Daily ReportSep 23, 2026
Anesthesiology, September 23 edition
We read 37 papers and selected 3.
Summary
Today's most impactful anesthesiology research addresses safer perioperative fasting, the limitations of postoperative hypotension prediction models, and the real-world effectiveness of videolaryngoscopy in neonates and infants. Collectively, these studies emphasize implementation quality, external validation, and evidence-based protocol redesign rather than relying solely on theoretical advantages or model discrimination.
Research Themes
- Evidence-based liberalization of perioperative fasting
- External validation and bias in perioperative prediction models
- Effectiveness of videolaryngoscopy in neonatal and infant intubation
Selected Articles
1. International multidisciplinary consensus statement on perioperative fasting in adults
This international, multidisciplinary consensus used systematic evidence review, GRADE assessment, and a three-stage Delphi process involving 68 stakeholders to formulate eight recommendations. It supports six-hour fasting for solid food and non-clear liquids while endorsing institutional protocols that permit clear liquids until two hours before anesthesia or, under defined protocols, even closer to the procedure. Early postoperative oral intake and selective use of gastric ultrasound are also recommended.
Impact: This statement challenges the traditional culture of prolonged preoperative fluid restriction and provides a methodologically rigorous basis for reducing fasting-related discomfort, dehydration, and metabolic disturbances. Its international and multidisciplinary composition increases its potential for implementation across perioperative systems.
Clinical Implications: Hospitals should revise perioperative fasting protocols to minimize clear-liquid fasting while maintaining appropriate restrictions for solids and non-clear liquids. Implementation should include staff education, standardized orders, clear exceptions, and consideration of gastric ultrasound when aspiration risk is uncertain.
Key Findings
- A 68-member international multidisciplinary panel reached agreement on eight perioperative fasting recommendations through a three-stage Delphi process.
- Six hours of fasting is recommended for solid food and non-clear liquids, while clear liquids may be permitted until two hours before anesthesia or sedation within institutional protocols.
- The consensus recommends resuming oral intake as soon as clinically feasible and using preprocedural gastric ultrasound when additional information is needed.
Methodological Strengths
- Systematic literature review with risk-of-bias assessment and GRADE methodology.
- International multidisciplinary Delphi process including clinicians, patients, safety organizations, and enhanced recovery experts.
Limitations
- This is a consensus statement rather than a prospective clinical trial, so several recommendations remain dependent on indirect or limited evidence.
- The statement is not an official guideline issued by a national or international professional society, and local aspiration-risk populations may differ.
Future Directions: Prospective implementation studies should evaluate whether liberal clear-liquid policies reduce fasting duration, improve patient-centered outcomes, and maintain aspiration safety across high-risk surgical populations. Standardized auditing and electronic fasting orders may support sustainable adoption.
INTRODUCTION: The aim of this consensus statement was to develop evidence-based recommendations on perioperative fasting, taking the growing global awareness of the negative effects of prolonged fasting before surgery into account, particularly with respect to clear liquids. METHODS: A systematic literature search was conducted, including assessments of the risk of bias and the overall level of evidence using GRADE methodology to develop 13 preliminary recommendations on perioperative fasting.
2. Videolaryngoscopy and first-attempt tracheal intubation success in neonates and infants: a retrospective cohort study using the Japan Pediatric Difficult Airway in Anesthesia (J-PEDIA) registry
In 3,250 neonatal and infant intubation encounters from a multicenter Japanese registry, videolaryngoscopy was associated with lower first-attempt success than direct laryngoscopy after propensity-based adjustment. Videolaryngoscopy improved the percentage of glottic opening score but was associated with more oxygen desaturation, while respiratory adverse-event rates were similar. The findings demonstrate a clinically important gap between improved visualization and successful intubation.
Impact: This large real-world registry study challenges the assumption that better glottic visualization automatically improves neonatal and infant intubation outcomes. Its negative findings have direct implications for airway-device selection, training, and implementation strategies in a high-risk population.
Clinical Implications: Videolaryngoscopy should not be considered a universal substitute for direct laryngoscopy in neonatal and infant intubation. Institutions should provide structured training, define appropriate indications, monitor first-attempt success and desaturation, and ensure clinicians retain proficiency with direct laryngoscopy.
