Daily Anesthesiology Research Analysis
Analyzed 109 papers and selected 3 impactful papers.
Summary
Three papers stand out today: a randomized trial shows opioid-free total intravenous anesthesia (OFA) reduces major postoperative adverse events in older adults undergoing short surgeries; an international consensus updates peri-operative fasting to safely liberalize clear-liquid intake and expedite postoperative oral intake; and a meta-analysis finds liposomal bupivacaine provides short-term analgesic benefits after thoracoscopic surgery without improving functional recovery.
Research Themes
- Opioid-free anesthesia to reduce perioperative complications in older adults
- Modernizing peri-operative fasting with liberal clear-liquid protocols and early oral intake
- Extended-release local anesthetics for postoperative analgesia after thoracoscopic surgery
Selected Articles
1. Comparison of opioid-free versus opioid-based total intravenous anaesthesia in elderly patients undergoing short-duration surgery: a randomized controlled trial.
In a single-center RCT of 400 older adults undergoing short surgeries, OFA reduced the primary composite of major postoperative adverse events (25.0% vs 43.5%; adjusted OR 0.40, 95% CI 0.25–0.62) compared with opioid-based TIVA. Benefits were driven by less hypoxemia and postoperative nausea and vomiting, though vigilance for OFA-related side effects remains important.
Impact: This pragmatic RCT provides high-level evidence supporting OFA to reduce hypoxemia and PONV in older adults undergoing short procedures, a population highly susceptible to opioid-related harm.
Clinical Implications: Consider OFA protocols for elderly patients having short-duration surgeries to reduce hypoxemia and PONV, with proactive monitoring for bradycardia, hypotension, or other regimen-related effects.
Key Findings
- Primary composite major adverse events were lower with OFA vs OBA (25.0% vs 43.5%; adjusted OR 0.40, 95% CI 0.25–0.62).
- Reductions were mainly due to lower rates of hypoxemia and postoperative nausea and vomiting.
- OFA was feasible in a single-center setting for short-duration surgeries in older adults, with attention required to manage regimen-related side effects.
Methodological Strengths
- Randomized controlled design with prespecified primary composite outcome
- Adequate sample size (n=400) targeting a high-risk elderly population
Limitations
- Single-center study limits generalizability across settings
- Details on blinding and specific OFA regimen components are not fully described in the abstract
Future Directions: Multicenter, pragmatic RCTs comparing distinct OFA protocols versus standardized opioid-based regimens across surgery types and risk strata, including cost-effectiveness and long-term outcomes.
INTRODUCTION: Older adults who undergo short-duration surgery are vulnerable to opioid-related complications. It is uncertain whether an opioid-free total intravenous anaesthesia (OFA) can reduce these events. We aimed to determine whether OFA reduces the incidence of major postoperative adverse events compared with standard opioid-based total intravenous anaesthesia (OBA). PATIENTS AND METHODS: This single-center randomized clinical trial was conducted in China. From May to August 2025, 400 patients aged ≥60 years undergoing elective, short-duration surgery (anticipated duration of less than 90 min) were randomized 1:1 to receive either OFA ( RESULTS: A total of 400 randomized patients (mean [SD] age, 69.5 [7.0] years; 125 [31.3%] women). The primary composite outcome occurred in 50 patients (25.0%) in the OFA group and 87 patients (43.5%) in the OBA group (adjusted odds ratio, 0.40; 95% CI, 0.25 to 0.62; CONCLUSION: These findings suggest that OFA is a viable alternative to opioid-based anesthesia for improving postoperative outcomes by reducing the incidence of hypoxemia and PONV in this population, while warranting careful management of its associated side effects. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2500102550.
2. Peri-operative fasting in adults: an international, multidisciplinary consensus statement.
An international, multidisciplinary panel used systematic review and a three-round Delphi process to issue eight recommendations: maintain current fasting for solids, encourage clear liquids up to 2 hours pre-anesthesia with institution-level protocols permitting more liberal intake, allow salivation stimulants until transfer, resume oral intake as early as feasible, and consider preprocedural gastric ultrasound when indicated.
