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Innovations in Perioperative Anesthesia: Advancing Non-Operating Room Anesthesia (NORA) and Regional Techniques

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Anesthesiology".

Deadline for manuscript submissions: 20 August 2026 | Viewed by 6851

Special Issue Editors

Dr. Francesco Coppolino

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Guest Editor
Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80134 Naples, Italy
Interests: non operative room anesthesia; anesthesia and regional anesthesia; nerve block; spinal anesthesia; postoperative pain; perioperative medicine; intensive care medicine
Special Issues, Collections and Topics in MDPI journals
Dr. Vincenzo Pota

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Guest Editor
Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 80134 Naples, Italy
Interests: non operative room anesthesia; anesthesia and regional anesthesia; nerve block; spinal anesthesia; postoperative pain; perioperative medicine; intensive care medicine
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Perioperative medicine is evolving rapidly, driven by the growing complexity of surgical procedures and patient populations. In this context, anesthesia care is expanding beyond the traditional operating room, with non-operating room anesthesia (NORA) emerging as a critical domain requiring tailored approaches to safety, monitoring, and anesthetic technique. Concurrently, ultrasound-guided regional anesthesia, including peripheral nerve blocks and fascial plane blocks, has become a cornerstone in perioperative pain management, offering enhanced analgesia, reduced opioid consumption, and improved recovery profiles across diverse surgical settings. 

This Special Issue aims to explore current challenges and innovations in perioperative anesthesia, with a focus on NORA and regional techniques. We invite contributions that address clinical, organizational, and technical aspects of anesthesia care in non-traditional settings, as well as research into the efficacy and safety considerations of ultrasound-guided blocks. Emphasis will also be placed on multidisciplinary strategies to optimize perioperative outcomes through evidence-based analgesia protocols and personalized anesthesia planning.

We welcome original research and reviews that advance our understanding and practice in this dynamic field.

You may choose our Joint Special Issue in Healthcare.

Dr. Francesco Coppolino
Dr. Vincenzo Pota
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 250 words) can be sent to the Editorial Office for assessment.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • perioperative medicine
  • non-operating room anesthesia (NORA)
  • ultrasound-guided regional anesthesia
  • fascial plane blocks
  • postoperative pain management

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Published Papers (4 papers)

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Research

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11 pages, 241 KB  
Article
The Role of High-Flow Nasal Cannula (HFNC) During Flexible Bronchoscopy in Adult Patients with Moderate Respiratory Dysfunctions: An Observational Study
by Francesco Coppolino, Pasquale Sansone, Gianluigi Cosenza, Simona Brunetti, Francesca Piccialli, Marco Fiore, Clelia Esposito, Maria Caterina Pace and Vincenzo Pota
J. Clin. Med. 2026, 15(2), 459; https://doi.org/10.3390/jcm15020459 - 7 Jan 2026
Viewed by 715
Abstract
Background/Objectives: Flexible bronchoscopy (FB) enables airway exploration and diagnosis of various respiratory pathologies, but the sedation and instrumentation required during the procedure raise oxygen demand while reducing ventilation, which can lead to hypoxemia. Conventional oxygen therapy (COT) may not adequately prevent desaturations [...] Read more.
Background/Objectives: Flexible bronchoscopy (FB) enables airway exploration and diagnosis of various respiratory pathologies, but the sedation and instrumentation required during the procedure raise oxygen demand while reducing ventilation, which can lead to hypoxemia. Conventional oxygen therapy (COT) may not adequately prevent desaturations in high-risk groups, as patients with moderate respiratory deficiency. High-flow nasal cannula (HFNC) can deliver heated, humidified oxygen at high flow rates, generating low-level positive airway pressure, improving oxygenation, reducing dead-space, and enhancing procedure tolerance. Prior studies have shown that HFNC can improve gas exchange and reduce desaturations during bronchoscopy. However, evidence remains limited for patients with moderate respiratory deficiency, who are particularly vulnerable. Evaluating the feasibility and safety of HFNC in this population is essential to guide safe procedural practice. Methods: A retrospective observational study including patients undergoing FB with HFNC support between January and May 2025. Inclusion criteria were BMI between 18 and 30; age > 18 years old; moderate respiratory dysfunction, defined by pulse oximetry, Pulmonary Functional Tests (PFTs) and Arterial Blood Gas (ABG) analysis. Exclusion criteria were intolerance/contraindication to HFNC. Procedures were performed under basic monitoring. Primary outcome was occurrence of severe hypoxemia (SpO2 < 90%). Secondary outcomes were needed for rescue maneuvers, interruption for conversion to other ventilatory strategies, and hemodynamic instability. Results: No severe desaturations were recorded, all procedures were completed without rescue maneuvers or other ventilatory strategies, and no hypoxemia occurred. Mean duration of the procedure was 9 min. Vital parameters were maintained within the normal ranges, with a mean SpO2 during bronchoscopy of 98%. Conclusions: HFNC enables oxygenation and ventilation without adverse events in sedations for FB in patients with moderate respiratory deficiency. Full article
(This article belongs to the Special Issue Innovations in Perioperative Anesthesia: Advancing Non-Operating Room Anesthesia (NORA) and Regional Techniques)

