Van Belleghem F, Rex S, Teunkens A, Vereecke H, Kalmar AF. Environmental and economic impacts of anaesthesia: A simulation study comparing total intravenous anaesthesia versus sevoflurane for maintenance of anaesthesia in 11 909 adult patients of a Belgian tertiary hospital. Eur J Anaesthesiol. 2026;43:567-574. doi:10.1097/EJA.0000000000002342

This study simulated total intravenous anaesthesia versus sevoflurane for maintenance and compared carbon dioxide equivalent emissions and costs. Low-certainty evidence suggests total intravenous anaesthesia has much lower emissions; cost savings are very uncertain. Internal numerical discrepancies and no uncertainty analysis limit exact estimates.

Study at a glance

- Design and setting: Retrospective simulation-based observational cohort study using electronic records from a single Belgian hospital, Sint-Jan Hospital, Bruges, Belgium. Anaesthesia time was defined as start of induction to end of surgery; results were standardised per 1000 procedures.

- Population: 11909 cases were analysed. Inclusion criteria were all general anaesthesia procedures lasting more than 10 min in patients older than 5 years from 1 April to 30 November 2022. Baseline characteristics: 49.9% female, 50.1% male, mean age 55 ± 21 years, anaesthesia time 92 ± 73 min, height 169 ± 12 cm, weight 77 ± 20 kg.

- Exposure and comparator: Each procedure was simulated under four maintenance scenarios with FiO2 50%: sevoflurane with minimal fresh gas flow using automatic gas control with a Flow-I ventilator; sevoflurane with 2 l min-1 fresh gas flow; total intravenous anaesthesia using 1% propofol vials and 6 l fresh gas flow; and total intravenous anaesthesia using 2% propofol vials and 6 l fresh gas flow. All scenarios used induction with propofol 2 mg kg-1 and maintenance with either volatile anaesthetic or propofol 6 mg kg-1 h-1.

- Primary outcome: CO2-equivalent emissions per 1000 procedures: 25593 kg for minimal-flow sevoflurane, 59489 kg for sevoflurane 2 l min-1 fresh gas flow, 1271 kg for total intravenous anaesthesia with 1% propofol, and 812 kg for total intravenous anaesthesia with 2% propofol. The article reported minimal-flow sevoflurane as 26.5 times more CO2e than total intravenous anaesthesia and sevoflurane 2 l min-1 fresh gas flow as 61.8 times more; this suggests lower emissions with total intravenous anaesthesia. No adjusted effect estimate, 95% CI, or p-value reported (low certainty).

- Key secondary outcome: Economic cost per 1000 procedures: €6805 for minimal-flow sevoflurane, €11961 for sevoflurane 2 l min-1 fresh gas flow, €5666 for total intravenous anaesthesia with 1% propofol, and €4264 for total intravenous anaesthesia with 2% propofol. The article reported total intravenous anaesthesia as 16.7 to 52.63% less expensive than sevoflurane, and as costing 36% and 63% of sevoflurane anaesthesia costs with minimal flow and 2 l min-1 fresh gas flow, respectively; exact cost savings are very uncertain. No adjusted effect estimate, 95% CI, or p-value reported (very low certainty).

- Confounding: Patient-level confounding by indication was partly avoided because the same 11909 recorded cases were simulated under each anaesthesia scenario. No causal DAG, covariate-adjusted analysis, propensity score diagnostics, formal validation, or sensitivity analysis was reported; residual concerns depend on fixed assumptions for dosing, fresh gas flow, equipment, vial use, resource use, lifecycle emissions, and local prices.

- Risk of bias and certainty: Overall ROBINS-I risk of bias was Serious. Key concerns were serious bias in selection of the reported result, moderate concerns for confounding, exposure classification, deviations from intended interventions, and outcome measurement, no information for missing data, and low concern for participant selection. Overall GRADE certainty for the primary CO2-equivalent emissions outcome was low; cost outcomes were very low certainty.

Zhao Q, Zhang Y, An R, Yi B, Huang G. An interpretable machine learning model for predicting emergence agitation in children: a multicenter development and validation study. BMC Anesthesiol. 2026;[epub ahead of print].

This multicenter retrospective study from two Chinese hospitals developed and externally validated several machine learning models to predict emergence agitation in children after general anesthesia. Using five routine perioperative predictors, a compact multilayer perceptron model showed excellent discrimination internally but only moderate performance and suboptimal calibration in an external cohort. Because variable selection, model choice, and key predictors are highly data- and center-dependent, the tool is best seen as a proof-of-concept rather than a ready-made decision aid for routine paediatric anesthesia practice.

Study at a glance

- Design and setting: Retrospective multicenter prediction-model study using electronic records from two tertiary hospitals in China: Center I (Third Affiliated Hospital of Zunyi Medical University) for model development and internal validation, and Center II (First Affiliated Hospital of Army Medical University) as an independent external validation cohort. Children aged 3–12 years with American Society of Anesthesiologists physical status I–II undergoing elective surgery under general anesthesia were included.

- Participants and primary outcome: A total of 445 pediatric patients were analyzed (321 in the development center, 124 in the external validation center). In Center I, emergence agitation occurred in 95 children, an incidence of 29.6%; in Center II, the reported incidence was about 25.8% (32–33 events, with slight inconsistencies across sections). The primary outcome was emergence agitation within 30 minutes after post-anesthesia care unit admission, defined as Pediatric Anesthesia Emergence Delirium (PAED) score >10, after pain was assessed and treated using the FLACC scale to limit misclassification from pain-related distress.

- Predictors and main model: From 63 perioperative variables, the authors used univariable screening followed by least absolute shrinkage and selection operator (LASSO) regression to select predictors, then trained six algorithms (logistic regression, support vector machine, multilayer perceptron, random forest, extreme gradient boosting, and Light Gradient Boosting Machine). The final five-variable clinical model used parental educational level, preoperative alanine aminotransferase (ALT), postoperative patient-controlled analgesia (PCA) pump use, postoperative antagonist (reversal agent) use, and extubation suctioning frequency. A multilayer perceptron (MLP) was chosen as the primary clinical model because it performed best in external validation; a support vector machine was used for detailed interpretability analyses with SHAP values.

