Anaesthesiology

Effect of sevoflurane-based or propofol-based anaesthesia on the incidence of postoperative acute kidney injury: A retrospective propensity score-matched analysis BACKGROUND Propofol may help to protect against ischaemic acute kidney injury (AKI); however, research on this topic is sparse. OBJECTIVE The current study aimed to investigate whether there were differences in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based total intravenous anaesthesia (TIVA) and those who received sevoflurane-based inhalational anaesthesia. DESIGN A retrospective observational study. SETTING A single tertiary care hospital. PATIENTS Medical records of patients aged 19 years or older who underwent curative lung resection surgery for nonsmall cell lung cancer between January 2005 and February 2018 were examined. MAIN OUTCOME MEASURES After propensity score matching, the incidence of AKI in the first 3 postoperative days was compared between patients who received propofol and those who received sevoflurane. Logistic regression analyses were also used to investigate whether propofol-based TIVA lowered the risk of postoperative AKI. RESULTS The analysis included 2872 patients (1477 in the sevoflurane group and 1395 in the propofol group). After propensity score matching, 661 patients were included in each group; 24 (3.6%) of the 661 patients in the sevoflurane group developed AKI compared with 23 (3.5%) of the 661 patients in the propofol group (95% confidence intervals of difference in incidence −0.019 to 0.022, P = 0.882). The logistic regression analyses revealed that the incidence of AKI was not different in the two groups (odds ratio 0.96, 95% confidence interval 0.53 to 1.71, P = 0.882). CONCLUSION In this retrospective study, no significant difference was found in the incidence of postoperative AKI after lung resection surgery between patients who received propofol-based TIVA and those who received sevoflurane-based inhalational anaesthesia. Considering the methodological limitation of this retrospective study, further studies are required to confirm these results. Correspondence to Tak Kyu Oh, Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam-si 13620, Gyeonggi-do, South Korea Tel: +82 31 787 7501; fax: +82 31 787 4063; e-mail: airohtak@hotmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Colour Doppler ultrasound after major cardiac surgery improves diagnostic accuracy of the pulmonary infection score in acute respiratory failure: A prospective observational study BACKGROUND Postoperative pneumonia is a frequent complication after cardiac surgery, and its diagnosis is difficult. Little is known about the diagnostic accuracy of lung ultrasound (LUS) in the detection of pneumonia in cardiac surgical patients. The substitution of chest radiography by colour Doppler LUS (LUS-sCPIS) in the simplified clinical pulmonary infection score (sCPIS) could improve the diagnosis of pneumonia following cardiac surgery. OBJECTIVE The aim of this study was to compare the diagnostic accuracy of LUS-sCPIS and of sCPIS alone in the detection of postoperative pneumonia after cardiac surgery. DESIGN A prospective study of diagnostic accuracy. SETTING A Surgical Intensive Care Unit of a French University Hospital. PATIENTS Fifty-one patients with acute respiratory failure within 72 h after cardiac surgery were enrolled between January and May 2015. MAIN OUTCOME MEASURE The two index tests, LUS-sCPIS and sCPIS, were calculated for all patients at the onset of acute respiratory failure. The reference standard for the diagnosis of pneumonia was based on the consensus of three physicians, blind to the sCPIS and LUS-sCPIS data, based on a posthoc review of all the clinical, radiological and microbiological evidence. The diagnostic accuracy of LUS-sCPIS was compared with that of sCPIS in the detection of postoperative pneumonia. RESULTS Pneumonia was diagnosed in 26 out of 51 patients. The LUS-sCPIS detected the presence of pneumonia with a sensitivity of 92% (95% CI 0.85 to 0.99) and a specificity of 68% (95% CI 0.55 to 0.81). The sCPIS detected the presence of pneumonia with a sensitivity of 35% (95% CI 0.22 to 0.48) and a specificity of 84% (95% CI 0.74 to 0.94). The area under the curve (AUC) of LUS-sCPIS at 0.80 (95% CI 0.69 to 0.91) was higher than the AUC of sCPIS at 0.59 (95% CI 0.47 to 0.71; P = 0.0008). CONCLUSION Compared with sCPIS, LUS-sCPIS improved diagnostic accuracy in the detection of postoperative pneumonia in patients with acute respiratory failure after cardiac surgery. It could be a useful bedside tool to guide pneumonia management. