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Drug abuse and addiction are persistent problems in the United States and around the world. This is an ongoing issue for health care providers, as substance abuse is seen in 25% to 40% of patients admitted to hospitals for general treatment. Many patients with substance use disorders have a higher risk for adverse events; however, only a small percentage will volunteer information regarding prior substance use. This article discusses the present opioid crisis, mechanisms behind chronic pain and substance abuse, current clinical findings, treatment therapies, and abuse deterrents.

The anesthetic management of pregnant patients can present a variety of challenges and a thorough preoperative assessment is necessary before initiating any anesthetic services. Both the mother and the fetus need to be considered when formulating an anesthetic plan and discussing informed consent. The overall aims in assessing a pregnant patient are to identity potential issues that can lead to catastrophic complications, provide adequate information allowing the mother to make informed decisions, and to obtain knowledge for tailoring an anesthetic that maintains maternal and fetal homeostasis.

Oxycodone, a semisynthetic opioid analgesic, is widely used in clinical practice. Oxycodone and morphine seem to be equally effective and equipotent; however, morphine is 10 times more potent than oxycodone when given epidurally. This article provides an updated review of the basic pharmacology of oxycodone with a special focus on pharmacokinetic/pharmacodynamics properties. The controversy regarding oxycodone-mediated effects for visceral pain via agonism and the possible role of peripheral opioid analgesia are discussed in the present investigation in an attempt to propose a plausible explanation to the perplexing question of oxycodone analgesia.

Appropriate nutrition in the hospital setting, particularly in critically ill patients, has long been tied to improving clinical outcomes. During critical illness, inflammatory mediators and cytokines lead to the creation of a catabolic state to facilitate the use of endogenous energy sources to meet increased energy demands. This process results in increasing the likelihood of overfeeding. The literature has revealed exponential advances in understanding the molecular basis of nutritional support and evolution of clinical protocols aimed at treating artificial nutritional support as a therapeutic intervention, preventing loss of lean body mass and metabolic deterioration to improve clinical outcomes in the critically ill.

Pain remains a tremendous burden on patients and for the health care system, with uncontrolled pain being the leading cause of disability in this country. There are a variety of medications that can be used in the treatment of pain, including ketorolac, oxymorphone, tapentadol, and tramadol. Depending on the clinical situation, these drugs can be used as monotherapy or in conjunction with other types of medications in a multimodal approach. A strong appreciation of pharmacologic properties of these agents and potential side effects is warranted for clinicians.

Despite an appreciation for many unwanted physiologic effects from inadequate postoperative pain relief, moderate to severe postoperative pain remains commonplace. Although treatment options have evolved in recent years, the use of nonopioid analgesics agents can reduce acute pain-associated morbidity and mortality. This review focuses on the importance of effective postoperative nonopioid analgesic agents, such as acetaminophen, nonsteroidal anti-inflammatory agents, gabapentinoid agents, NMDA antagonists, alpha 2 agonists, and steroids, in opioid sparing and enhancing recovery. A careful literature review focusing on these treatment options, potential benefits, and side effects associated with these strategies is emphasized in this review.

Acute pain in the pediatric population has important differences in terms of biology, intrapopulation variation, and epidemiology. Discussion as to the pharmacologic considerations of anesthetic agents, such as induction agents, neuromuscular blockers, opioids, local anesthetics, and adjuvant agents, is presented in this article. Special considerations and concerns, such as risk for propofol infusion syndrome and adverse potential side effects of anesthesia agents, are discussed. Anesthesiologists managing pediatric patients need to have a firm understanding of physiologic and pharmacologic differences compared with the adult population. Future studies to improve the understanding of pharmacokinetics in the pediatric population are needed.

A significant number of commonly administered medications in anesthesia show wide clinical interpatient variability. Some of these include neuromuscular blockers, opioids, local anesthetics, and inhalation anesthetics. Individual genetic makeup may account for and predict cardiovascular outcomes after cardiac surgery. These interactions can manifest at any point in the perioperative period and may also only affect a specific system. A better understanding of pharmacogenomics will allow for more individually tailored anesthetics and may ultimately lead to better outcomes, decreased hospital stays, and improved patient satisfaction.

