Daily ReportSep 22, 2026
Anesthesiology, September 22 edition
We read 46 papers and selected 3.
Summary
Today’s strongest anesthesiology research addressed large-scale improvement of perioperative documentation, the effectiveness of continuous blood-pressure monitoring, and nonpharmacological reduction of adverse postoperative behavior in children. The findings collectively emphasize implementation science, clinically meaningful monitoring metrics beyond binary outcomes, and low-risk interventions that can improve perioperative safety and recovery.
Research Themes
- Clinical decision support and implementation science
- Continuous hemodynamic monitoring and outcome measurement
- Pediatric perioperative psychological care
Selected Articles
1. Effect of In-line Clinical Decision Support to Improve Accuracy of American Society of Anesthesiologists Physical Status Documentation: A Two Center Evaluation of a Quality Intervention.
This two-center evaluation examined an in-line clinical decision support system that identified 51 conditions warranting consideration of ASA Physical Status 3 or higher. At the intervention site, 251,944 anesthetics were evaluated and assignment of ASA Physical Status 3 or higher increased from 52.9% to 61.7%, whereas the contemporaneous control site showed only a small increase from 47.2% to 48.4%.
Impact: The study demonstrates that a relatively simple, documentation-integrated intervention can alter a high-volume clinical classification at scale. It provides a pragmatic model for improving perioperative risk communication and data quality without relying solely on clinician education.
Clinical Implications: Anesthesia departments could consider integrating condition-aware prompts into electronic anesthesia records to reduce under-classification and improve consistency of ASA Physical Status assignment. Implementation should include monitoring for alert fatigue, workflow burden, and potential over-classification.
Key Findings
- The study included 251,944 anesthetics at the intervention site and 286,172 anesthetics at a contemporaneous external-control site.
- At the intervention site, ASA Physical Status 3 or higher increased from 52.9% to 61.7%, with an adjusted odds ratio of 1.42.
- Among patients with conditions addressed by the later CDS phase, ASA Physical Status 3 or higher increased from 83.6% to 94.0%, with an adjusted odds ratio of 3.54.
Methodological Strengths
- Very large real-world sample with a contemporaneous external control group.
- Difference-in-differences analysis directly evaluated change beyond secular trends.
- The intervention was embedded in routine clinical documentation rather than tested only in an artificial research setting.
Limitations
- The study was not a patient-level randomized trial, so residual confounding and concurrent institutional changes cannot be excluded.
- The primary outcome was documentation of ASA Physical Status rather than downstream patient outcomes such as complications, resource use, or mortality.
- The intervention was evaluated at two academic centers, which may limit generalizability to other institutions.
Future Directions: Future studies should assess whether improved ASA Physical Status documentation changes preoperative testing, anesthetic planning, perioperative resource allocation, complications, and patient-centered outcomes. External validation in community hospitals and assessment of alert fatigue are also needed.
BACKGROUND: American Society of Anesthesiologists Physical Status (ASA PS) classification is a widely used ordinal scale that captures comorbidity burden but has significant inter-rater variability. Previous efforts to enhance ASA PS documentation with Clinical Decision Support (CDS) are limited by inaccurate problem lists, poor user experience, or consideration of select comorbidities. We developed and implemented a CDS which uses the anesthesia clinicians' documentation to highlight potential under-classification at time of ASA PS assignment.
2. Continuous versus intermittent non-invasive blood pressure monitoring and intraoperative hypotension: a systematic review and meta-analysis.
This systematic review included 12 randomized controlled trials involving 1,466 randomized patients. Continuous finger-cuff monitoring did not significantly reduce the binary incidence of intraoperative hypotension, but it reduced time-weighted and area-under-the-curve measures of hypotension burden; the certainty of evidence ranged from very low to low.
Impact: The study challenges the assumption that improved blood-pressure sampling automatically reduces the occurrence of hypotension. Its emphasis on cumulative hypotension exposure provides a more clinically informative framework for evaluating monitoring technologies and perioperative hemodynamic management.
Clinical Implications: Continuous non-invasive monitoring may be useful when the goal is earlier recognition and reduction of cumulative hypotension burden, but routine adoption cannot yet be justified solely by a reduction in hypotension incidence. Clinicians should interpret continuous-monitoring benefits alongside device costs, workflow, and evidence certainty.
Key Findings
- Twelve randomized controlled trials included 1,466 randomized patients, with 1,340 contributing to eligible comparison arms.
- Continuous monitoring did not significantly reduce intraoperative hypotension incidence: risk ratio 0.90, 95% confidence interval 0.77-1.04, P=0.141.
- Continuous monitoring reduced time-weighted hypotension exposure and area-under-the-curve hypotension burden, with standardized mean differences of -0.42 and -0.40, respectively.