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03279887. https://clinicaltrials.gov/ct2/show/NCT03279887?term=bougl%C3%A9&rank=4 Correspondence to Adrien Bouglé, MD, PhD, Département d’Anesthésie et de Réanimation, Réanimation de Chirurgie Cardiaque, Institut de Cardiologie, Hôpital Universitaire La Pitié-Salpêtrière, 47–83 boulevard de l’Hôpital, Paris 75013, France; e-mail: adrien.bougle@aphp.fr Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Reintubation in the ICU following cardiac surgery: is it more difficult than first-time intubation in the operating room?: A prospective, observational study BACKGROUND After cardiac surgery, a patient's trachea is usually extubated; however, 2 to 13% of cardiac surgery patients require reintubation in the ICU. OBJECTIVE The objective of this study was to compare the initial intubation in the cardiac operating room with reintubation (if required) in the ICU following cardiac surgery. DESIGN A prospective, observational study. SETTING Department of Anesthesiology and Intensive Care Medicine, Clinical Hospital of Santiago, Spain. PATIENTS With approval of the local ethics committee, over a 44-month period, we prospectively enrolled all cardiac surgical patients who were intubated in the operating room using direct laryngoscopy, and who required reintubation later in the ICU. MAIN OUTCOME MEASURES The primary endpoint was to compare first-time success rates for intubation in the operating room and ICU. Secondary endpoints were to compare the technical difficulties of intubation (modified Cormack–Lehane glottic view, operator-reported difficulty of intubation, need for support devices for direct laryngoscopy) and the incidence of complications. RESULTS A total of 122 cardiac surgical patients required reintubation in the ICU. Reintubation was associated with a lower first-time success rate than in the operating room (88.5 vs. 97.6%, P = 0.0048). Reintubation in the ICU was associated with a higher incidence of Cormack–Lehane grades IIb, III or IV views (34.5 vs. 10.7%, P < 0.0001), a higher incidence of moderate or difficult intubation (17.2 vs. 6.5%, P = 0.0001) and a greater need for additional support during direct laryngoscopy (20.5 vs. 10.7%, P = 0.005). Complications were more common during reintubations in the ICU (39.3 vs. 5.7%, P < 0.0001). CONCLUSION Compared with intubations in the operating room, reintubation of cardiac surgical patients in the ICU was associated with more technical difficulties and a higher incidence of complications. CLINICAL TRIAL NUMBER Ethics committee of Galicia number 2015-012. Correspondence to Dr Manuel Taboada, Department of Anesthesiology and Intensive Care Medicine, Servicio de Anestesiología y Reanimación del Hospital Clínico Universitario de Santiago de Compostela, Choupana sn, CP:15706 Santiago de Compostela, A Coruña, España Tel: +00 34 678195618; e-mail: manutabo@yahoo.es © 2019 European Society of Anaesthesiology

Propofol intravenous anaesthesia with desflurane compared with desflurane alone on postoperative liver function after living-donor liver transplantation: A randomised controlled trial BACKGROUND Propofol is an anaesthetic that resembles α-tocopherol and it has been suggested that it protects against ischaemia-reperfusion injury in liver transplantation. Living-donor liver transplantation (LDLT) presents an opportunity to test this hypothesis in both donors and recipients. OBJECTIVES We compared clinical outcomes after LDLT following anaesthesia with propofol and desflurane against desflurane alone. DESIGN A prospective, randomised, parallel study. SETTING Single-centre trial, study period June 2014 and May 2017. PATIENTS Sixty-two pairs of adult donors and recipients who underwent LDLT. INTERVENTION Patients were randomised to receive either desflurane balanced anaesthesia or propofol total intravenous anaesthesia combined with desflurane anaesthesia. MAIN OUTCOME MEASURES The primary outcome was peak liver transaminase levels during the first 7 days after surgery. Liver function was assessed at 10 different time-points (before surgery, 1 h after reperfusion, upon arrival in