Daily Anesthesiology Research Analysis
Across anesthesiology-relevant studies, perioperative neurocognitive outcomes improved with targeted sedative choices: a meta-analysis showed esketamine reduces postoperative delirium and delayed neurocognitive recovery, while a randomized trial found dexmedetomidine sedation under regional anesthesia markedly lowers delirium, emergence agitation, and early POCD in older adults. Conversely, a randomized trial reported that adding perineural dexamethasone to ropivacaine for interscalene block pro
Summary
Across anesthesiology-relevant studies, perioperative neurocognitive outcomes improved with targeted sedative choices: a meta-analysis showed esketamine reduces postoperative delirium and delayed neurocognitive recovery, while a randomized trial found dexmedetomidine sedation under regional anesthesia markedly lowers delirium, emergence agitation, and early POCD in older adults. Conversely, a randomized trial reported that adding perineural dexamethasone to ropivacaine for interscalene block provided no additional analgesic benefit, underscoring the need to re-evaluate routine adjunct use.
Research Themes
- Perioperative neurocognitive protection with anesthetic adjuncts
- Optimization of sedation strategies under regional anesthesia in older adults
- Reappraisal of perineural steroid adjuvants for peripheral nerve blocks
Selected Articles
1. Impact of perioperative esketamine on the perioperative neurocognitive dysfunction: a systematic review and meta-analysis of randomised controlled studies.
Across 10 RCTs (n=854), perioperative esketamine halved the risk of postoperative delirium and reduced delayed neurocognitive recovery without increasing adverse events or length of stay; effects on 3-month neurocognitive outcomes were not significant. Pain on postoperative day 1 was also reduced.
Impact: Provides level I evidence that esketamine reduces short-term neurocognitive complications, directly informing anesthetic adjunct selection for high-risk patients.
Clinical Implications: Consider low-dose esketamine as part of multimodal anesthesia/analgesia to mitigate postoperative delirium and delayed neurocognitive recovery in adults, while counseling that long-term cognitive outcomes at 3 months may be unchanged.
Key Findings
- Reduced postoperative delirium: RR 0.46 (95% CI 0.30–0.71)
- Reduced delayed neurocognitive recovery: RR 0.41 (95% CI 0.21–0.78)
- No significant difference in 3-month postoperative neurocognitive disorder
- Lower pain severity on postoperative day 1; no increase in adverse events or hospital length of stay
Methodological Strengths
- Rigorous meta-analysis of RCTs with GRADE assessment
- Random-effects modeling and Cochrane risk-of-bias evaluation
Limitations
- Heterogeneity in dosing regimens and perioperative contexts
- Limited data on long-term (≥3 months) neurocognitive outcomes
Future Directions: Head-to-head dosing trials, standardized protocols, and longer follow-up are needed to define optimal esketamine regimens and their impact on long-term cognition.
2. A Randomized Clinical Trial of Dexmedetomidine on Delirium, Cognitive Dysfunction, and Sleep After Non-Ambulatory Orthopedic Surgery With Regional Anesthesia.
In older adults undergoing major lower-limb surgery under regional anesthesia, dexmedetomidine sedation (vs propofol) dramatically reduced POD (4.8% vs 38.4%), ED (2.4% vs 38.4%), and early POCD (2.4% vs 56.4%). Dexmedetomidine also improved immediate postoperative sleep and lowered 3-month pain scores, at the cost of more bradycardia/hemodynamic instability.
Impact: Provides randomized, double-blind evidence that a specific sedative choice under regional anesthesia can substantially reduce neurocognitive complications and improve sleep and pain outcomes in older adults.
Clinical Implications: For elderly patients receiving regional anesthesia, consider dexmedetomidine sedation to lower POD/ED/early POCD and improve sleep; implement vigilant hemodynamic monitoring and bradycardia management protocols.
Key Findings
- POD reduced from 38.4% to 4.8% with dexmedetomidine
- ED reduced from 38.4% to 2.4%; early POCD reduced from 56.4% to 2.4%
- Improved immediate postoperative PSQI and lower 3-month painDETECT scores
- Increased intraoperative bradycardia/hemodynamic instability with dexmedetomidine; airway obstruction occurred in 2.4% vs 30.8%
Methodological Strengths
- Double-blind randomized controlled design with active comparator
- Validated tools for delirium (CAM), agitation (Riker), cognition, sleep, and pain
Limitations
- Single-center, modest sample size (n=80)
- Regional anesthesia context may limit generalizability to general anesthesia cases
Future Directions: Multicenter trials to confirm external validity, dose-finding to balance neurocognitive benefit and hemodynamic risk, and cost-effectiveness analyses.
3. Postoperative Analgesia Effect Evaluation of Perineural Dexamethasone Plus Various Doses of Ropivacaine in Interscalene Brachial Plexus Block: A Randomized Controlled Trial.
In 140 patients undergoing shoulder arthroscopy with interscalene block and general anesthesia, adding 5 mg perineural dexamethasone to 0.25%, 0.5%, or 0.75% ropivacaine did not prolong analgesia duration nor improve pain scores or PONV compared with ropivacaine alone. Complication rates were similar.
Impact: Challenges a common practice of perineural steroid adjuvant use for interscalene block by showing no additive analgesic benefit across clinically used ropivacaine concentrations.
Clinical Implications: Routine perineural dexamethasone addition to interscalene block for shoulder arthroscopy may be unnecessary; focus on optimizing local anesthetic concentration/volume and multimodal systemic analgesia.
Key Findings
- No prolongation of analgesia with 5 mg perineural dexamethasone across 0.25%, 0.5%, 0.75% ropivacaine
- No significant differences in NRS pain scores or PONV between dexamethasone and control arms
- Similar intraoperative and postoperative complication rates among all groups
Methodological Strengths
- Randomized multi-arm comparison across clinically relevant ropivacaine concentrations
- Predefined primary endpoint (analgesia duration) with standardized ultrasound-guided technique
Limitations
- Single dose of dexamethasone (5 mg) tested; dose–response not explored
- General anesthesia co-administration may confound postoperative analgesic assessments
Future Directions: Evaluate different dexamethasone doses/routes (perineural vs IV), continuous catheter techniques, and patient-centered outcomes (rebound pain, function).