Daily Anesthesiology Research Analysis

INTRODUCTION: Emergence delirium affects 25-60% of children after surgery, manifesting as acute confusion, disorientation and agitation. This condition is particularly common following adenotonsillectomy and can lead to negative behavioural changes that persist for weeks in approximately 50% of affected children. METHODS: We conducted a single-centre, prospective, double-blind, randomised controlled trial in children aged 3-7 y undergoing adenotonsillectomy. Patients received either intravenous esketamine 0.2 mg.kg RESULTS: A total of 228 patients were allocated randomly. Emergence delirium was less frequent in children allocated to the esketamine group compared with those allocated to the 0.9% saline group (19/114, 17% vs. 49/114, 43%; relative risk 0.40, 97.5%CI 0.23-0.68, p < 0.001). Negative behavioural changes on postoperative day 7 were lower in children allocated to the esketamine group compared with those allocated to the 0.9% saline group (48/114, 42% vs. 70/114, 61%; relative risk 0.70, 97.5%CI 0.51-0.95, p = 0.009). Benefits extended to postoperative day 30, with improved analgesia and greater parental satisfaction. Adverse event rates were similar between groups. DISCUSSION: In children undergoing adenotonsillectomy, intra-operative low-dose intravenous esketamine significantly reduced emergence delirium and negative behavioural changes without increasing adverse events. This intervention offers a safe, effective approach to improving paediatric surgical outcomes. Many children wake up confused and upset after having their tonsils and adenoids removed, and may have problems like bad dreams, bed‐wetting or anxiety for weeks afterwards. We studied whether a small dose of a medicine called esketamine during surgery could prevent these problems by giving 228 children aged 3 to 7 years either esketamine or salt water during their operation, with no one knowing which treatment each child received. Children who got esketamine were much less likely to wake up distressed – only 2 in 10 compared to 4 in 10 who got salt water – and a week later, fewer children who received esketamine had behaviour problems like tantrums or sleep troubles (4 in 10 versus 6 in 10). These children also had better pain relief and their parents were happier with the recovery, while the medicine didn't cause extra side effects. This study shows that giving esketamine during tonsil surgery helps children wake up more peacefully and recover better at home, making the experience less stressful for families.

BACKGROUND: Hemodynamic instability frequently occurs in patients undergoing pheochromocytoma and paraganglioma (PPGL) resection. Magnesium sulfate has demonstrated efficacy in mitigating perioperative hemodynamic fluctuations. However, prospective clinical data confirming the safe and effective improvement of intraoperative hemodynamics by magnesium sulfate in PPGL patients are lacking. METHODS: This single-center, double-blind trial enrolled 92 patients who were scheduled for PPGL resection. The patients were randomly assigned to receive either magnesium sulfate (a loading dose of 50 mg · kg -1 followed by a continuous infusion of 15 mg · kg -1 · h -1 ) or placebo (normal saline) with administration initiated 30 min before surgery and discontinued upon complete tumor resection. The primary efficacy outcome was a composite measure of intraoperative hemodynamic instability, defined as the cumulative time outside the blood pressure and heart rate target ranges ( i.e. , systolic arterial pressure greater than 160 mmHg, mean arterial pressure less than 60 mmHg, and heart rate greater than 100 beats/min), expressed as a percentage of total anesthesia duration. RESULTS: A total of 88 patients were included in the modified intention-to-treat analysis. The cumulative time outside the blood pressure and heart rate target range was 4.3% (interquartile range, 2.4 to 9.6%) in the magnesium sulfate group compared to 8.3% (5.2 to 14.8%) in the placebo group ( P = 0.003). Compared with the placebo group, intraoperative maximum systolic arterial pressure (185 [170 to 197] mmHg vs. 196 [185 to 215] mmHg; P < 0.001), proportion of patients requiring phentolamine (66% vs. 89%; P = 0.011), and phentolamine dose (3 [0 to 7] mg vs. 9 [2 to 15] mg; P = 0.011) were all lower in the magnesium sulfate group. In the magnesium sulfate group, the magnesium sulfate concentration peaked at 1.82 (1.47 to 2.14) mmol l -1 upon completion of the loading dose infusion. No significant differences were observed in safety outcomes between groups. CONCLUSIONS: Preemptive magnesium sulfate infusion effectively reduced intraoperative hemodynamic instability in patients undergoing PPGL resection. The intervention regimen used in the trial was safe.

BACKGROUND: Functional capacity is an important determinant of surgical risk, yet the relationship between self-reported metabolic equivalents of task (MET) levels, treated as a multi-level variable, and postoperative outcomes remains unclear. This study evaluated the association between categorized MET levels and short- and long-term mortality and morbidity. METHODS: This dual-center prospective cohort study enrolled adults undergoing elective non-cardiac surgery at Karolinska University Hospital (Solna and Huddinge) between 2020-2023, excluding obstetric, transplant, day surgery, and non-operative cases. Preoperative functional capacity was assessed in MET categories (1, 2-3, 4-5, 6-8, ≥9). Primary outcomes were all-cause mortality at 30 and 365 days; secondary outcomes were DAH30 and DAH365. Analysis used Accelerated Failure Time models and logistic quantile regression. RESULTS: In total, 38,293 patients were included. The incidence of 30- and 365-day mortality was 220 (0.6%) and 2061 (5.4%), respectively. In the 365-day mortality analysis, adjusted AFT models showed progressively shorter relative median survival times with decreasing MET levels compared to MET ≥ 9: 0.75 (0.56-0.98) for MET 6-8, 0.52 (0.40-0.68) for MET 4-5, 0.39 (0.29-0.51) for MET 2-3, and 0.24 (0.16-0.34) for MET 1. The adjusted marginal absolute risk difference in 365-day mortality was distinct across all MET categories: 0.8% (95% CI: 0.1 to 1.5) for MET 6-8, 2.3% (1.6 to 2.90) for MET 4-5, 3.8% (2.91 to 4.6) for MET 2-3, and 7.2% (5.2 to 9.8) for MET 1. Lower MET levels were also associated with fewer days alive and at home at 365 days (DAH365), particularly in the lower quantiles. CONCLUSIONS: Self-reported functional capacity, categorized by MET levels, is associated with both short- and long-term postoperative mortality and morbidity in a dose-response-like manner. These findings support continued use of MET in preoperative assessments and suggest that granular MET categorization enhances risk stratification.