Vetrix Anesthesiology

Citation:Christensen MI, Creutzburg A, Vested M, Nørskov AK, Lundstrøm LH, Afshari A. Effects of avoidance versus use of neuromuscular blocking agents for facilitation of tracheal intubation in children and infants. Eur J Anaesthesiol. 2026;43:1–14. doi:10.1097/EJA.0000000000002358. (PROSPERO: CRD42024518195)Study at a glance- Design: Systematic review + pairwise random-effects meta-analysis (Mantel–Haenszel RR) of paediatric RCTs; trial sequential analysis (TSA) for the primary outcome; GRADE Summary of Findings.- Search: MEDLINE, EMBASE, CENTRAL, BIOSIS, Web of Science, CINAHL + registries (ClinicalTrials.gov, WHO ICTRP, CTIS, EudraCT) and other sources; last search 8 July 2025.- Population/setting: Patients <18 years undergoing oral or nasal tracheal intubation with direct or video laryngoscopy, in any setting (OR and NICU included).- Comparison: Avoidance of NMBAs (placebo/other drugs/no NMBA for intubation conditions) vs use of NMBAs (any NMBA, dose, duration).- Included evidence: 47 RCTs overall; primary outcome (difficult tracheal intubation) reported by 30 trials (n=2,276).Key results (avoidance vs use of NMBAs)1) Difficult tracheal intubation (primary)- Pooled effect: RR 3.47 (95% CI 2.52–4.77), P<0.00001; k=30; I²=18%.- Absolute risks (SoF): 61/1000 with NMBA use vs 212/1000 with NMBA avoidance (≈151 more/1000; 95% CI 93–231 more).- Aggregate events: 249/1197 (20.8%) vs 66/1079 (6.1%).- TSA: α-spending adjusted RR 3.68 (95% CI 2.22–6.11); required information size reached.2) Failed intubation- Pooled effect: RR 4.70 (95% CI 2.36–9.35), P<0.0001; k=20; I²=0%.- Absolute risks (SoF): 12/1000 with NMBA use vs 57/1000 with NMBA avoidance (≈45 more/1000; 95% CI 16–101 more).- Aggregate events: 33/682 (4.8%) vs 9/747 (1.2%).3) Serious adverse events (≥1 SAE)- Pooled effect: RR 0.63 (95% CI 0.33–1.21), P=0.17; k=47; I²=0%.- Absolute risks (SoF): 15/1000 with NMBA use vs 10/1000 with NMBA avoidance (≈6 fewer/1000; CI includes benefit and harm).- Aggregate events: 13/1630 (0.8%) vs 22/1456 (1.5%); events were rare.4) Upper airway discomfort or injury- Pooled effect: RR 1.12 (95% CI 0.40–3.16), P=0.83; I²=37%.- Detailed event totals were in Supplementary Material (not in the provided PDF), so absolute effects are uncertain.Robustness / sensitivity highlights- No important subgroup differences for difficult intubation by trial risk-of-bias strata (P=0.83) or by age (0–2 vs ≥2 years; P=0.64).- Post hoc: effect on difficult intubation remained >3 across publication eras; excluding neonatal opioid-only trials minimally changed RR (3.47 → 3.31).Quality / certainty (as reported/appraised)- GRADE: Difficult intubation = Moderate certainty; Failed intubation = Moderate; SAEs = Very low. (Upper airway outcome: not clearly GRADEd in accessible materials; effect estimate very imprecise.)- Review-level appraisal: AMSTAR 2 = Critically low confidence (notably no excluded-studies table; no formal publication-bias assessment). ROBIS overall risk of bias = High.Practical takeaway- Across paediatric RCTs, avoiding NMBAs substantially increases the risk of difficult and failed tracheal intubation (moderate-certainty evidence).- Differences in serious adverse events and upper airway injury/discomfort remain uncertain because events are rare and estimates are imprecise (very low/low certainty), and the review has methodological reporting gaps that reduce confidence in safety conclusions.

