease in mean arterial pressure as compared to the first measurement in the operating theater prior to general anesthesia induction 3.  

In addition to heightened morbidity postoperatively, PAIH is associated with increased risk of renal injury and postoperative intensive care admission. It is also significantly linked to postoperative myocardial injury 2. Research has identified several risk factors: age, hypertension, diabetes, and being male. 

A recent multicenter observational study assessed the data of subjects receiving general anesthesia with propofol and sufentanil, demonstrating that that the likelihood of PAIH increased with age 1. Another study found that being over 30 years of age in particular was linked to PAIH 2. The degree of hypertension at time of arrival to the operating theater has also been found to be associated with PAIH 3, in addition to the presence of diabetes 3 and being male 1.   

Furthermore, PAIH has been clearly linked to the physical well-being of patients. One study found that it was linked to American Society of Anesthesiologists (ASA) physical status (PS) class IV patients, i.e. patients “with severe systemic disease that is a constant threat to life” 1,4. A more recent study found that patients with an ASA PS class II and above were more likely to experience PAIH 2.  

Different research has pointed to different links to the type of anesthesia used and the mode of delivery. First, early intraoperative hypotension in particular has been associated with neuraxial anesthesia 1. Second, although one study found that the type of volatile anesthetic was not linked to the occurrence of PAIH 3, another found that the administration of propofol and thiopental contributed to a greater incidence of PAIH 2. In addition, the type of surgery is also a relevant factor: orthopedic surgery in particular is associated with a greater incidence of PAIH 2.  

It remains unknown whether interventions to improve or maintain blood pressure would improve outcomes in patients with various risk factors. However, most clinicians err on the side of caution and try to avoid hypotension all together 6. A number of interventions exist to correct hypotension to this end, the overall efficacy of which exceed 94% 3. Bolus fluids are the most frequently used intervention, with an established effectiveness of 96% 3.  

Naturally, however, any factor linked to PAIH should be avoided when possible in order to minimize risk proactively. As such, one study suggests that alternatives to propofol anesthetic induction (such as etomidate) should be used in patients with an ASA PS of 3 or above and over 50 years of age 7


1. Südfeld, S. et al. Post-induction hypotension and early intraoperative hypotension associated with general anaesthesia. Br. J. Anaesth. (2017). doi:10.1093/bja/aex127 

2. Nega, M. H., Ahmed, S. A., Tawuye, H. Y. & Mustofa, S. Y. Incidence and factors associated with post-induction hypotension among adult surgical patients: Prospective follow-up study. Int. J. Surg. Open 49, 100565 (2022). doi: 10.1016/j.amsu.2022.103321. 

3. Jor, O. et al. Hypotension after induction of general anesthesia: occurrence, risk factors, and therapy. A prospective multicentre observational study. J. Anesth. (2018). doi:10.1007/s00540-018-2532-6 

4. ​ASA Physical Status Classification System | American Society of Anesthesiologists (ASA). Available at: (Accessed: 8th December 2022) 

5. Saugel, B. et al. Mechanisms contributing to hypotension after anesthetic induction with sufentanil, propofol, and rocuronium: a prospective observational study. J. Clin. Monit. Comput. (2022). doi:10.1007/s10877-021-00653-9 

6. Wong, G. T. C. & Irwin, M. G. Post-induction hypotension: a fluid relationship? Anaesthesia (2021). doi:10.1111/anae.15065 

7. Reich, D. L. et al. Predictors of hypotension after induction of general anesthesia. Anesth. Analg. (2005). doi:10.1213/01.ANE.0000175214.38450.91