Daily Anesthesiology Research Analysis
Three anesthesiology-relevant studies stand out today: a randomized trial shows remimazolam does not increase postoperative delirium versus propofol in older adults and reduces intraoperative hypotension; a meta-analysis of 14 RCTs supports topical lidocaine to reduce pediatric airway adverse events; and a large validated cohort finds the Endothelial Activation and Stress Index (EASIX) predicts mortality and bleeding after cardiopulmonary bypass.
Summary
Three anesthesiology-relevant studies stand out today: a randomized trial shows remimazolam does not increase postoperative delirium versus propofol in older adults and reduces intraoperative hypotension; a meta-analysis of 14 RCTs supports topical lidocaine to reduce pediatric airway adverse events; and a large validated cohort finds the Endothelial Activation and Stress Index (EASIX) predicts mortality and bleeding after cardiopulmonary bypass.
Research Themes
- Perioperative neurocognitive outcomes and anesthetic selection in older adults
- Pediatric airway safety and topical anesthetics
- Endothelial dysfunction indices for risk stratification in cardiac surgery
Selected Articles
1. Effect of remimazolam on postoperative delirium in elderly patients undergoing major abdominal surgery: a randomized controlled Trial.
In 370 adults ≥65 years undergoing major abdominal surgery, remimazolam-based anesthesia produced a similar incidence of postoperative delirium compared with propofol (17.1% vs 19.7%; P=0.578). Age ≥75 years interacted with treatment, and remimazolam significantly reduced intraoperative hypotension without differences in pain or other adverse events.
Impact: Addresses a priority outcome (postoperative delirium) in older adults using a randomized design and evaluates a rapidly adopted anesthetic (remimazolam).
Clinical Implications: Remimazolam can be selected as an alternative to propofol in older adults without increasing delirium risk and with less hypotension, potentially benefiting patients at risk for hemodynamic instability.
Key Findings
- Postoperative delirium incidence was similar between remimazolam and propofol groups (17.1% vs 19.7%; P=0.578).
- Remimazolam was associated with lower intraoperative hypotension (OR 0.460; P=0.009).
- Subgroup interaction observed in patients aged ≥75 years (OR 2.700; interaction P<0.001).
Methodological Strengths
- Randomized controlled design with trained delirium assessment (CAM/CAM-ICU) over 5 postoperative days
- Direct comparison of two widely used anesthetic strategies with clinically relevant outcomes
Limitations
- Single trial with modest sample size may be underpowered for subgroup effects
- Blinding of anesthetic assignment is not specified; potential performance bias
Future Directions: Larger multicenter RCTs powered for age-stratified effects and mechanistic studies on hemodynamic-neurocognitive interplay under remimazolam anesthesia.
BACKGROUND: Older patients are at a high risk of postoperative delirium (POD), and the choice of general anesthesia may affect postoperative cognitive outcomes. As a new type of benzodiazepine, remimazolam has wide application prospects in clinical anesthesia owing to its rapid onset, non-organ metabolism, and low respiratory and circulatory depression. This study aimed to compare the effect of propofol-based versus remimazolam-based general anesthesia on the incidence of delirium after major abdominal surgery in older adults. PATIENTS AND METHODS: A total
2. Preoperative Endothelial Activation and Stress Index as a predictor of in-hospital mortality and postoperative complications in cardiac surgery with cardiopulmonary bypass: A retrospective cohort study.
Among 7,233 CPB patients, higher preoperative EASIX independently predicted in-hospital mortality (OR per log2 increase 2.08; P<0.001). Adding EASIX improved model AUC from 0.74 to 0.78 in validation (P=0.012). EASIX >2.32 identified patients with markedly higher mortality, longer ventilation/ICU stay, and more postoperative bleeding.
Impact: Validates a simple, inexpensive biomarker index (EASIX) for risk stratification in a large cardiac surgery cohort with independent validation.
Clinical Implications: Preoperative EASIX may be incorporated into risk models to identify high-risk CPB patients for intensified perioperative management (hemostasis, monitoring, resource planning).
Key Findings
- EASIX independently predicted in-hospital mortality (OR per log2 increase 2.08; P<0.001).
- In validation, adding EASIX improved AUC from 0.74 to 0.78 (P=0.012).
- EASIX >2.32 associated with higher mortality (training OR 9.37; validation OR 4.47), more ICU/ventilator days, and higher postoperative bleeding.
Methodological Strengths
- Large sample size with prespecified training/validation cohorts
- Multivariable modeling with discrimination improvement analysis (AUC) and clinically meaningful thresholds
Limitations
- Retrospective single-center design with potential residual confounding
- External generalizability beyond the institution and CPB practices may be limited
Future Directions: Prospective multicenter validation and integration of EASIX into perioperative decision-support tools; interventional trials targeting modifiable pathways in high EASIX patients.