Citation:Lam ND, Son LDT, Phat TM, Thu ND, Nga NT, Son VT, Hong BM. High-flow nasal oxygen versus face-mask ventilation for rapid sequence induction in non-elective surgical patients: a randomized controlled trial. BMC Anesthesiol. 2026 Jan 31. doi:10.1186/s12871-026-03654-w. (Trial: NCT06879600)Study at a glance- Design and setting: Prospective, single-centre, single-blind (outcome assessor) parallel-group RCT (1:1) in adult non-elective OR cases at Phu Tho Provincial General Hospital, Vietnam. Randomised 216; analysed 214 (107 per arm).- Population: Adults ≥18 years, ASA I–II, non-elective surgery requiring modified RSI + tracheal intubation; mostly abdominal surgery (~97–99%). Excluded ASA ≥III, anticipated difficult airway, respiratory disease, pregnancy, etc.- Intervention (HFNC): Heated/humidified 100% O₂ via HFNC at 60 L·min⁻¹ (37°C) for 3 min preoxygenation, continued through induction/apnoea/intubation.- Comparator (FMV): Tight face mask preoxygenation FiO₂ 1.0 with fresh gas flow 10 L·min⁻¹ for 3 min (no PEEP/inspiratory assist), then mask removed; no routine mask ventilation during apnoea (rescue only).- Common protocol: Modified RSI with fentanyl 2 µg·kg⁻¹ + propofol 2 mg·kg⁻¹ + rocuronium 1 mg·kg⁻¹; cricoid pressure after LOC; direct laryngoscopy (Macintosh); max 3 attempts; gentle rescue mask ventilation only if SpO₂ ≤94%. Monitoring included SpO₂/EtCO₂/TcCO₂ + arterial line for ABGs; gastric ultrasound before and after.Key results- Primary (SpO₂ desaturation <94% during apnoea/intubation): - HFNC: 0/107 (0%) - FMV: 13/107 (12.1%) - Absolute risk difference: −12.1 percentage points (HFNC lower). Approx NNT ≈ 9 to prevent one desaturation event (using 12.1% baseline risk).- Oxygenation (arterial oxygenation and first-breath oxygen reserve): - PaO₂ after 3 min preoxygenation: 445.7 ± 16.8 vs 314.2 ± 14.5 mmHg (HFNC higher) - PaO₂ immediately after intubation: 405.5 ± 17.7 vs 236.5 ± 58.5 mmHg (HFNC higher) - EtO₂ first breath after intubation: 86.0 ± 11.4% vs 75.7 ± 12.3% (HFNC higher)- CO₂ / ventilation surrogate outcomes (post-intubation): - PaCO₂ immediately after intubation: 43.8 ± 1.83 vs 47.43 ± 1.82 mmHg (HFNC lower) - TcCO₂ at end of intubation: 42.5 ± 2.1 vs 44.3 ± 2.1 mmHg (HFNC lower) - EtCO₂ first breath after intubation: 39.3 ± 2.9 vs 43.6 ± 3.4 mmHg (HFNC lower)- Gastric insufflation (ultrasound-derived change from baseline to after intubation): - ΔGRV (ml): 1.726 ± 0.455 vs 1.785 ± 1.005 (small, similar) - ΔCSA (cm²): 0.172 ± 0.092 vs 0.192 ± 0.078 (small, similar)- Comfort (0–10 NRS; higher=better): median 3 (IQR 1–5) HFNC vs 4 (IQR 3–5) FMV (subjective and unblinded → higher bias risk).- Reported adverse events: - Nasal dryness/mucosal irritation: 7/107 HFNC vs 1/107 FMV. - Aspiration: Table reports 1/107 in each group, but the Results text reportedly says “no aspiration events” (internal inconsistency to resolve).Bias / certainty (as provided)- RoB 2 overall: Some concerns (mainly “selection of reported result” due to limited visibility of prespecified outcomes/SAP and multiplicity; other domains judged low risk).- GRADE (selected outcomes): Moderate certainty for the key oxygenation/CO₂ outcomes (downgraded 1 level for study-level reporting/analysis-set concerns); Low certainty for comfort (unblinded subjective measure).Practical takeaway- In low-risk (ASA I–II) non-elective OR RSI cases using a “no routine mask ventilation” approach, HFNC (60 L·min⁻¹) during apnoea/intubation was associated with markedly fewer desaturation events and higher peri-intubation oxygenation, with small differences in CO₂ measures and no clear signal of increased gastric insufflation—while minor nasal irritation was more common and aspiration reporting needs clarification.

