Pain monitor: reality or fantasy in ambulatory patients Purpose of review In an unconscious patient, there can be significant challenges to monitoring nociception and proper dosing of analgesic medications. The traditional measures of intraoperative nociception have poor sensitivity and specificity with little predictive value in postoperative outcomes such as postoperative pain, opioid-induced side effects, length of stay or incidence of opioid use disorder. To date, several monitoring modalities are in development to establish objective measures of the balance between nociception and analgesia with the goal of guiding anesthesiologists and improve patient outcomes. In this review, some of the most promising monitoring modalities are discussed with the most recent findings. Recent findings Multiple modalities are beginning to demonstrate utility compared with traditional care. Most, but not all, of these studies show decreased intraoperative opioid use and some show lower pain scores and opioid requirements in the postanesthesia care unit. Summary Recent evidence points to promising efficacy for these monitoring modalities; however, this field is in its infancy. More investigation is required to demonstrate differences in outcome compared with traditional care, and these differences need to be of sufficient import to achieve widespread adoption. Correspondence to Donald M. Mathews, Professor and Chairman, Department of Anesthesiology, Larner College of Medicine, University of Vermont, 111 Colchester Ave, Burlington, VT 05401, USA. Tel: +1 802 847 2415; e-mail: donald.mathews@uvmhealth.org Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Moving boundaries in anaesthesiology No abstract available

How to optimize neuromuscular blockade in ambulatory setting? Purpose of review The purpose of this review is to discuss the optimal use of neuromuscular blocking agents (NMBA) during ambulatory surgery, and to provide an update on the routine use of neuromuscular monitoring and the prevention of residual paralysis. Recent findings The number of major surgical procedures performed in ambulatory patients is likely to increase in the coming years, following the development of laparoscopic and thoracoscopic procedures. To successfully complete these procedures, the proper use of NMBA is mandatory. The use of NMBA not only improves intubating conditions but also ventilation. Recent studies demonstrate that NMBA are much more the solution rather than the cause of airway problems. There is growing evidence that the paralysis of the diaphragm and the abdominal wall muscles, which are resistant to NMBA is of importance during laparoscopic surgery. Further studies are still required to determine when deep neuromuscular block [posttetanic count (PTC) < 5] is required perioperatively. There is now a consensus to use perioperatively neuromuscular monitoring and particularly objective neuromuscular monitoring in combination with reversal agents to avoid residual paralysis and its related morbidity (e.g. respiratory complications in the PACU). Summary Recent data suggest that it is now possible to obtain a tight control of neuromuscular block to maintain optimal relaxation tailored to the surgical requirements and to obtain a rapid and reliable recovery at the end of the procedure. Correspondence to Professor Claude Meistelman, Department of Anaesthesia and Intensive Care Medicine, ILM, CHU de Brabois, rue du Morvan, 54500 Vandoeuvre, France. Tel: +33 383 15 41 66; e-mail: c.meistelman@chru-nancy.fr Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia for thoracic ambulatory surgery Purpose of review Ambulatory surgery plays a major role in cost-effective patient care without compromising patient safety and satisfaction. This concept improves the patient support and decreases the length of stay sometimes until ambulatory surgery. The aim of this review is to examine the current state of the art of anesthesia for thoracic ambulatory surgery. Recent findings Guidelines for enhanced recovery after thoracic surgery (ERATS) have recently been published. They can be safely implemented without increasing hospital readmission or mortality. Video-assisted thoracoscopy may be the best approach within a fast-track program. Anesthetic management should focus on combination of regional analgesia and general anesthesia techniques. General anesthesia should be performed with short acting agent and prevention of residual paralysis. Thoracic epidural analgesia is the gold standard technique for pain control after major thoracic surgery but not compatible with a quick hospital discharge. Thoracic paravertebral block, Serratus plane block, intercostal nerve block, and more recently erector spinae plane block have all been used with success for analgesia in thoracic surgery. Conclusion ERATS program may lead to improved outcomes including decreased length of stay, but it is currently too early to show the impact on thoracic ambulatory surgery that concerned selected patients for lung resection. Correspondence to Julien Raft, Department of Anesthesiology, Institut de Cancerologie de Lorraine, 6 avenue de Bourgogne, 54500 Vandoeuvre-lès-Nancy, France. Tel: +33383598453; fax: +33383598609; e-mail: julien.raft@free.fr Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Pharmacological strategies in multimodal analgesia for adults scheduled for ambulatory surgery Purpose of review The present review aims to propose pharmacological strategies to enhance current clinical practices for analgesia in ambulatory surgical settings and in the context of the opioid epidemic. Recent findings Each year, a high volume of patients