Daily Anesthesiology Research Analysis

BACKGROUND: Postoperative delirium (POD) is a frequent complication among elderly surgical patients and is associated with adverse outcomes and increased mortality. Current preventive and therapeutic strategies remain limited. Repetitive transcranial magnetic stimulation (rTMS) has recently shown promise in enhancing cognitive function across various neurological and psychiatric conditions. OBJECTIVE: This trial aimed to investigate the efficacy of preoperative rTMS on POD in elderly patients undergoing elective non-cardiac surgery. METHODS: This double-blind, randomized controlled trial included 254 patients aged 60 years or older undergoing elective non-cardiac surgery, randomly assigned to either active rTMS group or sham rTMS group. Patients received two sessions of 10 Hz rTMS over the left DLPFC, at 110% RMT, totaling 1080 pulses before surgery. The primary outcome was the incidence of POD within 7 days after surgery. RESULTS: In the intention-to-treat analysis of 249 patients (median age 69 years [IQR 63 to 73] years; 46.2% women), the incidence of POD was significantly lower in the active rTMS group (10 of 124 [8.1%]) compared with the sham rTMS group (36 of 125 [28.8%]) (relative risk, 0.22; 95% CI 0.10 to 0.46; p < 0.001). Compared with the sham rTMS group, patients in the active rTMS group had significantly lower pain intensity and sleep quality on postoperative days 1 and 3 (p < 0.001 for each), lower anxiety and depression scores on postoperative days 3 and 7 (p < 0.001 for each), and lower frailty scores on postoperative days 1 and 7 (p < 0.001 for each), while there was no significant differences in PONV scores at any time pointy (p > 0.05 for each). CONCLUSIONS: Preoperative high-frequency rTMS targeting left DLPFC was associated with a reduced incidence of POD in elderly patients undergoing elective non-cardiac surgery.

OBJECTIVES: This non-inferiority trial compared intravenous esketamine with erector spinae plane block (ESPB) for postoperative recovery quality and analgesic efficacy in patients undergoing video-assisted thoracoscopic surgery (VATS). DESIGN: Randomized controlled non-inferiority study. SETTING: Single-center, university hospital. PARTICIPANTS: One hundred twelve patients undergoing VATS. INTERVENTIONS: The esketamine group received intravenous esketamine (0.25-mg/kg bolus + 0.25-mg/kg/h infusion) combined with a sham ESPB (25 mL of saline solution). The ESPB group received active ESPB (25 mL of 0.375% ropivacaine) plus intravenous saline solution. MEASUREMENTS AND MAIN RESULTS: Outcomes included 15-item quality of recovery (Quality of Recovery-15 [QoR-15]) scores, postoperative pain scores, Hospital Anxiety and Depression Scale (HADS) scores, and perioperative hemodynamic changes. The differences in the QoR-15 scores between the groups on postoperative day 1 (mean difference, 1.0; 95% confidence interval [CI], -2.9 to 4.8; p = 0.622) and postoperative day 2 (mean difference, 0.4; 95% CI, -3.4 to 4.3; p = 0.833) met the non-inferiority criterion (-6 points). The ESPB group showed significantly lower pain scores during coughing at 4 hours (p = 0.026) and 8 hours (p = 0.006) postoperatively. The esketamine group had lower HADS scores and a lower incidence of hypotension. CONCLUSIONS: Intravenous esketamine provides postoperative recovery quality that is non-inferior to ESPB after VATS, primarily because of its beneficial effects on mood, which compensates for its weaker early analgesia. Thus, esketamine may serve not as a direct analgesic substitute for ESPB, but as a rescue option when ESPB is not feasible, or as an analgesic adjunct with anxiolytic and antidepressant effects.

BACKGROUND: Intraoperative hypotension (IOH) is a common hemodynamic disturbance during major non-cardiac surgery, yet the prognostic significance of different temporal blood pressure patterns remains unclear. This study aimed to identify distinct IOH trajectories using group-based trajectory modeling (GBTM) and to evaluate their independent and incremental predictive value for major postoperative complications in high-risk surgical patients. METHODS: We conducted a retrospective cohort study of 789 adults undergoing elective major abdominal, urologic, or gynecologic surgery between January 2018 and December 2023. Continuous invasive minute-by-minute mean arterial pressure (MAP) recordings were extracted from the anesthesia information management system. IOH was defined as MAP <65 mmHg. GBTM modeled MAP over absolute intraoperative time using polynomial time functions to identify three latent IOH trajectories based on duration and recurrence: transient mild (<10 min), moderate sustained (10-30 min), and prolonged/fluctuating (>30 min or ≥3 episodes). The primary composite outcome included acute kidney injury, postoperative delirium, unplanned ICU admission within 48 h, and 30-day all-cause mortality. Associations were examined using multivariable logistic regression, and predictive performance was evaluated using ROC curves, calibration, bootstrap internal validation, and decision curve analysis. RESULTS: A clear exposure-response relationship was observed across trajectory groups: the primary composite complication occurred in 13.4% of patients in the transient mild group, 20.8% in the moderate sustained group, and 30.7% in the prolonged/fluctuating group (p for trend <0.001). Compared with transient mild hypotension, adjusted odds ratios were 1.58 (95% CI 1.03-2.43) for moderate sustained and 2.42 (95% CI 1.54-3.80) for prolonged/fluctuating trajectories. Incorporating trajectory classification into a clinical model markedly improved discrimination (AUC 0.860 vs. 0.578), calibration, and net clinical benefit compared with conventional IOH measures alone. CONCLUSION: Distinct intraoperative hypotension trajectories derived from high-resolution arterial pressure data were strongly and independently associated with major postoperative complications and substantially enhanced predictive accuracy beyond standard IOH metrics. Trajectory-based hemodynamic profiling may support individualized blood pressure management and early perioperative risk stratification.