Citation:Shih P-Y, Wei T-J, Lee C-T, Kang J, Shih M-C, Chen Y-H, Lee Y-S, Chen H-T, Wu C-Y. Proactive haemodynamic management using the hypotension prediction index during caesarean section: a randomised controlled study. Anaesthesia. 2026. doi:10.1111/anae.70161.Study at a glance- Design and setting: Single-centre, 3-arm randomised controlled trial (1:1:1) during elective caesarean section under spinal anaesthesia at National Taiwan University Hospital (Taipei, Taiwan). Screened 255; randomised 180; analysed 171.- Population: Adults aged 20–50 years undergoing elective caesarean section under spinal anaesthesia. Key exclusions: pre-eclampsia; significant cardiovascular disease; inadequate spinal level (≤T6).- Groups / monitoring strategies: - Oscillometric group: Oscillometric BP every 2.5 min; CNAP/HPI recorded but blinded to anaesthetist. - CNAP group: Continuous non-invasive arterial pressure (CNAP) displayed; HPI blinded. - HPI group: CNAP + HPI displayed; treatment triggered by MAP <65 mmHg OR HPI ≥85 (even if MAP ≥65).- Co-interventions (all groups): 1000 ml crystalloid co-load; hypotension treated with intermittent noradrenaline boluses 5–10 µg (as often as every minute); atropine 0.5 mg IV to keep HR >60 bpm.Primary outcome- Time-weighted average hypotension (MAP <65 mmHg), derived from CNAP MAP sampled every 20 s: - Oscillometric: 0.89 mmHg (IQR 0.08–2.06), n=59 - CNAP: 0.30 mmHg (IQR 0.07–0.74), n=55 - HPI: 0.08 mmHg (IQR 0–0.43), n=57 → Descriptively lowest hypotension burden with HPI-guided management.Selected secondary / safety and process outcomes (Table 2)- Area under the threshold for hypotension (mmHg·min): - Oscillometric 68.7 (IQR 5.5–145.3) vs CNAP 22.7 (4.8–57.2) vs HPI 5.7 (0–32.7)- Zero episodes of hypotension (no MAP <65 at all): - 13/59 (22%) oscillometric vs 13/55 (24%) CNAP vs 26/57 (46%) HPI; p=0.009- Noradrenaline dose (µg): - 50 (30–90) oscillometric vs 70 (30–145) CNAP vs 90 (48–133) HPI; p=0.016 (higher in HPI arm)- Maternal adverse effects: - Nausea: 43/59 vs 29/55 vs 30/57; p=0.038 - Vomiting: 13/59 vs 6/55 vs 3/57; p=0.023 - Bradycardia: 10/59 vs 5/55 vs 4/57; p=0.199- Neonatal outcomes: Apgar scores similar across groups (median 9 at 1 min and 5 min).- Device agreement (exploratory): Bland–Altman CNAP vs oscillometric MAP showed small mean bias (+1.37 mmHg; 95% CI 0.71–2.03).Important limitations / interpretation notes- Post-randomisation exclusions: 9/180 (5%) were not analysed (protocol violation with ephedrine n=3; inadequate spinal level not reaching T6 n=6), so results reflect a modified analysed cohort rather than strict ITT for all randomised patients.- Many outcomes are presented as medians/IQRs and p-values without effect sizes/CI for between-group differences; multiplicity adjustment is not described (many secondary comparisons in a 3-arm trial).

Citation: Haas TE, Kranke P, Stegemann MN, Helmer P, Schmid B, Diehl FM, et al. Benefits in adults allowed to drink clear liquids before anaesthesia until called to the operating room: A randomised pilot study. Eur J Anaesthesiol. 2025;43:207–216. doi:10.1097/EJA.0000000000002309.Study at a glance:- Design and setting: Prospective, three-arm, randomised controlled pilot trial at a single German academic centre (University Hospital Würzburg) in 174 adult ASA I–III patients (mainly gynaecology, trauma and urology) undergoing elective or less-urgent surgery with low aspiration risk; web-based 1:1:1 randomisation, single-blind (blinded outcome assessors), intention-to-treat analysis with 0% dropout; overall RoB 2: “some concerns” mainly due to unblinded patient-reported outcomes.- Interventions: • Control (usual care) – standard national guideline advice to stop clear fluids 2 h before anticipated induction, no extra support. • Conservative – same 2 h rule plus “instructed adherence”: yellow fasting card, information on schedule and extra ward visits when delayed to maintain the 2 h interval. • Liberal – same support as conservative but actively encouraged clear fluids up to 200 ml between 2 h before induction and call to the OR (≈100 ml h⁻¹ of delay), i.e. small volumes allowed right up to transfer.- Primary outcome (preoperative thirst before induction): Thirst (none / moderate / severe) via a modified Bauer item. Compared with usual care, both strategies reduced thirst severity: conservative vs control OR 0.41 (95% CI 0.20–0.82; p=0.013), liberal vs control OR 0.21 (95% CI 0.10–0.43; p<0.001). Symptom benefit was greatest with the liberal “drink-until-call” protocol (moderate-certainty evidence, limited by unblinded PROs).- Key secondary symptoms: • Postoperative thirst (~2 h post-op): conservative vs control OR 0.80 (95% CI 0.31–2.03; NS); liberal vs control OR 0.32 (95% CI 0.13–0.75; p=0.009), indicating less thirst post-op with liberal intake. • Preoperative headache: conservative vs control OR 0.52 (95% CI 0.21–1.25; NS); liberal vs control OR 0.24 (95% CI 0.07–0.66; p=0.009), suggesting reduced headache with liberal fluids. • Overall preoperative satisfaction and other PROs favoured the liberal strategy but were less completely reported and remain lower certainty.- Fasting behaviour, safety and feasibility: • Liquid fasting time (median [IQR], hours): control 5.38 [3.67–9.53], conservative 3.0 [2.23–4.25], liberal 1.97 [1.20–3.02] – both interventions shortened actual fasting, with liberal clustered near the 2 h boundary. • Pre-op oral liquid volume (median [IQR], ml): control 200 [20–300], conservative 400 [200–600], liberal 400 [212–500]. • No signal of haemodynamic or metabolic harm: similar blood glucose (≈95–98 mg/dl; out-of-range values 6 vs 4 vs 4), similar HR and BP changes around induction (RRsys fall ~54–58 mmHg; RRdia ~29–34 mmHg), and low vasopressor use (Akrinor median 0 ml in all arms). • Safety endpoints: no bronchopulmonary aspiration, no unplanned ICU/intermediate-care admission for respiratory insufficiency, no deaths, and no postoperative delirium (CAM-ICU) in any group; PONV rates were numerically lower with interventions (19% control, 12.1% conservative, 10.3% liberal) but underpowered for firm conclusions. Overall, in low-risk ASA I–III adults, structured support and especially liberal clear-fluid intake until call to the OR substantially improve thirst and headache without evident short-term harm, though rare aspiration-related events remain too infrequent in this pilot to definitively exclude risk.

