Daily ReportSep 24, 2026
Anesthesiology, September 24 edition
We read 60 papers and selected 3.
Summary
Today's most impactful anesthesiology studies address three high-priority issues: inadequate neuraxial anesthesia during emergency cesarean delivery, prevention of spinal-anesthesia-induced hypotension in elderly fracture patients, and postoperative pulmonary embolism risk after major surgery. Collectively, they identify important gaps in definitions and management, provide evidence for a simple hemodynamic intervention, and quantify risk factors associated with a rare but highly lethal complication.
Research Themes
- Definition and management of inadequate neuraxial anesthesia
- Hemodynamic optimization of spinal anesthesia in elderly patients
- Risk stratification and mortality associated with postoperative pulmonary embolism
Selected Articles
1. Inadequate Neuraxial Anesthesia in Patients Undergoing Emergency Cesarean Delivery: A Qualitative and Quantitative Scoping Review.
This scoping review included 63 studies and found substantial inconsistency in how inadequate neuraxial anesthesia during emergency cesarean delivery is defined, recognized, and treated. Reported incidence ranged from 0% to 27%, while intravenous opioids and S-ketamine were commonly used as supplements, despite limited comparative evidence.
Impact: The paper identifies a clinically important but poorly standardized perioperative safety problem in obstetric anesthesia. By demonstrating that incidence cannot be reliably estimated because definitions vary, it establishes a direct research and quality-improvement priority.
Clinical Implications: Institutions should develop explicit criteria for recognizing inadequate neuraxial anesthesia, structured escalation algorithms, and patient-centered documentation of intraoperative pain during emergency cesarean delivery. Current supplementation strategies should not be assumed to be equivalent or evidence-based.
Key Findings
- Sixty-three studies were included after screening 6,375 records.
- No common definition of inadequate neuraxial anesthesia was identified, preventing calculation of a reliable pooled incidence.
- Reported incidence ranged from 0% to 27%, and intravenous opioids followed by S-ketamine were common supplementation strategies.
Methodological Strengths
- Predefined eligibility criteria and a systematic search strategy were used.
- Three authors independently screened studies and methodological quality was assessed with the Mixed Methods Appraisal Tool.
Limitations
- The scoping design summarizes heterogeneous literature and does not establish comparative treatment effectiveness.
- Definitions and outcome reporting were sufficiently inconsistent that pooled incidence and treatment recommendations could not be derived.
Future Directions: Prospective multicenter studies should establish a consensus definition, standardized severity grading, patient-reported pain outcomes, and comparative evaluation of supplementation versus conversion to general anesthesia.
BACKGROUND: Neuraxial anesthesia is the preferred anesthetic technique for cesarean delivery, yet a systematic review found that 14% of blocks for elective cesarean delivery were inadequate. This scoping review aimed to explore patients' and anesthesiologists' experiences of inadequate neuraxial anesthesia during emergency cesarean delivery. Secondary objectives were to examine its definitions, management strategies, and reported prevalence. METHODS: A systematic literature search was conducted based on predefined inclusion criteria according to the PCC framework (Population, Concept, Context). Studies published since 1995 that reported clinical data were eligible. Three authors independently screened titles, abstracts, and full texts. Study quality was assessed using the Mixed Methods Appraisal Tool.
2. Fractionated versus Conventional Spinal Anesthesia for Prevention of Hypotension in Elderly Hip Fracture Surgery: A Randomized Controlled Study.
In this prospective randomized double-blind trial of 118 patients aged 60 years or older undergoing femur-fracture surgery, fractionated spinal dosing reduced vasopressor-requiring hypotension from 64.4% to 32.2%. It also reduced vasopressor use and prolonged sensory block without worsening motor recovery or adverse events.
Impact: The intervention is simple, inexpensive, and immediately translatable to high-risk geriatric anesthesia. The large absolute reduction in hypotension and low number needed to treat suggest meaningful potential for improving perioperative hemodynamic stability.
Clinical Implications: Fractionating the intrathecal dose may be considered as a hemodynamic-sparing strategy for selected elderly patients undergoing hip or femur-fracture surgery, provided adequate monitoring and rescue vasopressor capability are available.
Key Findings
- Vasopressor-requiring hypotension occurred in 32.2% with fractionated dosing versus 64.4% with conventional bolus dosing.