BACKGROUND: Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) are at risk for peri-operative complications, often linked to endothelial dysfunction. The Endothelial Activation and Stress Index (EASIX) has shown potential in predicting outcomes in various patient cohorts. OBJECTIVES: We aimed to assess the prognostic value of EASIX for in-hospital mortality and postoperative outcomes in cardiac surgery patients with CPB. DESIGN: A retrospective cohort study. SETTING: A review of patients undergoing cardiac surgery with CPB at University Hospital Heidelberg from 2015 to 2023. PATIENTS: A total of 9642 patients were considered. After applying the exclusion criteria, 7233 patients with available preoperative levels of creatinine, lactate dehydrogenase, and platelet counts for EASIX calculation were included. The cohort was divided into a training group (n = 4446, until December 2019) and validation group (n = 2787, from January 2020).
3. Topical Lidocaine During Airway Manipulation in Pediatric Anesthesia: A Systematic Review and Meta-Analysis.
Across 14 RCTs (n=1,937), topical lidocaine during pediatric airway manipulation halved laryngospasm risk and reduced desaturation and sore throat, with no clear effect on bronchospasm, cough, or hemodynamics. Benefits appear robust for airway reflex suppression but heterogeneous for other outcomes.
Impact: Synthesizes randomized evidence to support a simple, scalable intervention that can improve pediatric airway safety.
Clinical Implications: Consider topical lidocaine for pediatric airway topicalization to reduce laryngospasm and desaturation, particularly in high-risk cases; protocols should standardize dosing and application methods.
Key Findings
- Topical lidocaine reduced laryngospasm (OR 0.50; 95% CI 0.27–0.95; p=0.033).
- Desaturation events decreased with topical lidocaine (OR 0.49; 95% CI 0.25–0.98; p=0.043).
- Sore throat was less frequent (OR 0.31; 95% CI 0.16–0.58; p<0.001), with no significant effect on bronchospasm or cough.
Methodological Strengths
- Systematic review and meta-analysis of 14 randomized controlled trials with PROSPERO registration
- Random-effects modeling with effect sizes and 95% CIs for multiple clinically relevant outcomes
Limitations
- Heterogeneity in lidocaine dosing, delivery methods, and procedural contexts
- Limited data on high-risk subgroups and rare adverse events
Future Directions: Head-to-head RCTs to optimize dosing and application technique; evaluation in high-risk pediatric populations and integration into airway management bundles.
INTRODUCTION: Lidocaine is widely used in pediatric anesthesia for airway topicalization to modulate undesirable airway and circulatory reflexes, yet its effectiveness remains unclear. Therefore, we aimed to perform a meta-analysis evaluating the impact of topical lidocaine on respiratory adverse events in children undergoing airway management. METHODS: PubMed, Embase, and Cochrane databases were systematically searched for studies comparing topical lidocaine with placebo, no intervention, or intravenous lidocaine for pediatric airway management. Statistical analysis was performed using R (version 4.4.1). Odds ratios (ORs) were used for binary outcomes and mean differences for continuous outcomes, with 95% confidence intervals (CIs) computed using a random-effects model. RESULTS: Fourteen randomized controlled trials comprising 1937 pediatric patients were included, of whom 917 (47%) received airway topicalization. In those receiving topical lidocaine, there was a significant reduction in the incidence of laryngospasm (OR 0.50; 95% CI 0.27 to 0.95; p = 0.033), desaturation (OR 0.49; 95% CI 0.25 to 0.98; p = 0.043), and sore throat (OR 0.31; 95% CI 0.16 to 0.58; p < 0.001). However, no significant differences were observed for bronchospasm (OR 0.50; 95% CI 0.11 to 2.35; p = 0.382), cough (OR 0.56; 95% CI 0.28 to 1.11; p = 0.099), severe cough (OR 1.30; 95% CI 0.18 to 9.51; p = 0.793), hoarseness (OR 1.41; 95% CI 0.17 to 11.96; p = 0.754), vomiting (OR 1.95; 95% CI 0.47 to 7.99; p = 0.355), and heart rate (beats/min) (MD 0.08; 95% CI -6.31 to 6.47; p = 0.98). CONCLUSION: Our findings suggest that topical lidocaine may reduce the incidence of undesirable airway reflexes such as laryngospasm, desaturation, and sore throat in children undergoing airway management. However, its benefit for other perioperative respiratory adverse events requires further investigation, especially in high-risk populations. TRIAL REGISTRATION: PROSPERO registration number: CRD42024614863.