Daily Anesthesiology Research Analysis

BACKGROUND: Nondepolarizing neuromuscular blocking agents (ND-NMBAs) are dose-dependently associated with residual paralysis, delayed recovery, and prolonged hospitalization, factors that can predispose patients to postoperative delirium. We hypothesized that neuromuscular blockade is associated with a higher risk of delirium after surgery, and that this can be mitigated by administration of reversal agents. METHODS: In total, 53,772 adult hospitalized patients aged ≥60 years who underwent general anesthesia for noncardiac, nonneurosurgical, nontransplant procedures between 2008 and 2024 at a tertiary health care network in Massachusetts, were included. The exposure was the intraoperative administration of ND-NMBAs. The primary outcome was 7-day delirium, identified from nursing and physician charts using a keyword-based search strategy paired with manual chart review, Confusion Assessment Method assessments, and International Classification of Diseases (9th/10th Revision, Clinical Modification) diagnostic codes. RESULTS: In total, 43,723 (81.3%) patients received neuromuscular blockade. Approximately 2259 (4.2%) patients developed delirium, 1884 (4.3%) with, and 375 (3.7%) without ND-NMBA administration. In adjusted analyses, administration of ND-NMBAs was dose-dependently associated with a higher risk of postoperative delirium (adjusted odds ratio [OR adj ] 1.15; 95% confidence interval [CI], 1.01-1.31; P = .038 and 1.09; 95% CI, 1.06-1.12; P < .001 per each unit increase in the effective dose required to achieve a 95% twitch reduction). 38,143 (87.2%) patients who received ND-NMBAs also received a reversal agent, which was associated with a lower risk of impaired neuromuscular recovery (preextubation train-of-four ratio <95; OR adj 0.60; 95% CI, 0.49-0.74; P < .001) and delirium (OR adj 0.73; 95% CI, 0.64-0.83; P < .001), compared to no reversal. The adverse effect of ND-NMBAs on delirium risk was eliminated by reversal agent administration (OR adj 1.07; 95% CI, 0.94-1.23; P = .30 with and OR adj 1.52; 95% CI, 1.28-1.79; P < .001 without reversal agent administration). There was no association between administration of neostigmine, compared to sugammadex, with postoperative delirium (OR adj 0.91; 95% CI, 0.73-1.12; P = .36). CONCLUSIONS: Neuromuscular blockade during general anesthesia is dose-dependently associated with a higher risk of postoperative delirium. The administration of reversal agents mitigates this risk and might help reduce the occurrence of delirium after surgery.

Gastric point-of-care ultrasound (POCUS) may offer clinical value in assessing aspiration risk among medically complex patients undergoing regional anesthesia and pain procedures. While the American Society of Anesthesiologists (ASA) preoperative fasting guidelines primarily apply to healthy individuals, medically complex populations often present with differing gastric emptying and aspiration risk. This narrative review, conducted by the American Society of Regional Anesthesia and Pain Medicine (ASRA-PM), adhered to PRISMA guidelines and was registered with PROSPERO. It focused on seven medically complex patient groups: those who are pregnant, obese, diabetic, have gastroesophageal reflux disease (GERD), are receiving emergency care, are enterally fed, or are taking GLP-1 receptor agonists (GLP-1RA). Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Practice recommendations were developed using an iterative expert consensus process, with final recommendations based on evidence strength, clinical relevance, and expert agreement. Findings support the use of gastric POCUS in patients in active labor, those undergoing urgent cesarean sections, and those with diabetes. Conditional support is given for obesity, emergency care, enteral feeding, and GLP-1RA use. Routine use is not recommended in non-laboring pregnancies, elective cesarean delivery, or GERD. While gastric POCUS may aid with aspiration risk evaluation, its use should complement clinical judgment. Implementation may be limited by practical and training constraints, requiring individualized decision-making. These recommendations serve as a foundation for future research and potential clinical guideline development. PROSPERO registration number: CRD42023445927.

IntroductionBlood transfusion is associated with adverse events and should be prevented. Preoperative identification of patients at risk is necessary and makes subsequent preventive intervention possible. Many risk models have been developed of which the Transfusion Risk and Clinical Knowledge (TRACK) model includes criteria reflecting daily practice. The aim of this study is to validate and update the TRACK model in a low-transfusion-rate adult cardiac-surgery population.MethodsExternal validation of the TRACK model was performed using a database of 4072 adult patients receiving cardiac surgery between 2015 and 2022 (original TRACK model). Subsequently, the original TRACK model coefficients were updated by cross-validation (uTRACK model). Preoperative antiplatelet therapy was added as an extra variable to the updated TRACK model (uTRACK + APT model).ResultsIn our population, 26% of patients received red blood cell transfusions. The original TRACK model demonstrated good discrimination (AUC-ROC of 0.76; 95% CI 0.74 - 0.78) but inadequate calibration (