Daily Anesthesiology Research Analysis
Three impactful anesthesiology studies stood out: a multicenter RCT (SEGA) suggests general anesthesia may improve 90-day outcomes over moderate sedation during endovascular therapy for large-vessel stroke; a single-center RCT shows 40‑Hz light stimulation via VR reduces pediatric emergence delirium after sevoflurane anesthesia; and updated PROSPECT recommendations for laparoscopic sleeve gastrectomy endorse TAP blocks, port-site infiltration, and intraoperative dexamethasone while de-emphasizin
Summary
Three impactful anesthesiology studies stood out: a multicenter RCT (SEGA) suggests general anesthesia may improve 90-day outcomes over moderate sedation during endovascular therapy for large-vessel stroke; a single-center RCT shows 40‑Hz light stimulation via VR reduces pediatric emergence delirium after sevoflurane anesthesia; and updated PROSPECT recommendations for laparoscopic sleeve gastrectomy endorse TAP blocks, port-site infiltration, and intraoperative dexamethasone while de-emphasizing gabapentinoids.
Research Themes
- Anesthetic strategy for neurointerventional stroke care
- Nonpharmacologic neuromodulation to prevent emergence delirium
- Procedure-specific multimodal analgesia optimization in bariatric surgery
Selected Articles
1. Sedation vs General Anesthesia for Endovascular Therapy in Acute Ischemic Stroke: The SEGA Randomized Clinical Trial.
In a 10-center randomized trial (n=260), general anesthesia during EVT for LVO stroke showed a probabilistic advantage in 90-day functional outcomes, with an 81% posterior probability of superiority on ordinal mRS and numerically higher successful reperfusion. Symptomatic intracerebral hemorrhage was less frequent with GA.
Impact: This trial addresses a long-standing debate in neuroanesthesia, providing randomized evidence that GA may confer better outcomes during EVT for LVO stroke.
Clinical Implications: Centers performing EVT should consider standardized GA protocols as a default or strongly considered option, while acknowledging credible intervals straddled unity and local workflow/logistics.
Key Findings
- Ordinal 90-day mRS favored GA with OR 1.22 (95% CrI 0.79–1.87) and 81% posterior probability of superiority.
- Probability of GA superiority for achieving mRS 0–2 at 90 days was 89%.
- Successful reperfusion probability favored GA (69% probability of superiority).
- Symptomatic intracerebral hemorrhage: 0.8% (GA) vs 2.4% (sedation).
Methodological Strengths
- Multicenter randomized, intention-to-treat design with pre-registered protocol (NCT03263117).
- Use of ordinal mRS and Bayesian analysis providing posterior probabilities alongside effect estimates.
Limitations
- Credible intervals included the null; results indicate probabilistic but not definitive superiority.
- Potential variability in anesthetic and EVT techniques across centers; blinding not feasible.
Future Directions: Confirmatory pragmatic multicenter RCTs with standardized GA protocols, cost-effectiveness analyses, and subgroup analyses (e.g., airway risks, hemodynamic lability) are warranted.
IMPORTANCE: The optimal anesthetic strategy for patients undergoing endovascular therapy (EVT) for acute ischemic stroke (AIS) from large vessel occlusion (LVO) remains unclear. OBJECTIVE: To determine if general anesthesia (GA) or moderate sedation for patients who undergo EVT for AIS with LVO is associated with a different functional outcome in 90 days. DESIGN, SETTING, AND PARTICIPANTS: This was a multicenter randomized clinical trial conducted from July 2018 to August 2023 of patients with AIS who were receiving EVT due to LVO. Patients were recruited from 10 comprehensive stroke centers in the US. Adult patients with occlusion of the carotid artery and the proximal middle and anterior cerebral artery who underwent EVT were eligible for enrollment. INTERVENTIONS: Patients were randomized to receive either moderate sedation or GA in 1:1 ratio. MAIN OUTCOMES AND MEASURES: The primary outcome was the ordinal modified Rankin Scale (mRS) score at 90 days. RESULTS: A total of 1931 patients were screened for eligibility, and 1671 were excluded due to failure meeting the inclusion criteria. Among 260 individuals with a mean (SD) age of 66.8 (13.3) years included in this intention-to-treat study, 133 were male (52%), and 130 (50%) were randomized to GA and sedation each. At 90 days, a shift in the distribution of ordinal mRS was found favoring GA (odds ratio [OR], 1.22; 95% credible interval [CrI], 0.79-1.87) with an 81% posterior probability of GA superiority. The probability that GA was superior to sedation was 89% (relative risk [RR], 1.2; 95% CrI, 0.9-1.66) and 69% (RR, 1.01; 95% CrI, 0.96-1.08) for 90-day mRS 0 to 2 and successful reperfusion, respectively. Other secondary outcomes were similar. Symptomatic intracerebral hemorrhage was 0.8% (1 of 125 patients) in GA vs 2.4% (3 of 125 patients) in sedation with a posterior probability of GA was superior to sedation of 72% (RR, 0.71; 95% CrI, 0.23-2.16). CONCLUSIONS AND RELEVANCE: This randomized clinical trial found that patients with LVO AIS who were treated with EVT using GA had improved rates of 90-day outcomes and higher rates of successful reperfusion compared with those treated using moderate sedation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03263117.