Citation: Sjoblom A, Hoffman F, Hedberg M, Forsberg I-M, Jonsson Fagerlund M. Preoxygenation with high-flow nasal oxygen at various flow rates in elective surgical patients: a prospective, randomised, single-blind clinical trial. Br J Anaesth. 2025;[Epub ahead of print]. doi:10.1016/j.bja.2025.11.017.Study at a glance:- Design and setting: Prospective, randomised, single-blind 3-arm physiologic RCT in adults (18–84 yr, BMI <35 kg m−2, ASA ≤3) undergoing elective colorectal, urological or gynaecological surgery at a single Swedish university hospital (Karolinska); 75 randomised, 72 analysed after 3 exclusions in the 45 L min−1 arm (1 new Mobitz II AV block before induction, 2 protocol violations). Standardised IV induction (fast-acting opioid, propofol, rocuronium 1 mg kg−1), videolaryngoscopic intubation, and apnoeic oxygenation without mask ventilation until SpO2 93%.- Interventions: 3 min HFNO preoxygenation at FiO2 1.0 in 10° reverse Trendelenburg via Optiflow+ nasal cannula and Hamilton ventilator circuit: • 45 L min−1 HFNO (n=22 analysed) • 70 L min−1 HFNO (n=25) • 95 L min−1 HFNO (n=25; one patient down-titrated to 70 L min−1 for discomfort but kept in 95 L min−1 group). All groups had invasive arterial monitoring and serial ABGs before/during preoxygenation, at apnoea start, during apnoea and at termination; PaCO2 and PaO2 trajectories and PaCO2–ETCO2 gradient were recorded.- Primary outcome (safe apnoea time to SpO2 93%): Median apnoea times were similar across flows—45 L min−1: 472 s (IQR 402–670); 70 L min−1: 523 s (420–664); 95 L min−1: 483 s (375–605); global P=0.59. Most patients in all arms tolerated ≥360 s of apnoea without SpO2 <93% (86%, 96%, 80%; P=0.22). Thus, in relatively healthy, non-obese elective surgical patients, higher HFNO flows (70 or 95 L min−1) did not meaningfully prolong safe apnoea time compared with 45 L min−1 (low-certainty evidence, RoB 2 overall “some concerns” due to per-protocol analysis and unbalanced post-randomisation exclusions).- Key secondary and exploratory findings: PaO2 increased similarly during preoxygenation across groups, but at apnoea start PaO2 was higher with 95 vs 45 L min−1 (median 73.5 vs 65.1 kPa; P=0.001) without translating into longer safe apnoea time; PaCO2 at apnoea termination was similar (~8 kPa) regardless of flow. Preoxygenation-related discomfort (VAS 0–10) differed markedly: 45 L min−1 was best tolerated (median 1 [0–2]) versus 70 L min−1 5 (2–5) and 95 L min−1 3 (1–5); global P=0.002, with 45 L min−1 significantly less uncomfortable than both higher flows. Mouth closure during preoxygenation was high in all arms (closed throughout: 100%, 84%, 84%; P=0.37), and an exploratory analysis showed that failure to keep the mouth closed did not significantly shorten safe apnoea time. Serial ABGs demonstrated a nonlinear PaCO2 rise during apnoea (largest increase in the first minute) and a mean PaCO2–ETCO2 gradient of ~1.4 kPa at apnoea termination.- Applicability and implications: Small, single-centre, physiologic OR study in non-obese, ASA 1–3 elective patients; does not address obese, high-risk, emergency, ICU or rapid-sequence settings, nor compare HFNO with conventional facemask preoxygenation. Within this population, 45 L min−1 HFNO for 3 min appears to provide apnoeic oxygenation (safe apnoea time) comparable to 70–95 L min−1, with substantially less patient discomfort; use of higher flows may be reserved for specific scenarios where a modest PaO2 gain is desired, recognising the comfort trade-off and the current low–moderate certainty of evidence.