the ICU, and daily until postoperative day 7). Creatinine was measured to evaluate the incidence of acute kidney injury. TNF-α, IL-1β, IL-6 and TGF-β1 were assessed in 31 donors after induction, at hepatectomy and at the end of surgery and in 52 recipients after induction, and 1, 3 and 24 h after reperfusion. RESULTS Peak liver transaminase levels were not significantly different between the two groups. Liver function tests and creatinine were also similar between groups at all time-points. There was no difference in the incidence of postoperative complications, including acute kidney injury. With the exception of higher TNF-α in donors of the Propofol group at hepatectomy (0.60 ± 0.29 vs. 1.03 ± 0.53, P = 0.01) cytokine results were comparable between the two groups. CONCLUSION Despite the simultaneous administration of propofol infusion in both donors and recipients, no improvement in laboratory or surgical outcome was observed after LDLT compared with patients who received desflurane anaesthesia alone. TRIAL REGISTRATION NCT02504138 at clinicaltrials.gov. Correspondence to Young C. Yoo, Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea Tel: +82 2 2228 2420; fax: +82 2 2227 7897; e-mail: seaoyster@yuhs.ac © 2019 European Society of Anaesthesiology

Can quantitative sensory tests predict failed back surgery?: A prospective cohort study BACKGROUND Failed back surgery syndrome (FBSS) is a pain condition refractory to therapy, and is characterised by persistent low back pain after spinal surgery. FBSS is associated with severe disability, low quality of life and high unemployment. We are currently unable to identify patients who are at risk of developing FBSS. Patients with chronic low back pain may display signs of central hypersensitivity as assessed by quantitative sensory tests (QST). This can contribute to the risk of developing persistent pain after surgery. OBJECTIVE We tested the hypothesis that central hypersensitivity as assessed by QST predicts FBSS. DESIGN AND SETTING We performed a prospective cohort study in three tertiary care centres with 141 patients scheduled for up to three segment spinal surgery for chronic low back pain due to degenerative changes. PATIENTS Chronic low back pain was defined as at least 3 on a numerical rating scale on most days during the week and with a minimum duration of 3 months. OUTCOMES We defined FBSS as persistent pain, persistent disability or a composite outcome defined as either persistent pain or disability. The primary outcome was persistent pain 12 months after surgery. We applied 14 QST using electrical, pressure and temperature stimulation to predict FBSS and assessed the association of QST with FBSS in multivariable analyses adjusted for sociodemographic, psychological and clinical and surgery-related characteristics. RESULTS None of the investigated 14 QST predicted FBSS, with 95% confidence intervals of crude and adjusted associations of all QST including one as a measure of no association. Results remained robust in all sensitivity and secondary analyses. CONCLUSION The study indicates that assessment of altered central pain processing using current QST is unlikely to identify patients at risk of FBSS and is therefore unlikely to inform clinical decisions. Correspondence to Prof. Michele Curatolo, MD, PhD, Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific Street, Box 356540 Seattle, WA 98195-6540, USA Tel: +1 206 543 2568; fax: +1 206 543 2958; e-mail: curatolo@uw.edu Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Tidal volume challenge to predict fluid responsiveness in the operating room: A prospective trial on neurosurgical patients undergoing protective ventilation BACKGROUND Pulse pressure variation (PPV) and stroke volume variation (SVV) do not predict fluid responsiveness when using a protective ventilation strategy: the use of functional haemodynamic tests can be useful to overcome this limitation. OBJECTIVES We tested the use of a tidal volume challenge (VTC), during 6 ml kg−1 [predicted body weight (PBW)] ventilation, and the end-expiratory occlusion test (EEOT) for prediction of fluid responsiveness. DESIGN An interventional prospective study. SETTING Supine elective neurosurgical patients. INTERVENTIONS The study protocol was, first, the initial EEOT test was performed during baseline 6 ml kg−1 PBW ventilation; second, VTC was