Regional anesthesia and pain management in patients with sleep apnea: can they improve outcomes? Purpose of Review In several guidelines, regional anesthesia and analgesia have been suggested as safer alternatives for general anesthesia and systemic analgesia for their safety profile in patients suffering from obstructive sleep apnea (OSA). However, the underlying scientific basis is still evolving. The present review is intended to provide an up-to-date account on the question whether the use of regional anesthesia improves outcomes in patients with OSA. Recent Findings A number of studies found favorable effects of regional anesthesia used in patients with OSA, including reduced incidence of major perioperative complications such as the need for mechanical ventilation, reintubation and pulmonary/cardiac complications. No negative effects of regional anesthesia specific to patients with OSA were found. Regional anesthesia was most effective when used as a sole technique, but also carried benefits when added to general anesthesia. The majority of available literature focuses on orthopedic surgery and neuraxial anesthesia. Summary Regional anesthesia can be recommended as a good strategy to treat patients with OSA whenever feasible, as it reduces the incidence of potentially catastrophic perioperative complications. However, the breadth of both surgical and regional anesthetic techniques analyzed is limited; further research should focus on extending the knowledge base beyond neuraxial anesthesia and orthopedics. Correspondence to Ottokar Stundner, Department of Anesthesiology, Perioperative, Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg, Austria. Tel: +43 5 7255 55763; fax: +43 5 7255 24197; e-mail: otto.stundner@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Indications, contraindications, and safety aspects of procedural sedation Purpose of review There is a steadily increasing demand for procedural sedation outside the operating room, frequently performed in comorbid high-risk adult patients. This review evaluates the feasibility and advantages of sedation vs. general anesthesia for some of these new procedures. Recent findings Generally, sedation performed by experienced staff is safe. Although for some endoscopic or transcatheter interventions sedation is feasible, results of the intervention might be improved when performed under general anesthesia. For elected procedures like intra-arterial treatment after acute ischemic stroke, avoiding general anesthesia and sedation at all might be the optimal treatment. Summary Anesthesiologists are facing continuously new indications for procedural sedation in sometimes sophisticated diagnostic or therapeutic procedures. Timely availability of anesthesia staff will mainly influence who is performing sedation, anesthesia or nonanesthesia personal. While the number of absolute contraindications for sedation decreased to almost zero, relative contraindications are becoming more relevant and should be tailored to the individual procedure and patient. Correspondence to Benedikt Preckel, Department of Anesthesiology, Amsterdam University Medical Centers UMC, Location AMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Tel: +31 20 5669111; e-mail: b.preckel@amsterdamumc.nl Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Essential elements of an outpatient total joint replacement programme Purpose of review To summarize the safety and feasibility of outpatient total joint arthroplasty (TJA) from the perspectives of short-term complications, long-term functional outcomes, patient satisfaction and financial impact, and to provide evidence-based guidance on how to establish an outpatient TJA programme. Recent findings TJA has been recently transitioned from an exclusively inpatient procedure for all Medicare and Medicaid patients to an outpatient surgery in properly selected total knee arthroplasty patients. This change may decrease costs while maintaining comparable rates of readmission, adverse events, positive surgical outcomes and patient satisfaction. Summary With a standardized clinical pathway, outpatient TJA can be safe and effective in a subset of patients. Essential components of a successful outpatient TJA programme include proper patient selection, preoperative patient/family education, perioperative multidisciplinary coordination and opioid-sparing analgesia, and early and effective postdischarge planning. More studies are needed to further assess and optimize this new care paradigm. Correspondence to Jinlei Li, MD, PhD, Associate Professor, Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA 06510. E-mail: jinlei.li@yale.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Regional anesthesia for cardiac surgery Purpose of review Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery. Recent findings Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking. Summary New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks. Correspondence to Ban C. H. Tsui, MD, Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pediatric Anesthesia, Stanford University School of Medicine, Stanford, CA 94304, USA. Tel: +1 650 723 5728; e-mail: bantsui@stanford.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Cannabis-based medicines for chronic pain management: current and future prospects Purpose of review The medicinal use of cannabis has recently become the focus of much medical, as well as political, attention. This reality of growing use but limited evidence creates unique dilemmas for the prescribing clinician. The purpose of this review is to explore current evidence and gaps in knowledge and offer some practical considerations. Recent findings There is robust preclinical data regarding the relevance of the endocannabinoid system to many pain-relevant processes. However, evidence to support cannabis-based medicines clinical use is still lacking. The best evidence to date is in managing neuropathic pain, although whether effects are clinically significant remains undetermined. However, the safety profile of cannabinoids seems favorable, especially by comparison to other medications used for pain control. Summary The endocannabinoid system is undoubtedly a new and exciting pharmaceutical target for chronic pain management, but transition from preclinical to clinical studies has so far proved difficult. Although it is reasonable to consider cannabinoids for otherwise unresponsive pain, care should be taken in frail clinical populations. As this has become a socioeconomic and political issue in which agendas often take precedence over due diligence, there is a pressing need for unbiased empirical data and high quality evidence to better inform prescribers and patients. Correspondence to Haggai Sharon, MD, PhD, Department of Anesthesiology and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Institute of Pain Medicine, Weizmann 6, Tel Aviv, Israel. Tel: +97236974477; e-mail: haggaisharon@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Awake videolaryngoscopy versus fiberoptic bronchoscopy Purpose of review The difficult airway remains an ongoing concern in daily anesthesia practice, with awake intubation being an important component of its management. Classically, fiberoptic bronchoscope-assisted tracheal intubation was the method of choice in the awake patient. The development of new generation