- Key performance results: In internal holdout validation at Center I, discrimination was high across models, with area under the receiver operating curve (AUC) around 0.87–0.92; the support vector machine achieved AUC 0.918 (95% confidence interval 0.844–0.973, Brier score 0.098), and logistic regression AUC 0.915. In external validation at Center II, performance dropped noticeably. The primary clinical MLP model achieved AUC 0.705 (95% confidence interval 0.59–0.804) with a Brier score of 0.190, reflecting only moderate discrimination and imperfect calibration; other models performed worse (e.g., logistic regression AUC 0.587, LightGBM AUC 0.494). No decision-curve or net benefit analyses were reported.

- Risk of bias and applicability: Using a structured prediction-model appraisal, overall risk of bias was judged high, mainly due to the analysis domain. Concerns include data-driven predictor selection from many candidates, testing and informally selecting among six algorithms, limited optimism correction (formally reported only for the support vector machine), and a relatively small, case-mix–different external validation cohort. Applicability is further constrained because three of the five final predictors (PCA pump use, antagonist use, suctioning frequency) are early postoperative management decisions that vary by center and over time, rather than stable baseline risk factors.

- Practice implications: For practising clinicians, this study underscores that emergence agitation after pediatric anesthesia is common and potentially predictable, and it highlights perioperative features—such as parental education, preoperative ALT, and postoperative analgesia and reversal strategies—that may correlate with risk. However, the current models should not be used as stand-alone decision aids: external performance is only moderate, calibration is imperfect, and the models depend strongly on center-specific management choices. At present, these tools are best viewed as research prototypes and a stimulus for locally developed and rigorously validated prediction models, rather than as ready-to-implement clinical calculators.

Schmidt L, Genty F, Delaire T, Valero B, Rey I, Galan L, Mairet-Mabboux S, Douplat M, Schlatter S, Rimmele T, Mazza S, Lilot M. Clinical Performance in Critical Care Simulation Under Sleep Deprivation: Effects of Power Napping in the R-NAP Randomized Controlled Trial. Anesthesiology. 2026; doi:10.1097/ALN.0000000000006135.

In this single-centre randomized controlled trial, anesthesia and intensive care residents finishing an overnight on-site shift were assigned either to a brief supervised nap opportunity or to quiet wakefulness before a high-fidelity critical care simulation. The nap group achieved higher overall and non-technical performance scores without reported harms, but the trial is small, uses simulation rather than real patient outcomes, and has some missing data, so confidence in the size of benefit is moderate and the findings mainly support, rather than replace, broader fatigue management strategies.

Study at a glance

- Design and setting: Prospective individually randomized parallel-group behavioural trial conducted in a single French university simulation centre, comparing a supervised thirty-minute nap opportunity versus quiet wakefulness after an overnight on-site shift in anesthesia and intensive care residents.

- Participants: Thirty-five second to fifth year anesthesia and intensive care residents were randomized (nineteen to nap, sixteen to no nap); twenty-seven with complete actigraphy sleep data were included in the primary adjusted analysis, with similar baseline characteristics between groups.

- Primary outcome: Overall simulated clinical performance (sum of technical and non-technical scores, range zero to two hundred) after the overnight shift was higher with a nap; the adjusted mean difference was 14.84 points in favour of the nap group, with a ninety-five percent confidence interval from 2.8 to 26.88 and a P value of 0.018, yielding moderate certainty that a brief nap improves overall simulated performance.

- Key secondary outcomes: Total non-technical skills score (zero to one hundred) was higher with a nap, with an adjusted mean difference of 11.03 points (ninety-five percent confidence interval 2.22 to 19.84; P value 0.016). Among Ottawa Global Rating Scale subscales, Overall performance (mean difference 0.77; ninety-five percent confidence interval 0.05 to 1.48; P value 0.036), Leadership (0.73; ninety-five percent confidence interval 0.05 to 1.41; P value 0.037), and Resource utilization (1.02; ninety-five percent confidence interval 0.03 to 2.00; P value 0.043) favoured the nap group, whereas purely technical checklist scores showed smaller, imprecise differences.

- Harms and safety: No intervention-related adverse events or harms were reported in either the nap group (zero of nineteen) or the control group (zero of sixteen) during or after the brief nap or quiet wakefulness periods.

- Risk of bias and certainty: Overall risk of bias was judged as having some concerns, mainly due to missing outcome data (eight of thirty-five randomized residents excluded from the primary model because of missing actigraphy) and lack of participant blinding, although assessors were blinded and outcomes were structured and video-based. Using this and the reasonably precise effect estimate, certainty in the primary outcome was rated as Moderate.

- Applicability and limitations: Findings apply most directly to anesthesia and intensive care residents in similar academic settings and to high-fidelity simulation; they are indirect for attending physicians, other specialties, or real-world patient outcomes. The trial is small and single-centre, with multiple secondary and exploratory analyses without adjustment for multiplicity, so apparent benefits on individual subscales should be interpreted cautiously and used to support, not replace, broader fatigue risk management policies.

Giannakis P, Restrepo M, Stone AB, Zhuang ST, Wang J, Cozowicz C, et al. Outcome Differences Between General and Neuraxial Anesthesia for Hip Fracture by Frailty and Age in the Elderly: A Retrospective Cohort Study. Anesth Analg. 2026;XXX(00):00–300. doi:10.1213/ANE.0000000000008062

Using a large United States hospital claims database, Giannakis and colleagues compared neuraxial versus general anesthesia for more than six hundred thousand hip fracture surgeries across age and frailty strata. Neuraxial anesthesia was associated with very small differences in in-hospital mortality and a composite of major complications, a clearer reduction in high opioid use, and slightly more discharges home, but also small increases in some complications and intensive care admissions. Because anesthesia type was not randomized and key clinical confounders and outcomes were captured only through billing codes, overall certainty is very low and the results should inform, not dictate, anesthetic choice.

Study at a glance

- Design and setting: Retrospective cohort study using the Premier Healthcare Database, including 623,122 adults undergoing surgical treatment of hip fracture in United States hospitals between 2016 and 2023. Exposure was anesthesia type (general vs neuraxial) coded from billing data; outcomes (in-hospital mortality, major complications, intensive care unit admission, length of stay, opioid use, discharge disposition) were defined from ICD-10-CM diagnosis codes and billing records. Associations were estimated with mixed-effects multivariable logistic regression adjusted for demographics, comorbidities, hospital characteristics, procedure type, peripheral nerve block use, fracture type, and time to surgery.