performed by increasing the VT up to 8 ml kg−1 PBW and PPV and SVV changes were recorded after 1 min; third, a second EEOT was performed during 8 ml kg−1 PBW ventilation; and VT was reduced back to 6 ml kg−1 PBW and a third EEOT was performed. Finally, a 250 ml fluid challenge was administered over 10 min to identify fluid responders (increase in stroke volume index ≥10%). RESULTS In the 40 patients analysed, PPV and SVV values at baseline and EEOT performed at 6 ml kg−1 PBW did not predict fluid responsiveness. A 13.3% increase in PPV after VTC predicted fluid responsiveness with a sensitivity of 94.7% and a specificity of 76.1%, while a 12.1% increase in SVV after VTC predicted fluid responsiveness with a sensitivity of 78.9% and a specificity of 95.2%. After EEOT performed at 8 ml kg−1 PBW, a 3.6% increase in cardiac index predicted fluid responsiveness with a sensitivity of 89.4% and a specificity of 85.7%, while a 4.7% increase in stroke volume index (SVI) with a sensitivity of 89.4% and a specificity of 85.7%. CONCLUSION The changes in PPV and SVV obtained after VTC are reliable and comparable to the changes in CI and SVI obtained after EEOT performed at 8 ml kg−1 PBW in predicting fluid responsiveness in neurosurgical patients. TRIAL REGISTRATION ACTRN12618000351213. Correspondence to Antonio Messina, MD, PhD, Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas, Humanitas University, Via Alessandro Manzoni, 56, Rozzano – Milan 20089, Italy. Tel: +39(0)2 8224 8282; e-mail: mess81rc@gmail.com Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.ejanaesthesiology.com). © 2019 European Society of Anaesthesiology

Effect of pre-operative oral carbohydrate loading on recovery after day-case cholecystectomy: A randomised controlled trial BACKGROUND Pre-operative carbohydrate loading has been shown to reduce pre-operative discomfort and postoperative nausea and vomiting in general surgical patients. Few studies have considered day-case surgery. OBJECTIVE The aim of this prospective randomised study was to determine whether pre-operative carbohydrate loading enhanced recovery after day-case cholecystectomy. DESIGN A randomised controlled trial. SETTING Secondary care in a district general and a university hospital in Finland between 2013 and 2016. PATIENTS A total of 113 patients American Society of Anesthesiologists physical status I or II aged 18 to 70 undergoing day-case cholecystectomy were included in the study. Exclusion criteria were bleeding or coagulation disorders, BMI more than 40 kg m−2, dementia, insulin-treated diabetes, migraine, Meniere's disease or a history of alcohol or drug abuse. INTERVENTION The carbohydrate-rich drink group received oral carbohydrate (200 ml) 2 to 3 h before surgery, and the control (fasting) group fasted from midnight according to standard protocol. MAIN OUTCOME MEASURES Visual analogue scales (VAS) were used to score six forms of discomfort: the need for analgesia and antiemetics, the time to drinking, eating and first mobilisation after surgery and the time to discharge. Any hospital re-admission was also recorded. RESULTS The highest VAS scores were seen for mouth dryness and tiredness 2 h after surgery in the fasting group. There were no significant differences in any VAS scores between the study groups. No differences in time to mobilisation, need for pain or antiemetic medication or time to discharge were seen between the groups. CONCLUSION Compared with overnight fasting, pre-operative carbohydrate loading did not significantly enhance peri-operative well being or recovery in patients undergoing day-case cholecystectomy. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT03757208. Correspondence to Heli Helminen, Senior Physician, Department of Surgery, Seinäjoki Central Hospital, Hanneksenrinne 7, 60220 Seinäjoki, Finland Tel: +358 64155888; e-mail: heli.helminen@epshp.fi © 2019 European Society of Anaesthesiology