undergoes ambulatory surgery worldwide. The multimodal analgesia proposed to ambulatory patients must provide the best analgesic effect and patient satisfaction while respecting the rules of safety for ambulatory surgery. The role of nurses, anesthesiologists, and surgeons around said surgery is to relieve suffering, achieve early mobilization and patient satisfaction, and reduce duration of stay in hospital. Currently, and particularly in North America, overprescription of opioids has reached a critical level constituting a ‘crisis’. Thus, we see the need to offer more optimal multimodal analgesia strategies to ambulatory patients. Summary These strategies must combine three key components when not contraindicated: regional/local analgesia, acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs). Adjuvants such as gabapentinoids, N-methyl-D-aspartate receptor modulators, glucocorticoids, α2-adrenergic receptor agonists, intravenous lidocaine might be added to the initial multimodal strategy, however, caution must be used regarding their side effects and risks of delaying recovery after ambulatory surgery. Weaker opioids (e.g. oxycodone, hydrocodone, tramadol) could be used rather than more powerful ones (e.g. morphine, hydromorphone, inhaled fentanyl, sufentanil). This, combined with education about postoperative weaning of opioids after surgery must be done in order to avoid long-term reliance of these drugs. Correspondence to Philippe Richebé, MD, PhD, DESAR, Associate Professor, Department of Anesthesiology and Pain Medicine, Maisonneuve-Rosemont Hospital, CEMTL, University of Montréal, 5415, Boulevard de l’Assomption, Montreal, QC, H1T2M4, Canada. Tel: +1-514-743-6558; e-mail: philippe.richebe@umontreal.ca Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Pediatric ambulatory anesthesia: an update Purpose of review Ambulatory surgery is the standard for the majority of pediatric surgery in 2019 and adenotonsillectomy is the second most common ambulatory surgery in children so it is an apt paradigm. Preparing and managing these children as ambulatory patients requires a thorough understanding of the current literature. Recent findings The criteria for undertaking pediatric adenotonsillectomy on an ambulatory basis, fasting after clear fluids, postoperative nausea and vomiting (PONV), perioperative pain management and discharge criteria comprise the themes addressed in this review. Summary Three criteria determine suitability of adenotonsillectomy surgery on an ambulatory basis: the child's age, comorbidities and the severity of the obstructive sleep apnea syndrome (OSAS). Diagnosing OSAS in children has proven to be a challenge resulting in alternate, noninvasive techniques, which show promise. Abbreviating the 2 h clear fluid fasting guideline has garnered attention, although the primary issue is that parents do not follow the current clear fluid fasting regimen and until that is resolved, consistent fasting after clear fluids will remain elusive. PONV requires aggressive prophylactic measures that fail in too many children. The importance of unrecognized genetic polymorphisms in PONV despite prophylactic treatment is understated as are the future roles of palonosetron and Neurokinin-1 receptor antagonists that may completely eradicate PONV when combined with dexamethasone. Pain management requires test doses of opioids intraoperatively in children with OSAS and nocturnal desaturation to identify those with lowered opioid dosing thresholds, an uncommon practice as yet. Furthermore, postdischarge nonsteroidal anti-inflammatory agents as well as other pain management strategies should replace oral opioids to prevent respiratory arrests in those who are ultra-rapid CYP2D6 metabolizers. Finally, discharge criteria are evolving and physiological-based criteria should replace time-based, reducing the risk of readmission. Correspondence to Dr Jerrold Lerman, Department of Anesthesia, Oishei Children's Hospital, 1001 Main St, Suite K-3502, Buffalo, NY 14203, USA. Tel: +1 716 323 6570; e-mail: Jerrold.Lerman@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019 Purpose of review Office-based anesthesia (OBA) is rapidly growing across the world. Availability of less invasive interventions has facilitated the opportunity of offering new procedures in office-based settings to patient populations that would not have been considered in the past. This article provides a practical approach to discuss and analyze newest literature supporting different practices in the field of OBA. In addition, an update of the most recent guidelines and practice management directives is included. Recent findings Selected procedures may be performed in the office-based scenario with exceedingly low complication rates, when the right patient population is selected, and adequate safety protocols are followed. Current regulations are focused on reducing surgical risk through the implementation of patient safety protocols and practice standardization. Strategies include cognitive aids for emergencies, safety checklists, facility accreditation standards among other. Summary New evidence exists supporting procedures in the office-based scenario in areas such as plastic and cosmetic surgery, dental and oral surgery, ophthalmology, endovascular procedures and otolaryngology. Different systematic approaches have been developed (guidelines and position statements) to promote standardization of safe practices through emergency protocols, safety checklists, medication management and surgical risk reduction. New regulations and accreditation measures have been developed to homogenize practice and promote high safety standards. Correspondence to Fred E. Shapiro, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA. Tel: +1 617 667 3112; e-mail: fshapiro@bidmc.harvard.