Daily Anesthesiology Research Analysis
Three randomized trials highlight actionable advances in anesthesiology: high-flow nasal cannula (HFNC) enabled thoracoscopic surgery with spontaneous ventilation and faster recovery compared with laryngeal mask or double-lumen intubation; postoperative low-dose esketamine infusion reduced depressive symptoms and opioid needs after traumatic fractures; and intravenous lidocaine during endoscopic submucosal dissection improved short-term cognitive recovery while reducing propofol use and hypotens
Summary
Three randomized trials highlight actionable advances in anesthesiology: high-flow nasal cannula (HFNC) enabled thoracoscopic surgery with spontaneous ventilation and faster recovery compared with laryngeal mask or double-lumen intubation; postoperative low-dose esketamine infusion reduced depressive symptoms and opioid needs after traumatic fractures; and intravenous lidocaine during endoscopic submucosal dissection improved short-term cognitive recovery while reducing propofol use and hypotension.
Research Themes
- Airway-sparing oxygenation strategies for thoracoscopic surgery
- Perioperative neurocognitive and mood protection
- Opioid-sparing multimodal analgesia within ERAS pathways
Selected Articles
1. Randomized trial of high-flow nasal cannula versus double lumen endotracheal tube or laryngeal mask for thoracoscopic surgery.
In thoracoscopic surgery with spontaneous ventilation, HFNC achieved similar intraoperative oxygenation to LMA and double-lumen intubation but improved post-extubation oxygenation, shortened extubation and PACU times, and reduced nausea, sore throat, and dizziness. HFNC also lowered propofol and opioid use (with higher dexmedetomidine) and improved early mobility, sleep, and pain scores, while transient intraoperative hypercapnia normalized postoperatively.
Impact: This RCT operationalizes an airway-sparing approach to thoracoscopic anesthesia that accelerates recovery and reduces adverse symptoms, challenging routine reliance on endotracheal intubation or LMA. It provides pragmatic evidence for integrating HFNC into ERAS-aligned thoracic anesthesia pathways.
Clinical Implications: HFNC can be considered for selected thoracoscopic cases to avoid airway instrumentation, reduce anesthetic/opiates, and enhance recovery. Vigilant monitoring of CO2 and sedation choices (e.g., dexmedetomidine) are essential; patient selection (e.g., low aspiration risk, manageable hypercapnia) remains key.
Key Findings
- HFNC achieved comparable intraoperative oxygenation but higher post-extubation oxygenation than LMA or double-lumen intubation.
- Extubation time and PACU length of stay were significantly shorter with HFNC.
- HFNC reduced postoperative nausea, sore throat, and dizziness within 24 hours and lowered propofol/opioid consumption.
- Intraoperative CO2 was higher with HFNC/LMA but normalized after surgery; early mobility, sleep, and pain scores were improved.
Methodological Strengths
- Prospective three-arm randomized design with clinically meaningful outcomes.
- Comprehensive perioperative assessment including gas exchange, recovery metrics, adverse effects, and drug consumption.
Limitations
- Single-center design without blinding; sedation regimens differed (higher dexmedetomidine in HFNC), which may confound recovery outcomes.
- Generalizability to complex thoracoscopic procedures and high-risk patients is uncertain; intraoperative hypercapnia requires careful management.
Future Directions: Multicenter trials comparing HFNC with standardized sedation protocols and carbon dioxide management algorithms are needed, including safety endpoints (CO2 retention, hypoxemia) and cost-effectiveness analyses.