Deep neuromuscular blockade improves surgical conditions during gastric bypass surgery for morbid obesity: A randomised controlled trial BACKGROUND There is a controversy in the literature whether deep compared with moderate neuromuscular block (NMB) improves surgical conditions for laparoscopic surgery. OBJECTIVES The primary outcome measure was to examine whether switching from moderate to deep NMB improves surgical conditions for laparoscopic surgery in the obese; secondary outcome measures were changes in intra-abdominal pressure, time required to perform the gastrojejunal anastomosis and peri-operative surgical complications. DESIGN A single-centre, randomised controlled study. Each patient was taken as their own control and examined twice: at the first evaluation (E1), all patients had a moderate NMB, thereafter patients were randomised to deep or moderate block and a second evaluation (E2) was performed within 10 min. Patients with excellent rating at E1 were excluded from E2, as their surgical condition could not be further improved. SETTING University Hospital France. PATIENTS Patients undergoing laparoscopic gastric bypass surgery under general anaesthesia were included. Main exclusion criteria were hypersensitivity to the drugs used and absence of written informed consent. INTERVENTIONS According to the group assignment, patients received bolus doses of rocuronium or 0.9% saline. MAIN OUTCOME MEASURES Surgical conditions were assessed with a 4-point rating scale. Intra-operative adverse events were assessed with the Kaafarani-classification and postoperative complications with the Clavien-Dindo classification. RESULTS Eighty-nine patients were initially included and data from 85 could be assessed at E1; surgical rating was excellent in 20, good in 35, acceptable in 18, poor in 12. After excluding those with an excellent rating, the remaining 65 patients were randomly assigned to deep or moderate block. At E2, an improvement of surgical conditions was observed in 29 out of 34 patients with deep block and in four out of 31 with moderate block; P < 0.0001. Poor surgical conditions were more frequently associated with surgical complications (61.5 versus 15.3%; P < 0.001). CONCLUSION Switching from moderate to deep block improves surgical conditions. Poor surgical conditions were associated with a higher incidence of surgical complications. TRIAL REGISTRATION NCT02118844 (www.clinicaltrial.gov). Correspondence to Prof. Thomas Fuchs-Buder, University de Lorraine, CHRU Nancy, Brabois University Hospital, Department of Anesthesiology & Critical Care, 7 allée du Morvan, Vandoeuvre-les-Nancy 54511, France; E-mail: t.fuchs-buder@chru-nancy.fr © 2019 European Society of Anaesthesiology

A randomised controlled pragmatic trial of acupressure therapy on quality of recovery after surgery BACKGROUND Acupressure therapy is associated with favourable efficacies on postoperative nausea, pain and sleep disturbance, although the quality of the evidence is generally low. No randomised clinical trial has yet assessed the effect of acupressure on postoperative quality of recovery (QoR). OBJECTIVE The objective was to study acupressure efficacy on patient-reported postoperative recovery. DESIGN We conducted a single centre, three-group, blind, randomised controlled, pragmatic trial assessing acupressure therapy on the PC6, LI4 and HT7 acupoints. PATIENTS Postoperative patients expected to stay in hospital at least 2 days after surgery. INTERVENTIONS In the acupressure group, pressure was applied for 6 min (2 min per acupoint), three times a day after surgery for a maximum of 2 postoperative days during the hospital stay. In the sham group, extremely light touch was applied to the acupoints. The third group did not receive any touch. MAIN OUTCOME MEASURES The primary outcome was the change in the QoR, using the QoR-15 questionnaire, between postoperative days 1 and 3. Key secondary outcomes included patients’ satisfaction, postoperative nausea and vomiting, pain score and opioid (morphine equivalent) consumption. Assessors for the primary and secondary endpoints were blind to the group allocation. RESULTS Overall, 163 patients were randomised (acupressure n=55, sham n=53, no intervention n=55). The mean (SD) postoperative change in QoR-15 did not differ statistically (P = 0.27) between the acupressure, sham and no intervention groups: 15.2 (17.8), 14.2 (21.9), 9.2 (21.7), respectively. Patient satisfaction (on a 0 to 10 scale) was statistically different (P = 0.01) among these three groups: 9.1 (1.5), 8.4 (1.6) and 8.2 (2.2), respectively. Changes in pain score and morphine equivalent consumption were not significantly different between the groups. CONCLUSION Two days of postoperative acupressure therapy (up to six treatments) did not significantly improve patient QoR, postoperative nausea and vomiting, pain score or opioid consumption. Acupressure, however, was associated with improved patient satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02762435. Correspondence to Eric Noll, MD, PhD, Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires de Strasbourg, Avenue Molière, 67098 Strasbourg, France Tel: +33 3 88127076; fax: +33 3 88127074; e-mail: eric.noll@chru-strasbourg.fr © 2019 European Society of Anaesthesiology