Postoperative nausea and vomiting (PONV) is associated with delayed recovery and dissatisfaction after surgical procedures. A key component to management is identifying risk factors and high-risk populations. Advances in pharmacologic therapeutics have resulted in agents targeting different pathways associated with the mediation of nausea and vomiting. This review focuses on these agents and the clinical aspects of their use in patients postoperatively. Combination therapies are reviewed, and studies demonstrate that when 2 or more antiemetic agents acting on different receptors are used, an overall improved efficacy is demonstrated when compared with a single agent alone in patients.

Many patients presenting with a history of foregut, midgut neuroendocrine tumors (NETs) or carcinoid syndrome can experience life-threatening carcinoid crises during anesthesia or surgery. Clinicians should understand the pharmacology of octreotide and appreciate the use of continuous infusions of high-dose octreotide, which can minimize intraoperative carcinoid crises. We administer a prophylactic 500-μg bolus of octreotide intravenously (IV) and begin a continuous infusion of 500 μg/h for all NET patients. Advantages include low cost and excellent safety profile. High-dose octreotide for midgut and foregut NETs requires an appreciation of the pathophysiology involved in the disease, pharmacology, drug-drug interactions, and side effects.

Therapeutic duration of traditional local anesthetics when used in peripheral nerve blocks is normally limited. This article describes novel approaches to extend the duration of peripheral nerve blocks currently available or in development. Three newer approaches on extending the duration of peripheral nerve blocks include site-1 sodium channel blockers, novel local anesthetics delivery systems, and novel adjuvants of local anesthetics. Compared with plain amide-based and ester-based local anesthetics, alternative approaches show significant promise in decreasing postoperative pain, rescue opioid requirement, hospital length-of-stay, and overall health care cost, without compromising the established safety profile of traditional local anesthetics.

Cardiovascular disease remains a leading cause of morbidity and mortality worldwide. The development of therapeutic agents for the treatment of cardiovascular diseases has always been a priority because of the huge potential market for these drugs. These medications should be part of the anesthesiologist's armamentarium because the typical surgical patient is older and has more comorbidities than in the past. This article reviews commonly used cardiovascular medications that are important in managing patients with unstable hemodynamics.

Since the public demonstration of ether as a novel, viable anesthetic for surgery in 1846, the field of anesthesia has continually sought the ideal anesthetic-rapid onset, potent sedation-hypnosis with a high therapeutic ratio of toxic dose to minimally effective dose, predictable clearance to inactive metabolites, and minimal side effects. This article aims to review current progress of novel induction agent development and provide an update on the most promising drugs poised to enter clinical practice. In addition, the authors describe trends in novel agent development, implications for health care costs, and implications for perioperative care.

Pain remains a tremendous burden on patients and for the health care system, with uncontrolled pain being the leading cause of disability in this country. There are a variety of medications that can be used in the treatment of pain, including ketorolac, oxymorphone, tapentadol, and tramadol. Depending on the clinical situation, these drugs can be used as monotherapy or in conjunction with other types of medications in a multimodal approach. A strong appreciation of pharmacologic properties of these agents and potential side effects is warranted for clinicians.

Acute pain in the pediatric population has important differences in terms of biology, intrapopulation variation, and epidemiology. Discussion as to the pharmacologic considerations of anesthetic agents, such as induction agents, neuromuscular blockers, opioids, local anesthetics, and adjuvant agents, is presented in this article. Special considerations and concerns, such as risk for propofol infusion syndrome and adverse potential side effects of anesthesia agents, are discussed. Anesthesiologists managing pediatric patients need to have a firm understanding of physiologic and pharmacologic differences compared with the adult population. Future studies to improve the understanding of pharmacokinetics in the pediatric population are needed.

