Daily Anesthesiology Research Analysis
Three studies stand out for perioperative anesthesiology today: a large real-world cohort links prophylactic dexamethasone in cardiac surgery with improved composite outcomes but potential harm in patients over 80; a network meta-analysis across 42 RCTs compares remimazolam, ciprofol, and propofol for endoscopy sedation; and a nationwide cohort shows preoperative cognitive impairment independently predicts higher postoperative mortality under general anesthesia.
Summary
Three studies stand out for perioperative anesthesiology today: a large real-world cohort links prophylactic dexamethasone in cardiac surgery with improved composite outcomes but potential harm in patients over 80; a network meta-analysis across 42 RCTs compares remimazolam, ciprofol, and propofol for endoscopy sedation; and a nationwide cohort shows preoperative cognitive impairment independently predicts higher postoperative mortality under general anesthesia.
Research Themes
- Perioperative risk stratification and geriatric anesthesia
- Sedation pharmacology and agent selection for endoscopy
- Real-world evidence and practice variation in cardiac anesthesia
Selected Articles
1. The safety and efficacy of remimazolam, ciprofol, and propofol anesthesia in endoscopy: a systematic review and network meta-analysis.
Across 42 RCTs, remimazolam reduced cardiovascular and respiratory adverse events compared with propofol, while propofol provided faster recovery. Both remimazolam and ciprofol markedly lowered injection pain compared with propofol, supporting agent selection tailored to patient risk and procedural turnover.
Impact: This network meta-analysis provides the most comprehensive comparative safety-efficacy profile to date for contemporary endoscopy sedatives, informing agent choice in high-risk populations.
Clinical Implications: Prefer remimazolam in patients with cardiovascular/respiratory vulnerability; consider propofol where rapid recovery is critical; ciprofol may be a balanced alternative with reduced injection pain.
Key Findings
- Remimazolam reduced cardiovascular adverse events vs propofol (RR 0.44, 95%CrI 0.35–0.54).
- Remimazolam had the lowest respiratory depression risk (RR 0.36, 95%CrI 0.28–0.46).
- Propofol enabled faster recovery than remimazolam (MD −14.22 min).
- Both remimazolam and ciprofol significantly reduced injection pain vs propofol.
Methodological Strengths
- Network meta-analysis of 42 randomized controlled trials (n=10,540) with Bayesian random-effects modeling.
- Prospective registration (PROSPERO CRD42024569405) and comparative assessment across multiple safety and efficacy endpoints.
Limitations
- Heterogeneity in dosing regimens, procedural types, and sedation protocols across trials.
- Indirect comparisons inherent to network meta-analysis and potential publication bias.
Future Directions: Head-to-head RCTs in defined high-risk subgroups and standardized recovery metrics are needed to refine agent selection algorithms.
BACKGROUND: While propofol remains widely used for endoscopic sedation, its cardiovascular depression and injection pain limitations have prompted exploration of novel agents (remimazolam, ciprofol). This study aimed to compare their safety and efficacy profiles systematically. METHODS: We conducted a network meta-analysis to evaluate remimazolam, ciprofol, and propofol for gastrointestinal endoscopy. Bayesian random-effects models were used to estimate relative risks (RR) and mean differences (MD) with 95% credible intervals(CrI). RESULTS: Forty-two randomized controlled trials (N = 10,540 patients) were included. Remimazolam demonstrated superior cardiovascular safety (RR = 0.44, 95%CrI 0.35-0.54 vs propofol) and lowest respiratory depression risk (RR = 0.36, 0.28-0.46). Propofol showed faster recovery (MD -14.22 min, -2.35 to -30.83 vs remimazolam). Both remimazolam (RR = 0.045) and ciprofol (RR = 0.054) significantly reduced injection pain versus propofol. CONCLUSION: Remimazolam should be prioritized for high-risk patients (cardiovascular/respiratory comorbidities) despite slightly longer recovery times. Propofol remains suitable for low-risk procedures requiring rapid turnover, while ciprofol offers balanced efficacy for endoscopy. TRIAL REGISTRATION: The study was registered with the UK National Institute for Health Research's PROSPERO platform (CRD42024569405; https://www.crd.york.ac.uk/prospero/ ).
2. The Effects of Dexamethasone in Cardiac Surgery: A Registry-Based, Real-World Data Analysis of Clinical Outcomes From the Netherlands Heart Registration.
In a propensity-matched national cohort of 54,694 cardiac surgery patients, perioperative dexamethasone was linked to fewer adverse composite outcomes—driven by reduced renal failure—and shorter hospital stays. A safety signal emerged in patients aged >80 with higher 30-day mortality, and substantial practice variation was observed.
Impact: Real-world data at national scale refine the risk–benefit profile of steroid prophylaxis in cardiac surgery, highlighting subgroup-specific harm in the oldest patients.
Clinical Implications: Consider routine dexamethasone for adult cardiac surgery to reduce renal failure and adverse composites, but exercise caution or dose-adjust/avoid in patients >80; harmonize protocols to reduce practice variation.
Key Findings
- Dexamethasone was associated with a lower composite adverse outcome (OR 0.82, 95% CI 0.72–0.92).
- Renal failure was significantly reduced (OR 0.57, 95% CI 0.47–0.70).
- Length of hospital stay decreased modestly (β −0.17 days).
- In patients >80 years, 30-day mortality increased (OR 1.52, 95% CI 1.01–2.28).
Methodological Strengths
- Very large, population-based registry with propensity score matching to mitigate confounding.
- Assessment of national practice variation via anesthesiologist survey alongside outcomes analysis.