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Procedural sedation in ambulatory anaesthesia: what's new? Purpose of review Although sedation traditionally has been regarded as an easy, straight forward and simple variety of general anaesthesia; the trends are to make sedation more sophisticated and dedicated. Also to have a critical look at old dogmas, as they are usually derived from the practice of general anaesthesia. Safety always has to be first priority, especially as the practice grows out of traditional theatres and frequently are being practiced by nonanaesthetic personnel. Recent findings Safety comes from learning of rare cases with severe problems as well as better guidelines and rules of accreditation. Further, there is a growing quest for evidence on pragmatic, high-quality, cost-effective practice; in terms of logistics, monitoring, choice of drugs and quality assurance. The traditional drugs, such as propofol, midazolam and remifentanil, are still defending their dominant position but are being challenged by ketamine and etomidate. Remimazolam and dexmedetomidine are new promising drugs in this area, whereas metoxyflurane may have a revival in some situations. Further, there is growing evidence into specific protocols, practice for special procedures and for patients with special challenges. Summary Procedural sedation deserves to have high degree of attention for further developments, both from a scientific and pragmatic point of view, as the practice is very diversified and growing. Correspondence to Johan Raeder, MD, Dr. Med/PhD, Department of Anaesthesiology, Oslo University Hospital, Ullevaal, PO Box 4950 Nydalen, N-0424 Oslo, Norway. Tel: +00 47 22119690; e-mail: johan.rader@medisin.uio.no Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

From the ICU to the operating room: how to manage the patient? Purpose of review To outline key points for perioperative ICU optimization of nutrition, airway management, blood product preparation and transfusion, antibiotic prophylaxis and transport. Recent findings Optimization entails glycemic control for all, with specific attention to type-1 diabetic patients. Transport-related adverse events may be averted with surgery in the ICU. If moving the patient is unavoidable, transport guidelines should be followed and hemodynamic optimization, airway control, and stabilization of mechanical ventilation ensured before transport. Preinduction preparation includes assessment of the airway and high-flow oxygen to prolong apneic oxygenation. Postintubation, a protective positive ventilation strategy, should be employed. Ideal transfusion thresholds are 7 g/dl for hemodynamically stable adult patients, 8 g/dl in orthopedic/cardiac surgery/cardiovascular disease and higher in specific disease states. Antimicrobial prophylaxis within 120 min of incision prevents most surgical site infections. Antibiotic therapy depends on the antibiotics being received in the ICU, the time elapsed since ICU admission, local epidemiology and the type of surgery. Tailored antimicrobial regimens may be continued periprocedurally. If more than 70% of the nutritional requirement cannot be met enterally, parenteral nutrition should be initiated within 5–7 days of surgery or earlier if the patient is malnourished. Summary ICU patients who require surgery may benefit from appropriate perioperative management. Correspondence to Professor Sharon Einav, MSc, MD, Director, Surgical Intensive Care Unit, Shaare Zedek Medical Centre, Affiliated with the Hebrew University, POB 3235, Jerusalem 91031, Israel. Tel: +972 2 6666664; fax: +972 2 6555144; e-mail: einav_s@szmc.org.il Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Office-based anesthesia: an update on safety and outcomes (2017–2019) Purpose of review Although both cost and patient preference tend to favor the office-based setting, one must consider the hidden costs in managing complications and readmissions. The purpose of this review is to provide an update on safety outcomes of office-based procedures, as well as to identify common patient-specific factors that influence the decision for office-based surgery or impact patient outcomes. Recent findings Office-based anesthesia (OBA) success rates from the latest publications of orthopedic, plastic, endovascular, and otolaryngologic continue to improve. A common thread among these studies is the ability to predict which patients will benefit from going home the same day, as well as identifying comorbid factors that would lead to failure to discharge or readmission after surgery. Specifically, patients with active infection, cardiovascular disease, coagulopathy, insulin-dependent diabetes, obesity, obstructive sleep apnea, poorly controlled hypertension, and thromboembolic disease are presumed to be poor candidates for outpatient office procedures. Summary Overall, anesthesia and surgery in the office is becoming increasingly safe. Recent data suggest that the improved safety in the office-based setting is attributable to proper patient selection. Anesthesiologists play a critical role in prescreening eligible patients to ensure a safe and productive process. Patients treated in the office seem to be selected based on their low risk for complications, and our review reflects this position. Correspondence to Richard D. Urman, MD, MBA, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA. Tel: +1 617 732 8222; e-mail: rurman@bwh.harvard.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.