BACKGROUND: High-flow nasal cannula (HFNC) oxygen therapy is widely used primarily for preoxygenation and post-extubation respiratory support. However, its intraoperative application remains uncommon. This study evaluated the effects of HFNC on respiratory mechanics and hemodynamics in thoracoscopic surgery under spontaneous ventilation. METHODS: This randomized trial included 165 patients scheduled for thoracoscopic surgery from 2023 to 2024. Patients were assigned to three ventilation supports: double-lumen endotracheal tube (Intubation group, n=55), laryngeal mask airway (LMA group, n=55), or HFNC (n=55). Intraoperative respiratory and hemodynamic changes, postoperative recovery, and adverse effects were analyzed. RESULTS: The oxygenation index was comparable intraoperatively, but higher in the HFNC group 5 min post-extubation (P = 0.018). Intraoperative carbon dioxide was higher in the HFNC and LMA groups (P < 0.05), but gradually normalized postoperatively. HFNC shortened extubation time (30 vs 33 vs 37 min, P = 0.005) and postoperative anesthesia care unit stay (70 vs 75 vs 85 min, P < 0.001), and reduced the incidence of nausea, sore throat, and dizziness in postoperative 24 hour (P = 0.005, P = 0.001, P = 0.002). HFNC patients demonstrated improved early mobility and nocturnal sleep and lower numeric pain rating scale score at rest and during activity (P < 0.05). Propofol and opioid use was lower in the HFNC group (P = 0.016, P < 0.001), while dexmedetomidine consumption was higher (P = 0.002). CONCLUSIONS: HFNC provides a stable form of anaesthesia compared with laryngeal mask and intubation, and is associated with early improved rehabilitation in thoracoscopic surgery.
2. Effect of esketamine on postoperative pain relief and depressive status in patients with traumatic fractures.
In a triple-blind RCT of 225 fracture patients, continuous esketamine infusion (0.5–0.75 mg/kg over 24 h) reduced postoperative depressive symptoms (lower HAMD on POD1 and POD3), spared opioids, and decreased nausea/vomiting. Biomarkers suggested mechanistic plausibility with increased BDNF and decreased IL-6.
Impact: Addresses the common and undertreated problem of postoperative depressive symptoms while simultaneously optimizing analgesia and reducing opioid-related adverse effects, aligning with perioperative brain health and opioid-sparing priorities.
Clinical Implications: Consider low-dose postoperative esketamine infusion in traumatic fracture patients to mitigate early postoperative depression and reduce opioid requirements, with monitoring for dose-related adverse effects and integration into multimodal analgesia pathways.
Key Findings
- Esketamine infusion (0.5–0.75 mg/kg over 24 h) reduced HAMD scores on POD1 and POD3 versus control.
- Opioid-sparing analgesia with reductions in opioid-related adverse effects (nausea, vomiting).
- Biomarker changes consistent with mechanistic action: increased BDNF and decreased IL-6.
- Triple-blind, placebo-controlled methodology enhances internal validity.
Methodological Strengths
- Randomized, triple-blind, placebo-controlled design with trial registration.
- Assessment of both clinical outcomes (HAMD, analgesia, adverse events) and mechanistic biomarkers (BDNF, IL-6).
Limitations
- Single-center population aged 18–64; generalizability to elderly, polytrauma, or other surgeries is uncertain.
- Short follow-up limited to early postoperative days; long-term mood, functional, and safety outcomes are unknown.
Future Directions: Multicenter, pragmatic trials across surgical populations with longer follow-up should validate mood and analgesic benefits, define optimal dosing/timing, and evaluate neurocognitive and functional recovery.
OBJECTIVE: To investigate the effects of different doses of esketamine combined with sufentanil on postoperative pain relief and depressive states in patients with traumatic fractures. METHODS: This prospective, randomized, triple-blind, placebo-controlled trial (registered at the Chinese Clinical Trial Registry, Identifier: ChiCTR2100054238) enrolled 225 patients with traumatic lower limb fractures (ASA I-III, aged 18-64) at Jiangxi Provincial People's Hospital between September 2021 and June 2024. Patients were randomly allocated to three groups ( RESULTS: Both esketamine groups (L and H) demonstrated significantly lower HAMD scores on postoperative days 1 and 3 compared to group C (all CONCLUSION: Continuous postoperative infusion of esketamine (0.5-0.75 mg/kg over 24 h) in patients with traumatic lower limb fractures effectively alleviates postoperative depressive symptoms, provides opioid-sparing analgesia, reduces opioid-related adverse effects like nausea and vomiting, and is associated with increased BDNF and decreased IL-6 levels.