Limitations
- Observational design with residual confounding and potential indication bias.
- Steroid dosing/timing heterogeneity and unmeasured confounders (e.g., frailty) may influence subgroup effects.
Future Directions: Pragmatic RCTs or target-trial emulation focusing on very elderly patients and dosing strategies are warranted; develop age-adjusted steroid protocols.
BACKGROUND: In cardiac surgery, modulating the inflammatory response with prophylactic steroids may reduce morbidity and mortality. We aimed to evaluate the association of dexamethasone use with clinical outcomes and its variation in clinical practice in a real-world setting. METHODS: This retrospective, population-based study evaluated data of elective and urgent to on-pump cardiac surgery patients from the Netherlands Heart Registration between 2013 and 2021. Patients who received perioperative dexamethasone were compared to those who did not. The primary outcomes were 30-day mortality and a composite of 30-day mortality, in-hospital stroke, and 30-day renal or respiratory failure. Secondary outcomes included the individual components of the composite outcome, a composite of infection-related outcomes, arrhythmias, and length of hospital stay. Propensity score matching was applied to adjust for confounders. Clinical practice variation was assessed through a national survey of Dutch cardiac anesthesiologists. RESULTS: In the study, 54,694 patients were included, with 40,891 patients (74.8%) receiving dexamethasone. After propensity score matching, dexamethasone use was associated with a lower risk of the composite clinical outcome (odds ratio [OR] 0.82, 95% confidence interval [CI], 0.72-0.92, P < .001), with a significant reduction in renal failure (OR 0.57, 95% CI, 0.47-0.70, P < .001). The length of hospital stay was significantly shorter (B -0.17, 95% CI, -0.32 to -0.02, P = .025). Other individual components of the composite outcome and secondary outcomes did not show a significant association with dexamethasone use. However, in patients >80 years, dexamethasone use was associated with increased 30-day mortality (OR 1.52, 95% CI, 1.01-2.28, P = .044). The observed benefits were consistent across other demographic and clinical subgroups. The survey indicated substantial variability in dexamethasone use across centers and anesthesiologists. CONCLUSIONS: Prophylactic dexamethasone during adult cardiac surgery was associated with reduced composite clinical outcomes, renal failure, and shorter hospital stays, and seemed associated with 30-day mortality in patients >80 years old.
3. Preoperative cognitive function and surgical outcomes under general anesthesia among older patients.
Among 108,158 older adults undergoing general anesthesia, preoperative cognitive impairment measured by KDSQ-C independently predicted higher 90-day and 1-year mortality and postoperative complications, with a graded risk increase at higher scores. Screening thresholds ≥11 identified particularly vulnerable patients.
Impact: This large, population-based study operationalizes a scalable cognitive screening tool for perioperative risk stratification with clear prognostic gradients.
Clinical Implications: Integrate brief cognitive screening (e.g., KDSQ-C) into preoperative assessment to identify high-risk patients, guide delirium prevention, perioperative care planning, and informed consent discussions.
Key Findings
- KDSQ-C ≥6 was associated with 35% higher 90-day mortality (HR 1.35, 95% CI 1.15–1.57).
- Graded risk: HR increased with higher KDSQ-C categories (e.g., 16–20 HR 1.98; 26–30 HR 2.03).
- Associations persisted for 1-year all-cause mortality and postoperative complications.
Methodological Strengths
- Large, nationwide, population-based cohort with standardized cognitive screening instrument (KDSQ-C).
- Multivariable Cox regression with stratified analyses demonstrating consistent gradients.
Limitations
- Observational design with potential residual confounding and misclassification (biennial screening intervals).
- Generalizability outside the Korean healthcare system requires validation.
Future Directions: Prospective interventional studies testing cognitive prehabilitation, delirium prevention bundles, and geriatric co-management in high KDSQ-C groups.
PURPOSE: To investigate whether preoperative cognitive impairment is associated with postoperative outcomes under general anesthesia. METHODS: This population-based cohort study utilized a nationwide database in South Korea. We included patients who underwent surgery under general anesthesia at the hospital between January 1, 2021, and December 31, 2021. The Korean Dementia Screening Questionnaire-Cognition (KDSQ-C), a tool designed for efficient dementia screening, was used to evaluate preoperative cognitive impairment. The KDSQ-C is administered during biennial National Health Insurance Service medical evaluations beginning at age 66 years. RESULTS: This study included 108,158 older patients who underwent surgery under general anesthesia. In a multivariable Cox regression model, patients with KDSQ-C ≥ 6 had a 35 % higher risk of 90-day mortality than those with KDSQ-C of 0-5 (hazard ratio [HR]: 1.35, 95 % confidence interval [CI]: 1.15, 1.57; P < 0.001). Increased 90-day mortality was observed in the following KDSQ-C groups compared to those with a score of 0-5: KDSQ-C 11-15 (HR: 1.54, 95 % CI: 1.13, 2.11; P = 0.007), KDSQ-C 16-20 (HR: 1.98, 95 % CI: 1.31, 2.99; P = 0.001), KDSQ-C 21-25 (HR: 1.99, 95 % CI: 1.29, 2.57; P = 0.004), and KDSQ-C 26-30 (HR: 2.03, 95 % CI: 1.26, 3.28; P = 0.004). Similar results were found in the analyses of one-year all-cause mortality and postoperative complications. CONCLUSIONS: Older patients with preoperative cognitive impairment undergoing general anesthesia have higher mortality and morbidity rates, particularly in patients with KDSQ-C scores ≥11.