Background: General anesthesia may counteract the neuroprotective effects of S-ketamine, so previous trials may have underestimated the efficacy of S-ketamine to reduce postoperative delirium (POD). The authors hypothesized that administration of S-ketamine in a non–general anesthesia setting would reduce the risk of POD. Methods: This study was conducted at a high-volume arthroplasty referral center where standardized, evidence-based perioperative protocols are implemented with high fidelity. This study included 372 elderly patients undergoing total hip or knee arthroplasty under neuraxial anesthesia. Patients were enrolled from November 2023 to October 2024, and in-person follow-up assessments were conducted from admission to 3 days after surgery. Patients were randomized to receive either S-ketamine (n = 186) or normal saline placebo (n = 186). The primary outcome was risk of POD within 3 days after surgery. Secondary outcomes were number of POD episodes, POD onset time and duration, POD severity, POD subtype, pain score (numeric rating scale), opioid consumption, number of patients requiring rescue analgesia, sleep quality, clinical outcomes, and harms. Results: Within 3 days after surgery, 15 patients in the S-ketamine group (8.06%) developed POD, compared to 38 patients (20.43%) in the placebo group (adjusted odds ratio, 0.29; 95% CI, 0.14 to 0.63; P = 0.002). On postoperative day 1, patients in the S-ketamine group experienced significantly less pain during exercise and physical therapy and had a lower incidence of rescue analgesia use compared to the placebo group. The incidence of hallucinations, dizziness, and nightmares was higher in the S-ketamine group than in the placebo group. The incidence of other complications was low in both groups, with no statistically significant differences. Conclusions: S-ketamine can reduce risk of POD in elderly patients undergoing total hip or knee arthroplasty under neuraxial anesthesia. However, generalizability of these findings may be limited due to the study’s setting.

Background: Parturients are prone to postdural puncture headache (PDPH) after epidural puncture. Cerebral venous sinus thrombosis (CVST) is a fatal complication of PDPH. The main symptom of both is headache, however, the mechanism is not similar. For persistent PDPH, early differential diagnosis from CVST is essential. Optic nerve sheath diameter (ONSD) measurements can be used to identify changes in intracranial pressure as an auxiliary tool to distinguish the cause of headache.Case presentation: The dura of a 32-year-old woman undergoing cesarean section was accidentally penetrated while administering epidural anesthesia, and the patient developed PDPH the subsequent day. The patient refused epidural blood patch (EBP) treatment and was discharged after conservative treatment. Fourteen days post-discharge, she was readmitted for a seizure. Magnetic resonance imaging (MRI) and Magnetic resonance angiography (MRA) indicated low cranial pressure syndrome and superior sagittal sinus thrombosis with acute infarction. The next morning, the EBP was performed with 15 ml autologous blood. Subsequently, the headache symptoms decreased during the day and worsened at night. ONSD measurement suggested dilation of the optic nerve sheath, and subsequently, the patient showed intracranial hypertension with papilledema. After dehydration and anticoagulant treatment, the patient’s symptoms were relieved and she was discharged from the hospital 49 days later.Conclusions: Headache is the main symptom of PDPH and cerebral venous thrombosis, which are difficult to distinguish. ONSD measurement may help to estimate the intracranial pressure, and early measurement may be helpful for women with PDPH to avoid serious complications, such as CVST.

Opioid anesthesia (OA) is currently the predominant anesthetic method. However, its associated side effects, such as nausea and vomiting, coupled with the principle of enhanced recovery after surgery (ERAS), have spurred the adoption of opioid-free anesthesia (OFA) in select surgical procedures. For small and medium-sized operations, ERAS is particularly important. The aim of this study was to investigate the effect of OFA, utilizing esketamine in combination with dexmedetomidine and sevoflurane, on postoperative recovery quality following small and medium-sized surgical interventions. A total of 120 patients who underwent various small and medium-sized operations were randomly allocated to OFA and OA groups. The OA group received sufentanyl and sevoflurane, while the OFA group received esketamine, dexmedetomidine, and sevoflurane. The primary outcome measure was the postoperative quality of recovery-40 scores (QoR-40) 24 hours after surgery. Secondary outcomes included hemodynamic changes at different time intervals, the incidences of adverse events were recorded. Patients in the OFA group exhibited a higher QoR-40 score of 184.0 (182.0, 186.2) compared to 182.0 (180.0, 184.0) in the OA group (P<0.001). The disparities were particularly noble in terms of Physical comfort and Emotional status. Multivariable analysis identified postoperative nausea and vomiting (PONV) as a significant independent factor impacting QoR-40 (β=-4.49 [-6.1, -2.87], P<0.001). Hemodynamic stability was more pronounced in the OFA than in the OA group. The incidence of PONV was substantially lower in the OFA group (one [1.6%] vs. 14 [25%], P<0.001), with a reduced need for vasoactive drugs (five [7.8%] vs. 15 [26.8%], P=0.005), and a lower incidence of respiratory depression (0 [0%] vs. six [10.7%], P=0.009). OFA improves the postoperative recovery quality in small and medium-sized surgical procedures, potentially attributed to decreased incidence of PONV. Additionally, OFA facilitates the maintenance of more stable hemodynamics throughout the operation.