Impact: This consensus provides timely, implementable guidance to safely minimize fasting times, improving patient experience and potentially recovery, while supporting adoption of modern, protocolized fasting practices.
Clinical Implications: Implement institutional protocols that allow clear liquids up to 2 hours before anesthesia (or more liberal per protocol), permit chewing gum/salivation stimulants until transfer, resume oral intake early post-procedure, and use gastric ultrasound selectively.
Key Findings
- Adults should stop solids and milk products 6 hours pre-anesthesia (8 hours after heavy/fatty meals) and may take clear liquids until 2 hours before anesthesia.
- Institutions are encouraged to adopt protocols allowing more liberal clear-liquid intake within 2 hours based on operational safety.
- Postoperative oral intake should be resumed as early as clinically feasible; salivation stimulants are acceptable until transfer; gastric ultrasound can guide individualized decisions.
Methodological Strengths
- Systematic literature review underpinning a structured Delphi process
- International, multidisciplinary stakeholder engagement (patients and clinicians) with consensus across eight recommendations
Limitations
- Consensus statements are not interventional trials and rely on indirect evidence synthesis
- Implementation and safety of more liberal protocols may vary by institution and patient populations
Future Directions: Prospective implementation studies and randomized trials examining liberalized clear-liquid protocols with patient-centered outcomes, aspiration risk metrics, and cost-effectiveness across diverse settings.
INTRODUCTION: Evidence suggests that existing pre-operative fasting guidelines are associated with prolonged fasting times. Prolonged fasting, particularly from clear liquids, has the potential to harm patients through reduced peri-operative wellbeing; impaired glucose metabolism and peri-operative inflammatory response; delayed return of bowel function; and reduced muscle strength. Liberalisation of fasting practices has, therefore, become increasingly common. Such a change in practice dictates the need for updated practice guidance. We aimed to develop recommendations on peri-operative fasting that reflect increasing global awareness of the adverse effects of prolonged fasting. METHODS: Following a systematic literature review, 13 draft recommendations related to peri-operative fasting were developed iteratively. These were modified during a three-round Delphi process by an international, multidisciplinary stakeholder panel, which included: patients; anaesthetists; surgeons; physicians; nurses; and members of relevant international organisations from five continents. RESULTS: Sixty-eight stakeholders participated in the Delphi consensus process. The panel subsequently agreed on eight recommendations. We recommend continuing current practices on pre-operative fasting for solid food and non-clear liquids. We recommend encouraging clear liquids until 2 h before the start of anaesthesia or sedation, unless institutional protocols allow for more liberal liquid intake. We further recommend implementation of institutional protocols that allow more liberal clear liquid intake < 2 h before the start of anaesthesia or sedation. Salivation stimulants can be used until transfer for the procedure. Oral intake should be resumed as soon as clinically feasible. Preprocedural gastric ultrasound performed by a trained provider may be used to guide clinical decisions when additional information is required. DISCUSSION: This international, multidisciplinary consensus statement aims to improve the quality of patient care by minimising periprocedural fasting times, within safe margins. To achieve this, liberalised pre-operative clear liquid intake regimens may be implemented with institutional protocols. WHAT WE DID: An international group of doctors, nurses and patients worked together to create new recommendations that make fasting safer and more comfortable for people needing anaesthesia. They reviewed research and reached agreement on eight main recommendations. WHY WE DID IT: Before an operation or procedure, people are told not to eat or drink for several hours so that their stomachs are empty when they receive anaesthesia. This is meant to reduce the small risk of food or liquid going into the lungs during anaesthesia. But many patients fast for much longer than needed, with some finding that this is often more than 14 hours without food and 9 hours without drinks. Long fasting times can make people feel tired, thirsty, anxious or weak, and can affect their recovery after surgery. WHAT WE FOUND: Adults should stop eating solid food and milk products 6 hours before anaesthesia (8 hours after a heavy or fatty meal). Clear drinks like water, tea, coffee with a little milk or juice can usually be taken until 2 hours before surgery. Hospitals may also make protocols allowing clear drinks closer to the time of anaesthesia, such as permitting them to drink clear liquids until they are called for their procedure. Patients should start drinking and eating again as soon as they are able after the operation. Chewing gum or sucking sweets is acceptable until patients are taken for surgery. Overall, these recommendations aim to improve patient comfort, prevent harm from long fasting and support hospitals in adopting safe, modern fasting practices.