- Primary outcome – composite of death and major complications: The prespecified primary endpoint was a composite of in-hospital mortality, respiratory complications, cardiac complications, acute renal failure, and delirium. Overall, neuraxial anesthesia versus general anesthesia was associated with an adjusted odds ratio (OR) of 0.97 (95% confidence interval [CI] 0.94–0.997; p=0.053), a very small relative difference compatible with little to no effect. Given the nonrandomized, claims-based design and serious residual confounding, GRADE certainty for this outcome is Very Low; the apparent benefit could easily be due to unmeasured differences between patients selected for each technique.

- In-hospital mortality: In-hospital death was lower in the neuraxial group overall, with an adjusted OR of 0.83 (95% CI 0.74–0.93; p=0.003), and a more pronounced association in older, more frail subgroups (for example, OR 0.77, 95% CI 0.65–0.91 in patients aged ≥87 years with intermediate/high frailty). However, choice of anesthesia is strongly confounded by clinical status, cognitive function, and hemodynamic reserve, which are incompletely measured in claims. With Serious overall risk of bias and no advanced causal methods, GRADE certainty for any mortality benefit is Very Low.

- Key secondary outcomes – opioid use, discharge home, length of stay: Neuraxial anesthesia was associated with a moderate reduction in high postoperative opioid use (overall adjusted OR 0.69, 95% CI 0.66–0.72; p<0.001), consistent across age and frailty strata, and with slightly higher odds of discharge to home among survivors (overall OR 1.08, 95% CI 1.04–1.12; p<0.001). Prolonged length of stay (≥75th percentile) showed a very small reduction with neuraxial anesthesia (overall OR 0.97, 95% CI 0.94–0.998; p=0.046). High opioid use is a process measure rather than a direct patient-important endpoint, and discharge disposition and length of stay are influenced by social and system factors; all three outcomes are rated Very Low certainty due to serious confounding and, for opioid use, additional indirectness.

- Potential harms – respiratory, cardiac, and ICU outcomes: Across the overall cohort, neuraxial anesthesia was associated with slightly higher rates of several coded complications and intensive care unit use: respiratory complications (OR 1.06, 95% CI 1.01–1.10; p=0.03), cardiac complications (OR 1.07, 95% CI 1.02–1.12; p=0.008), and intensive care unit admission (OR 1.07, 95% CI 1.03–1.12; p=0.002). Subgroup and sensitivity analyses showed some heterogeneity by age, frailty, and hospital neuraxial use, but effects remained small. Because these outcomes rely on diagnosis codes without validation and are highly susceptible to confounding by severity and practice patterns, GRADE certainty is Very Low, and the direction of true effect is uncertain.

- Risk of bias, certainty, and practice implications: Overall risk of bias is judged Serious due to residual confounding by indication, selection related to coding completeness, and outcome misclassification from claims data. All appraised outcomes, including the primary composite, mortality, complications, length of stay, opioid use, intensive care unit admission, and discharge home, are rated Very Low certainty with GRADE. Clinically, the study suggests that neuraxial and general anesthesia for hip fracture have broadly similar in-hospital risks, with neuraxial associated with less high opioid use and more home discharges but also small increases in some complications, all very uncertain. These findings should not, on their own, drive a major practice shift; instead, anesthetic choice should remain individualized, and system-level improvements in timely surgery, hemodynamic management, multimodal analgesia, delirium prevention, and early mobilization are likely to have larger and more reliable impact than anesthesia type alone.

Keck WL, Deng E, Liu WM, Kanekar R, Lomivorotov V, Sharma S. Effect of low-dose propofol infusion with sevoflurane versus propofol-only total intravenous anesthesia on postoperative nausea and vomiting in high-risk patients: a single-blind randomized controlled clinical trial. BMC Anesthesiol. 2026;26:136. doi:10.1186/s12871-026-03649-7

Single-center randomized trial in high-risk adults undergoing elective laparoscopic surgery compared a hybrid anesthetic (low-dose propofol infusion plus sevoflurane) with propofol-only total intravenous anesthesia, with all patients receiving dexamethasone and ondansetron prophylaxis. Rates of postoperative nausea and vomiting over 24 hours and rescue antiemetic use were similar, and adjusted odds ratios had very wide confidence intervals spanning benefit and harm. Overall certainty for differences between techniques in postoperative nausea and vomiting or antiemetic use is very low, so these findings are best viewed as exploratory rather than practice-changing.

Study at a glance

- Design and setting: Prospective, single-blind, individually randomized controlled trial in a single United States academic medical center, enrolling high-risk adults undergoing elective laparoscopic general, gynecologic, or urologic surgery under general anesthesia.

- Participants: Sixty-five adults aged 18 years or older with a history of postoperative nausea and vomiting and/or motion sickness, predominantly American Society of Anesthesiologists physical status II–III and mostly female, were randomized to hybrid anesthesia (n=32) or propofol-only total intravenous anesthesia (n=33).

- Intervention and comparator: Hybrid group: induction with propofol plus opioids and neuromuscular blockade, then low-dose propofol infusion combined with sevoflurane for maintenance under bispectral index guidance. Comparator group: propofol-based total intravenous anesthesia for maintenance under bispectral index guidance without volatile agents. Both groups received standardized prophylaxis with dexamethasone 4 milligrams after induction and ondansetron 4 milligrams at closure, similar fluid and vasoactive management, and opioid-based analgesia.

- Primary outcome: 24-hour postoperative nausea and vomiting: Cumulative postoperative nausea and vomiting (any nausea, retching, or vomiting within 24 hours after surgery) occurred in 19 of 32 patients (59%) in the hybrid group versus 14 of 33 (42%) in the propofol-only group. Adjusted odds ratio 1.59; 95% confidence interval 0.51 to 4.93; p=0.80. GRADE certainty for this outcome is rated Very Low due to some concerns about selective reporting and very serious imprecision.