Many patients presenting with a history of foregut, midgut neuroendocrine tumors (NETs) or carcinoid syndrome can experience life-threatening carcinoid crises during anesthesia or surgery. Clinicians should understand the pharmacology of octreotide and appreciate the use of continuous infusions of high-dose octreotide, which can minimize intraoperative carcinoid crises. We administer a prophylactic 500-μg bolus of octreotide intravenously (IV) and begin a continuous infusion of 500 μg/h for all NET patients. Advantages include low cost and excellent safety profile. High-dose octreotide for midgut and foregut NETs requires an appreciation of the pathophysiology involved in the disease, pharmacology, drug-drug interactions, and side effects.

An increasing number of oral anticoagulants have become available over the past decade. Each of these agents has differing implications on both regional and neuraxial anesthetic techniques. This article describes the pharmacology, pharmacokinetics, and pharmacodynamics of the most commonly used novel oral anticoagulants (NOACs). It also outlines recent guidelines for the use of NOACs in the perioperative setting, especially with regard to neuraxial anesthesia.

The prevalence of chronic low back pain (CLBP) is increasing. Treatment is effective in less than 50% of patients after 1 year. This review investigates new treatments for CLBP. An extensive literature review focuses on new treatments for CLBP. Their safety and efficacy were evaluated and are described in detail in this review. The investigation identified new treatments for CLBP including chemonucleolysis, platelet-rich plasma injections, artemin, tanezumab, and stem cells. Further research and innovation are needed to implement these methods into practice and assess clinical significance. The current evidence suggests that there are promising new agents for the treatment of CLBP.

Oxycodone, a semisynthetic opioid analgesic, is widely used in clinical practice. Oxycodone and morphine seem to be equally effective and equipotent; however, morphine is 10 times more potent than oxycodone when given epidurally. This article provides an updated review of the basic pharmacology of oxycodone with a special focus on pharmacokinetic/pharmacodynamics properties. The controversy regarding oxycodone-mediated effects for visceral pain via agonism and the possible role of peripheral opioid analgesia are discussed in the present investigation in an attempt to propose a plausible explanation to the perplexing question of oxycodone analgesia.

Pulmonary hypertension (PH) is a complex disease process of the pulmonary vasculature system characterized by elevated pulmonary arterial pressures. Patients with PH are at increased risk for morbidity and mortality, including intraoperatively and postoperatively. Appreciation by the clinical anesthesiologist of the pathophysiology of PH is warranted. Careful and meticulous strategy using appropriate anesthetic medications, pulmonary vasodilator and inotropic agents, and careful fluid management all increase the likelihood of the best possible outcome in this challenging patient population.

Cardiovascular disease remains a leading cause of morbidity and mortality worldwide. The development of therapeutic agents for the treatment of cardiovascular diseases has always been a priority because of the huge potential market for these drugs. These medications should be part of the anesthesiologist's armamentarium because the typical surgical patient is older and has more comorbidities than in the past. This article reviews commonly used cardiovascular medications that are important in managing patients with unstable hemodynamics.

Appropriate nutrition in the hospital setting, particularly in critically ill patients, has long been tied to improving clinical outcomes. During critical illness, inflammatory mediators and cytokines lead to the creation of a catabolic state to facilitate the use of endogenous energy sources to meet increased energy demands. This process results in increasing the likelihood of overfeeding. The literature has revealed exponential advances in understanding the molecular basis of nutritional support and evolution of clinical protocols aimed at treating artificial nutritional support as a therapeutic intervention, preventing loss of lean body mass and metabolic deterioration to improve clinical outcomes in the critically ill.

Perioperative multimodal analgesia uses combinations of analgesic medications that act on different sites and pathways in an additive or synergistic manner to achieve pain relief with minimal or no opiate consumption. Although all medications have side effects, opiates have particularly concerning, multisystemic, long-term, and short-term side effects, which increase morbidity and prolong admissions. Enhanced recovery is a systematic process addressing each aspect affecting recovery. This article outlines the evidence base forming the current multimodal analgesia recommendations made by the Enhanced Recovery After Surgery Society (ERAS). We describe current evidence and important future directions for effective perioperative multimodal analgesia in enhanced recovery pathways.

