Anesthesiology Manual:
Best Practices and Case Management

Long-acting local anesthetics have become a cornerstone of modern perioperative pain management, enabling clinicians to provide prolonged analgesia while reducing opioid requirements and improving postoperative recovery. Over the past decade, advances in drug delivery technologies have generated considerable excitement, particularly with the introduction of liposomal formulations and the development of innovative carrier-based and carrier-free anesthetic systems. However, despite growing commercial adoption and ongoing technological innovation, a new review published in Current Opinion in Anaesthesiology suggests that enthusiasm should be balanced by evidence. While several novel formulations show promise in extending analgesia and improving drug pharmacokinetics, the clinical advantages of currently available products—particularly liposomal bupivacaine—appear more modest than initially anticipated. At the same time, concerns regarding local anesthetic systemic toxicity (LAST), dosing variability, and cost-effectiveness continue to influence clinical decision-making. Long-acting local anesthetics remain central to multimodal analgesia Regional anesthesia has transformed perioperative pain management by allowing targeted pain control while minimizing systemic opioid exposure. Traditional long-acting local anesthetics—including bupivacaine, levobupivacaine, ropivacaine, and tetracaine—have been widely used for decades in peripheral nerve blocks, neuraxial anesthesia, wound infiltration, and fascial plane blocks. More recently, these agents have become integral components of enhanced recovery after surgery (ERAS) protocols, where prolonged analgesia facilitates earlier mobilization, shorter hospital stays, and improved patient satisfaction. The review notes that current research is focused less on discovering entirely new anesthetic molecules and more on developing innovative delivery systems capable of prolonging drug action while minimizing systemic toxicity and adverse effects. Drug delivery technology is driving the next generation of local anesthetics Instead of relying solely on the pharmacological properties of existing drugs, researchers are engineering sophisticated delivery platforms that release local anesthetics gradually. Two major approaches are currently under investigation: Carrier-based formulations Carrier-free formulations Both strategies aim to maintain effective tissue concentrations for longer periods without increasing peak […]

A large 2026 international study suggests that continuing metformin on the day of elective surgery may offer modest benefits for patients with type 2 diabetes mellitus, while no clear advantage or disadvantage was found for continuing or withholding SGLT2 inhibitors or GLP-1 receptor agonists. The findings come from a secondary analysis of the multinational MOPED (Management and Outcomes of Perioperative Care among European Diabetic Patients) study, published in the British Journal of Anaesthesia (Buggy et al.).  Why this study matters The perioperative management of glucose-lowering medications remains controversial. Different professional organizations recommend different approaches, particularly for newer medications such as: Metformin Sodium-glucose cotransporter-2 (SGLT2) inhibitors Glucagon-like peptide-1 (GLP-1) receptor agonists Stopping these medications may worsen glycemic control, while continuing some drugs has raised concerns about complications such as euglycemic diabetic ketoacidosis or delayed gastric emptying. Study overview Researchers analyzed data from the prospective MOPED study involving patients with type 2 diabetes undergoing elective surgery. Study population Nearly 5,000 patients undergoing elective surgery 89 hospitals 21 European countries Average age: approximately 64 years 57% male Median diabetes duration: 9 years Key findings Metformin Patients who continued metformin on the day of surgery experienced: Slightly more days alive and at home within 30 days after surgery (DAH-30) Lower rates of postoperative ketoacidosis Fewer episodes of hypoglycemia No reported cases of metformin-associated lactic acidosis After adjusting for differences in patient characteristics and surgical complexity, the benefit remained statistically significant but modest, approximately 0.5 additional days alive at home. SGLT2 inhibitors Researchers found: No significant improvement in the primary outcome (DAH-30) No increase in diabetic ketoacidosis in this cohort Sample size was relatively small, limiting firm conclusions The authors therefore recommend that current guideline recommendations regarding temporary withholding of SGLT2 inhibitors before surgery should remain unchanged until stronger evidence becomes available. GLP-1 receptor agonists […]