2. 40-Hz Light Stimulation and Emergence Delirium Incidence After Sevoflurane Anesthesia in Children: A Randomized Clinical Trial.
In 98 children undergoing elective vascular malformation surgery under sevoflurane anesthesia, 1 hour of 40‑Hz light stimulation via VR reduced emergence delirium by C‑CAPD (22.4% vs 44.9%; RR 0.57) and PAED (14.3% vs 34.7%; RR 0.51). Adjusted analyses remained significant.
Impact: Introduces a nonpharmacologic, scalable neuromodulatory intervention that reduces pediatric emergence delirium, a common and consequential postoperative complication.
Clinical Implications: 40‑Hz visual stimulation can be considered as an adjunct to standard ERAS pathways to prevent emergence delirium in pediatric sevoflurane anesthesia, particularly when pharmacologic strategies are limited.
Key Findings
- C‑CAPD–defined emergence delirium reduced with 40‑Hz stimulation: 22.4% vs 44.9% (RR 0.57; 95% CI 0.33–0.92; P=.02).
- PAED-defined delirium also reduced: 14.3% vs 34.7% (RR 0.51; 95% CI 0.26–0.91; P=.02).
- Adjusted analyses showed significantly lower delirium incidence (adjusted RR 0.86; 95% CI 0.77–0.95; P=.004).
Methodological Strengths
- Randomized, sham-controlled design with validated delirium scales (C-CAPD, PAED).
- Pre-registered trial (NCT06493513) with prespecified adjustments for key confounders.
Limitations
- Single-center study limited to vascular malformation surgery; generalizability to other pediatric surgeries is uncertain.
- Short follow-up (72 hours) and no long-term behavioral outcomes.
Future Directions: Multicenter trials across pediatric procedures, dose–response and timing optimization, and mechanistic EEG/biomarker studies of gamma entrainment are needed.
IMPORTANCE: Emergence delirium is common in children undergoing surgery under general anesthesia and is associated with prolonged recovery times and an increased risk of postoperative behavioral disturbances. Light stimulation, 40 Hz, has shown promise for cognitive modulation, but evidence for mitigating emergence delirium is limited. OBJECTIVE: To evaluate the effects of 40-Hz light stimulation in reducing emergence delirium. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted from April to August 2024 at a single tertiary center (Henan Provincial People's Hospital). Children aged 3 to 14 years scheduled for elective vascular malformation resection were included. Children were excluded if they refused consent, had intellectual disability, neuropsychiatric disorders (or history thereof), severe hepatic or kidney dysfunction, severe cardiopulmonary disorders, autoimmune disorders, cephalofacial vascular malformations, or major life changes within 1 month preoperatively. INTERVENTIONS: Participants were randomized 1:1 to 40-Hz light stimulation via virtual reality glasses or sham (identical glasses without light) for 1 hour after induction. MAIN OUTCOMES AND MEASURES: The primary efficacy end point was emergence delirium incidence, defined as a score of 10 or higher on the Chinese version of the Cornell Assessment of Pediatric Delirium (C-CAPD) scale between extubation and 72 hours postsurgery. RESULTS: Ninety-eight children were randomized (49 per group; mean [SD] age, 7.7 [3.2] years; 59 [60.2%] male). More children had an excellent outcome with 40-Hz light stimulation than with sham stimulation (C-CAPD score, 22.4% vs 44.9%, unadjusted risk ratio, 0.57; 95% CI, 0.33-0.92; P = .02). Similar results were obtained when assessing emergence delirium using the Pediatric Anesthesia Emergence Delirium scale (14.3% vs 34.7%; unadjusted risk ratio, 0.51; 95% CI, 0.26-0.91; P = .02). After adjusting for age, sex, preoperative anxiety, anesthesia time, postoperative pain, and history of surgical procedures, 40-Hz light stimulation remained significantly associated with reduced incidence of emergence delirium (adjusted risk ratio, 0.86; 95% CI, 0.77-0.95; P = .004). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of children undergoing vascular malformation surgery, 40-Hz light stimulation was associated with a lower incidence of emergence delirium. These findings support further evaluation of nonpharmacologic sensory stimulation to prevent pediatric emergence delirium. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT06493513.