Citation: Bijkerk V, Jacobs LMC, Rijnen WHC, Keijzer C, Warlé MC, Visser J. Deep versus Moderate Neuromuscular Blockade During Total Hip Replacement Surgery on Postoperative Recovery and Immune Function: A Randomized Controlled Trial. Anesthesia & Analgesia. 2026;142(2):355-364.Study at a glance:- Design and setting: Single-centre double-blind RCT (Netherlands) in adults undergoing elective primary or revision total hip arthroplasty under general anaesthesia (n=100; 50 deep vs 50 moderate block).- Interventions: Rocuronium-based moderate neuromuscular blockade (TOF 1–2, bolus dosing, sugammadex 2 mg/kg) vs deep blockade (PTC 1–2 with absent TOF, infusion, sugammadex 4 mg/kg), both with opioid-based anaesthesia and standard perioperative care.- Primary outcome (QoR-40 POD1): Mean QoR-40 scores were similar (163 with moderate vs 167 with deep block; mean difference −4.1 points, 95% CI −10.9 to 2.8; p=0.241), not reaching the minimally important difference and indicating no clear benefit of deep block; moderate-certainty evidence.- Key secondary outcomes: Deep block showed slightly lower pain at rest on POD1 (about 1 NRS point) and lower PACU opioid use (~2 mg morphine equivalent), but estimates were imprecise; pain on movement, QoR-40 at day 30, opioid use over 24 h, surgical field rating, time to mobilisation, and length of hospital stay were all similar.- Immune function and complications: Ex vivo TNF and IL-1β production on POD1 did not differ meaningfully between groups, and 30-day infectious (4/50 vs 1/50) and non-infectious complications (20/50 vs 18/50) were comparable, though the trial was too small for precise safety estimates.- Certainty and applicability: Overall risk of bias was judged as “some concerns”, with GRADE rating mostly moderate but limited by imprecision; findings apply to elective hip arthroplasty in centres using quantitative neuromuscular monitoring and sugammadex and do not clearly support routine deep blockade solely to improve recovery or immune outcomes.

Citation: de Carvalho, El-Boghdadly, Guedes, Dantas, Tome, Ramos, Gomes, Alves, Bezerra, Santos Neto, Pandit, Braz. Opioid-free vs. opioid-inclusive anaesthesia with or without regional anaesthesia for postoperative pain: a systematic review with network meta-analysis of randomised controlled trials. Anaesthesia. 2026; doi:10.1111/anae.70121.Study at a glance:- Design and setting: Prospectively registered systematic review and Bayesian network meta-analysis (PRISMA-NMA; PROSPERO CRD42022318894) of 885 RCTs including 74,880 adults (mainly elective surgery). Six intra-operative strategies were compared, grouped by opioid use (opioid-free, remifentanil-only, other opioids) and presence/absence of regional anaesthesia. Last search: 15 January 2025.- Interventions: (1) Opioid-inclusive anaesthesia with regional techniques (reference); (2) opioid-free with regional; (3) remifentanil as sole opioid with regional; (4) opioid-inclusive without regional; (5) opioid-free without regional; (6) remifentanil as sole opioid without regional.- Primary outcome – pain (0–10) at 2–48 h: Versus opioid-inclusive with regional anaesthesia, opioid-free with regional produced very similar pain scores at all time-points (e.g. 2 h MD −0.14, 95%CrI −0.69 to 0.38; 48 h MD −0.01, −0.43 to 0.41; low-certainty evidence). All three non-regional strategies had clearly higher pain (e.g. at 2 h MD +1.45 to +2.18 points vs reference), suggesting that adding regional anaesthesia is far more important for analgesia than removing intra-operative opioids.- Opioid consumption and recovery: Across 2–48 h, opioid-free with regional anaesthesia consistently ranked best for minimising postoperative opioid use, whereas remifentanil-only without regional ranked worst. At 24 h, differences between techniques often had wide credible intervals and should not be interpreted as proof of equivalence. Techniques without regional anaesthesia were associated with longer PACU stays, and opioid-inclusive anaesthesia without regional prolonged hospital stay compared with opioid-inclusive with regional (MD ~15.7 h longer).- Adverse effects: Opioid-free with regional anaesthesia substantially reduced postoperative nausea and vomiting relative to opioid-inclusive with regional (OR ~0.54, 95%CrI 0.41–0.71) and had the best overall ranking (SUCRA 99%), whereas opioid-inclusive and remifentanil-only techniques without regional roughly doubled PONV odds. Both opioid-free strategies (with and without regional) ranked highest for minimising pruritus, and remifentanil-heavy regimens (especially without regional) markedly increased dizziness. At 24 h, urinary retention was less frequent with opioid-free and remifentanil-based techniques than with opioid-inclusive plus regional (moderate-certainty evidence).- Risk of bias and certainty: Outcome-level RoB 2 showed mostly “some concerns” (60%) and relatively few high-risk judgements (4.6%), but the review itself was rated critically low by AMSTAR 2 and high risk of bias by ROBIS due to lack of a full excluded-studies list and no formal assessment of small-study effects, publication bias, or network inconsistency. The authors’ GRADE ratings indicate Low certainty for all pain outcomes and Moderate certainty for urinary retention, so while regional anaesthesia combined with more opioid-sparing strategies likely improves pain and side-effect profiles compared with opioid-heavy, non-regional techniques, the exact effect sizes and rankings should be interpreted with caution.