- Postoperative vomiting was less frequent with continuous monitoring, but the number of events was small and overall certainty was low to very low.
Methodological Strengths
- Systematic review and meta-analysis restricted to randomized controlled trials.
- Risk of bias was assessed with Cochrane RoB 2 and certainty was evaluated using GRADE.
- The analysis distinguished binary hypotension incidence from cumulative hypotension burden, addressing an important measurement issue.
Limitations
- The certainty of evidence ranged from very low to low.
- Definitions of hypotension, monitoring protocols, treatment thresholds, and surgical populations varied across trials, contributing to heterogeneity.
- The review did not establish whether reduced hypotension burden improves major postoperative morbidity or mortality.
Future Directions: Future randomized trials should use standardized hypotension definitions, prespecified treatment algorithms, and patient-centered outcomes such as acute kidney injury, myocardial injury, delirium, and mortality. Studies should also determine which surgical and patient-risk groups derive the greatest benefit from continuous monitoring.
BACKGROUND: Intraoperative hypotension is associated with postoperative morbidity and mortality. Standard intermittent oscillometric blood pressure monitoring may fail to detect short-lived hypotensive episodes occurring between measurement cycles. Continuous non-invasive finger-cuff monitoring provides beat-to-beat arterial pressure assessment and may reduce cumulative hypotension exposure. This systematic review and meta-analysis evaluated the effect of continuous versus intermittent non-invasive blood pressure monitoring on intraoperative hypotension and related perioperative outcomes.
3. Effects of Video-Guided Preoperative Simulation Training on Negative Postoperative Behavioral Changes in Children: A Randomized Controlled Trial.
In this randomized trial of 184 children undergoing tonsillectomy and adenoidectomy, video-guided preparation plus mask-and-straw simulation reduced the 28-day cumulative incidence of negative postoperative behavioral changes from 53.4% to 27.3%. The intervention also reduced preinduction anxiety and emergence delirium and improved induction compliance, with benefits assessed through 180 postoperative days.
Impact: The intervention is inexpensive, nonpharmacological, readily scalable, and directly targets modifiable perioperative anxiety. The magnitude of benefit suggests that structured preparation may be a meaningful component of pediatric enhanced recovery and psychological safety programs.
Clinical Implications: Hospitals may consider incorporating age-appropriate videos and brief hands-on simulation into routine pediatric preoperative visits, particularly for procedures associated with substantial anxiety. Implementation should be adapted to developmental stage and evaluated across different surgeries and healthcare settings.
Key Findings
- The randomized trial included 184 children assigned 1:1 to usual preoperative care or video-guided simulation training.
- Negative postoperative behavioral changes within 28 days occurred in 27.3% of the training group versus 53.4% of the control group, with an odds ratio of 0.33.
- The training group had lower preinduction anxiety, higher induction compliance, and less emergence delirium: 17.0% versus 37.5% in controls.
- Post-Hospitalization Behavior Questionnaire assessments were performed on postoperative days 3, 14, 28, 90, and 180.
Methodological Strengths
- Age-stratified randomized controlled design with a clinically relevant behavioral primary outcome.
- Repeated follow-up assessments extended to 180 postoperative days.
- The study evaluated multiple perioperative psychological outcomes and explored anxiety as a potential mediator.
Limitations
- The trial involved children undergoing tonsillectomy and adenoidectomy, so generalizability to other procedures and age groups is uncertain.
- Blinding of children, parents, and clinical staff was likely not feasible, creating potential performance and reporting bias.
- The behavioral questionnaire threshold may capture a broad range of changes, and the long-term clinical significance of these changes requires further study.
Future Directions: Larger multicenter trials should determine whether the effect persists across different operations, developmental stages, cultural settings, and baseline anxiety levels. Future studies should also examine cost-effectiveness, caregiver outcomes, adherence to the training protocol, and whether benefits persist beyond six months.
BACKGROUND: Negative postoperative behavioral changes (NPOBCs) are common postoperative complications in children and can affect children's emotional and cognitive development if not addressed. This study aimed to investigate whether simulation training could reduce the incidence of negative postoperative behavioral changes in children undergoing tonsillectomy and adenoidectomy. METHODS: In this randomized controlled clinical trial, 184 patients were randomly assigned (1:1, stratified by age) to either the control or training group. The control group received only a preoperative visit, while the training group viewed an animated instructional video and underwent simulation training using an anesthetic mask and straw following the preoperative visit. Children were evaluated using the Post-Hospitalization Behavior Questionnaire on postoperative days 3, 14, 28, 90, and 180, and negative postoperative behavioral changes were diagnosed based on a Post-Hospitalization Behavior Questionnaire score >0. The primary outcome was the cumulative incidence of negative postoperative behavioral changes during the first 28 postoperative days.