- Secondary outcomes: early postoperative nausea and vomiting and rescue antiemetics: Post-anesthesia care unit postoperative nausea and vomiting occurred in 9 of 32 (28%) hybrid versus 7 of 33 (21%) propofol-only patients; adjusted odds ratio 1.83; 95% confidence interval 0.52 to 6.48; p=0.34 (Very Low certainty). Rescue antiemetic use in the post-anesthesia care unit occurred in 9 of 32 (28%) versus 7 of 33 (21%); adjusted odds ratio 1.59; 95% confidence interval 0.51 to 4.92; p=0.48 (Very Low certainty).

- Secondary outcomes: 24-hour rescue antiemetic use and overall antiemetic consumption: Within 24 hours, rescue antiemetics were used in 12 of 32 (38%) hybrid versus 8 of 33 (24%) propofol-only patients; adjusted odds ratio 1.84; 95% confidence interval 0.56 to 6.04; p=0.31 (Very Low certainty). Overall, any postoperative rescue antiemetic (post-anesthesia care unit or 24 hours) was given to 16 of 32 hybrid versus 13 of 33 propofol-only patients (no adjusted estimate reported; Very Low certainty).

- Pain and opioid use: Visual analog scale pain scores in the post-anesthesia care unit and total perioperative morphine milligram equivalents did not differ meaningfully between groups (for example, median total morphine equivalents 20 vs 27.5, p=0.19), and no clear analgesic or opioid-sparing advantage of the hybrid technique was demonstrated; these outcomes were not formally graded for certainty in this appraisal.

- Risk of bias and certainty: Randomization, protocol adherence, and outcome measurement were generally robust, with low risk of bias for most domains. However, incomplete visibility of the prespecified analysis plan and selective emphasis on adjusted models led to an overall risk-of-bias judgement of "some concerns." All key postoperative nausea and vomiting and antiemetic outcomes (24-hour and post-anesthesia care unit) were rated Very Low certainty by GRADE because of this risk-of-bias concern and very serious imprecision from the small sample and wide confidence intervals.

- Bottom line for practice: In high-risk adults undergoing elective laparoscopic surgery with standardized dexamethasone and ondansetron prophylaxis, hybrid low-dose propofol plus sevoflurane did not clearly reduce 24-hour postoperative nausea and vomiting, early postoperative nausea and vomiting, or rescue antiemetic use compared with propofol-only total intravenous anesthesia. Given the Very Low certainty of evidence, these findings should not on their own drive a change in anesthetic technique for the purpose of postoperative nausea and vomiting prevention; choice of hybrid versus propofol-only anesthesia should instead be guided by other clinical considerations until larger, higher-certainty trials are available.

Qiao Y, Zhang H, Yu J, You J, Hou K, Zhao T, Feng H. Effect of intermittent recruitment manoeuvre combined with positive end expiratory pressure on postoperative atelectasis in obese patients: a randomized controlled trial. BMC Anesthesiology. 2026;[Epub ahead of print].

In a single-centre randomized controlled trial of obese adults undergoing elective laparoscopic sleeve gastrectomy, Qiao and colleagues compared three intraoperative ventilation strategies: zero end-expiratory pressure with a single recruitment manoeuvre, low positive end expiratory pressure alone, and the combination of positive end expiratory pressure plus intermittent recruitment manoeuvres. Moderate-certainty evidence suggests that the combined strategy substantially reduces computed tomography-defined postoperative atelectasis and improves intraoperative lung mechanics and oxygenation, but very-low-certainty data mean that any effects on short-term clinical complications such as hypoxemia or pneumonia remain highly uncertain.

Study at a glance

- Design and setting: Single-centre, parallel-group randomized controlled trial in obese adults (body mass index 30–60 kilograms per square metre), American Society of Anesthesiologists class I–III, aged 18–60 years, undergoing elective laparoscopic sleeve gastrectomy under general anaesthesia at a tertiary hospital in China. Ninety-five patients were randomised and ninety (30 per arm) were included in the analysed population; follow-up for outcomes extended to 48 hours postoperatively. Overall risk of bias was judged as having some concerns.

- Interventions: Three intraoperative ventilation strategies were compared: (1) recruitment manoeuvre group: volume-controlled ventilation with zero end-expiratory pressure throughout and a single standardized recruitment manoeuvre at the end of surgery (positive end expiratory pressure ramped up to 30 centimetres of water for 30 seconds, then stepped down); (2) positive end expiratory pressure group: volume-controlled ventilation with 5 centimetres of water positive end expiratory pressure maintained until extubation, without recruitment manoeuvres; (3) combined group: 5 centimetres of water positive end expiratory pressure plus two recruitment manoeuvres (30 minutes after pneumoperitoneum creation and again at the end of surgery), using the same 30 centimetres of water pattern. Anaesthetic drugs, inspired oxygen fraction, and positioning were standardized across groups.

- Primary outcome: postoperative atelectasis: The primary endpoint was incidence of computed tomography-defined postoperative atelectasis within 48 hours, with atelectasis defined as non-ventilated lung areas between −100 and +100 Hounsfield units on chest computed tomography. Atelectasis occurred in 14 of 30 patients (46.7%) in the recruitment manoeuvre group, 13 of 30 (43.3%) in the positive end expiratory pressure group, and 4 of 30 (13.3%) in the combined group, indicating a large relative reduction with the combined strategy. Among patients with atelectasis, the proportion of atelectatic lung volume was also lowest in the combined group (2.56%±0.51%) versus the recruitment manoeuvre group (5.94%±1.01%) and the positive end expiratory pressure group (4.13%±0.83%). Certainty of evidence for both incidence and extent of atelectasis was rated as moderate (downgraded one level for trial-level risk of bias).

- Secondary outcomes: physiology and mechanics: Dynamic lung compliance at the end of surgery (T3) was higher with positive end expiratory pressure and with the combined strategy (22.42±2.88 and 23.37±3.06 millilitres per centimetre of water, respectively) than with recruitment manoeuvre alone (18.16±1.98). Arterial partial pressure of oxygen at 10 minutes after extubation (T4) was highest in the combined group (83.17±14.91 millimetres of mercury) compared with the positive end expiratory pressure group (72.47±12.52) and the recruitment manoeuvre group (68.13±10.00), and respiratory index at T4 was lowest (0.74±0.34 vs 1.22±0.44 and 1.33±0.49). These findings, supported by consistent trends in oxygenation index and pulse oximetry, are judged to be of moderate certainty (one-level downgrade for risk of bias).