There is interpatient variability to analgesic administration. Much can be traced to pharmacogenomics variations between individuals. Certain ethnicities are more prone to reduced function of CYP2D6. Weak opioids are subject to interpatient variation based on their CYP2D6 type. Strong opioids have variations based on their transport and individual metabolism. Several cytochrome enzymes have been found to be involved with ketamine but there is no strong evidence of individual polymorphisms manifesting in clinical outcomes. Nonsteroidal anti-inflammatory drugs have adverse outcomes that certain CYP variants are more prone toward. There are now recommendations for dosing based on specific genomic makeup.

Despite an appreciation for many unwanted physiologic effects from inadequate postoperative pain relief, moderate to severe postoperative pain remains commonplace. Although treatment options have evolved in recent years, the use of nonopioid analgesics agents can reduce acute pain-associated morbidity and mortality. This review focuses on the importance of effective postoperative nonopioid analgesic agents, such as acetaminophen, nonsteroidal anti-inflammatory agents, gabapentinoid agents, NMDA antagonists, alpha 2 agonists, and steroids, in opioid sparing and enhancing recovery. A careful literature review focusing on these treatment options, potential benefits, and side effects associated with these strategies is emphasized in this review.

Novel anticoagulants (NAGs) have emerged as the preferred alternatives to vitamin K antagonists. In patients being considered for regional anesthesia, these drugs present a layer of complexity in the preprocedure evaluation. There are no established tests to monitor anticoagulant activity and our experience is short with these drugs. These authors believe it is important to review the relevant hematology, orthopedics, and anesthesiology literature to provide a valuable reference for the clinician who is met with these challenges. In addition to discussing NAGs, we also review the existing American Society of Regional Anesthesia guidelines for heparin, low-molecular-weight heparin, and antiplatelet agents.

Postoperative nausea and vomiting (PONV) is associated with delayed recovery and dissatisfaction after surgical procedures. A key component to management is identifying risk factors and high-risk populations. Advances in pharmacologic therapeutics have resulted in agents targeting different pathways associated with the mediation of nausea and vomiting. This review focuses on these agents and the clinical aspects of their use in patients postoperatively. Combination therapies are reviewed, and studies demonstrate that when 2 or more antiemetic agents acting on different receptors are used, an overall improved efficacy is demonstrated when compared with a single agent alone in patients.

With a growing number of new anticoagulant/antiplatelet agents being developed, it is likely that an increasing number of patients taking these drugs will present for surgery and other procedures. A familiarity with mechanisms of action and drug interactions helps to maintain optimal patient safety in the perioperative period. Furthermore, it is crucial for anesthesiologists to remain current on recommendations regarding discontinuation or need to continue the newer anticoagulants/antiplatelet drugs in patients presenting for surgery and/or regional anesthesia. Further studies are needed for monitoring of many of these newer agents and to identify antidotes.

HMG CoA reductase inhibitors (statins) are a proven modality to reduce serum cholesterol and have been shown to reduce morbidity and mortality in cardiovascular patients. Statins have also demonstrated improvements in postoperative outcomes among patients taking them in the perioperative period. Many of the studies are limited to select patient populations and/or select surgeries. This review will give an overview of the pharmacology of statins, summarize the mechanisms of the beneficial effects of statins, and provide an overview of evidence in the use of statins in the perioperative period.

Cardiovascular diseases are a leading cause of hospitalizations and death in the United States and elsewhere in the world. Developing new therapeutic agents for cardiovascular diseases has always been the priority for the pharmaceutical industry because of the huge potential market for these drugs. Some of these newer drugs are frequently used in the practice of cardiovascular anesthesiology. This article reviews the recent advances in cardiovascular medications related to the practice of cardiac anesthesia.