The efficacy of the Hypotension Prediction Index (HPI) for reducing Intraoperative Hypotension (IOH) among patients undergoing non-cardiac surgeries remains unclear. We aimed to perform a systematic review, meta-analysis, and trial sequential analysis to determine whether the HPI is effective for adult patients undergoing non-cardiac surgeries. This study was prospectively registered in the PROSPERO database (CRD42024571931). PubMed, Embase, and Cochrane were systematically searched for Randomized Controlled Trials (RCTs) comparing HPI-guided therapy with standard care in non-cardiac surgeries. We computed Mean Difference (MD) and Risk Ratios (RR) for continuous and binary outcomes, respectively, with 95 % Confidence Intervals (95 % CI). Statistical analyses were performed using R Software, version 4.2.3. We included 11 RCTs, comprising a total of 789 patients, of whom 395 (50.1 %) received HPI-guided management. HPI significantly reduced the Time-Weighted Average (TWA) of Mean Arterial Pressure (MAP) < 65 mmHg (MD = -0.23 mmHg.min^-1; 95 % CI -0.35 to -0.10; p < 0.01) and the Area Under the Curve (AUC) of MAP < 65 mmHg (MD = -97.2 mmHg.min^-1; 95 % CI -143.4 to -50.98; p < 0.01). HPI also decreased the duration of MAP < 65 mmHg (MD = -16.22 min; 95 % CI -25.87 to -6.57; p < 0.01) and the number of hypotensive episodes per patient (MD = -3.38; 95 % CI -5.38 to -1.37; p < 0.01). No significant differences were observed in the number of hypotensive events, phenylephrine use, or AKI incidence (p > 0.05). In adult patients undergoing non-cardiac surgeries, HPI use was associated with a reduction in the duration and severity of IOH, with no significant difference for adverse events. Limitations include significant heterogeneity across studies, differences in HPI implementation, and lack of long-term outcome data.

Introduction: Craniotomy, a common neurosurgical procedure, is frequently associated with substantial perioperative challenges and delayed recovery. While Enhanced Recovery After Surgery (ERAS) protocols have demonstrated clear benefits in multiple surgical fields, their application in neurosurgery, particularly elective craniotomy, remains emerging. Objective: This systematic review and meta-analysis aimed to evaluate the efficacy and safety of ERAS protocols in adult patients undergoing elective craniotomy, focusing on key outcomes such as length of hospital stay (LOS), postoperative pain, complications, and functional recovery. Methods: Following PRISMA guidelines, a comprehensive search was conducted in PubMed, Embase, Scopus, Web of Science, and the Cochrane Library up to June 2025. Eligible studies included adult patients (≥18 years) undergoing elective craniotomy and compared ERAS protocols to conventional perioperative care. Primary outcomes were LOS, postoperative complications, pain, early oral intake, and early mobilization. Data extraction and risk of bias assessment (RoB 2.0) were independently performed by two reviewers. Results: Nine randomized controlled trials (RCTs), totaling 1453 patients, were included. Meta-analysis showed that ERAS protocols significantly reduced length of hospital stay (mean difference: −2.17 days; 95% CI: −2.92 to −1.42; p < 0.00001) and decreased the incidence of postoperative nausea and vomiting (odds ratio [OR]: 0.29; 95% CI: 0.19 to 0.44; I² = 0%). ERAS protocols were associated with higher odds of early mobilization (OR: 6.88; 95% CI: 3.46 to 13.68) and early oral intake (OR: 14.04; 95% CI: 7.80 to 25.26). Postoperative complications were significantly reduced in the ERAS group (OR: 0.49; 95% CI: 0.24 to 0.99; p = 0.048; I² = 0%). While early urinary catheter removal showed a favorable trend (OR: 13.48), high heterogeneity (I² = 95.7%) limits interpretability. Postoperative pain on day 1 did not differ significantly between groups (mean difference: −0.37; 95% CI: −2.38 to 1.63; p = 0.72). The overall risk of bias was rated low to moderate across studies. Conclusions: ERAS protocols in elective craniotomy are associated with shorter hospital stays, lower complication rates, reduced PONV, and earlier return to function, without increasing adverse events. These findings support broader implementation of ERAS in neurosurgical practice. Further multicenter RCTs are warranted to standardize and refine ERAS components for craniotomy.