Review

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16 pages, 798 KB  
Review
Fascial Plane Blocks for Analgesia in Non-Operating Room Anesthesia Settings
by Huseyin Ulas Pinar, Asina Pinar and Ayşe Heves Karagöz
J. Clin. Med. 2026, 15(6), 2143; https://doi.org/10.3390/jcm15062143 - 11 Mar 2026
Viewed by 334
Abstract
Non-operating room anesthesia (NORA) has emerged as one of the fastest-growing domains of modern anesthetic practice. Increasing procedural complexity and an aging, comorbid patient population demand analgesic strategies that enhance safety, comfort, and procedural success while minimizing physiological disturbance. Although systemic opioids and [...] Read more.
Non-operating room anesthesia (NORA) has emerged as one of the fastest-growing domains of modern anesthetic practice. Increasing procedural complexity and an aging, comorbid patient population demand analgesic strategies that enhance safety, comfort, and procedural success while minimizing physiological disturbance. Although systemic opioids and sedatives remain commonly used in NORA settings, their dose-dependent adverse effects may compromise patient safety and delay recovery, particularly in environments with limited postprocedural monitoring. Ultrasound-guided fascial plane blocks (FPBs) have therefore gained prominence as key components of opioid-sparing and opioid-free anesthetic strategies. By providing targeted regional analgesia with preserved hemodynamic stability, FPBs reduce systemic analgesic requirements and opioid-related side effects while improving patient comfort. This review summarizes the anatomical basis, proposed mechanisms of action, and current clinical evidence supporting the use of thoracic and abdominal fascial plane blocks in NORA settings, with particular emphasis on interventional cardiology and interventional radiology procedures. The expanding role of FPBs suggests that these techniques may become integral elements of standard analgesic protocols in contemporary non-operating room anesthesia practice. Full article
(This article belongs to the Special Issue Innovations in Perioperative Anesthesia: Advancing Non-Operating Room Anesthesia (NORA) and Regional Techniques)
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18 pages, 274 KB  
Review
Regional Anesthesia: A Narrative Review of Impact on Oxidative Stress Biomarkers
by Karolina Jaruga, Anna Puścion-Jakubik and Piotr Jakubów
J. Clin. Med. 2025, 14(21), 7503; https://doi.org/10.3390/jcm14217503 - 23 Oct 2025
Cited by 2 | Viewed by 1211
Abstract
Background/Objectives: Oxidative stress results from an imbalance between reactive oxygen species (ROS) production and antioxidant defenses and has been implicated in the pathogenesis of numerous diseases, including cardiovascular and neurodegenerative disorders. In the perioperative setting, both surgical trauma and anesthetic agents may [...] Read more.
Background/Objectives: Oxidative stress results from an imbalance between reactive oxygen species (ROS) production and antioxidant defenses and has been implicated in the pathogenesis of numerous diseases, including cardiovascular and neurodegenerative disorders. In the perioperative setting, both surgical trauma and anesthetic agents may contribute to oxidative stress. While this phenomenon has been extensively studied under general anesthesia, the role of regional anesthesia remains less defined. This review aims to compare the impact of general and regional anesthesia techniques on oxidative stress and its biomarkers across various surgical disciplines. Methods: A literature search was conducted using PubMed and EBSCO databases, focusing on studies published between 2010 and 2024. Search terms included “anesthesiology”, “oxidative stress”, “regional anesthesia”, “general anesthesia”, and related biomarkers (e.g., MDA, TAS, TOS, thiol/disulfide). Inclusion criteria required that studies compare general and regional anesthesia techniques and assess at least one biomarker of oxidative stress. Seventeen studies were included in the final analysis. Results: Findings were heterogeneous. Some studies reported that regional anesthesia, particularly spinal and peripheral nerve blocks, was associated with lower levels of malondialdehyde (MDA), reduced total oxidant status (TOS), and improved total antioxidant status (TAS), suggesting reduced oxidative stress. In contrast, other studies showed higher levels of oxidative stress markers under regional anesthesia or no significant differences between techniques. Outcomes varied by surgical type, biomarker used, patient population, and methodological quality. Conclusions: Current evidence is insufficient to establish definitive recommendations regarding the choice of anesthetic technique based on oxidative stress outcomes. However, regional anesthesia appears to be associated with a more favorable oxidative profile in some settings, such as cesarean section and selected orthopedic procedures. Further standardized, large-scale studies are needed to clarify these findings and guide anesthetic decision-making in the context of oxidative balance. Full article
(This article belongs to the Special Issue Innovations in Perioperative Anesthesia: Advancing Non-Operating Room Anesthesia (NORA) and Regional Techniques)