- Fractionated dosing reduced total vasopressor requirement and produced a relative risk of 0.50 with a number needed to treat of 3.1.
- Sensory block duration was longer with fractionated dosing, while motor block duration and adverse events were comparable.
Methodological Strengths
- Prospective randomized double-blind design with a prespecified primary hemodynamic outcome.
- Frequent hemodynamic measurements and reporting of both relative and absolute treatment effects.
Limitations
- The study was conducted at a single center with 118 patients, limiting generalizability.
- The intervention was evaluated only in elderly femur-fracture surgery and may not apply to other procedures or neuraxial drug regimens.
Future Directions: Multicenter trials should test fractionated dosing across different hip-fracture populations, local-anesthetic doses, intrathecal adjuvants, and patient-centered outcomes such as delirium, myocardial injury, renal injury, and functional recovery.
BACKGROUND: Spinal anesthesia (SA), though preferred for lower limb orthopedic surgery, produces rapid sympathectomy following bolus intrathecal injection, which may precipitate significant hypotension in elderly patients. Fractionated dosing may improve hemodynamic stability. This study compared fractionated versus bolus SA on hypotension requiring vasopressor support. METHODS: This prospective, randomized, double-blind trial included 118 American Society of Anesthesiologists I-III participants aged ≥60 years undergoing femur fracture surgery under SA. Participants were randomized to receive fractionated dosing (two-thirds initial dose followed by one-third after 60 s) or conventional bolus dosing of 0.5% hyperbaric bupivacaine with 60 μg intrathecal buprenorphine.
3. Risk Factors and Outcomes of Postoperative Pulmonary Embolism in Southeast-Asian Patients Undergoing Major Surgery: A Nested Case-Control Study.
This nested case-control study evaluated 113,660 major-surgery patients and identified 140 postoperative pulmonary embolism cases, corresponding to an incidence of 0.123%. Active cancer, emergency surgery, arthroplasty or fracture surgery, prolonged immobilization, and higher Caprini scores were independent risk factors, while 90-day mortality was 32.86% among cases versus 2.14% in controls.
Impact: The study provides contemporary, large-scale Asian data on a rare complication with very high mortality. Its risk-factor profile supports systematic perioperative risk stratification while appropriately cautioning that the apparent benefit of early ambulation may be confounded.
Clinical Implications: Preoperative Caprini-based assessment should be integrated with cancer status, urgency, procedure type, and postoperative mobility planning. Early ambulation should complement, not replace, guideline-concordant pharmacologic and mechanical thromboprophylaxis.
Key Findings
- Among 113,660 major-surgery patients, 140 developed radiologically confirmed postoperative pulmonary embolism, an incidence of 0.123%.
- Independent predictors included active cancer, emergency surgery, arthroplasty or fracture surgery, immobilization for at least 3 days, and increasing Caprini score.
- Ninety-day mortality was 32.86% in patients with pulmonary embolism versus 2.14% in controls; early ambulation was associated with lower odds but may be confounded.
Methodological Strengths
- The source cohort was large and contemporary, with radiologic confirmation of pulmonary embolism.
- Age-matched controls and multivariable logistic regression were used to address measured confounding.
Limitations
- The retrospective observational design cannot establish causal effects of early ambulation or other perioperative exposures.
- Pulmonary embolism detection was triggered by clinical suspicion, so asymptomatic events may have been missed and incidence may be underestimated.
Future Directions: Prospective multicenter studies should evaluate standardized thromboprophylaxis, structured early-mobilization pathways, serial risk reassessment, and competing risks of bleeding in high-risk surgical populations.
INTRODUCTION: Postoperative pulmonary embolism (PE) remains a rare but catastrophic perioperative complication. Anesthesia-related factors, perioperative physiological instability, and delayed postoperative mobilization may contribute to its development and associated mortality. However, data on contemporary outcomes in Asian surgical populations are limited. METHODS: A retrospective nested case-control study of adult patients undergoing major surgery was performed. The source cohort comprised all 113,660 adults who underwent major surgery at Ramathibodi Hospital from January 2020 to December 2024. Patients with radiologically confirmed PE were identified and individually matched at a 1:3 ratio with age-matched controls. The independent risk factors for PE were identified using multivariate logistic regression.