Daily Anesthesiology Research Analysis

BACKGROUND: Delirium is a serious neuropsychiatric condition common among older adults, associated with prolonged hospital stays, increased morbidity and mortality. Although guidelines emphasise prevention, identifying most effective measures is crucial. OBJECTIVE: To evaluate the efficacy of non-pharmacological and pharmacological interventions in preventing delirium in older adults (≥65 years). METHODS: We conducted a systematic review and meta-analysis of randomised controlled trials across settings, excluding ICU-only studies. MEDLINE, Cochrane, Web of Science and PsycINFO were searched through October 2024. Comparators included standard care, placebo, or other drugs. Random-effects models estimated pooled risk ratios. Risk of bias was assessed using RoB 2.0. Subgroup analyses were performed by setting and drug type. PROSPERO: CRD42024500387. RESULTS: Eighty-seven trials (19,289 randomised patients) were included. Non-pharmacological multicomponent interventions (k = 17) significantly reduced delirium occurrence (risk ratio [RR] = 0.56, 95% CI 0.45-0.72; I2 = 63%) versus usual care, although certainty of evidence was very low. Effects were significant in non-cardiovascular surgical and medical patients. Single-component non-pharmacological interventions (k = 9) showed mixed or inconclusive findings. Among pharmacological trials (k = 53), dexmedetomidine reduced delirium risk (RR = 0.49; 95% CI 0.43-0.57; low-certainty) in non-cardiovascular surgical patients. Corticosteroids and intranasal insulin showed significant effects (high-certainty), based on a small number of trials. Mixed strategies, such as haemodynamic or cerebral oxygen-guided approaches, suggested potential benefit but were heterogeneous. CONCLUSIONS: Non-pharmacological multicomponent interventions reduce delirium occurrence and should be prioritised. Dexmedetomidine showed benefit in non-cardiac surgical populations, while evidence for other drugs remains inconclusive. Overall, certainty was low to very low, highlighting the need for further high-quality randomised trials to ensure generalisability.

IMPORTANCE: The optimal timing of extubation after endovascular thrombectomy performed under general anesthesia for patients with acute ischemic stroke remains uncertain. OBJECTIVE: To evaluate whether early extubation (<6 hours) compared with delayed extubation (6-12 hours) after successful thrombectomy under general anesthesia improves 90-day functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted at a single tertiary academic referral center from April 2023 to June 2025 with 90 days of follow-up. Participants were adults (age ≥18 years) with acute ischemic stroke due to anterior circulation large-vessel occlusion who underwent successful endovascular thrombectomy under general anesthesia. INTERVENTIONS: Participants were randomly assigned (1:1) to receive early (<6 hours) or delayed (6-12 hours) extubation following thrombectomy. MAIN OUTCOMES AND MEASURES: The primary outcome was functional independence at 90 days (as indicated by a modified Rankin Scale [mRS] score of 0-2). Secondary outcomes included the ordinal distribution of mRS scores, length of hospital stay, respiratory and procedure-related complications, and 90-day mortality. RESULTS: Of 312 patients assessed, 174 were randomized, 87 to receive early extubation and 87 to delayed extubation. Ninety-eight patients (56.3%) were women and 76 (43.7%) were men; the median (IQR) age was 76 (69-86) years. Functional independence at 90 days occurred in 41 of 86 patients (47.7%) in the early group and 39 of 85 (45.9%) in the delayed group (risk ratio [RR], 1.04; 95% CI, 0.76 to 1.43). The ordinal analysis of mRS scores showed no significant difference between groups (generalized odds ratio, 0.93; 95% CI, 0.66 to 1.31). Median (IQR) length of hospital stay was 6 (3-9.5) days in the early group and 6 (4-10) days in the delayed group (median difference, 0.0 days; 95% CI, -1.81 to 1.81). The incidence of pneumonia was 19 patients (21.8%) in the early group and 26 patients (29.9%) in the delayed group (RR, 0.73; 95% CI, 0.44 to 1.22), and reintubation occurred in 4 patients (4.6%) vs 2 patients (2.3%), respectively (RR, 2.00; 95% CI, 0.37 to 10.9). Mortality at 90 days was 20 of 86 patients (23.3%) in the early group vs 19 of 85 patients (22.4%) in the delayed group (RR, 1.04; 95% CI, 0.60 to 1.81). CONCLUSIONS AND RELEVANCE: Among patients with acute ischemic stroke undergoing successful thrombectomy under general anesthesia, early extubation (<6 hours) did not improve functional independence compared with delayed extubation (6-12 hours). TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05847309.

BACKGROUND: The best intraoperative hemodynamic strategy in liver transplantation remains uncertain. No high-quality clinical trials or observational studies have comprehensively assessed the association between intraoperative hemodynamic management and postoperative outcomes in liver transplantation. In this study, we aimed to measure the association between two key components of intraoperative hemodynamic management, fluid balance and vasopressor doses, and 7-day graft dysfunction or non-function and other postoperative complications following liver transplantation. METHODS: We conducted a multicenter cohort study across 8 liver transplantation centers in Canada and France. We included consecutive liver transplant recipients over at least 1-year between January 2021 and May 2023. Our exposures were intraoperative fluid balance (volume of blood products, transfused cell saver, colloids, and crystalloids (divided by 1.5), minus estimated blood loss, expressed in liters) and intraoperative vasopressor doses (expressed in increments of 25 µg/kg norepinephrine equivalents). Our primary outcome was 7-day early allograft dysfunction or primary graft non-function. We used regression models adjusted for confounders, including intraoperative hypotension. RESULTS: We included 852 liver transplant recipients (836 with complete data). Participants had a mean (standard deviation) age of 54 years (12), and a median [quartiles] MELD 3.0 score of 20 [11, 29]. The incidence of 7-day early allograft dysfunction or primary graft non-function was 28% (occurring in 236 patients). Neither fluid balance (RR = 1.02 [95% CI, 0.97 to 1.06] for each liter of fluid balance) nor vasopressor doses (RR = 1.03 [95% CI, 0.99 to 1.06] for each increment of 25 ug/kg of norepinephrine equivalent) were associated with the risk of this outcome. CONCLUSION: A higher fluid balance and higher doses of vasopressors were not associated with a higher risk of 7-day early allograft dysfunction or primary graft non-function after liver transplantation.