Citation:Buhre W, Díaz-Cambronero O, Schaefer S, Novacek M, Soro Domingo M, Stessel B, et al. Safety and efficacy of 6% hydroxyethyl starch in patients undergoing major surgery: The randomised controlled PHOENICS trial. Eur J Anaesthesiol. 2025;43:1–10. doi:10.1097/EJA.0000000000002307.Study at a glance:- Design and setting: Double-blind, multicentre, parallel-group phase IV noninferiority RCT in adults (40–85 years, ASA II–III) undergoing elective major abdominal surgery with expected blood loss ≥500 ml in 53 European centres (N=1,946 with primary outcome data).- Interventions: Haemodynamic-guided intra-operative and early postoperative volume replacement with balanced 6% HES 130/0.4 (Volulyte; up to 30 ml kg−1 in 24 h) vs balanced crystalloid-only (Ionolyte) within the same goal-directed algorithm.- Primary outcome (change in cystatin C–eGFR to lowest value within 3 postop days): LS mean difference HES vs crystalloid −2.6 ml min−1 1.73 m−2 (95% CI −4.1 to −1.1), well within the prespecified noninferiority margin (−8.1 ml min−1 1.73 m−2) — no clinically important short-term renal impairment; moderate-certainty evidence.- Key secondary: 90-day composite of all-cause mortality and major postoperative complications in 35% of patients in both groups (adjusted risk difference 0.6%, 95% CI −3.8 to 5.1) — no clear difference; 90-day and 1-year mortality and need for renal replacement therapy were also similar but imprecisely estimated (low-certainty for hard outcomes).- Perioperative haemodynamics and safety: HES yielded slightly lower net positive fluid balance (0.6 vs 1.2 l), smaller MAP decrease (−14 vs −16 mmHg), and fewer patients needing vasoactive/inotropic drugs (26% vs 35%); overall adverse events, serious events, AKI (RIFLE/AKIN), and adverse drug reactions were comparable, with findings applicable to stable elective abdominal surgery patients without sepsis or pre-existing renal dysfunction (not to ICU/sepsis resuscitation).

Citation:Dorland G, Gama de Abreu M, Hemmes SNT, Hol L, Hollmann MW, van Meenen DMP, Nijbroek SGLH, et al. Intraoperative driving pressure–guided high PEEP vs standard low PEEP for postoperative pulmonary complications. JAMA. 2025;[published online December 3]. doi:10.1001/jama.2025.23373.Study at a glance- Design and setting: International, multicentre, assessor-blinded parallel-group RCT in adults at intermediate/high risk of postoperative pulmonary complications undergoing open abdominal surgery (29 hospitals in 5 European countries; N=1435 analysed).- Interventions: Individualized driving pressure–guided high PEEP with repeated recruitment maneuvers vs standard low PEEP (5 cm H2O) without recruitment; both groups received low tidal volume volume-controlled ventilation and contemporary perioperative care.- Primary outcome (composite postoperative pulmonary complications ≤5 days): 19.8% with high PEEP vs 17.4% with low PEEP; absolute risk difference 2.5 percentage points (95% CI −1.5 to 6.4; p=0.23) — no clear reduction in pulmonary complications; low-certainty evidence.- Key secondary: Intraoperative complications were more frequent with high PEEP, mainly hypotension (54.0% vs 45.0%) and vasoactive drug use (32.0% vs 18.8%), while desaturation was less common (0.8% vs 2.8%); postoperative extrapulmonary complications, ICU/hospital length of stay, and in-hospital mortality (3.6% vs 3.3%) were similar between groups.- Safety: High PEEP increased intraoperative hemodynamic instability without demonstrable benefit on postoperative pulmonary outcomes or mortality; overall evidence suggests avoiding routine driving pressure–guided high PEEP for this population (moderate certainty for intraoperative harms, low to very low for most other clinical endpoints).

