Daily Anesthesiology Research Analysis
Three anesthesia-focused studies stand out today: a double-blind RCT shows opioid-free anesthesia (esketamine + dexmedetomidine + bilateral cervical plexus blocks) improves quality of recovery after thyroidectomy; a randomized trial demonstrates BMI-based PEEP (BMI/3 cmH2O) lowers driving pressure and postoperative loss of lung aeration; and a meta-analysis finds esketamine significantly reduces pediatric emergence delirium without prolonging PACU stay or increasing PONV.
Summary
Three anesthesia-focused studies stand out today: a double-blind RCT shows opioid-free anesthesia (esketamine + dexmedetomidine + bilateral cervical plexus blocks) improves quality of recovery after thyroidectomy; a randomized trial demonstrates BMI-based PEEP (BMI/3 cmH2O) lowers driving pressure and postoperative loss of lung aeration; and a meta-analysis finds esketamine significantly reduces pediatric emergence delirium without prolonging PACU stay or increasing PONV.
Research Themes
- Opioid-free anesthesia and enhanced recovery
- Personalized intraoperative ventilation strategies
- Esketamine for preventing pediatric emergence delirium
Selected Articles
1. Opioid-Free Anesthesia Improved the Quality of Recovery After Thyroidectomy Through Pre-Emptive and Preventive Analgesia: A Randomized Controlled Trial.
In a double-blind RCT of 204 thyroidectomy patients, opioid-free anesthesia with esketamine, dexmedetomidine, and bilateral superficial cervical plexus blocks increased QoR-15 by 9.4 points and improved sleep, pain, and PONV compared with opioid-based anesthesia, albeit with prolonged emergence. These findings support OFA as a patient-centered strategy for thyroid surgery with careful depth monitoring to mitigate delayed emergence.
Impact: High-quality randomized evidence demonstrates improved patient-reported recovery with an OFA regimen tailored to thyroidectomy, addressing the opioid-sparing agenda while quantifying a tradeoff (longer emergence).
Clinical Implications: Consider OFA (esketamine + dexmedetomidine + bilateral superficial cervical plexus blocks) for thyroidectomy to enhance QoR and reduce PONV and pain. Plan for potential prolonged emergence by optimizing dosing, depth monitoring (e.g., processed EEG), and PACU readiness.
Key Findings
- QoR-15 score on POD1 was higher with OFA vs opioid-based anesthesia (mean difference 9.4; 95% CI 7.0–11.7).
- OFA reduced postoperative pain burden and PONV and improved sleep quality.
- OFA was associated with prolonged emergence, highlighting a safety/efficiency tradeoff.
Methodological Strengths
- Double-blind randomized controlled design with trial registration
- Patient-centered primary endpoint (QoR-15) and multiple relevant secondary outcomes
Limitations
- Single procedure type and single regimen; generalizability to other surgeries uncertain
- Prolonged emergence not fully mechanistically explored; optimal dosing requires further study
Future Directions: Multicenter trials comparing different OFA compositions and dosing to minimize emergence delay while preserving recovery benefits; cost-effectiveness and implementation studies.
2. Adjustment of positive end-expiratory pressure based on body mass index during general anaesthesia: a randomised controlled trial.
In a patient-blinded randomized trial (n=60), setting PEEP to BMI/3 cmH2O reduced intraoperative driving pressure and decreased postoperative loss of lung aeration compared with a fixed PEEP of 5 cmH2O. This pragmatic rule individualized ventilation in non-cardiothoracic surgical patients without major lung disease.
Impact: Provides a simple, actionable PEEP rule (BMI/3) that improves lung mechanics and aeration, potentially standardizing individualized lung-protective ventilation during anesthesia.
Clinical Implications: For adults without significant lung disease undergoing general anesthesia, consider targeting PEEP ≈ BMI/3 cmH2O to lower driving pressure and mitigate postoperative atelectasis; integrate with low tidal volumes and recruitment as appropriate.
Key Findings
- BMI-based PEEP (BMI/3 cmH2O) significantly reduced intraoperative driving pressure compared with standard PEEP 5 cmH2O.
- Postoperative lung aeration loss was reduced with BMI-tailored PEEP.
- Approach is pragmatic, patient-blinded, and easily implementable in non-cardiothoracic surgeries.
Methodological Strengths
- Randomized, patient-blinded design
- Objective physiologic and imaging endpoints (driving pressure, lung aeration)
Limitations
- Single-center, small sample size limits generalizability
- Clinical outcomes (e.g., PPCs) not powered/assessed as primary endpoints
Future Directions: Multicenter trials powered for postoperative pulmonary complications and oxygenation; evaluation in obese, lung disease, and high-risk cohorts; integration with individualized driving pressure targets.
3. The effect of esketamine on emergence delirium in pediatric patients undergoing general anesthesia: a meta-analysis of randomized controlled trials.
Meta-analysis of 10 RCTs (n=853) shows esketamine reduces pediatric emergence delirium (RR 0.40) without prolonging PACU stay or increasing nausea/vomiting. Subgroup analyses suggest single bolus before induction or at the end of surgery is more effective than intraoperative infusion.
Impact: Synthesizes randomized evidence to inform a practical, opioid-sparing strategy for a common pediatric anesthesia complication with clear dosing/timing implications.
Clinical Implications: Consider esketamine to prevent emergence delirium in children, favoring a single bolus before induction or at surgery end. Incorporate into pediatric ERAS and PACU protocols; monitor hemodynamics and psychomimetic effects as per local standards.
Key Findings
- Esketamine reduced emergence delirium by 60% (RR 0.40; 95% CI 0.30–0.53).
- No increase in PACU length of stay or nausea/vomiting.
- Single bolus dosing (pre-induction or end of surgery) outperformed continuous intraoperative infusion.
Methodological Strengths
- Meta-analysis of randomized controlled trials with prespecified outcomes
- Prospective registration (PROSPERO) and subgroup analyses on dosing strategy
Limitations
- Heterogeneity across anesthetic techniques and surgical types; incomplete reporting of I2
- Pediatric dose ranges and safety profiles may vary; limited long-term neurobehavioral data
Future Directions: Head-to-head RCTs of dosing/timing regimens, standardized PAED-based definitions, and safety monitoring for psychomimetic or hemodynamic effects; cost-effectiveness within pediatric ERAS.