Daily Anesthesiology Research Analysis

Former preterm and term infants are at risk for postanesthesia apnea, but the lack of uniform standards for monitoring and discharge criteria leads to inconsistent practice. The primary aim of this study was to identify major risk factors for postanesthesia apnea. This systematic review and meta-regression analysis used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Agency for Healthcare Research and Quality guidelines. The literature search included English language case reports, case series, clinical studies, and clinical trials. Major databases were queried from inception to October 2025. A total of 6,191 articles underwent title and abstract screening, 491 underwent full-text screening, and 173 underwent detailed reviews. Data were extracted from 115 of 173 articles (98 studies, 17 case reports or series). Across studies (preterm or full term infants), the median incidence of apnea was 7.6% (range, 0 to 85%). Univariable meta-regression analysis (96 eligible articles) identified five significant predictors of apnea: gestational age, postmenstrual age at time of procedure, birth weight, procedure duration, and year of publication. Odds for apnea incidence decreased with later publication year, older gestational age at birth, older postmenstrual age at time of surgery, higher birth weight, and shorter procedure duration. A multivariable "best fitting model" (64 eligible articles) including publication year (1986 to 2025) and postmenstrual age (32 to 63 weeks) found a decrease in odds of apnea incidence with later publication year (odds ratio [OR], 0.936; CI, 0.91 to 0.964; P < 0.001) and higher postmenstrual age (OR, 0.889; CI, 0.828 to 0.954; P = 0.001). Recommended postanesthesia monitoring duration ranged from 6 to 24 h based on postmenstrual age. Meta-regression showed significantly lower apnea odds with neuraxial versus general anesthesia (OR, 0.236; CI, 0.094 to 0.592; P = 0.003). Postmenstrual age appears to be the strongest and most consistent risk factor for postanesthesia apnea; neuraxial anesthesia may reduce this risk. An individual participant data meta-analysis in a follow-up article will shed further light on the at-risk postmenstrual age threshold for increased risk and help refine monitoring recommendations for these vulnerable infants.

BACKGROUND: Acute postoperative pain is highly prevalent following surgical procedures. Identifying N-methyl-d-aspartate (NMDA) receptor antagonists with potential for preventing acute postoperative pain is clinically critical, yet individual randomized controlled trials (RCT) often lack sufficient statistical power. Network meta-analysis mitigates this limitation by boosting statistical power, enabling comprehensive comparison of multiple interventions to identify the most effective therapeutic options for preventing acute postoperative pain. METHODS: We systematically searched Pubmed, Embase, Cochrane and MEDLINE databases for RCTs evaluating the efficacy of NMDA receptor antagonists in preventing acute postoperative pain. Studies were carefully selected based on the PICOS framework. We performed the network meta-analysis with R using the GeMTC and BUGSnet packages. The primary outcome was defined as the pain score at 24 h postoperatively. Secondary outcomes included morphine consumption at 24 h postoperatively, time to the first postoperative analgesic request, rescue analgesic requirements and incidence of postoperative nausea and vomiting (PONV). RESULTS: A total of 47 eligible RCTs involving 3055 participants were included in this analysis. In terms of reducing 24-h postoperative pain scores, esketamine (MD -1.39; 95% credible interval [Crl] -2.57 to -0.37), high-dose dextromethorphan (MD -1.17; 95% Crl -1.81 to -0.53) and medium-dose ketamine (MD -0.93; 95% Crl -1.74 to -0.08) exhibited significant effects. For secondary outcomes, medium-dose dextromethorphan (MD -10.50; 95% Crl -19.66 to -1.45) was optimal for reducing 24-h postoperative morphine consumption; high-dose dextromethorphan (MD 206.41; 95% Crl 24.39 to 394.30) effectively prolonged the time to first postoperative analgesic request; and magnesium sulphate (OR 6.91; 95% Crl 1.64 to 24.97) was the only intervention that significantly reduced rescue analgesic requirements. Medium-dose dextromethorphan (OR 15.32; 95% CrI 1.48 to 334.61) and ketamine administered via patient-controlled epidural analgesia (OR 5.88; 95% CrI 1.31 to 30.88) significantly reduced the incidence of PONV. CONCLUSIONS: Esketamine and high-dose dextromethorphan achieved clinically meaningful reductions in VAS pain scores at 24 h postoperatively. Additionally, medium-dose dextromethorphan decreased 24-h morphine consumption, high-dose dextromethorphan significantly prolonged the time to first analgesic request, and magnesium sulphate reduced rescue analgesia requirements. Medium-dose dextromethorphan and ketamine administered via patient-controlled epidural analgesia reduced the incidence of PONV. However, the increasingly limited clinical availability of dextromethorphan restricts the generalizability of our findings. Furthermore, the certainty of evidence for most outcomes was low to very low, mainly due to residual heterogeneity and imprecision, supporting the need for further high-quality studies. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (CRD420251116678).

BACKGROUND: Recently, various anesthesiology societies have reported cases involving pediatric patients of Venezuelan origin who underwent surgery under general anesthesia and subsequently developed serious neurologic impairment or died. However, the cause of this condition was unknown. METHODS: Clinical and genetic studies were conducted on seven patients who experienced severe acute neurologic deterioration after the administration of general anesthetics during predominantly minor surgical procedures. Genetic-molecular, biochemical, and cellular studies were also performed on fibroblasts and cybrids treated with general anesthetics. RESULTS: In our cohort, acute perioperative events were observed in temporal association with anesthetic exposure. No adverse events were observed in a subset of the same individuals when only intravenous anesthesia was used. All patients shared a mitochondrial DNA haplotype that includes the m.11232T>C genetic variant, which results in the substitution of proline for leucine at position 158 (L158P) of the ND4 subunit of respiratory complex I in the electron transport chain. In vitro studies showed that sevoflurane exposure in cells carrying this genetic variant induces a pronounced suppression of mitochondrial oxygen consumption, with prominent effects on complex I-dependent respiratory pathways. In contrast, propofol did not elicit a differential effect in cells harboring this genetic variant. CONCLUSIONS: These findings suggest that individuals carrying the m.11232T>C mitochondrial DNA variant may be at increased risk of severe neurologic deterioration after exposure to anesthetic agents. Further studies are needed to define the underlying mechanisms and to determine anesthetic-specific risks. These results have important implications for improving the safety of surgical interventions and open new avenues in the field of mitochondrial pharmacogenetics of general anesthesia.