3. Intravenous Lidocaine and Cognitive Recovery After Endoscopic Submucosal Dissection: A Randomized Controlled Trial.
In a double-blind RCT of colorectal ESD, IV lidocaine improved cognitive recovery on POD3 and sustained benefits to day 7, while reducing propofol requirements by 25%, injection pain, and hypotensive episodes, without toxicity. These data support lidocaine as a neuroprotective and hemodynamically favorable adjunct to endoscopic sedation.
Impact: Demonstrates a simple, widely available intervention that improves short-term postoperative cognitive outcomes and hemodynamic stability while reducing hypnotic dose in endoscopic sedation—an area with growing procedural volume.
Clinical Implications: Consider IV lidocaine (1.5 mg/kg bolus then 2 mg/kg/h) in ESD sedation protocols to enhance cognitive recovery and reduce propofol exposure and hypotension; ensure appropriate monitoring and contraindication screening (e.g., arrhythmia risk).
Key Findings
- IV lidocaine improved PostopQRS cognitive recovery on POD3 with benefits persisting to day 7.
- Propofol requirements were reduced by approximately 25% with lidocaine.
- Injection pain and hypotensive episodes were significantly reduced; no lidocaine toxicity observed.
- Trial was prospectively registered and double-blinded, enhancing validity.
Methodological Strengths
- Randomized, double-blind, placebo-controlled design with trial registration.
- Objective cognitive assessment (PostopQRS) across multiple timepoints and comprehensive perioperative endpoints.
Limitations
- Single procedure type (colorectal ESD) limits generalizability to other endoscopic or surgical contexts.
- Short-term cognitive endpoints; long-term neurocognitive trajectories were not assessed.
Future Directions: Evaluate IV lidocaine across diverse endoscopic and surgical procedures, define optimal dosing windows, and assess longer-term neurocognitive outcomes and cost-effectiveness.
BACKGROUND AND PURPOSE: While intravenous lidocaine reduces propofol requirements during procedures, its effects on postoperative cognitive function remain uncertain. This study evaluated whether lidocaine enhances cognitive recovery in patients undergoing endoscopic submucosal dissection (ESD) with propofol sedation. PATIENTS AND METHODS: In this randomized, double-blind, placebo-controlled trial, 234 patients undergoing colorectal ESD received either intravenous lidocaine (1.5 mg/kg bolus followed by 2 mg/kg/h infusion) or a saline placebo. The standard sedation protocol included sufentanil 0.1 μg/kg and propofol for induction, with additional propofol as needed to maintain adequate sedation depth. The primary outcome was cognitive recovery on postoperative day 3 assessed by the PostopQRS cognitive domain. Secondary outcomes included recovery patterns at four timepoints (30 minutes, 1, 3, and 7 days), propofol consumption, injection pain, satisfaction scores, and adverse events. RESULTS: The lidocaine group demonstrated significantly better cognitive recovery than the placebo group [relative risk 1.15, 95% confidence interval (CI) 1.04-1.28, p=0.008], with benefits lasting through day 7 (p=0.035). Lidocaine administration resulted in a 25% reduction in propofol consumption [230 (208-258) mg compared to 305 (261-354) mg, with a median difference of -71 mg, 95% CI -85 to -57, p<0.001]. Additionally, injection pain scores were significantly lower in the lidocaine group [median score of 0 (0-1) versus 1 (0-3), p<0.001]. The incidence of hypotensive episodes was also reduced with lidocaine administration (12.8% compared to 24.8%, p=0.019). Importantly, no lidocaine toxicity was observed. CONCLUSION: Intravenous lidocaine was associated with enhanced cognitive recovery on postoperative day 3, as well as decreased propofol requirements, injection pain, and hypotensive episodes during ESD. These results indicate that lidocaine may serve as an effective adjuvant in endoscopic sedation protocols. REGISTRATION: ClinicalTrials.gov, NCT05750056.