Citation:D'Amico F, Turi S, Manazza M, Lo Bianco G, Monti G, Zangrillo A, et al. Interventions to prevent postoperative neurocognitive complications: an umbrella review of meta-analyses of randomised controlled trials. Anaesthesia. 2025;doi:10.1111/anae.70061.Study at a glance- Design and scope: PROSPERO-registered umbrella review of meta-analyses of RCTs in adults undergoing cardiac and non-cardiac surgery; 114 meta-analyses (257,077 patients) searched to 23 August 2025.- Interventions: 12 intervention categories (pharmacological and non-pharmacological), including dexmedetomidine, cerebral monitoring, acupuncture, sleep interventions, steroids, antipsychotics, peripheral nerve blocks, esketamine, remimazolam, neuraxial and inhalational techniques, and remote ischaemic preconditioning.- Primary outcome: Any postoperative neurocognitive complication (delirium and/or postoperative cognitive dysfunction). Overall pooled effect for “any intervention vs control” OR 0.57 (95% CI 0.53–0.61; I2=94%), suggesting reduced odds but with extreme heterogeneity and very-low-certainty evidence.- Selected interventions with apparent benefit: Dexmedetomidine (OR 0.48), cerebral monitoring (0.52), acupuncture (0.39), sleep interventions (0.54), antipsychotics (0.48), peripheral nerve blocks (0.55), esketamine (0.42) and remimazolam (0.71) were each associated with lower odds of neurocognitive complications; certainty mostly low or very low.- Interventions without clear benefit or possible harm: Neuraxial anaesthesia, low-dose anaesthesia, remote ischaemic preconditioning and acetylcholinesterase inhibitors showed no convincing reduction in complications. In non-cardiac surgery, inhalational anaesthesia was associated with higher odds of complications vs comparator techniques (OR about 1.6); low-certainty evidence.- Risk of bias and certainty: Many contributing meta-analyses were low or critically low quality. ROBIS rated the umbrella review overall at high risk of bias (likely favouring interventions). GRADE for the overall pooled effect was downgraded to very low (risk of bias, marked inconsistency, indirectness, and suspected publication bias).- Clinical takeaway: A broad range of perioperative strategies look potentially protective against postoperative delirium and cognitive dysfunction, but the body of evidence is very uncertain; results are mainly hypothesis-generating and insufficient for strong practice-changing recommendations.

Citation:Raymond BL, Allen BFS, Freundlich RE, McEvoy MD, Parrish CG, Ruble SR, et al. IMpact of PerioperAtive KeTamine on Enhanced Recovery After abdominal Surgery (IMPAKT ERAS): a pragmatic randomised single-cluster trial. Br J Anaesth. 2025;135(6):1770–1778. doi:10.1016/j.bja.2025.08.001.Study at a glance- Design and setting: Pragmatic, double-blind, placebo-controlled single-centre cluster RCT by week (Vanderbilt, USA) in adults ≥18 yr undergoing elective major abdominal ERAS surgery (colorectal, surgical oncology, complex ventral hernia; N=1,522 analysed ITT).- Interventions: Ketamine arm received 0.5 mg kg−1 i.v. bolus at induction, then 5 μg kg−1 min−1 intraoperatively and 2.5 μg kg−1 min−1 for 48 h postoperatively; placebo arm received volume- and rate-matched saline. Both arms followed an intensive multimodal ERAS analgesic pathway (regional block, lidocaine, NSAIDs, gabapentin, opioids as needed).- Primary outcome (hospital length of stay): Median LOS 5 days in both arms (ketamine IQR 4–8; placebo 3–7). Cluster- and covariate-adjusted OR for longer stay with ketamine 1.21 (95% CI 1.00–1.47) – no reduction in LOS, possible small increase; moderate-certainty evidence.- Key secondary (opioids and recovery): Total in-hospital opioid use was similar (median 82.5 vs 90 MME; adjusted OR 0.85, 95% CI 0.71–1.01). Fewer patients on ketamine met early discharge milestones by 48 h (12.5% vs 17.3%; adjusted OR 0.68, 95% CI 0.50–0.93), suggesting no functional recovery benefit.- Safety: Ketamine increased adverse effects and early infusion discontinuation (any early stop for side-effects 32.3% vs 13.3%; OR ≈2). Debilitating hallucinations (2.7% vs 0.9%; OR 2.69) and debilitating dizziness (8.3% vs 1.5%; adjusted OR 6.05) were more frequent; ICU transfer was also higher with ketamine (5.7% vs 2.9%; adjusted OR 2.03, 95% CI 1.14–3.63). Thirty-day readmissions were similar.- Certainty and take-home: Well-conducted, double-blind cluster RCT with objective EHR outcomes and low attrition; overall RoB 2 judgement “some concerns” (selective reporting of some exploratory outcomes) but generally robust. Moderate-certainty evidence that adding a 48 h ketamine infusion to high-intensity ERAS multimodal analgesia does not improve LOS or opioid use and increases neuropsychiatric and other adverse effects.

Citation:Gong F, Gui Q, Lan L, Zhou G, Wen Q, Wei Y, Li X, Cao X. Comparative effects of remimazolam and propofol on hemodynamic stability during sedation for painless gastroscopy: a randomized clinical trial. BMC Anesthesiol. 2025;25:587. doi:10.1186/s12871-025-03484-2.Study at a glance- Design and setting: Single-centre, prospective, randomized, single-blind parallel-group trial (n=300) in adults undergoing painless gastroscopy in China.- Population: Low-risk outpatients, 18–65 years, BMI 18–30 kg/m², ASA I–II; all received topical lidocaine, butorphanol, and nasal oxygen.- Interventions: Remimazolam tosilate 0.2 mg/kg IV (0.1 mg/kg top-ups; propofol rescue allowed) versus propofol 2 mg/kg IV (0.5 mg/kg top-ups) for gastroscopy sedation.- Primary hemodynamics: Remimazolam maintained higher MAP at the start and end of endoscopy (T1 MD ≈ +7.5 mmHg, T2 MD ≈ +5.0 mmHg; both statistically significant) with similar or slightly higher cardiac output (no clear difference at T1; small increase at T2).- Safety: Compared with propofol, remimazolam markedly reduced hypotension (37/150 vs 8/150), bradycardia (22/150 vs 0/150), hypoxia (8/150 vs 0/150), and injection pain (38/150 vs 10/150).- Recovery profile: Endoscopy duration was similar (~5 min), but remimazolam had slower onset and longer recovery (time to MOAA/S 5 median 10 vs 6 minutes).- Risk of bias and certainty: Overall RoB 2 judgment “some concerns” (mainly unclear allocation concealment and reporting of prespecified analyses); GRADE certainty for key hemodynamic and safety outcomes rated moderate.

