Daily Anesthesiology Research Analysis

PURPOSE: Postoperative delirium (POD) is frequent and consequential in older adults, especially those with preexisting sleep disorders. While perioperative intravenous dexmedetomidine may lower POD risk, the benefit of preoperative intranasal administration is unknown. This study aimed to determine whether preoperative intranasal dexmedetomidine reduces POD in elderly patients with sleep disorders undergoing major noncardiac surgery. PATIENTS AND METHODS: In this randomized, triple-blind, placebo-controlled trial, 348 elderly patients (≥60 years) with a Pittsburgh Sleep Quality Index >7 undergoing major noncardiac surgery were enrolled between November 2023 and August 2024. Participants received either intranasal dexmedetomidine (n=174) or placebo (n=174) the night before surgery (20:30-00:00). Dexmedetomidine was administered using a weight-based regimen (≤45 kg: 45 μg; 45-75 kg: 60 μg; ≥75 kg: 75 μg), with a rescue dose of 30 μg allowed if sleep onset did not occur within 30 minutes. The primary outcome was the incidence of POD within 5 days postoperatively. Secondary outcomes included preoperative sleep quality, delayed neurocognitive recovery (dNCR) at 7 and 30 days postoperatively, and adverse events on the night before surgery. RESULTS: The incidence of POD was significantly lower in the dexmedetomidine group than in the placebo group (18.4% vs 32.8%, RR:0.56, 95% CI:0.38-0.82, CONCLUSION: Preoperative intranasal dexmedetomidine reduced the incidence of POD and enhanced preoperative sleep quality in elderly patients with sleep disorders undergoing major noncardiac surgery. Given the increased risk of bradycardia, these benefits should be weighed against the need for perioperative monitoring.

BACKGROUND AND OBJECTIVE: Achieving optimal antibacterial dosing in critically ill patients is challenging owing to the pathophysiological changes that alter drug pharmacokinetics. Extracorporeal membrane oxygenation (ECMO) further complicates pharmacokinetics, hypothesized to act as another pharmacokinetic compartment influencing drug concentrations. Ensuring therapeutic antibacterial concentrations is crucial to prevent treatment failure and resistance. This systematic review aimed to identify and evaluate published population pharmacokinetic studies of antibacterials in critically ill adult ECMO patients. METHODS: A systematic search of PubMed, Embase, and Cochrane databases was conducted from database inception to March 2025. Studies were included if they were population pharmacokinetic analyses of antibacterial agents in adult (aged ≥ 18 years) ECMO patients; non-compartmental analyses and non-antibacterial agents were excluded. Data on study characteristics, patient demographics, ECMO parameters, pharmacokinetic models, and covariates were extracted. RESULTS: The search yielded 31 eligible population pharmacokinetic studies. Most studies indicated that ECMO-specific variables (mode, flow rate, oxygenator type) did not significantly influence the pharmacokinetics of the majority of antibacterials. Instead, pharmacokinetic variability was primarily driven by critical illness-related factors, notably renal function and presence of renal replacement therapy. Dosing recommendations frequently highlighted the need for individualized therapy and therapeutic drug monitoring. CONCLUSIONS: Our findings indicate that ECMO itself does not consistently alter the pharmacokinetics of most antibacterials in critically ill adult patients. Observed pharmacokinetic variability and subsequent dosing recommendations are primarily attributable to critical illness factors. Therapeutic drug monitoring is recommended to optimize exposure but minimize toxicity. Further prospective studies with standardized reporting of covariates and clinical endpoints are needed to enhance the evidence base. CLINICAL TRIAL REGISTRATION: PROSPERO Registration and date: CRD420251165914 (15 October, 2025).

INTRODUCTION: The routine use of preoperative electrocardiograms (ECGs) in patients scheduled for cataract surgery is a deeply entrenched practice in Singapore, despite a lack of evidence supporting its role. Unnecessary ECGs and downstream referrals result in increased healthcare costs, strain on healthcare resources and poorer patient experience from multiple hospital visits, investigations and operation delays. International guidelines recommend against routine use of preoperative ECGs. We launched a quality improvement project to reduce the routine use of preoperative ECGs in low-risk patients undergoing cataract surgery, with the aim of aligning our practice with international guidelines and assessing the impact of this on the incidence of surgical cancellations, perioperative morbidity, and mortality. METHODS: One thousand patients scheduled for elective cataract surgery were assigned to either a control group, where routine ECG is performed (current practice) or an intervention group where the need for ECG was determined through standardised screening of relevant symptoms and vitals as per international guidelines. Adverse medical events and surgery postponement were recorded. RESULTS: There was no statistically significant difference in overall cancellation rates between the control and intervention groups (4% vs. 3.2%, P = 0.79). There were no significant differences in the rate of intraoperative events or unplanned admissions between the control and intervention arms. CONCLUSION: The results of this project indicate no benefit from the current practice of routine preoperative ECG for cataract surgery in asymptomatic individuals. The study also provides local data to support international guidelines which recommend against this routine practice.