Pediatric ambulatory anesthesia: an update Purpose of review Ambulatory surgery is the standard for the majority of pediatric surgery in 2019 and adenotonsillectomy is the second most common ambulatory surgery in children so it is an apt paradigm. Preparing and managing these children as ambulatory patients requires a thorough understanding of the current literature. Recent findings The criteria for undertaking pediatric adenotonsillectomy on an ambulatory basis, fasting after clear fluids, postoperative nausea and vomiting (PONV), perioperative pain management and discharge criteria comprise the themes addressed in this review. Summary Three criteria determine suitability of adenotonsillectomy surgery on an ambulatory basis: the child's age, comorbidities and the severity of the obstructive sleep apnea syndrome (OSAS). Diagnosing OSAS in children has proven to be a challenge resulting in alternate, noninvasive techniques, which show promise. Abbreviating the 2 h clear fluid fasting guideline has garnered attention, although the primary issue is that parents do not follow the current clear fluid fasting regimen and until that is resolved, consistent fasting after clear fluids will remain elusive. PONV requires aggressive prophylactic measures that fail in too many children. The importance of unrecognized genetic polymorphisms in PONV despite prophylactic treatment is understated as are the future roles of palonosetron and Neurokinin-1 receptor antagonists that may completely eradicate PONV when combined with dexamethasone. Pain management requires test doses of opioids intraoperatively in children with OSAS and nocturnal desaturation to identify those with lowered opioid dosing thresholds, an uncommon practice as yet. Furthermore, postdischarge nonsteroidal anti-inflammatory agents as well as other pain management strategies should replace oral opioids to prevent respiratory arrests in those who are ultra-rapid CYP2D6 metabolizers. Finally, discharge criteria are evolving and physiological-based criteria should replace time-based, reducing the risk of readmission. Correspondence to Dr Jerrold Lerman, Department of Anesthesia, Oishei Children's Hospital, 1001 Main St, Suite K-3502, Buffalo, NY 14203, USA. Tel: +1 716 323 6570; e-mail: Jerrold.Lerman@gmail.com Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019 Purpose of review Office-based anesthesia (OBA) is rapidly growing across the world. Availability of less invasive interventions has facilitated the opportunity of offering new procedures in office-based settings to patient populations that would not have been considered in the past. This article provides a practical approach to discuss and analyze newest literature supporting different practices in the field of OBA. In addition, an update of the most recent guidelines and practice management directives is included. Recent findings Selected procedures may be performed in the office-based scenario with exceedingly low complication rates, when the right patient population is selected, and adequate safety protocols are followed. Current regulations are focused on reducing surgical risk through the implementation of patient safety protocols and practice standardization. Strategies include cognitive aids for emergencies, safety checklists, facility accreditation standards among other. Summary New evidence exists supporting procedures in the office-based scenario in areas such as plastic and cosmetic surgery, dental and oral surgery, ophthalmology, endovascular procedures and otolaryngology. Different systematic approaches have been developed (guidelines and position statements) to promote standardization of safe practices through emergency protocols, safety checklists, medication management and surgical risk reduction. New regulations and accreditation measures have been developed to homogenize practice and promote high safety standards. Correspondence to Fred E. Shapiro, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Ave, Boston, MA 02215, USA. Tel: +1 617 667 3112; e-mail: fshapiro@bidmc.harvard.edu Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

Procedural sedation in ambulatory anaesthesia: what's new? Purpose of review Although sedation traditionally has been regarded as an easy, straight forward and simple variety of general anaesthesia; the trends are to make sedation more sophisticated and dedicated. Also to have a critical look at old dogmas, as they are usually derived from the practice of general anaesthesia. Safety always has to be first priority, especially as the practice grows out of traditional theatres and frequently are being practiced by nonanaesthetic personnel. Recent findings Safety comes from learning of rare cases with severe problems as well as better guidelines and rules of accreditation. Further, there is a growing quest for evidence on pragmatic, high-quality, cost-effective practice; in terms of logistics, monitoring, choice of drugs and quality assurance. The traditional drugs, such as propofol, midazolam and remifentanil, are still defending their dominant position but are being challenged by ketamine and etomidate. Remimazolam and dexmedetomidine are new promising drugs in this area, whereas metoxyflurane may have a revival in some situations. Further, there is growing evidence into specific protocols, practice for special procedures and for patients with special challenges. Summary Procedural sedation deserves to have high degree of attention for further developments, both from a scientific and pragmatic point of view, as the practice is very diversified and growing. Correspondence to Johan Raeder, MD, Dr. Med/PhD, Department of Anaesthesiology, Oslo University Hospital, Ullevaal, PO Box 4950 Nydalen, N-0424 Oslo, Norway. Tel: +00 47 22119690; e-mail: johan.rader@medisin.uio.no Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

From the ICU to the operating room: how to manage the patient? Purpose of review To outline key points for perioperative ICU optimization of nutrition, airway management, blood product preparation and transfusion, antibiotic prophylaxis and transport. Recent findings Optimization entails glycemic control for all, with specific attention to type-1 diabetic patients. Transport-related adverse events may be averted with surgery in the ICU. If moving the patient is unavoidable, transport guidelines should be followed and hemodynamic optimization, airway control, and stabilization of mechanical ventilation ensured before transport. Preinduction preparation includes assessment of the airway and high-flow oxygen to prolong apneic oxygenation. Postintubation, a protective positive ventilation strategy, should be employed. Ideal transfusion thresholds are 7 g/dl for hemodynamically stable adult patients, 8 g/dl in orthopedic/cardiac surgery/cardiovascular disease and higher in specific disease states. Antimicrobial prophylaxis within 120 min of incision prevents most surgical site infections. Antibiotic therapy depends on the antibiotics being received in the ICU, the time elapsed since ICU admission, local epidemiology and the type of surgery. Tailored antimicrobial regimens may be continued periprocedurally. If more than 70% of the nutritional requirement cannot be met enterally, parenteral nutrition should be initiated within 5–7 days of surgery or earlier if the patient is malnourished. Summary ICU patients who require surgery may benefit from appropriate perioperative management. Correspondence to Professor Sharon Einav, MSc, MD, Director, Surgical Intensive Care Unit, Shaare Zedek Medical Centre, Affiliated with the Hebrew University, POB 3235, Jerusalem 91031, Israel. Tel: +972 2 6666664; fax: +972 2 6555144; e-mail: einav_s@szmc.org.il Copyright © 2019 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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.