- Clinical pulmonary complications and safety: Postoperative hypoxemia, pneumonia, and pleural effusion within 48 hours were recorded as pulmonary complications, but exact per-arm event counts were only available in a supplementary table not fully accessible in the extracted data. Events appeared infrequent across all groups, and no clear between-group differences could be reliably quantified. Because of the small sample, sparse events, and incomplete numerical reporting, certainty for effects on these clinical complications is very low (downgraded one level for risk of bias and two levels for very serious imprecision). Hemodynamic parameters such as mean arterial pressure and heart rate, as well as peak airway pressures, remained broadly similar between groups, and no major safety signal related to recruitment manoeuvres or positive end expiratory pressure was reported.

Wegner GRM, Wegner BFM, González GL, Miranda AM, Felippe VA, Spagnol LW, Spagnol VW, Nascimento TSd. Does peripartum intravenous calcium administration reduce the occurrence of uterine atony in caesarean sections? A systematic review and meta-analysis. Eur J Anaesthesiol. 2026;43:1–4.

This systematic review and random effects meta-analysis pooled six small randomised controlled trials of peripartum intravenous calcium in caesarean section. Intravenous calcium may reduce uterine atony and blood loss and probably reduces intraoperative fluid requirements, without a clear effect on transfusion or hypotension, but certainty is very low for most clinical outcomes. The authors suggest calcium only as a conditional adjunct in high‑risk patients pending larger, standardised trials.

Study at a glance

- Design and setting: Prospectively registered systematic review and random effects meta-analysis of six randomised controlled trials including 746 women undergoing caesarean section, comparing peripartum intravenous calcium (calcium chloride or calcium gluconate, various doses and timings) with placebo or standard care plus standard uterotonic prophylaxis; overall review-level confidence was critically low by AMSTAR 2 and overall risk of bias unclear by ROBIS due to incomplete search reporting and possible publication bias.

- Primary outcome: uterine atony: Three randomised controlled trials reported uterine atony, defined as need for second-line uterotonics; pooled ratio of risks was 0.56 with a ninety five percent confidence interval from 0.42 to 0.75, very low statistical heterogeneity, but prediction interval 0.27 to 1.18 and leave-one-out analysis indicated study-dependent results. Certainty of evidence was rated very low (GRADE) after downgrades for clinical heterogeneity, imprecision and suspected publication bias, despite trial sequential analysis reaching the required information size.

- Uterine tone and blood loss: For uterine tone, calcium modestly increased five-minute tone scores (mean difference 0.53 points on a zero to ten scale; ninety five percent confidence interval 0.01 to 1.06) with high heterogeneity and study-dependent results, while ten-minute scores showed essentially no difference (mean difference 0.03; ninety five percent confidence interval minus 0.16 to 0.22); both outcomes were very low certainty. Pooled blood loss was lower with calcium by a mean of 46 millilitres (ninety five percent confidence interval minus 67 to minus 26 millilitres), but this reduction was judged not clinically meaningful, measurement methods varied widely, trial sequential analysis did not confirm the result, and certainty was very low (multiple GRADE downgrades).

- Transfusion, fluids and haemodynamic safety: Blood transfusion (four randomised controlled trials; ratio of risks 0.55, ninety five percent confidence interval 0.23 to 1.33) and hypotension (three randomised controlled trials; ratio of risks 0.68, ninety five percent confidence interval 0.45 to 1.05) did not differ clearly between calcium and control groups; prediction intervals were wide and included both benefit and harm, and certainty was very low. Intravenous fluid volume was consistently lower with calcium (six trials; mean difference minus 52 millilitres, ninety five percent confidence interval minus 83 to minus 22 millilitres, negligible heterogeneity, beneficial prediction interval), and with confirmation by leave-one-out and trial sequential analysis this outcome reached moderate certainty (GRADE) despite indirectness and suspected publication bias.

- Risk of bias and certainty of evidence: Four of six trials were judged at overall low risk of bias and two at some concerns using a modern risk-of-bias tool, but all pooled outcomes were downgraded at least once for clinical heterogeneity (different calcium formulations, doses, timing and baseline bleeding risk) and once for suspected publication bias. Additional downgrades for imprecision, driven by wide confidence and prediction intervals and unconfirmed trial sequential analysis for several endpoints, meant that certainty was very low for uterine atony, uterine tone, blood loss, transfusion and hypotension, and only moderate for intravenous fluid volume.

- Clinical implications: The evidence base suggests that peripartum intravenous calcium may reduce uterine atony, may modestly reduce blood loss, and probably reduces intraoperative fluid requirements, but effect sizes are small, many outcomes are study-dependent, and almost all clinically important endpoints rest on very low-certainty evidence. The authors propose only a conditional, adjunctive role for intravenous calcium in women at high risk of uterine atony, emphasising that standard uterotonic prophylaxis and haemorrhage protocols remain primary and that larger, standardised randomised controlled trials in diverse and high-risk populations are needed before recommending routine use.

Zhang Y, Wang X, Zhang Z, Zhang Y, Deng Z, Lei X, et al. Mechanical power during one-lung ventilation is associated with postoperative pulmonary complications in patients undergoing lobectomy: a single-center prospective cohort study. BMC Anesthesiology. 2026; Epub ahead of print.

This single-center prospective cohort of thoracoscopic lobectomy patients found that higher mechanical power during one-lung ventilation was statistically associated with more postoperative pulmonary complications, mainly pneumonia. However, residual confounding, a single time-point exposure measure, and wide confidence intervals mean the evidence is very uncertain for a causal effect, so proposed mechanical power thresholds should be viewed as hypothesis-generating rather than practice-changing.

Study at a glance

- Design and setting: Prospective single-center observational cohort at a university-affiliated hospital in China, enrolling adults with low American Society of Anesthesiologists physical status undergoing elective thoracoscopic lobectomy with one-lung ventilation between August two thousand twenty two and July two thousand twenty four (one hundred eighteen patients).