videolaryngoscopes has revolutionized the approach to tracheal intubation in the anesthetized patient. The question whether videolaryngoscopes have a place in the intubation of the difficult airway in the awake patient is currently being addressed. Recent findings Randomized controlled trials and their meta-analysis have shown that videolaryngoscopes provide similar success rates and faster intubation times when compared with fiberoptic bronchoscope intubation in awake patients with difficult airways. Summary Videolaryngoscopy is a valid technique that should be considered for difficult airway management in the awake patient. Correspondence to Albert Moore, MD, MSc, Department of Anaesthesia, Royal Victoria Hospital, McGill University Health Center, 1001 Decarie Boulevard, Montreal, QC, Canada H4A 3J1. Tel: +1 514 934 1934 x34880;. e-mail: albert.moore@mcgill.ca Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Can recent chronic pain techniques help with acute perioperative pain? Purpose of review This article discussed how the knowledge and technique of a few chronic pain procedures benefited the perioperative clinicians in their care of patients receiving specific orthopaedic surgical procedures. Recent findings Recent emerging interest in hip and knee denervation for chronic pain management secondary to osteoarthritis stimulates publications on the new understanding of hip and knee joint innervation. The improved understanding of the anatomy allows better precision in targeting the articular branches. The procedures for chronic joint pain such as radiofrequency ablation, chemical neurolysis and neuromodulation procedure have recently been applied to the perioperative care in orthopaedic procedures because of the potential long-lasting analgesia, opioid-sparing effect and consequent improvement in physical function and health-related quality of life after surgery. Summary Despite the widespread use of regional anaesthesia and multimodal analgesia in the perioperative pain management, more than two-third of the patients reported severe postoperative pain. Therefore, other therapeutic strategies used in chronic pain management such as radiofrequency ablation and neuromodulation have been proposed to optimize acute postsurgical pain. The early experience with those techniques is encouraging, and more studies are required to explore the incorporation of these procedures in the perioperative care. Correspondence to Philip W.H. Peng, MBBS, FRCPC, Founder (Pain Medicine), Department of Anesthesia, University of Toronto, Toronto, ON M5T 2S8, Canada. E-mail: philip.peng@uhn.ca Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Persistent postoperative pain: mechanisms and modulators Purpose of review Persistent postoperative pain (PPP) is a significant source of morbidity in our population. An excellent opportunity to understand the transition from acute to chronic pain states. Understanding the mechanisms that drive this and modulators that influence this transition is essential to both prevent and manage this condition. Recent findings Although the exact mechanism for the development of PPP is still poorly understood, hypotheses abound. Basic science research with animal models implicates nociceptive and neuropathic pain signals leading to pain sensitization due to persistent noxious signaling. Effects on the inhibitory modulation of noxious signaling in medullary-spinal pathways and descending modulation have also been implicated. Summary Persistent maladaptive neuroplastic changes secondary to neurotrophic factors and interactions between neurons and microglia may well explain the phenomenon. This article reviews the current thought processes on mechanisms and modulators from a basic science and epidemiological perspective. Correspondence to Padma Gulur, MD, Professor of Anesthesiology and Population Health, Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710, USA. Tel: +1 919 681 4660; e-mail: Padma.gulur@duke.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Emerging indications for hyperbaric oxygen Purpose of review To identify and discuss emerging trends in the therapeutic use of hyperbaric oxygen. Recent findings There has been a maturing of the clinical evidence to support the treatment of sudden hearing loss, a wide range of problematic chronic wound states and the prevention and treatment of end-organ damage associated with diabetes mellitus. On the other hand, the controversy continues concerning the use of hyperbaric oxygen therapy (HBOT) to treat sequelae of mild traumatic brain injury. HBOT remains poorly understood by many medical practitioners despite more than 50 years of clinical practice. Pharmacological actions arise from increased pressures of oxygen in the blood and tissues. Most therapeutic mechanisms identified are not the simple result of the reoxygenation of hypoxic tissue, but specific effects on immunological and metabolic pathways by this highly reactive element. HBOT remains controversial despite biological plausibility and a solid clinical evidence base in several disease states. Summary Multiple proposals for new indications for HBOT continue to emerge. Although many of these will likely prove of limited clinical importance, some show significant promise. Responsible practitioners remain acutely aware of the need for high-quality clinical evidence before introducing emerging indications into routine practice. Correspondence to Michael H. Bennett, Academic Head, Department of Diving and Hyperbaric Medicine, Prince of Wales Hospital and University of New South Wales, Sydney, New South Wales, Australia. Tel: +61 2 9382 4746; e-mail: m.bennett@unsw.edu.au Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

The role of gabapentinoids in acute and chronic pain after surgery Purpose of review Gabapentinoid use has increased substantially in the past several years after initial promising data with regard to acute perioperative pain control. The purpose of this review is to critically appraise the evidence for the use of gabapentinoids for acute pain management and its impact on the development of chronic pain after surgery. Recent findings Recent meta-analyses have revealed that prior data likely have overestimated the beneficial effects of gabapentinoids in acute perioperative pain while underestimating the associated adverse effects. The utility of gabapentinoids in the setting of enhanced recovery pathways and for the prevention of chronic postsurgical pain is still unclear. Moreover, there has been increasing concern regarding the potential for misuse and abuse of gabapentinoids. Summary Current evidence does not support the routine use of gabapentinoids as part of a multimodal analgesic regimen in enhanced recovery pathways. We recommend being selective with regard to using gabapentinoids for acute postoperative pain management after careful consideration of the potential side effect profile based on patient comorbidities as well as the expected severity of postoperative pain. Large, high-quality trials are needed to identify the impact of gabapentinoids in the context of multimodal anagelsia. Correspondence to Amanda H. Kumar, Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, DUMC 3094, Durham, NC 27710, USA. Tel: +1 216 385 5529; fax: +1 919 681 8994; e-mail: amanda.kumar@duke.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.