Daily Anesthesiology Research Analysis
Three high-impact studies in anesthesiology refine perioperative decision-making: a comprehensive meta-analysis shows total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) are comparably safe but differ in recovery and PONV; a meta-analysis in obstetric anesthesia suggests quadratus lumborum blocks may match intrathecal morphine’s analgesia with fewer opioid-related side effects; and a nationwide cohort clarifies real-world outcomes after surgery in patients aged ≥80 years, emphas
Summary
Three high-impact studies in anesthesiology refine perioperative decision-making: a comprehensive meta-analysis shows total intravenous anesthesia (TIVA) and inhalational anesthesia (IA) are comparably safe but differ in recovery and PONV; a meta-analysis in obstetric anesthesia suggests quadratus lumborum blocks may match intrathecal morphine’s analgesia with fewer opioid-related side effects; and a nationwide cohort clarifies real-world outcomes after surgery in patients aged ≥80 years, emphasizing patient-centered metrics.
Research Themes
- Choosing between TIVA and inhalational anesthesia using evidence on safety, recovery, and PONV
- Opioid-sparing obstetric analgesia: fascial plane blocks versus intrathecal morphine
- Perioperative outcomes and recovery metrics in very old surgical patients
Selected Articles
1. Safety and recovery profile of patients after inhalational anaesthesia versus target-controlled or manual total intravenous anaesthesia: a systematic review and meta-analysis of randomised controlled trials.
Across 385 RCTs, TIVA and IA had comparable rates of serious intraoperative adverse events. IA shortened recovery and reduced costs, while TIVA lowered PONV and emergence agitation; subgroup analyses found similar safety whether TIVA was delivered by TCI or manual infusion. Signals suggest TCI-TIVA may reduce postoperative cognitive dysfunction but prolong recovery, warranting direct head-to-head comparisons.
Impact: This meta-analysis consolidates practice-defining evidence to tailor anesthetic technique to outcomes patients value (PONV vs speed of recovery) and operational priorities (costs), informing personalized anesthesia plans.
Clinical Implications: Use IA when faster emergence and lower cost are prioritized; favor TIVA for PONV-sensitive patients or to reduce emergence agitation. Be cautious interpreting TCI-specific cognitive benefits pending direct TCI vs manual trials.
Key Findings
- No difference in ClassIntra grade 3–4 adverse events between TIVA and IA (RR 1.00, 95% CI 0.88–1.12).
- IA favored for shorter recovery times and lower costs.
- TIVA favored for lower PONV and reduced emergence agitation.
- Subgroup: no safety difference between TCI-TIVA and manual TIVA; potential signal that TCI may decrease postoperative cognitive dysfunction while prolonging recovery.
Methodological Strengths
- Large-scale meta-analysis including 385 randomized controlled trials.
- Pre-registered protocol (PROSPERO) with planned subgroup analyses (TCI vs manual).
Limitations
- Heterogeneity in recovery metrics and costing across trials.
- Lack of direct head-to-head RCTs isolating TCI versus manual TIVA on cognitive outcomes.
Future Directions: Conduct adequately powered head-to-head RCTs of TCI versus manual TIVA focusing on postoperative cognitive outcomes, time to recovery, and environmental impact, with standardized recovery metrics.