Initial end-tidal carbon dioxide as a predictive factor for return of spontaneous circulation in nonshockable out-of-hospital cardiac arrest patients: A last straw to cling to? BACKGROUND Early outcome prediction in out-of-hospital cardiac arrest is still a challenge. End-tidal carbon dioxide (ETCO2) has been shown to be a reliable parameter to reflect the quality of cardiopulmonary resuscitation and the chance of return of spontaneous circulation (ROSC). OBJECTIVES This study assessed the validity of early capnography as a predictive factor for ROSC and survival in out-of-hospital cardiac arrest victims with an underlying nonshockable rhythm. DESIGN Retrospective observational study. SETTING/PATIENTS During a 2-year observational period, data from 2223 out-of-hospital cardiac arrest victims within the city of Vienna were analysed. The focus was on the following patients: age more than 18 years, an underlying nonshockable rhythm, and advanced airway management within the first 15 min of advanced life support with subsequent capnography. INTERVENTION No specific intervention was set in this observational study. MAIN OUTCOME MEASURES The first measured ETCO2, assessed immediately after placement of an advanced airway, was used for further analysis. The primary outcome was defined as sustained ROSC, and the secondary outcome was 30-day survival. RESULTS A total of 526 patients met the inclusion criteria. These were stratified into three groups according to initial ETCO2 values (<20, 20 to 45, >45 mmHg). Baseline data and resuscitation factors were similar among all groups. The odds of sustained ROSC and survival were significantly higher for patients presenting with higher values of initial ETCO2 (>45 mmHg): 3.59 [95% CI, 2.19 to 5.85] P = 0.001 and 5.02 [95% CI, 2.25 to 11.23] P = 0.001, respectively. On the contrary ETCO2 levels less than 20 mmHg were associated with significantly poorer outcomes. CONCLUSION Patients with a nonshockable out-of-hospital cardiac arrest who presented with higher values of initial ETCO2 had an increased chance of sustained ROSC and survival. This finding could help decision making as regards continuation of resuscitation efforts. Correspondence to Michael Poppe, Universitätsklinik für Notfallmedizin, Medizinische Universität Wien, Währinger Gürtel 18–20/6D, 1090 Wien, Austria Tel: +43 14040019640; fax: +43 14040019650; e-mail: michael.poppe@meduniwien.ac.at © 2019 European Society of Anaesthesiology Awake craniotomy: anesthetic considerations based on outcome evidence Purpose of review This review highlights anaesthesia management options for awake craniotomy and discusses the advantages and disadvantages of different approaches, intraoperative complications and future directions. Recent findings For lesions located within or adjacent to eloquent regions of the brain, awake craniotomy allows maximal tumour resection with minimal consequences on neurological function. Various techniques have been described to provide anaesthesia or sedation and analgesia during the initial craniotomy, and rapid return to consciousness for intraoperative testing and tumour resection; there is no evidence that one approach is superior to another. Although very safe, awake craniotomy is associated with some well recognized complications; most are minor and self-limiting or easily reversed. In experienced hands, failure of awake craniotomy occurs in fewer than 2% of cases, irrespective of anaesthesia technique. Although brain tumour surgery remains the most common indication for awake craniotomy, the technique is finding utility in other neurosurgical procedures. Summary Several anaesthetic approaches are available for the management of patients during awake craniotomy. The choice of technique should be based on individual patient factors, location and duration of surgery, and anaesthesiologist expertise and experience. Appropriate patient