3. Liposomal bupivacaine for postoperative analgesia after thoracoscopic surgery: a systematic review and meta-analysis.
Across nine RCTs (n=915), liposomal bupivacaine reduced opioid consumption at 24, 48, and 72 hours and lowered pain scores at 24 and 48 hours after thoracoscopic surgery, without differences in total hospitalization opioid use, length of stay, time to ambulation, or overall pain burden. Short-term analgesia improved, but functional recovery metrics were unchanged.
Impact: This RCT-based meta-analysis clarifies the role of liposomal bupivacaine in thoracoscopic surgery: meaningful short-term analgesia with no demonstrable gains in functional recovery, informing evidence-based ERAS decisions and cost–benefit discussions.
Clinical Implications: LB can be considered to reduce early postoperative pain and opioid use after thoracoscopic surgery, while clinicians should not expect shortened LOS or faster ambulation; selection should weigh costs and institutional pathways.
Key Findings
- LB reduced opioid consumption at 24 h (MD −1.83 MMEs), 48 h (MD −2.22), and 72 h (MD −1.73) versus controls.
- Pain scores were lower with LB at 24 h (MD −0.99) and 48 h (MD −0.42), but not at 72 h.
- No significant differences in length of stay, time to first ambulation, total hospitalization opioid use, or overall hospitalization pain scores.
Methodological Strengths
- Exclusive inclusion of randomized controlled trials with Cochrane RoB1 assessment
- GRADE framework applied to rate certainty of evidence
Limitations
- Heterogeneity in LB dosing, infiltration sites, and comparator regimens across trials
- No demonstrated improvements in functional outcomes despite analgesic benefits
Future Directions: Head-to-head RCTs comparing LB strategies within standardized ERAS pathways, with cost-effectiveness, patient-reported outcomes, and opioid-sparing endpoints across varied thoracic procedures.
BACKGROUND: Thoracoscopic surgery has become the standard approach for many thoracic conditions. Despite its advantages, postoperative pain remains a significant cause of complications. Liposomal bupivacaine (LB), an extended-release local analgesic, has been introduced to enhance recovery. This meta-analysis of randomized controlled trials (RCTs) compares the efficacy of LB METHODS: We systematically searched PubMed, the Cochrane Library, Embase, and Web of Science for RCTs published from the inception of each database to November 2025. The risk of bias of the included studies was evaluated with the Cochrane Risk of Bias 1 (RoB 1) tool, and the quality of evidence was graded using the GRADE system. The primary outcome was postoperative opioid consumption at 24 hours, measured in morphine milligram equivalents (MMEs). Secondary outcomes included opioid consumption at 48 hours, 72 hours, and during total hospitalization; pain scores assessed using the visual analogue scale (VAS) at 24 hours, 48 hours, 72 hours, and over the entire hospitalization period; length of hospital stay (LOS); and time to first ambulation. Data were synthesized using Review Manager (RevMan; version 5.4). RESULTS: Nine RCTs involving 915 patients were included. Compared to the control group, LB significantly reduced opioid consumption at 24 hours [mean difference (MD) =-1.83; 95% confidence interval (CI): -2.42, -1.24; P<0.001], 48 hours (MD =-2.22; 95% CI: -2.78, -1.66; P<0.001), and 72 hours (MD =-1.73; 95% CI: -2.21, -1.25; P<0.001). Pain scores were also significantly lower in the LB group at 24 hours (MD =-0.99; 95% CI: -1.57, -0.41; P<0.001) and 48 hours (MD =-0.42; 95% CI: -0.77, -0.06; P=0.02), but the difference was not statistically significant at 72 hours (MD =-0.41; 95% CI: -0.95, 0.13; P=0.14). No significant differences were found in total opioid consumption, pain scores over the entire hospitalization period, LOS, or time to first ambulation. CONCLUSIONS: LB provides superior short-term analgesia but does not improve functional recovery outcomes compared to non-liposomal local anesthetics.