Daily Anesthesiology Research Analysis
Analyzed 79 papers and selected 3 impactful papers.
Summary
Three perioperative studies stand out today. A large double-blind RCT shows that adding perineural esketamine to ropivacaine for genicular/IPACK blocks markedly reduces chronic postsurgical pain after total knee arthroplasty. Another RCT suggests ephedrine lowers early postoperative delirium versus phenylephrine in elderly arthroplasty patients, while a 116,996-patient cohort links accelerated biological aging to higher intraoperative hypotension risk, informing preoperative risk stratification.
Research Themes
- Prevention of chronic postsurgical pain with adjuvant regional anesthesia
- Vasopressor choice and neurocognitive outcomes (postoperative delirium)
- Biological aging metrics for perioperative hemodynamic risk stratification
Selected Articles
1. Esketamine as an Adjuvant to Ropivacaine in Genicular Nerve and IPACK Blocks for Total Knee Arthroplasty: A Double-Blind Randomized Trial.
In a double-blind RCT of 367 TKA patients, perineural esketamine (0.2 mg/kg) added to 0.5% ropivacaine for genicular and IPACK blocks reduced 6-month CPSP to 4.9% versus 17.9% (ropivacaine) and 27.0% (control). Pain burden and early functional recovery improved without increased adverse events.
Impact: Demonstrates a pragmatic, scalable strategy to prevent chronic postsurgical pain after TKA using a familiar regional anesthesia framework with a novel adjuvant.
Clinical Implications: Consider perineural esketamine (0.2 mg/kg) as an adjuvant to ropivacaine for genicular and IPACK blocks to mitigate CPSP risk and improve early recovery after TKA, with ongoing vigilance for neurotoxicity or local reactions.
Key Findings
- Esketamine adjuvant reduced 6-month CPSP to 4.9% versus 17.9% (ropivacaine) and 27.0% (control).
- Overall pain burden (AUC) and early functional metrics (eg, TUG, walking distance, QoR-15) improved in the esketamine group.
- No increase in adverse events was reported with perineural esketamine.
Methodological Strengths
- Prospective, randomized, double-blind design with three-arm comparison
- Clinically meaningful primary endpoint at 6 months with functional secondary outcomes
Limitations
- Single-trial setting with journal not field-top; external validation needed
- Details on long-term safety of perineural esketamine remain limited
Future Directions: Replicate in multicenter settings, define optimal dose ranges and formulations, and assess durability beyond 6–12 months and in other orthopedic procedures.
PURPOSE: Chronic postsurgical pain (CPSP) following total knee arthroplasty (TKA) affects up to 44% of patients and markedly impairs recovery and quality of life. Although regional anesthesia is integral to multimodal analgesia, its preventive effect on CPSP remains limited. Esketamine, a potent N-methyl-D-aspartate receptor antagonist with analgesic and neuroprotective properties, may enhance local anesthetic efficacy and reduce the development of chronic pain. PATIENTS AND METHODS: In this prospective, randomized, double-blind trial, 367 patients undergoing unilateral TKA under general anesthesia with peripheral nerve blocks were allocated to three groups: CTRL (normal saline), ROP (0.5% ropivacaine), and ESK (0.5% ropivacaine plus esketamine 0.2 mg/kg) for genicular nerve and IPACK blocks. The primary outcome was the incidence of CPSP (Numerical Rating Scale ≥ 4) at 6 months. Secondary outcomes included opioid consumption, NRS pain scores, Timed Up and Go (TUG) test, walking distance, Quality of Recovery-15 (QoR-15) scores, and adverse events. RESULTS: At 6 months, the incidence of CPSP was significantly lower in the ESK group (4.9%) than in the ROP (17.9%) and CTRL (27.0%) groups. Esketamine significantly reduced overall pain burden (AUC = 559.3 ± 59.0 vs 641.9 ± 55.8 and 679.2 ± 58.5;
2. Effect of Ephedrine versus Phenylephrine on Postoperative Delirium in Elderly Patients Undergoing Total Hip or Knee Arthroplasty: A Randomized Controlled Trial.
In elderly arthroplasty patients, ephedrine to treat intraoperative hypotension reduced 3-day postoperative delirium from 22.4% to 7.7% versus phenylephrine. Ephedrine also lowered intraoperative bradycardia but required more intraoperative opioids, with no difference in postoperative pain.
Impact: Provides actionable evidence that vasopressor selection may influence early neurocognitive outcomes, a modifiable factor in enhanced recovery pathways for older adults.
Clinical Implications: When correcting intraoperative hypotension in elderly arthroplasty patients, ephedrine may be preferred over phenylephrine to reduce early postoperative delirium, while monitoring for higher intraoperative opioid needs.
Key Findings
- Postoperative delirium within 3 days: 7.7% (ephedrine) vs 22.4% (phenylephrine), RR 0.344, p=0.019.
- Ephedrine reduced intraoperative bradycardia versus phenylephrine.
- Higher intraoperative opioid consumption with ephedrine did not translate into higher postoperative pain.
Methodological Strengths
- Randomized controlled design with standardized delirium assessment (3D-CAM)
- Clear, clinically relevant primary endpoint within a defined postoperative window
Limitations
- Single-center trial with modest sample size; limited generalizability
- No cerebral oxygen saturation monitoring; delirium follow-up limited to 3 days
Future Directions: Confirm in multicenter trials with longer delirium follow-up, cerebral oximetry, and mechanistic endpoints (e.g., cerebral perfusion/EEG).