selection and excellent multidisciplinary team working is associated with high levels of procedural success and patient satisfaction. Correspondence to Martin Smith, MBBS, FRCA, FFICM, Department of Neuroanaesthesia and Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK;. E-mail: martin.smith@ucl.ac.uk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved. Anesthesia and airway management for gastrointestinal endoscopic procedures outside the operating room Purpose of review To review the anesthestic and airway management for gastrointestinal procedures outside of the operating room. Recent findings The number of gastrointestinal endoscopic procedures performed is steadily increasing worldwide. As complexity, duration and invasiveness of procedures increase, there is ever greater requirement for deeper sedation or general anesthesia. A close relationship between anesthetic practitioners and endoscopists is required to ensure safe and successful outcomes. The American Society of Gastrointestinal endoscopy and the British Society of Gastroenterology have recently released guidelines for sedation and general anesthesia in gastrointestinal endoscopy, highlighting the need for careful monitoring for all cases, and anesthetic expertise in complex cases. The recent advances in high-flow nasal oxygenation in sedation may provide alternative options for oxygenation during gastrointestinal sedation, especially in deep sedation and this may reduce the need for general anesthesia. Summary The advances in gastrointestinal endoscopic intervention have increased the requirement for deep sedation and anesthetic involvement outside of the operating room. Careful titration of anesthetic intervention and close monitoring are required to ensure patient safety. Correspondence to Jaideep J. Pandit, St John's College, Oxford OX1 3JP, UK. Tel: +44 1865 221590; e-mail: jaideep.pandit@dpag.ox.ac.uk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved. Anesthesia practice for endovascular therapy of acute ischemic stroke in Europe Purpose of review Anesthetic assistance is often required during endovascular therapy (EVT) of large vessel occlusion in patients with acute ischemic stroke. It is currently debated whether EVT should be performed under general anesthesia or conscious sedation. This review will summarize the recent literature with emphasis on the influence of anesthesia method on neurological outcome. Recent findings Recent randomized trials have reported no difference in outcome after EVT performed under either conscious sedation or general anesthesia. This is in contrast to a substantial number of retrospective studies, which found that EVT performed under general anesthesia was associated with a worse neurologic outcome compared with conscious sedation. Anesthetic drugs affect vessel tone and the level of blood pressure may influence outcome. The most favorable choice of anesthetic agents and ventilatory strategy is still debated. Summary The optimal anesthetic practice for EVT remains to be identified. Currently, conscious sedation is often an easy first-line strategy, but general anesthesia can be considered an equal and safe alternative to conscious sedation when there is a carefully administered anesthetic that maintains strict hemodynamic control. Attention to ventilation is advocated. The presence of a specialized neuroanesthesiologist or otherwise dedicated anesthesia personnel is highly recommended. Correspondence to Mads Rasmussen, Section of Neuroanesthesia, Department of Anesthesia, Aarhus University Hospital, Nørrebrogade 44, 8000 Aarhus C, Denmark. Tel: +45 30566977; e-mail: mads.rasmussen@vest.rm.dk Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved. Nonoperating room anesthesia education: preparing our residents for the future Purpose of review Nonoperating room anesthesia (NORA) is the fastest growing segment of anesthetic practice. This review provides an overview of knowledge and trends that will need to be introduced to residents as part of their education. Recent findings Topics for the future include, but are not limited to, new medications, artificial intelligence and big data, monitoring depth of hypnosis, translational innovation and collaboration, demographic changes, financial driving forces, destination hubs, medical tourism, and new approaches to education training and self-management. Summary