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.

Anaesthetic considerations in nonagenarians and centenarians Purpose of review The ageing population is a global public health issue and we can expect to encounter more and more older patients requiring anaesthetic care. Age itself is no longer the sole reason for declining a patient for anaesthesia and surgery. Undoubtedly, managing patients at the extremities of age is challenging and demanding, not only because of multiple comorbidities, but also the poorer functional status, frailty and decline in general well being that must be managed during the perioperative journey. In this article, we will focus on three important aspects of anaesthetic care for this patient group, namely, comorbidity, frailty and perioperative cognitive dysfunction; and give recommendations on how anaesthetists should tackle these aspects for the ‘older old’ and the ‘oldest old’, based on current best evidence. Recent findings The ‘oldest old’ (nonagerians and centenarians) are the fastest-growing geriatric population worldwide. Evidence has demonstrated that an enhanced care programme designed for elderly patients is safe, feasible and could diminish both complications and length of stay after surgery. Studies are emerging on frailty measurement and the association with outcomes of anaesthesia and surgery and have resulted in new recommendations on best practices for postoperative brain health and nomenclature of perioperative neurocognitive disorder. Summary Comorbidity, frailty and perioperative cognitive dysfunction are significant perioperative concerns specific to elderly patients and clearly associated with adverse outcomes after surgery. These anaesthetic concerns should be anticipated and properly managed through the perioperative pathway so that their potential complications can be mitigated. Correspondence to Kam Y. Ip, Department of Anaesthesiology, Queen Mary Hospital, 2/F, Pokfulam, Hong Kong Special Administrative Region, China. Tel: +852 22555791; fax: +852 22553384; e-mail: ipkamyuen@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia-induced immune modulation Purpose of review Surgery, invasive procedures and anesthesia itself may induce an inflammatory response in the patient. This represents an evolutionary inherited and conserved response of the host to environmental stimuli and may lead to both beneficial and potentially harmful effects. This review highlights the mechanisms of anesthesia-induced and perioperative immune modulation. Recent findings The innate and adaptive immune system serve the host in protection against invading pathogens. Yet, an inflammatory immune response may also be induced by different noninfectious stimuli, for example invasive perioperative procedures and the surgical trauma itself. These stimuli may lead to the activation of the immune system with the consequence of perturbation of cell, tissue of even organ functions in cases of an overshooting immune response. Several perioperative factors have been identified that modulate the immune response, for example different anesthetic drugs and surgical tissue injury, but their impact on immune system modulation may also vary with respect to the procedural context and include both pro-inflammatory and anti-inflammatory effects. Summary The current review will highlight the current knowledge on the perioperative anesthesia-induced and surgery-induced modulation of the immune response and also address possible intervention strategies for the development of future therapeutic approaches. Correspondence to Alexander Zarbock, Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, 48149 Münster, Germany. Tel: +49 251 83 47252; fax: +49 251 88704; e-mail: zarbock@uni-muenster.de Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Benefits and harms of increased inspiratory oxygen concentrations Purpose of review The topic of perioperative hyperoxia remains controversial, with valid arguments on both the ‘pro’ and ‘con’ side. On the ‘pro’ side, the prevention of surgical site infections was a strong argument, leading to the recommendation of the use of hyperoxia in the guidelines of the Center for Disease Control and the WHO. On the ‘con’ side, the pathophysiology of hyperoxia has increasingly been acknowledged, in particular the pulmonary side effects and aggravation of ischaemia/reperfusion injuries. Recent findings Some ‘pro’ articles leading to the Center for Disease Control and WHO guidelines advocating perioperative hyperoxia have been retracted, and the recommendations were downgraded from ‘strong’ to ‘conditional’. At the same time, evidence that supports a tailored, more restrictive use of oxygen, for example, in patients with myocardial infarction or following cardiac arrest, is accumulating. Summary The change in recommendation exemplifies that despite much work performed on the field of hyperoxia recently, evidence on either side of the argument remains weak. Outcome-based research is needed for reaching a definite recommendation. Correspondence to Lothar A. Schwarte, MD, PhD, MBA, EDIC, DESA, Department of Anaesthesiology, Amsterdam University Medical Center, Vrije Universiteit, De Boelelaan 1117, 1007 MB, Amsterdam, The Netherlands. Tel: +31 20 4444 382; e-mail: L.Schwarte@AmsterdamUMC.NL Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Total intravenous anaesthesia in ambulatory care Purpose of review The purpose of this article is to review the use of total intravenous anaesthesia (TIVA) in ambulatory care. Recent findings The number of ambulatory surgery cases is likely to increase in coming years. Recent meta-analyses suggest that TIVA offers decreased postoperative nausea and vomiting (PONV) and decreased pain scores in the postanaesthesia care unit (PACU) in day case/ambulatory surgery patients when compared with volatile anaesthesia. Particular improvements have also been shown in endoscopic nasal surgery in terms of decreased blood loss. TIVA consistently scores higher than volatile techniques in patient satisfaction surveys. Surveys of anesthetists suggest that TIVA is not in widespread use. This may be because of the perceived lack of training or confidence in the technique, therefore, recent internationally agreed guidelines aimed at formalizing its practice are welcome. There is also some recent evidence to suggest that intraoperative dexmedetomidine is superior to remifentanil with respect to postoperative pain and speed of recovery, and that intraoperative lignocaine infusion may reduce chronic pain incidence in breast surgery. Summary Review of recent evidence of TIVA's use in ambulatory surgery and summary of new international guidelines on its use. Correspondence to Professor Kate Leslie, AO, FAHMS, Department of Anaesthesia and Pain Management, Parkville, VIC 3050, Australia. Tel: +61 3 93427540; e-mail: kate.leslie@mh.org.au Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Recovery and discharge criteria after ambulatory anesthesia: can we improve them? Purpose of review Day surgery coming and leaving hospital day of surgery is growing. From minor and intermediate procedure performed on health patient, day surgery is today performed on complex procedures and elderly patient and on patients with comorbidities. Thus, appropriate discharge assessment is of huge importance to secure safety and quality of care. Recent findings Discharge has since decades been assessed on a combination of stable vital signs, control of pain and postoperative nausea and vomiting and securing that patients can stand walk unaided. There is controversy around whether patients must drink and void before discharge. The absolute need for escort when leaving hospital and someone at home first night after surgery is argued but it does support safety. Discharge is not being ‘street fit,’ it merely allows patients to go back home for further recovery in the home environment. A structured discharge timeout checklist securing that patients are informed of further plans, signs, and symptoms to watch out for and what to do in case recovery don’t follow plans facilitate safety. Summary Discharge following day surgery must be based on appropriate assessment of stable vital signs and reasonable resumption of activity of daily living performance. Rapid discharge must not jeopardize safety. Classic discharge criteria are still basis for safe discharge, adding a structured discharge checklist facilitates safe discharge. Correspondence to Jan G. Jakobsson, Department of Anaesthesia & Intensive Care, Danderyds hospital, 18288 Stockholm Sweden. Tel: +46 70 250 09 60; e-mail: Jan.Jakobsson@ki.se 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.

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.

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.