BACKGROUND: Postoperative delirium (POD) is a common complication in elderly patients. Since ephedrine and phenylephrine have different effects on cerebral perfusion and oxygenation, this randomized controlled trial aimed to compare the impact of these two drugs on the incidence of POD in elderly patients undergoing total hip or knee arthroplasty under general anesthesia. PATIENTS AND METHODS: A total of 142 elderly patients, aged 65 to 80 years, who underwent elective surgery for total hip or knee arthroplasty were randomly assigned to either the ephedrine group (Group E) or the phenylephrine group (Group P). POD was evaluated using the 3-minute Diagnostic Confusion Assessment Method (3D-CAM). The primary outcome was the incidence of POD within three days after surgery, while secondary outcomes included the subtypes of delirium, intraoperative hemodynamic changes, intraoperative analgesic consumption, and the occurrence of intraoperative and postoperative adverse events. RESULTS: Delirium occurred in 5 out of 65 cases (7.7%) in Group E and in 15 out of 67 cases (22.4%) in Group P (relative risk [RR], 0.344; 95% confidence interval [CI], 0.132 to 0.891; p = 0.019). Compared to Group P, Group E exhibited a significantly lower incidence of intraoperative bradycardia (RR, 0.241; 95% CI, 0.114 to 0.508; p < 0.001). However, Group E also demonstrated a significantly higher consumption of intraoperative opioids (median difference [MD], 23.0; 95% CI, 2.0 to 25.0 mg; p = 0.020). Notably, despite the higher intraoperative opioid consumption in Group E, there was no statistically significant difference in postoperative pain scores between the two groups (p > 0.05). Additionally, there were no statistically significant differences between the two groups in other indicators, including intraoperative hemodynamic changes and the incidence of postoperative nausea and vomiting (p > 0.05). CONCLUSION: In conclusion, among elderly patients undergoing hip or knee arthroplasty, the use of ephedrine to correct intraoperative hypotension was associated with a reduced incidence of POD within three days compared to phenylephrine. However, the absence of cerebral oxygen saturation monitoring and the limited follow-up period of only three days for POD assessment represent significant limitations.
3. Associations of accelerated biological aging with intraoperative hypotension in major surgery: a multicenter cohort study of 116,996 patients.
Across 116,996 surgical patients at three centers, higher Phenotypic Age Acceleration was independently associated with increased incidence, duration, and AUC of intraoperative hypotension (MAP <60 mmHg). The findings support incorporating biological aging metrics into preoperative risk stratification.
Impact: Introduces a scalable, biology-informed predictor for a common and harmful intraoperative event, enabling precision perioperative management beyond chronological age.
Clinical Implications: Use biological aging metrics (e.g., PhenoAgeAccel) to identify patients at higher risk for IOH, prompting proactive hemodynamic strategies (e.g., monitoring intensity, vasopressor planning, fluid responsiveness guidance).
Key Findings
- Phenotypic Age Acceleration was independently associated with higher IOH incidence.
- Higher biological aging correlated with longer IOH duration and greater MAP<60 mmHg AUC.
- Associations were robust across sensitivity and subgroup analyses in 116,996 patients.
Methodological Strengths
- Very large multicenter cohort with standardized MAP thresholds and integrated AUC metrics
- Adjusted analyses with multiple sensitivity and subgroup checks
Limitations
- Retrospective design; residual confounding cannot be excluded
- External generalizability outside the included health systems requires validation
Future Directions: Prospective validation integrating biological aging with dynamic hemodynamic monitoring and testing targeted interventions for high-risk phenotypes.
BACKGROUND: Intraoperative hypotension (IOH) is a prevalent hemodynamic complication associated with adverse postoperative outcomes. Identifying patients at high risk for IOH remains a challenge. Accelerated biological aging, reflecting cumulative physiological decline, may heighten susceptibility to hypotensive events by impairing cardiovascular homeostasis and autonomic regulation, making it a potent yet underutilized predictor in perioperative medicine. MATERIALS AND METHODS: This multicenter retrospective cohort study analyzed 116,996 adults undergoing major cardiac and non-cardiac surgery across three tertiary academic medical centers in Eastern China. Accelerated biological aging was measured using Phenotypic Age Acceleration (PhenoAgeAccel). Outcomes included incidence of IOH (Mean arterial pressure (MAP) < 60 mmHg), cumulative duration, and area under curve (AUC) below this threshold. AUC was calculated using the trapezoidal integration method to quantify the integrated area where MAP < 60 mmHg. Associations were assessed using generalized linear regression, adjusting for key confounders. RESULTS: Accelerated biological aging was significantly associated with elevated IOH risk (adjusted odds ratio per unit increase 1.04, 95% confidence intervals 1.02-1.06, CONCLUSIONS: Accelerated biological aging was significantly associated with both increased risk and greater severity of intraoperative hypotension. These findings support the integration of biological aging metrics, such as PhenoAgeAccel, into preoperative risk assessment to optimize hemodynamic management in vulnerable surgical populations. Despite being a common perioperative complication, large-scale evidence examining the relationship between biological aging and susceptibility to intraoperative hypotension (IOH) has been lacking.This multicenter cohort study of 116,996 surgical patients found that accelerated biological aging was significantly associated with increased risk and severity of IOH.Multiple sensitivity analyses and subgroup analyses demonstrated robust associations between IOH and biological aging.