BACKGROUND: In the UK, total intravenous anaesthesia (TIVA) is used in 25% of general anaesthetics and is gaining traction because of its lower environmental impact and effectiveness in reducing postoperative nausea and vomiting (PONV). Although meta-analyses have compared TIVA and inhalational anaesthesia (IA), the optimal delivery method-manual infusion or target-controlled infusion (TCI)-remains underexplored. This review addresses this gap, leveraging the rapidly growing body of evidence to guide optimal anaesthetic practice. METHODS: We searched PubMed, Embase, Cochrane CENTRAL and Web of Science from inception to October 10, 2024. Studies comparing TIVA and IA across several patient-related and efficiency outcomes were included. Meta-analyses were performed for all outcomes. Subgroup analyses were performed to assess the contribution of different factors including a comparison of TCI with manual infusion in TIVA. RESULTS: In total, 385 RCTs were included. No significant difference in ClassIntra grade 3-4 adverse events was observed between TIVA and IA (risk ratio [RR]: 1.00, 95% confidence interval [CI]: 0.88-1.12; P=0.97). Subgroup analysis also showed no significant difference for TCI (RR: 0.89, 95% CI: 0.66-1.21; P=0.46) or manual infusion (RR: 1.03, 95% CI: 0.90-1.17; P=0.70) groups. IA was favoured in recovery times and costs, whereas the incidence of PONV and agitation on emergence favoured TIVA. No statistical difference was observed in our other outcomes. CONCLUSIONS: TIVA and IA are comparably safe, with TIVA reducing PONV and agitation, whereas IA offers faster recovery and lower costs. The use of TCI in TIVA might decrease postoperative cognitive dysfunction and increase recovery time, highlighting the need for a systematic review directly comparing TCI and manual infusion. SYSTEMATIC REVIEW PROTOCOL: This review was registered prospectively with PROSPERO (CRD42024413368) on October 10, 2024. A single amendment to the title and order of outcomes was performed on November 21, 2024.
2. The analgesic effects of novel fascial plane blocks compared with intrathecal morphine after Caesarean delivery: a systematic review and meta-analysis.
Across 18 trials (n=1525), intrathecal morphine outperformed TAP blocks for early postoperative pain, whereas quadratus lumborum blocks showed comparable analgesia with fewer opioid-related adverse effects. Evidence for ESP was limited. These findings support QL as a viable intrathecal morphine alternative in multimodal post-Cesarean analgesia.
Impact: Clarifies the relative roles of fascial plane blocks versus intrathecal morphine after Cesarean, potentially reducing opioid-related side effects without compromising analgesia.
Clinical Implications: For patients at risk of opioid-related side effects or where intrathecal morphine is contraindicated/unavailable, consider quadratus lumborum blocks as an effective alternative; TAP alone may be insufficient for early analgesia compared to intrathecal morphine.
Key Findings
- Intrathecal morphine provided superior pain relief versus TAP at 6 and 12 hours post-Cesarean.
- Quadratus lumborum blocks achieved comparable analgesia to intrathecal morphine with fewer opioid-related side effects.
- Evidence for erector spinae plane blocks was limited and insufficient to conclude equivalence.
- Secondary outcomes included reduced opioid consumption and timings of mobilization/breastfeeding favoring intrathecal morphine over TAP.
Methodological Strengths
- Focused head-to-head comparisons across three fascial plane blocks versus intrathecal morphine.
- Use of standardized pain VAS time points and comprehensive secondary outcomes.
Limitations
- Heterogeneity in block techniques, local anesthetic regimens, and multimodal adjuncts across trials.
- Limited number of ESP studies restricts confident conclusions for this technique.
Future Directions: Conduct high-quality RCTs comparing QL versus intrathecal morphine with standardized protocols, and adequately powered trials evaluating ESP versus QL/IT morphine focusing on maternal and neonatal outcomes.
BACKGROUND: Intrathecal morphine is the mainstay for post-Caesarean multimodal analgesia but is associated with important side-effects. Novel ultrasound-guided abdominal wall fascial plane blocks are proposed as intrathecal morphine alternatives, but evidence of effectiveness is conflicting. We compared the analgesic effects of fascial plane blocks with those of intrathecal morphine after Caesarean delivery. METHODS: We sought trials comparing the analgesic effects of intrathecal morphine with quadratus lumborum (QL), transversus abdominus plane (TAP), or erector spinae plane (ESP) blocks after Caesarean delivery. The primary outcome was rest pain intensity at 6 h on a visual analogue scale (VAS) ranging from 0 to 10 cm, with 10 cm indicating severe pain. Secondary outcomes included pain at 12 and 24 h; cumulative 24-h opioid consumption in milligrams of oral morphine; times to first analgesic request, ambulation, and breast feeding in hours; lengths of recovery room and hospital stay in hours; incidence of opioid-related side-effects; and block-related complications. RESULTS: Eighteen trials (1525 subjects) were included. TAP block was evaluated in 11 studies, QL block in five, and ESP block in two. Intrathecal morphine was superior to TAP block for pain at 6 and 12 h, with mean differences (Hartung-Knapp-Sidik-Jonkman [HKSJ] 95% confidence interval [CI]) of 1.21 cm (0.42-2.00) (P=0.01, I CONCLUSIONS: Quadratus lumborum block, rather than erector spinae or transversus abdominus plane blocks, may be a better intrathecal morphine alternative owing to similar post-Caesarean analgesic effects and reduced opioid-related side-effects. SYSTEMATIC REVIEW PROTOCOL: CRD42024543371.