- Exposure and comparator: Mechanical power delivered by the ventilator during one-lung ventilation, measured at one hour after the start of one-lung ventilation and derived from tidal volume, pressures, respiratory rate, elastance, resistance, and inspiratory to expiratory ratio; analyses considered mechanical power as a continuous predictor, its elastic and resistive components, and a threshold around three point seven joules per minute, comparing higher versus lower mechanical power under routine anaesthetic care.

- Primary outcome: Postoperative pulmonary complications during the in-hospital period, defined as a composite of pneumonia, atelectasis, acute respiratory distress syndrome, or clinically evident aspiration using standardized perioperative endpoint criteria; forty of one hundred eighteen patients developed at least one complication (about one third), predominantly pneumonia, with no cases of acute respiratory distress syndrome or aspiration observed.

- Key findings: After adjustment for body mass index, hypertension, side of surgery, propofol dose, and inspired oxygen fraction at one hour, higher mechanical power at that time point was associated with increased odds of postoperative pulmonary complications (for example, mechanical power per unit increase odds ratio about one point six seven, ninety five percent confidence interval roughly one point zero one to two point seven six). Driving pressure alone at the same time point showed little to no association, while elastic and resistive components of mechanical power and mechanical power scaled to ventilated lung volume showed similar harmful patterns.

- Threshold analysis and oxygenation: A data-derived threshold around three point seven joules per minute suggested that patients at or above this level had higher odds of complications (adjusted odds ratio about two point nine one, ninety five percent confidence interval approximately one point zero eight to seven point eight six), but estimates were imprecise. Impaired postoperative oxygenation within twenty four hours and higher inflammatory cytokine levels, particularly interleukin six, interleukin eight, and interleukin ten on postoperative day two, were more frequent among patients with complications, consistent with an inflammatory lung injury phenotype.

- Certainty and risk of bias: Overall certainty that higher mechanical power causally increases postoperative pulmonary complications is rated very low, due to serious risk of bias from residual and unmeasured confounding (limited adjustment set, no advanced causal modelling), potential exposure misclassification from relying on a single one-hour measurement, possible outcome misclassification, and imprecision with only forty events and wide confidence intervals around the odds ratios.

- Practice implications: Findings support paying attention to mechanical power as an integrative marker of ventilator stress during one-lung ventilation and considering reductions in unnecessary ventilatory energy where feasible, in the context of established lung-protective strategies. However, the data are hypothesis-generating only; clinicians should not adopt a rigid mechanical power threshold from this study, and high-quality interventional trials are needed to test whether actively targeting lower mechanical power improves clinical outcomes.

Reysner M, Reysner T, Kowalski G, Janusz P, Mularski A, Daroszewski P, Kolasiński J, Wieczorowska-Tobis K. Erector spinae plane block in pediatric surgery: a systematic review and meta-analysis. BMC Anesthesiol. 2026; doi:10.1186/s12871-026-03617-1.

This systematic review and meta-analysis synthesised ten prospectively registered randomized controlled trials of erector spinae plane block in children undergoing cardiothoracic, abdominal, or hip surgery. Erector spinae plane block produced a small, high-certainty reduction in early postoperative pain compared with pooled alternatives and probably offers clear benefit over no regional block, but it showed little or no advantage over caudal, quadratus lumborum, or paravertebral blocks for later pain. Apparent large reductions in opioid use and longer time to first rescue analgesia are based on low-certainty, highly heterogeneous data, so erector spinae plane block should be seen as a reasonable option rather than a clearly superior new standard.

Study at a glance

- Design and setting: Systematic review and random-effects meta-analysis of 10 prospectively registered randomized controlled trials involving pediatric patients undergoing cardiothoracic, abdominal, or hip surgery, comparing ultrasound guided erector spinae plane block with no regional block or with other regional techniques (caudal, quadratus lumborum, or paravertebral blocks).

- Primary pain outcomes: Across eight randomized controlled trials (approximately 449 children), erector spinae plane block showed no important difference in pain within 2 hours after surgery (standardized mean difference minus 0.02, 95 percent confidence interval minus 0.24 to 0.21; moderate certainty). At about 4 hours, six trials (329 participants) demonstrated a small reduction in pain (standardized mean difference minus 0.27, 95 percent confidence interval minus 0.55 to 0.00; high certainty), largely driven by comparisons with no regional block. By 12 and 24 hours, high-certainty evidence showed little to no difference in pain (standardized mean difference minus 0.08 and minus 0.04 respectively, confidence intervals spanning no effect).

- Opioid-related outcomes: Nine trials (564 participants) suggested that erector spinae plane block may prolong time to first rescue analgesia and six trials (313 participants) suggested reduced total postoperative opioid consumption (pooled standardized mean difference minus 1.12, 95 percent confidence interval minus 2.12 to minus 0.13). However, both outcomes had very high heterogeneity (I squared around 93 to 96 percent), effects differed markedly by comparator (clearer benefit versus no block, little or none versus other blocks), and certainty was rated low. Intraoperative fentanyl consumption (three trials, 182 participants) showed no clear difference overall (standardized mean difference minus 0.21, 95 percent confidence interval minus 1.14 to 0.71; low certainty).

- Risk of bias and certainty of evidence: Individual randomized controlled trials were generally at low risk of bias, with Jadad scores of 5 in all 10 studies and mainly low risk assessments on standard domains, aside from one study with incomplete outcome data. For the meta-analyses, pain outcomes at 4, 12, and 24 hours were rated high certainty, while very early pain and 6-hour pain were moderate certainty. Time to first rescue analgesia, total postoperative opioid consumption, and intraoperative fentanyl use were all rated low certainty because of serious concerns about risk of bias and extreme heterogeneity. An independent methodological appraisal judged overall confidence in the review as low, citing incomplete searching and limited exploration of heterogeneity.

- Key limitations and clinical implications: The review pooled erector spinae plane block against clinically heterogeneous comparators, did not search trial registries or grey literature, and did not report a detailed table of excluded full texts. Very high and unexplained heterogeneity for opioid-related outcomes, plus an internal discrepancy in the effect size reported for time to first rescue analgesia (standardized mean difference 1.30 in the main text versus minus 1.08 in the GRADE table), further reduce confidence. Clinically, the evidence supports using erector spinae plane block as a reasonable component of multimodal analgesia, particularly when the alternative is no regional block, but it does not justify replacing well-established techniques such as caudal or quadratus lumborum block solely for better analgesia or opioid sparing.

