Preclinical and clinical studies have sought to better understand the effect of anesthetic agents, both volatile and intravenous, and perioperative adjuvant medications on immune function. The immune system has evolved to incorporate both innate and adaptive components, which are delicately interwoven and essential for host defense from pathogens and malignancy. This review summarizes the complex and nuanced relationship that exists between each anesthetic agent or perioperative adjuvant medication studied and innate and adaptive immune function with resultant clinical implications. The most commonly used anesthetic agents were chosen for review including volatile agents (sevoflurane, isoflurane, desflurane, and halothane), intravenous agents (propofol, ketamine, etomidate, and dexmedetomidine), and perioperative adjuvant medications (benzodiazepines, opioids, nonsteroidal anti-inflammatory drugs [NSAIDs], and local anesthetic agents). Patients who undergo surgery experience varying combinations of the aforementioned anesthetic agents and adjuncts, depending on the type of surgery and their comorbidities. Each has unique effects on immunity, which may be more or less ideal depending on the clinical situation. Further study is needed to better understand the clinical effects of these relationships so that patient-specific strategies can be developed to improve surgical outcomes.

Background Enhanced recovery after surgery (ERAS) attempts to decrease the surgical stress response to minimize postoperative complications and improve functional rehabilitation after major surgery, but it have not been widely utilized in spinal surgery. This study is to evaluate the implementation of an ERAS pathway for patients undergoing oblique lumbar interbody fusion (OLIF) surgery. Methods This was a retrospective cohort study of patient who underwent OLIF in 2018 prior to ERAS ("pre-ERAS" ,n=23) and in 2019 after ERAS was instituted ("ERAS", n=24). Major outcomes were collected included demographics, length of hospital stay, nancial cost, postoperative complications, off-bed time and perioperative factors. Visual Analogue Scale (VAS) was used to evaluate the pain. The ERAS pathway and compliance with pathway elements were also recorded. Results After ERAS implementation, we found no signi cant differences in the baseline characteristics between the two groups. In our study, the mean stay in the hospital was signi cantly lower (p= 0.033) in the ERAS group (15.3±3.9 days) compared to the standard pathway group (13.0±3.1 days). In comparison to the standard group, we also found a variation between the nancial costs of surgery and hospitalization [(16446.5±4353.3)vs(14237.7±2784.9) USD, P < 0.05]. The ERAS group manifested a lower blood loss compared with the pre-ERAS group with statistical signi cance [(68.3±57.1)vs(119.3±104.8) ml, P < 0.05]. There was no signi cant difference in operative time, complications, and 30-d readmission rates (P > 0.05). Pain scores between the two groups showed a signi cant difference during the 3th hour and 6th hour (P < 0.05). Conclusion Institution of an ERAS protocol appears to accelerate functional recovery and reduce length of stay, nancial costs and decreased pain.

Preoperative carbohydrate loading is a contemporary element of the enhanced recovery after surgery (ERAS) paradigm. In addition to intraoperative surgical and anesthetic modifications and postoperative care practices, preoperative optimization is essential to good postsurgical outcomes. What was long held as dogma, a period of prolonged fasting prior to the administration of anesthesia, was later re‐examined and challenged. Along with the proposed physiologic effects of decreasing the surgical stress response and insulin resistance, preoperative carbohydrate loading was also demonstrated to improve patient satisfaction and well‐being, without an increase in perioperative complications. The benefits are most strongly observed in abdominal and cardiac surgery patients, but there has also been data which support its use in other specialties and surgeries. Barriers to the adoption of perioperative carbohydrate loading are few, but importantly include overcoming the inertia to modify older and more restrictive fasting guidelines and achieving the multidisciplinary consensus necessary to implement such changes. Despite these challenges, and with an existing body of evidence supporting its benefits, preoperative carbohydrate loading presents a significant contribution to the ERAS programs.

Paramedics are able to identify the disease process category in patients dispatched as having "difficulty breathing," with a moderate degree of accuracy.

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With the increasing popularity, frequency, and acceptance of the robotic-assisted laparoscopic radical prostatectomy procedure, an awareness of unique intra- and postoperative complications is heightened, including that of increases in intraocular pressure. The steep Trendelenburg positioning required for operative exposure has been shown to increase this value. While the literature is infrequent and undeveloped, certain anesthetic parameters including deep neuromuscular blockade, modified positioning, and the use of dexmedetomidine have been shown to have mild-to-modest decreases in intraocular pressure for baseline. In the four randomized control trials and four observational studies that were found via PubMed/Medline search, the aforementioned techniques demonstrate some preliminary evidence of operative considerations in this unique patient population. These modifications may prove to have even greater significance in patients with pre-existing ophthalmologic pathologies, such as glaucoma, which were excluded from the studies' analyses. This review summarizes the early literature obtained in this subject, with the intent of emphasizing the initial hypotheses and identifying areas for future study.

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Purpose of ReviewFor patients with cancer, treatment may include combination therapy, including surgery and immunotherapy. Here, we review perioperative considerations for the patient prescribed immunotherapeutic agents. Recent Findings The perioperative period is a poignant moment in the journey of a patient with cancer, potentially deemed most influential compared to other moments in the care continuum. Several immunotherapeutic medications have been employed near the time of surgery to potentially increase effectiveness. Of the various drug classes, including immune checkpoint inhibitors, cytokines, toll-like receptor agonists, and oncolytic viruses, among others, several notable immunerelated adverse effects were noted. They range from minor effects to more serious ones, such as renal failure, myocarditis, and tumor growth. Summary Surgery and immunotherapy are often employed in combination for primary treatment and prevention of cancer recurrence. Careful review and consideration of the pharmacokinetics, pharmacodynamics, and toxicities of immunotherapy benefit the perioperative physician and their patients.