3. Surgery in patients aged ≥ 80 years: mortality and recovery in a nationwide cohort study.
In 118,359 patients aged ≥80 years, 30-day mortality was 1.2% after elective and 9.9% after acute surgery, with risk increasing notably in those ≥90. Patient-centered metrics (days alive and at home at 30 and 90 days) were substantially worse after acute procedures, highlighting the burden of postoperative complications and prolonged recovery.
Impact: Provides robust, contemporary benchmarks for mortality and recovery in very old surgical patients using nationwide data and patient-centered outcomes, informing shared decision-making and perioperative planning.
Clinical Implications: Age alone should not exclude elective surgery, but acute surgery in very old patients carries high risk and warrants enhanced risk stratification, optimization, and postoperative support focused on functional recovery and return home.
Key Findings
- 30-day mortality: 1.2% (elective) vs 9.9% (acute) in patients ≥80 years.
- Higher mortality with advancing age, especially ≥90 years versus 80–84 years.
- Days alive and at home at 30 and 90 days were significantly lower after acute surgery, indicating prolonged recovery and complications.
- Nationwide linkage of perioperative, comorbidity, and mortality registers enabled comprehensive outcome capture.
Methodological Strengths
- Very large nationwide cohort with registry linkage (perioperative, comorbidity, mortality).
- Use of patient-centered outcomes (days alive and at home) alongside mortality.
Limitations
- Observational design with potential residual confounding.
- Lack of granular data on surgical complexity, intraoperative management, and rehabilitation pathways.
Future Directions: Prospective studies to evaluate targeted perioperative optimization bundles in acute geriatric surgery and randomized trials of postoperative support models to improve days alive and at home.
INTRODUCTION: As the global population ages, the demand for surgical interventions in older adults is rising. Older patients face increased risks due to age-related physiological changes and comorbidities, making surgery and postoperative care challenging. This study aimed to assess short- and long-term mortality, as well as patient-centred outcomes such as days alive and at home 30 and 90 days after surgery, in patients aged ≥ 80 y undergoing surgical procedures. METHODS: This nationwide cohort study utilised data from the Swedish Perioperative Register, including surgeries in patients aged ≥ 80 y in Sweden from January 2019 to March 2023. We linked peri-operative data with the National Patient Register for comorbidities and with the National Cause of Death Register. The primary outcome was all-cause 30-day mortality, with secondary outcomes of 365-day mortality and days alive and at home 30 and 90 days after surgery. RESULTS: A total of 118,359 patients were included, with 54,320 undergoing elective and 64,039 acute surgeries. Thirty-day mortality was 1.2% for elective and 9.9% for acute surgeries. Mortality increased significantly with age, particularly for patients aged ≥ 90 y compared with those aged 80-84 y. Days alive and at home 30 and 90 days after surgery were significantly lower for acute surgery patients, indicating longer recovery times and more postoperative complications. DISCUSSION: Older adults, especially those aged ≥ 90 y, experience high mortality and significant challenges in postoperative recovery after acute surgeries. Elective surgeries are associated with lower short-term mortality, suggesting that age alone should not preclude surgical interventions. Tailored peri-operative care and patient-centred decision-making are essential to improve outcomes in this vulnerable population.