3. Pain management for laparoscopic sleeve gastrectomy: An update of the systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations.
This PROSPECT update synthesizes 39 RCTs and two meta-analyses to recommend paracetamol plus NSAIDs/COX‑2 inhibitors, bilateral TAP blocks (ultrasound or laparoscopic-guided), port‑site local anesthetic infiltration, and intraoperative IV dexamethasone for sleeve gastrectomy. Opioids are reserved for rescue, and gabapentinoids are no longer advised.
Impact: Provides procedure-specific, evidence-based guidance likely to standardize and improve postoperative analgesia for a high-volume bariatric procedure.
Clinical Implications: Adopt TAP blocks and port-site infiltration within multimodal regimens (paracetamol + NSAIDs/COX‑2) and administer intraoperative dexamethasone; avoid routine gabapentinoids and reserve opioids as rescue in sleeve gastrectomy pathways.
Key Findings
- Update recommends bilateral TAP blocks (US- or laparoscopic-guided) and port-site local anesthetic infiltration as part of multimodal analgesia.
- Intraoperative IV dexamethasone is recommended for analgesia and PONV prevention.
- Opioids are reserved for rescue; gabapentinoids are no longer advised compared with 2019 recommendations.
- Evidence base expanded to 39 RCTs and 2 meta-analyses since the prior review.
Methodological Strengths
- Systematic search across multiple databases with PROSPECT methodology and RoB 2 bias assessment.
- Procedure-specific synthesis enabling actionable recommendations.
Limitations
- Heterogeneity among included RCTs in techniques, dosing, and outcome measures.
- Evidence primarily short-term; limited data on long-term opioid use or chronic pain.
Future Directions: Head-to-head RCTs comparing TAP techniques, dose-finding for local anesthetics, and pragmatic implementation studies on opioid-sparing ERAS pathways in bariatric populations.
BACKGROUND: Bariatric surgery, particularly laparoscopic sleeve gastrectomy, is an effective and pivotal treatment for obesity. Patients undergoing laparoscopic sleeve gastrectomy commonly experience moderate pain in the immediate postoperative period. Therefore, optimal pain management is crucial. OBJECTIVE: The aim of this review was to update the recommendations for pain management following laparoscopic sleeve gastrectomy, building upon the 2019 guidelines. DESIGN: A systematic review was conducted using the PROSPECT methodology. DATA SOURCES: Randomised controlled clinical trials (RCTs) and systematic reviews concerning analgesic, anaesthetic and operative interventions, focusing on pain management for patients undergoing laparoscopic sleeve gastrectomy, were identified through searches in MEDLINE, EMBASE and Cochrane Databases from September 2018 until February 2024. Primary outcome included pain scores. We used the Rob 2 tool as our method to assess the risk of bias in the included studies. RESULTS: The previous review included data from 18 RCTs. Since then, 188 eligible studies were identified, of which 39 RCTs and two meta-analyses met our inclusion criteria. In addition to paracetamol and NSAIDs or cyclooxygenase (COX)-2 specific inhibitors, ultrasound or laparoscopic-guided bilateral transversus abdominis plane (TAP) blocks and port-site local anaesthetic infiltration are recommended. In addition, intra-operative intravenous dexamethasone is recommended for analgesia and prevention of postoperative nausea and vomiting. Opioids are reserved for rescue treatment. CONCLUSIONS: This systematic review identified an evidence-based analgesic regimen for laparoscopic sleeve gastrectomy. Our current recommendations differ from the previous ones in that a TAP block is now recommended, and gabapentinoids are no longer advised. PROSPERO REGISTRATION NUMBER: CRD42023487108.