Citation:O’Carroll JE, Conti D, Gao N, Carvalho B, Sultan P. Incidence of pain during cesarean delivery with neuraxial anesthesia: an international, prospective cohort study. Anesthesiology. 2025. doi:10.1097/ALN.0000000000005868.Study at a glance- Design and setting: Prospective, international multicenter cohort (15 mainly high-resource obstetric centers); consecutive cesarean deliveries under neuraxial anesthesia with day-1 postpartum interviews (N=3,693).- Population and overall incidence: Women undergoing elective (n=1,684) and non-elective (n=2,009) cesarean delivery; 7.6% reported intraoperative pain (≈1 in 13), typically moderate–severe (median NRS 6/10 among those with pain).- By neuraxial technique: Pain was least frequent with spinal anesthesia (4.4%), higher with combined spinal–epidural (8.2%) and highest with epidural top-up (13.1%); adjusted odds of pain vs spinal were OR 2.01 for CSE and OR 2.92 for epidural top-up.- Other predictors: No clear independent association with age, race, ethnicity, urgency, or intrapartum status; Spanish as preferred language was associated with higher adjusted odds of intraoperative pain vs English (OR 1.79; 95% CI 1.02–3.14).- Satisfaction: Among those who experienced intraoperative pain, about 10% reported dissatisfaction with how their pain was managed.- Certainty: Observational design with multivariable adjustment but moderate overall risk of bias and likely residual confounding; GRADE certainty for causal interpretations of these associations is low.

Citation:Lee D, Lee H, Lee C, Lee C. The Impact of Preoperative Positive Suggestions on Dreaming With Intravenous Sedation: A Randomized Controlled, Blinded Trial. Anesth Analg. 2025;XXX(00):00-00. doi:10.1213/ANE.0000000000007818.Study at a glance- Design and setting: Single-centre, double-blinded 2×2 factorial RCT in adults (n=188) having elective upper extremity surgery under brachial plexus block with IV sedation (Republic of Korea).- Interventions: Propofol vs ketamine sedation, each with or without standardised preoperative positive suggestions about pleasant dreams (four groups of 47 patients).- Primary outcome (drug-induced dream recall, DIDR): Dreams were recalled in about 23% with propofol (22/94) vs 40% with ketamine (38/94); ketamine increased the odds of DIDR compared with propofol (OR 2.14, 95% CI 1.23–3.72; p=0.007; moderate-certainty evidence).- Effect of suggestions: Preoperative positive suggestions did not clearly increase overall dream recall (OR 1.16, 95% CI 0.67–2.01; p=0.598), though they may have influenced qualitative dream characteristics.- Key secondary: Patient satisfaction with sedation was high overall but lower with ketamine than propofol (approximately 82 vs 93–95 out of 100).- Safety and bias: Sixteen patients (8.5%) discontinued sedation because of hypoxia, hypotension, or hypertension; missing DIDR data were imputed as ‘no dream’. Overall risk of bias was judged as “some concerns,” and certainty for the main DIDR result was rated moderate.

Citation:Bastianello M, Torre M, Bonfiglio R, Calevo MG, Palomba L, Uva P, et al. Cryoanalgesia for Pain Management After Pectus Excavatum Repair (COPPER) in Adolescents: A Randomized Controlled Trial. Pediatric Anesthesia. 2025;35:347–358. doi:10.1111/pan.15090.Study at a glance- Design and setting: Single-centre parallel-group RCT (Italy) in adolescents (≥12 years) undergoing elective MIRPE (N=88).- Interventions: Thoracoscopic intercostal cryoanalgesia plus standard multimodal analgesia vs thoracic epidural infusion (levobupivacaine–clonidine) plus the same systemic regimen.- Primary outcome (14-day PedsQL total): Median 67.9 with epidural vs 59.8 with cryoanalgesia; mean difference 6.5 points (95% CI −0.46 to 13; p=0.067) — no clear superiority; low-certainty evidence.Key secondary: Length of stay shorter with cryoanalgesia (3.4 vs 4.4 days; moderate-certainty evidence); immediate pain at awakening lower with epidural (NRS approximately 3 vs 5).- Safety: Overall medical/surgical complications were uncommon and similar; thoracic sensory changes at about three months were frequent in both groups, with more hypo-aesthesia after cryoanalgesia.