Background: Liposomal bupivacaine (LB) can provide prolonged analgesia, which may reduce patients’ opioid consumption, improve comfort, and facilitate recovery. Looser tissue and lower vascularity in the paravertebral space may facilitate LB diffusion and duration, so we investigated the effects of LB in multimodal analgesia after thoracic surgery with paravertebral block. Methods: In this single-center, double-blind, randomized, parallel-controlled trial, 102 patients undergoing elective thoracoscopic surgery were randomized 1:1 to thoracic paravertebral block with LB (6.67 mg/mL) or ropivacaine hydrochloride (RH; 0.33%). The primary outcome was opioid consumption within 72 h postoperatively. Secondary outcomes included pain ratings at 6, 12, 24, 48, and 72 h postoperatively; rescue analgesia; time to first ambulation and defecation; post-anesthesia care unit and hospital length of stay; and adverse events. Results: One patient was excluded due to block failure, leaving 101 patients (LB group, n = 51; RH group, n = 50). LB significantly reduced 72-h opioid consumption compared to RH (difference = – 181.4 mg; 95% CI: – 232.8, – 130.0 mg; P < 0.001), and fewer patients in the LB group required rescue analgesia compared to the RH group (OR: 0.33; 95% CI: 0.13, 0.82; P < 0.05). Pain scores at 24 h were lower in the LB group than RH group (difference = – 0.44; 95% CI: – 0.84, – 0.04; P < 0.05), with no differences at other timepoints. The LB group had shorter time to first ambulation than the RH group [median time (IQR): 20 (18– 24) h vs 26 (22– 32) h; HR: 3.81; 95% CI: 2.32, 6.19; P < 0.001] and shorter time to defecation [median time (IQR): 56 (42– 65) h vs 72 (57– 80) h; HR: 3.98; 95% CI: 2.46, 6.44; P < 0.001]. Conclusion: Ultrasound-guided paravertebral block with LB may reduce postoperative opioid consumption and enhance recovery in patients undergoing thoracic surgery. Trial Registration: Chinese Clinical Trials Registry Platform (chictr.org.cn): ChiCTR2400091217.

Objective: To examine the effect of preoperative sleep disorders on delirium in patients older than 60 years of age who underwent surgery for proximal femoral fracture. Methods: This is a prospective observational study. We prospectively selected 143 patients with proximal femoral fracture who underwent surgery between April 2021 and April 2022. The primary outcome was postoperative delirium (PD). Multiple logistic regression analyses were performed and a receiver operating characteristic (ROC) curve was generated. The preoperative sleep quality of all eligible participants was assessed through the Pittsburgh Sleep Quality Index (PSQI). The Confusion Assessment Method (CAM) was used to assess PD from the first to the seventh day postoperatively. Patients were divided into two groups according to the PD diagnosis: (1) the no PD (NPD) group and (2) the PD (PD) group. Results: Of 143 eligible patients, 43 (30.1%) were diagnosed with PD. Multiple logistic regression analysis demonstrated that postoperative ICU admissions (OR = 2.801, p = 0.049) and preoperative sleep disorders (OR = 1.477 p < 0.001) were independently associated with PD. A receiver operating characteristic (ROC) curve demonstrated that the preoperative PSQI score was predictive of PD (AUC 0.808, 95% CI 0.724 ~ 0.892, p < 0.001). Conclusion: Preoperative sleeping disorders may be an independent risk factor leading to PD and an independent predictive factor for the development of delirium in proximal femoral surgery patients aged 60 or older.

Purpose: Neuropathic pain is a chronic intractable disease characterized by allodynia and hyperalgesia. Effective treatments are unavailable because of the complicated mechanisms of neuropathic pain. Transient receptor potential canonical 6 (TRPC6) is a nonselective calcium (Ca²⁺)-channel protein related to hyperalgesia. Dexmedetomidine (Dex) is an alpha-2 (α 2) adrenoreceptor agonist that mediates intracellular Ca²⁺ levels to alleviate pain. However, the relationship between TRPC6 and Dex is currently unclear. We speculated that the α 2 receptor agonist would be closely linked to the TRPC6 channel. We aimed to investigate whether Dex relieves neuropathic pain by the TRPC6 pathway in the dorsal root ganglia (DRG). Methods: The chronic constriction injury (CCI) model was established in male rats, and we evaluated the mechanical withdrawal threshold (MWT) and thermal withdrawal latency (TWL). The expression of TRPC6 and Iba-1 in the DRG were analyzed using quantitative real-time polymerase chain reaction, Western blot, and immunofluorescence assay. The levels of inflammatory cytokines were measured using an enzyme-linked immunosorbent assay. Results: Compared with the CCI normal saline group, both the MWT and TWL were significantly improved after 7 days of Dex administration. Results demonstrated that TRPC6 expression was increased in the DRG following CCI but was suppressed by Dex. In addition, multiple administrations of Dex inhibited the phosphorylation level of p38 mitogen-activated protein kinase and the upregulation of neuroinflammatory factors. Conclusion: The results of this study demonstrated that Dex exhibits anti-nociceptive and anti-inflammatory properties in a neuropathic pain model. Moreover, our findings of the CCI model suggested that Dex has an inhibitory effect on TRPC6 expression in the DRG by decreasing the phosphorylation level of p38 in the DRG.