Key Findings
- Among 3,250 encounters, videolaryngoscopy was associated with lower first-attempt success than direct laryngoscopy after inverse probability of treatment weighting adjustment (adjusted risk ratio 0.89, 95% CI 0.83-0.96).
- Videolaryngoscopy improved the percentage of glottic opening score but increased the risk of oxygen desaturation (adjusted risk ratio 2.18, 95% CI 1.57-2.79).
- Respiratory adverse-event rates were similar between videolaryngoscopy and direct laryngoscopy, indicating that improved visualization did not translate into better overall intubation performance.
Methodological Strengths
- Large multicenter registry covering 3,250 neonatal and infant intubation encounters.
- Propensity score-based inverse probability of treatment weighting was used to address measured confounding.
Limitations
- The retrospective observational design cannot establish causality, and residual confounding by operator experience, device selection, or clinical urgency may remain.
- The study was conducted within a Japanese registry, so findings may not generalize to institutions with different training systems, devices, or patient populations.
Future Directions: Prospective multicenter studies should compare standardized videolaryngoscopy and direct-laryngoscopy training pathways, stratify results by operator expertise and device type, and determine which neonatal and infant subgroups benefit from videolaryngoscopy.
BACKGROUND: First-attempt tracheal intubation success is critical in neonates and infants. Although videolaryngoscopy (VL) is recommended for neonatal and infant intubation, uncertainty remains regarding its effectiveness in real-world practice. We evaluated the association between use of VL for the initial tracheal intubation attempt and first-attempt tracheal intubation success in neonates and infants using a multicentre airway registry.
3. Prediction models for post-induction hypotension in patients undergoing general anesthesia: a systematic review and meta-analysis
This systematic review and meta-analysis included 17 studies, 50 prediction models, and 40,864 patients. Although the pooled area under the receiver operating characteristic curve was 0.81, 15 of 17 studies had a high overall risk of bias, and only one model underwent external validation at another institution. Age and propofol dose were consistent risk predictors, but current models are not yet ready for uncritical clinical deployment.
Impact: The paper separates apparent discrimination from methodological credibility, highlighting that good area-under-the-curve values do not guarantee transportable or clinically useful prediction. This negative assessment provides a clear roadmap for improving perioperative artificial intelligence and risk-prediction research.
Clinical Implications: Existing post-induction hypotension prediction tools should not be implemented without local validation, calibration assessment, and prospective evaluation of clinical benefit. Clinicians should continue using established hemodynamic monitoring and preventive strategies while prediction models undergo rigorous external testing.
Key Findings
- Seventeen studies comprising 50 prediction models and 40,864 patients were included.
- The pooled AUC of the 17 optimal models was 0.81, but validation-group AUCs ranged from 0.654 to 0.893.
- Fifteen studies, representing 88.2% of the evidence base, had a high overall risk of bias, and only one model was externally validated at another institution.
Methodological Strengths
- Systematic searches across six databases with independent screening and data extraction by two reviewers.
- Use of PROBAST for risk-of-bias assessment and random-effects meta-analysis of predictive performance.
Limitations
- Substantial heterogeneity in the definition of post-induction hypotension, predictors, modeling methods, and validation procedures limits direct comparison.
- Most included studies lacked external validation, and pooled discrimination may not reflect clinical utility, calibration, or net benefit.
Future Directions: Future studies should adopt standardized definitions of post-induction hypotension, prespecify predictor selection, report calibration and clinical utility, and conduct prospective multicenter external validation. Impact analyses should determine whether model-guided interventions actually reduce hypotension and patient harm.
BACKGROUND: Post-induction hypotension (PIH) is a frequent perioperative complication during general anesthesia and adversely affects patient outcomes. Although machine-learning techniques have been widely applied to develop PIH prediction models, the methodological quality and predictive performance of existing models lack systematic evaluation. OBJECTIVE: To systematically review the predictive performance, methodological quality, and common predictors of PIH prediction models in patients undergoing general anesthesia.