Implementing new medical technologies for anesthesia outside the operating room will help to successfully master this ever evolving subspecialty. Anesthesiologists require specific preparation for the diverse settings that they will encounter during their training. In this rapidly changing field, cognitive fitness must be factored into teaching and evaluation of residents. We describe the most important topics to consider when educating anesthesiology residents, and highlight research that addresses upcoming challenges. Correspondence to Steven D. Boggs, MD, MBA, Department of Anesthesiology, The University of Tennessee School of Health Sciences Memphis, Chandler Building, Suite 600, 877 Jefferson Avenue, Memphis, TN 38103, USA. Tel: +1 901 448 5988; e-mail: sboggs6@uthsc.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved. Anesthesia-administered sedation for endoscopic retrograde cholangiopancreatography: monitored anesthesia care or general endotracheal anesthesia? Purpose of review The decision to undertake monitored anesthesia care (MAC) or general endotracheal anesthesia (GEA) for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is influenced by many factors. These include locoregional practice preferences, procedure complexity, patient position, and comorbidities. We aim to review the data regarding anesthesia-administered sedation for ERCP and identify the impact of airway management on procedure success, adverse event rates and endoscopy unit efficiency. Recent findings Several studies have consistently identified patients at high risk for sedation-related adverse events during ERCP. This group includes those with higher American Society of Anesthesiologists class and (BMI). ERCP is commonly performed in the prone position, which can make the placement of an emergent advanced airway challenging. Although this may be alleviated by performing ERCP in the supine position, this technique is more technically cumbersome for the endoscopist. Data regarding the impact of routine GEA on endoscopy unit efficiency remain controversial. Summary Pursuing MAC or GEA for patients undergoing ERCP is best-approached on an individual basis. Patients at high risk for sedation-related adverse events likely benefit from GEA. Larger, multicenter randomized controlled trials will aid significantly in better delineating which sedation approach is best for an individual patient. Correspondence to Zachary L. Smith, DO, University Hospitals Digestive Health Institute, 11100 Euclid Ave, Wearn 2nd Floor, Cleveland, OH 44106, USA. Tel: +1 216 844 6172; fax: +1 216 844 7480; e-mail: zachary.smith2@uhhospitals.org Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved. Anesthesia for peroral endoscopic myotomy in Japan Purpose of review Peroral endoscopic myotomy (POEM) was developed in Japan as a less invasive treatment for esophageal achalasia requiring general anesthesia under positive pressure ventilation. In 2018, the Japan Gastroenterological Endoscopy Society published the first guidelines describing the standard care for POEM. Based on these guidelines, we discuss the typical approach to anesthesia during POEM for the management of esophageal achalasia in Japan. Recent findings Prior cleansing of the esophagus is essential to prevent both aspiration during induction of anesthesia and contamination of the mediastinum and thoracic/abdominal cavity by esophageal remnants after endoscopic resection of the esophageal mucosa. Although rare, adverse events related to intraoperative carbon dioxide insufflation occur. These are treated through percutaneous needle decompression and insertion of a chest drainage tube for pneumoperitoneum and pneumothorax, respectively. Caution should be exercised regarding the development of subcutaneous emphysema and its involvement in airway obstruction. Summary Prevention of aspiration pneumonia and adverse events related to the insufflation of carbon dioxide is essential in the management of esophageal achalasia through POEM. Close cooperation between gastrointestinal endoscopic surgeons and anesthesiologists is indispensable in POEM. Correspondence to Hiroaki Murata, Department of Anesthesiology, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan. Tel: +81-95-819-7370; fax: +81-95-819-7373; e-mail: h-murata@nagasaki-u.ac.jp Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.