Background: Opioid‐free anesthesia (OFA) has been proposed as a strategy to reduce opioid exposure and opioid‐related adverse events in laparoscopic surgery. However, evidence from randomized trials remains heterogeneous regarding pain control, postoperative nausea and vomiting (PONV), and opioid consumption. Methods: We performed a systematic review and meta‐analysis of randomized controlled trials (RCTs) comparing OFA with opioid‐based anesthesia (OBA) in adult patients undergoing elective laparoscopic surgery. Primary outcomes included postoperative pain scores (0–10 scale), PONV, and 24‐h opioid consumption. Secondary outcomes included hemodynamic events, recovery quality, and hospital length of stay. Results: Sixteen RCTs ( n = 1322) were included. OFA reduced PONV by approximately 40% (RR 0.60; 95% confidence interval [CI] 0.48–0.75) and modestly decreased postoperative opioid use by 6.4 mg morphine equivalents (95% CI −9.1 to −3.7). Pain scores during the first 24 h were similar between OFA and OBA (MD −0.3 on a 0–10 scale; 95% CI −0.7 to +0.1). Hemodynamic instability (bradycardia and hypotension) occurred more frequently with dexmedetomidine‐based regimens but was transient and clinically manageable. No differences were observed in recovery time or hospital length of stay. Conclusion: OFA provides clinically meaningful reductions in PONV and opioid exposure without compromising postoperative analgesia. These findings support OFA as a safe and effective alternative to OBA in laparoscopic surgery and a potential component of enhanced recovery pathways.

Background and objectives: Perioperative intravenous lidocaine infusion has been proposed as an opioid-sparing analgesic adjunct in spine surgery, but previous meta-analyses pooled heterogeneous procedures and may have obscured procedure-specific treatment effects. We evaluated the analgesic and opioid-sparing effects of perioperative intravenous lidocaine in adult spine surgery and whether efficacy differs by procedure type. Methods: We searched PubMed, Embase, Web of Science, and the Cochrane Library from inception through June 2026 for randomized controlled trials comparing perioperative intravenous lidocaine infusion with placebo or standard care in adults undergoing spine surgery. The primary outcome was postoperative pain intensity at 24 hours. Secondary outcomes were opioid consumption, postoperative nausea and vomiting (PONV), and hospital length of stay (LOS). Random-effects meta-analyses, a post hoc subgroup analysis by procedure type, and meta-regression were performed. Results: 10 randomized trials were included. Intravenous lidocaine reduced postoperative pain at 24 hours (9 trials, 655 patients; mean difference (MD), −0.83; 95% CI −1.36 to −0.30; p=0.002; I²=89%, 95% CI 81% to 93%; prediction interval, −2.69 to 1.02; moderate certainty) and opioid consumption (9 trials; MD, −11.64 mg intravenous morphine equivalents; 95% CI −16.14 to −7.14; p<0.001). In a post hoc exploratory analysis, the analgesic effect differed by procedure type (test for subgroup differences, p=0.005): the reduction was clinically meaningful after instrumented fusion or complex spine surgery (MD, −1.23; 95% CI −1.81 to −0.64), exceeding the minimal clinically important difference of 1.0 point, but minimal after decompression (MD, −0.20; 95% CI −0.61 to 0.21). Baseline pain severity explained approximately 53% of between-study heterogeneity, whereas lidocaine infusion rate did not modify the treatment effect (p=0.97). No significant effects were observed for PONV or LOS. Conclusions: There is moderate-certainty evidence that perioperative intravenous lidocaine reduces postoperative pain and opioid consumption after adult spine surgery. Its analgesic benefit appeared procedure-specific, with the greatest benefit after instrumented fusion and complex procedures; this difference emerged from a post hoc, exploratory analysis and should be regarded as hypothesis-generating.

Objective: To evaluate whether deep neuromuscular blockade (DNMB) improves surgical conditions and facilitates low-pressure pneumoperitoneum compared with moderate neuromuscular blockade (MNMB) during minimally invasive surgery. Data Sources PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, Scopus, Web of Science, and LILACS were searched from inception through May 2026. Study Selection Randomized controlled trials comparing DNMB versus MNMB in adults undergoing laparoscopic or robot-assisted surgery were included. Data Extraction Two reviewers independently screened studies, extracted data, and assessed risk of bias using the revised Cochrane Risk of Bias tool (RoB 2). Certainty of evidence was evaluated using the GRADE approach. Primary Outcomes: Primary outcomes were surgical workspace quality and intra-abdominal pressure requirements. Secondary Outcomes: Secondary outcomes included postoperative pain at 24 hours and referred shoulder pain. Data Synthesis: Seventeen randomized controlled trials involving more than 1700 patients were included. DNMB consistently improved surgical workspace conditions and facilitated lower pneumoperitoneum pressures compared with MNMB. Pooled analyses additionally suggested reductions in postoperative pain and referred shoulder pain in selected studies, although postoperative outcomes demonstrated greater heterogeneity across procedures and perioperative protocols. Conclusions: Current evidence suggests that the principal clinical value of DNMB during minimally invasive surgery is optimization of surgical exposure and facilitation of low-pressure pneumoperitoneum strategies. Benefits related to postoperative pain may occur in selected settings but appear less consistent across procedures.