Anesthesiology, September 18 edition

This global prospective cohort included 1,466 donor-recipient pairs and evaluated anesthetic technique in living donor hepatectomy. Volatile anesthesia was independently associated with higher donor Comprehensive Complication Index scores, more major complications, greater blood loss, higher transfusion rates, and more biliary complications, whereas recipient outcomes were similar.

Impact: It is the largest international prospective comparison identified in this dataset and directly addresses anesthetic selection in a high-stakes, otherwise healthy donor population. The consistent association between TIVA and fewer donor complications provides a strong hypothesis for practice-changing randomized trials.

Clinical Implications: Living donor hepatectomy programs may consider TIVA as a preferred or strongly considered anesthetic strategy, particularly when donor safety is prioritized. However, technique selection should remain individualized because the observational design cannot exclude residual confounding by center, surgeon, patient, or anesthetic practice.

Future Directions: Large multicenter randomized trials should compare standardized TIVA and volatile anesthesia protocols in living donor hepatectomy, with donor-centered outcomes, recovery quality, hepatic function, cost, and long-term safety as prespecified endpoints.

In this randomized trial of 606 patients, preprocedural lactated Ringer's solution at 10 mL/kg reduced hypotension during propofol-sedated gastroenteroscopy from 25.4% to 14.2%. The intervention also reduced inferior vena cava collapsibility changes and ephedrine use without prolonging recovery or increasing adverse events.

Impact: This is a simple, inexpensive, and readily implementable intervention that produced an absolute risk reduction of 11.2% and a number needed to treat of 9. It directly addresses a common outpatient anesthesia complication and could be incorporated into procedural sedation protocols after external validation.

Clinical Implications: For appropriately selected patients undergoing propofol-sedated gastroenteroscopy, preprocedural crystalloid administration may reduce hypotension and vasopressor requirements. Fluid loading should nevertheless be individualized in patients at risk of fluid overload, including those with significant heart or renal disease.

Future Directions: Further multicenter trials should validate the protocol in diverse outpatient populations, compare different fluid types and volumes, and identify patients most likely to benefit while monitoring fluid-related complications.

This single-center randomized non-inferiority trial randomized 316 older adults undergoing total knee or hip arthroplasty. Postoperative delirium occurred in 9.5% after intranasal dexmedetomidine given the night before surgery versus 7.6% after intravenous dexmedetomidine before induction, meeting the prespecified non-inferiority criterion.

Impact: The study supports a less invasive route and earlier timing for dexmedetomidine administration in older surgical patients, potentially improving preoperative sleep and anxiety while avoiding intravenous administration before induction. The result is clinically relevant but requires confirmation because it was single-center and the confidence interval permits a modest difference between strategies.

Clinical Implications: Intranasal dexmedetomidine administered the night before elective arthroplasty may be considered when intravenous pre-induction administration is inconvenient or undesirable. Implementation should include monitoring for sedation, bradycardia, hypotension, and institution-specific delirium prevention protocols.

Future Directions: Multicenter non-inferiority trials should confirm the findings, use standardized delirium prevention bundles, evaluate longer-term cognitive and functional outcomes, and determine optimal intranasal dosing and timing across different surgical populations.