Gao Z-Z, Sun Z-L, He Z-J, Zhao H-S, Song H, Sun D-F, Yang L. Dexmedetomidine reduces pulmonary complications in older patients undergoing abdominal laparoscopic surgery: a prospective, single-blinded, randomized controlled trial. BMC Anesthesiol. 2026. doi:10.1186/s12871-026-03633-1

Single-centre randomized data in older adults undergoing major abdominal laparoscopy suggest that adding an intraoperative dexmedetomidine infusion to standard anesthesia probably reduces clinically important postoperative pulmonary complications over the first week and improves short-term lung mechanics and oxygenation, without a clear safety penalty. However, unclear randomization methods, post-randomization exclusions, and modest sample size mean the certainty of evidence is moderate rather than definitive, and applicability is best to similar elective laparoscopic populations within structured perioperative pathways.

Study at a glance

- Design and setting: Prospective, single-blinded randomized controlled trial at a tertiary academic hospital in China, enrolling older adults undergoing elective major abdominal laparoscopic surgery and assigning them to intraoperative dexmedetomidine infusion versus volume-matched saline, with 106 of 120 randomized patients analysed; overall risk of bias was judged as having some concerns due to limited reporting of randomization and complete-case analysis after post-randomization exclusions.

- Primary outcome: postoperative pulmonary complications: The primary outcome was grade at least 2 postoperative pulmonary complications within 7 days, defined by a prespecified clinical grading system. Clinically important pulmonary complications occurred in 16 of 53 patients in the dexmedetomidine group versus 28 of 53 in the control group, corresponding to a risk ratio of 0.68 (95% confidence interval 0.47 to 0.94; p value 0.018). Adjusted logistic models and inverse probability weighting analyses showed similar direction and magnitude of effect, and certainty of evidence for this outcome was rated moderate.

- Key secondary pulmonary outcome: hypoxemia: Hypoxemia within 7 days, defined as arterial oxygen saturation below 90 percent on room air for at least 30 seconds, occurred in 7 of 53 dexmedetomidine patients and 17 of 53 control patients, giving a risk ratio of 0.78 (95% confidence interval 0.62 to 0.96; p value 0.02). This supports a modest reduction in clinically relevant desaturation events with dexmedetomidine, with moderate certainty of evidence.

- Other efficacy outcomes: Dexmedetomidine was associated with higher perioperative oxygenation index values, lower intrapulmonary shunt fraction, lower peak inspiratory and driving pressures, and higher dynamic lung compliance at key intraoperative timepoints, as well as higher vital capacity on postoperative days 1, 3, and 7. These physiological and spirometric benefits were consistent in direction and statistically significant, generally with moderate certainty, but postoperative hospital stay differed little between groups (median 12 vs 13 days; estimated difference 1 day, 95% confidence interval minus 1 to 2; p value 0.289, low certainty).

- Safety and adverse events: Postoperative agitation and nausea and vomiting were less frequent with dexmedetomidine, while delirium, ileus, anastomotic fistula, heart failure, reoperation, second admission, unplanned intensive care admission, and death were all rare and similar between groups. The trial was not powered for uncommon harms, and certainty for specific adverse events is generally low to very low, but there was no signal that dexmedetomidine increased serious postoperative complications.

- Applicability and key caveats: Findings apply best to older, relatively fit adults (physical status classes I to III, moderate body mass index) undergoing elective laparoscopic colorectal, gastric, hepatic, or pancreatic surgery within a standardized ventilation and recovery pathway. Evidence that dexmedetomidine probably reduces short-term clinically important pulmonary complications and hypoxemia is of moderate certainty, but limitations include unclear details of sequence generation and allocation concealment, approximately 12 percent post-randomization exclusions handled with complete-case analysis, and single-centre conduct with only 7 days of follow up.

Tomobi O, Gouge C, Brashear A, Totzkay D, Chen F, Huffmyer J, Scalzo D, Nemergut EC, Guillow R. Evaluating Perspectives on Empathy in Anesthesiology Trainees: A Mixed-Methods Study of Pre-Anesthesia Encounters. Anesth Analg. 2026;XXX(00):1-8. doi:10.1213/ANE.0000000000007919

This prospective mixed-methods study from a single United States academic center followed twenty four anesthesiology trainees across one hundred fifty one pre-anesthesia encounters, measuring empathy from trainee, patient, and observer perspectives alongside trainee wellness and encounter time. Empathy scores were generally high, but statistical analyses suggested that more senior training level, trainee gender, wellness, encounter duration, and patient age were associated with small differences in empathy ratings. Because of serious risk of confounding, small sample size, measurement limitations, and cross-sectional design, certainty is very low and the findings are best seen as hypothesis-generating prompts for reflection on communication and education rather than as a basis for practice change.

Study at a glance

- Design and setting: Prospective observational mixed-methods study at a single United States academic anesthesiology department, enrolling anesthesiology trainees (postgraduate years 1 through 5 and fellows) and their adult surgical patients in pre-anesthesia holding areas between March 2024 and June 2024. Quantitative data included empathy and wellness scales plus timed encounters; qualitative data involved thematic analysis of perspectives on empathy (not detailed in this episode).

- Participants and measures: Twenty four anesthesiology trainees contributed one hundred fifty one observed pre-anesthesia encounters (mean patient age 56 years, approximately sixty two percent female, mostly American Society of Anesthesiologists physical status II–III). Trainees completed the Jefferson Scale of Empathy (self-rated empathy) and a ten item Resident Wellness Scale; patients completed the Jefferson Scale of Patient Perceptions of Physician Empathy after the encounter; a physician observer completed the Jefferson observer empathy scale and timed each encounter.

- Key quantitative findings: Mean self-rated empathy on the Jefferson physician scale was 118 (standard deviation 13.7) on a possible range of 20 to 140, indicating medium to high empathy. Mean patient-rated empathy was 32.9 (standard deviation 3.0) and mean observer-rated empathy was 33.9 (standard deviation 1.27) on scales ranging from 5 to 35, both in the high range. More senior postgraduate year was statistically correlated with shorter encounter time (correlation coefficient minus 0.52, P = 0.01) and lower scores in the “walking in the patient’s shoes” empathy subdomain (correlation coefficient minus 0.45, P = 0.03).