Other

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13 pages, 1381 KB  
Technical Note
A Novel Modified Ultrasound-Guided Venipuncture Technique for Non-Tunneled PICC Insertion in a Non-Operating Room Anesthesia (NORA) Setting: A Technical Report with Real-World Experience
by Dario Cirillo, Giorgio Ranieri, Gaetano Castellano, Domenico Pietro Santonastaso, Maria Silvia Barone, Isabella Russo and Antonio Coviello
J. Clin. Med. 2026, 15(3), 1234; https://doi.org/10.3390/jcm15031234 - 4 Feb 2026
Viewed by 745
Abstract
Background: Peripherally inserted central catheters (PICCs) are widely used for medium- and long-term intravenous therapies but remain associated with mechanical and thrombotic complications, particularly during venipuncture and guidewire insertion. The growing use of Non-Operating Room Anesthesia (NORA) environments, where anesthesiologists frequently perform ultrasound-guided [...] Read more.
Background: Peripherally inserted central catheters (PICCs) are widely used for medium- and long-term intravenous therapies but remain associated with mechanical and thrombotic complications, particularly during venipuncture and guidewire insertion. The growing use of Non-Operating Room Anesthesia (NORA) environments, where anesthesiologists frequently perform ultrasound-guided vascular access under conditions of limited resources and support, underscores the need for simple, reproducible, and inherently safe techniques. The objective of this technical note is to describe a modified ultrasound-guided venipuncture technique for non-tunneled PICC insertion, specifically developed for NORA settings, aimed at reducing procedure-related complications and preserving patient safety in routine clinical practice. Methods: The proposed technique consists of controlled intraluminal advancement of the needle tip (approximately 0.3–0.5 cm) under continuous ultrasound visualization, combined with progressive reduction in the insertion angle to achieve stable central intraluminal alignment before guidewire insertion. The technique has been applied in routine clinical practice across multiple Italian centers over the last two years, within a large multicenter real-world experience exceeding 5000 non-tunneled PICC procedures. Results: Based on real-world clinical observations, the systematic application of the technique was associated with a low incidence of early mechanical complications, including failed guidewire advancement, multiple venipuncture attempts, local pain, and hematoma formation. During standardized post-procedural ultrasound follow-up of the catheterized upper-extremity veins, no cases of catheter-related deep vein thrombosis were detected. Conclusions: This modified ultrasound-guided venipuncture technique represents a feasible and reproducible procedural refinement for non-tunneled PICC insertion in NORA environments. By enhancing intraluminal needle stability during guidewire advancement, it may contribute to improving procedural reliability and supporting patient safety in routine clinical practice. Further prospective and comparative studies are warranted to confirm these findings and define the generalizability of this approach. Full article
(This article belongs to the Special Issue Innovations in Perioperative Anesthesia: Advancing Non-Operating Room Anesthesia (NORA) and Regional Techniques)
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