- Gender, wellness, and multivariable results: In gender-stratified analyses, male and female trainees had similar self-rated and observer-rated empathy, but patient-rated empathy was slightly higher for male trainees (mean 33.1 versus 32.2; P = 0.02). Multivariable linear regression suggested trainee gender remained associated with patient-rated empathy (confidence interval for the gender coefficient 0.321 to 1.80; P = 0.011) after adjustment for selected covariates. Higher trainee wellness scores were correlated with lower self-rated empathy (correlation coefficient minus 0.55, P = 0.01) and shorter encounter time (correlation coefficient minus 0.421, P = 0.041), and older patient age was correlated with lower patient-rated empathy (correlation coefficient minus 0.41, P = 0.047).

- Risk of bias and certainty of evidence: Overall risk of bias is judged serious, driven mainly by likely residual and unmeasured confounding, potential selection bias in trainee participation, and multiple exploratory analyses without prespecified primary hypotheses. Outcome measurement is based on validated scales, but observer-rated empathy shows poor internal consistency (Cronbach alpha 0.38), and clustering of encounters within trainees was not clearly handled. For all key outcomes (self-rated, patient-rated, and observer-rated empathy, encounter time, and wellness), certainty of evidence about any causal effects of trainee characteristics is rated very low by the GRADE approach.

- Practice implications: The study suggests that empathy in pre-anesthesia encounters is generally perceived as high, and that there may be subtle associations between training level, gender, wellness, encounter duration, and empathy scores. However, because the evidence is very low certainty and observational, it should not drive structural changes such as preferential assignment by gender or assumptions that shorter visits are inherently less empathic. Reasonable responses include using the findings to stimulate trainee reflection on maintaining empathic behaviors as efficiency increases, expanding explicit teaching and feedback around empathic communication in pre-anesthesia consultations, and designing more rigorous multicenter studies with adequate adjustment for confounding and clustering to clarify causal relationships.

Vlaeminck N, Van de Putte P, Dekeyser M, Baert N, Wallyn A, Vernieuwe L, et al. Gastric ultrasound in patients receiving semaglutide: a prospective, multicentre, matched control study. Anaesthesia. 2026. doi:10.1111/anae.70129

This episode examines a prospective matched case control study of semaglutide treated adults having elective surgery with pre operative gastric ultrasound. The study suggests semaglutide users may be more likely to have ultrasound defined full stomachs and solid gastric contents than matched non users (low certainty). Because the evidence is observational from a single small cohort, these results are hypothesis generating rather than practice changing.

Study at a glance

- Design and setting: Prospective, multicentre, matched case control study using individual matching, conducted at one academic and three large community hospitals in Belgium (Antwerp University Hospital, Imelda Hospital, AZ Delta Hospital, AZ Klina Hospital). Pre operative point of care gastric ultrasound was performed in the holding area approximately 30 minutes before elective surgery under general anaesthesia.

- Population: Eighty eight adults scheduled for elective surgery under general anaesthesia were included: 44 receiving semaglutide and 44 matched controls. Inclusion required adherence to fasting guidelines (>2 h liquids, >6 h solids) and guideline recommended glucagon like peptide receptor agonist withholding, plus matching on age (within 5 years), body mass index category (<25, 25–30, 30–35, >35 kg.m-2) and diabetes status. Mean age was 59 (14.0) vs 58 (13.8) years and body mass index 32.6 (4.7) vs 32.5 (5.6) kg.m-2 in semaglutide and control groups, respectively.

- Exposure and comparator: Exposure was current semaglutide treatment (any dose, administration route, frequency or indication) with pre operative withholding per American Society of Anesthesiologists and European guidance (1 week for weekly dosing, 1 day for daily dosing). The comparator group comprised matched control patients not receiving semaglutide, undergoing similar elective surgery under general anaesthesia.

- Primary outcome: Primary outcome was a full stomach on pre operative gastric ultrasound, defined as visible solid content in any position or calculated gastric volume > 1.5 ml.kg-1 in right lateral decubitus. Full stomach was observed in 21/43 semaglutide patients (49%) vs 8/44 controls (18%), adjusted odds ratio 4.29 (95% confidence interval 1.63 to 11.29), p = 0.003 (low certainty). This suggests semaglutide use may increase the odds of an ultrasound defined full stomach compared with matched non users.

- Key secondary outcome: A key secondary outcome was solid gastric contents on ultrasound. Solids were seen in 18/43 semaglutide patients (42%) vs 3/44 controls (7%), adjusted odds ratio 9.85 (95% confidence interval 2.57 to 37.76), p < 0.001 (low certainty), indicating semaglutide treatment may greatly increase the odds of visible solid gastric contents despite standard fasting and drug withholding.

- Confounding: Confounding was addressed by prospective individual matching on age, body mass index category and diabetes status, and by excluding conditions known to delay gastric emptying; analyses used logistic regression with generalised estimating equations for matched pairs. However, no propensity score or broader multivariable adjustment was reported, and baseline differences such as American Society of Anesthesiologists physical status distribution and prevalence of gastrointestinal symptoms remained, so residual confounding is likely and its direction is unpredictable.

- Risk of bias and certainty: Overall risk of bias was judged Moderate by ROBINS I, mainly due to residual confounding and potential unblinded, expectation influenced assessment of ultrasound outcomes, which could exaggerate harms in semaglutide users; selection, exposure classification, deviations from intended interventions, missing data, and selective reporting were at Low risk. For the primary outcome (full stomach) and solid contents, certainty of evidence was rated Low; for change in anaesthetic plan (24/44 vs 8/43, adjusted odds ratio 5.26, 95% confidence interval 1.96 to 14.11, p < 0.001) and for total and weight adjusted gastric volume (medians 61 vs 52 ml, p = 0.568; 0.58 vs 0.57 ml.kg-1, p = 0.520, with 13 vs 1 inconclusive scans), certainty was Very Low due to risk of bias and imprecision.

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.

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.

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).

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.

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.

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.

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.

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).

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).

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.

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.

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.

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.

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.

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.