Daily ReportSep 26, 2026
Anesthesiology, September 26 edition
We read 52 papers and selected 3.
Summary
Today's most impactful anesthesiology studies include two randomized trials evaluating strategies to optimize neuromuscular blockade and a randomized trial of alveolar recruitment during laparoscopic surgery. The findings support rocuronium priming in selected younger adults, demonstrate that ephedrine does not accelerate rocuronium onset in patients aged 80 years or older and may increase arrhythmias, and suggest that recruitment maneuvers can improve intraoperative respiratory mechanics without clinically important hemodynamic instability.
Research Themes
- Optimization and safety of neuromuscular blockade
- Age-specific pharmacologic effects during induction
- Intraoperative lung recruitment and respiratory mechanics
Selected Articles
1. Ephedrine for Reducing Onset Time of Rocuronium in Elderly Patients: A Randomised Study.
In this blinded randomized study of patients aged 80 years or older, ephedrine did not significantly shorten the time to train-of-four count zero after rocuronium administration: 134 seconds versus 139 seconds with placebo (P = 0.60). Ephedrine produced a greater increase in mean arterial pressure and was associated with significantly more cardiac arrhythmias, without improving intubating conditions.
Impact: This study provides clinically relevant negative evidence against extrapolating the rocuronium-accelerating effect of ephedrine from younger adults to very elderly patients. The increased arrhythmia signal is particularly important because ephedrine is commonly available during anesthetic induction.
Clinical Implications: Routine ephedrine administration solely to accelerate rocuronium onset should not be recommended in patients aged 80 years or older. Clinicians should consider alternative airway-management strategies and remain alert to tachyarrhythmias and other cardiovascular effects when ephedrine is used for hypotension or induction-related hemodynamic support.
Key Findings
- Time to train-of-four count zero was 134 seconds with ephedrine versus 139 seconds with placebo; the difference was not significant (P = 0.60).
- Ephedrine increased mean arterial pressure by approximately 10 mmHg relative to placebo.
- Cardiac arrhythmias occurred significantly more often with ephedrine, while intubating conditions were not improved.
Methodological Strengths
- Blinded randomized placebo-controlled design with a prespecified clinical population of patients aged 80 years or older.
- Objective neuromuscular monitoring and registration in ClinicalTrials.gov (NCT06681662).
Limitations
- The analyzed primary endpoint included only 75 patients because of technical or evaluability exclusions from the randomized population.
- The study was not powered to establish whether ephedrine-related arrhythmias translate into major postoperative cardiovascular outcomes.
Future Directions: Larger multicenter trials should evaluate alternative methods for achieving rapid neuromuscular blockade in very elderly patients and should prospectively quantify clinically important cardiovascular outcomes associated with ephedrine exposure.
INTRODUCTION: Onset time of rocuronium is prolonged in elderly patients compared to younger patients. Ephedrine reduces onset time of rocuronium in younger adults, but in elderly patients, the effect of ephedrine on onset time of rocuronium has not been investigated. The aim of this study was to determine the onset time of rocuronium 0.6 mg kg METHODS: We included patients aged ≥ 80 years with American Society of Anesthesiologists physical health Classes I-III scheduled for surgery under total intravenous anaesthesia with rocuronium.
2. A Prospective Randomized Study Comparing Intubating Conditions With and Without Priming With Rocuronium.
Among 60 healthy adults undergoing elective surgery, a 0.06 mg/kg rocuronium priming dose followed three minutes later by 0.6 mg/kg significantly reduced time to intubation compared with saline pretreatment (68.03 versus 100.73 seconds, P < 0.001). Priming also improved intubating conditions and was associated with a smaller post-intubation hemodynamic response, with stable oxygen saturation and no observed adverse effects.
Impact: The study offers a simple, low-cost modification of rocuronium administration that may improve intubation conditions when succinylcholine is undesirable or unavailable. Its strongest relevance is to otherwise healthy adults, while safety in vulnerable populations remains unresolved.
Clinical Implications: Rocuronium priming may be considered as an option for selected healthy adult patients when a faster onset is desired, provided that airway readiness, neuromuscular monitoring, and aspiration-risk precautions are maintained. The approach should not be generalized to elderly, respiratory-compromised, or high-risk patients without further evidence.
Key Findings
- Time to intubation was shorter with priming than with saline pretreatment: 68.03 ± 1.19 versus 100.73 ± 3.40 seconds (P < 0.001).
- Excellent intubating conditions occurred in 53.3% of primed patients and 0% of controls.
- The priming group had greater hemodynamic stability after intubation, with stable oxygen saturation and no observed adverse effects.
Methodological Strengths
- Prospective randomized double-blind allocation with a clearly defined dosing protocol.
- Assessment included intubation time, graded intubating conditions, hemodynamics, oxygen saturation, and adverse effects.
Limitations
- The sample was small and limited to American Society of Anesthesiologists I-II adults aged 18-60 years undergoing elective surgery.
- The study did not evaluate difficult-airway scenarios, rapid-sequence induction, or clinically important postoperative outcomes.
Future Directions: Multicenter trials should compare priming with higher-dose rocuronium or other onset-accelerating strategies in elderly patients, obese patients, emergency surgery, and rapid-sequence induction while systematically monitoring aspiration, hypoxemia, and residual neuromuscular blockade.
BACKGROUND: Rocuronium is widely used as an alternative to succinylcholine for facilitating endotracheal intubation, but at conventional doses its clinical onset may be slower. The priming technique has been proposed as a means of shortening the time to clinically acceptable intubation with non-depolarizing neuromuscular blocking agents. METHODS: In this prospective, randomized, double-blind study, 60 American Society of Anesthesiologists I-II patients aged 18-60 years undergoing elective surgery under general anesthesia were allocated into two groups (n = 30 each). The priming group received rocuronium 0.06 mg/kg intravenously, followed 3 min later by an intubating dose of rocuronium 0.6 mg/kg.
3. The effect of alveolar recruitment maneuver on intraoperative hemodynamics: A randomized controlled trial.
In 70 American Society of Anesthesiologists I-II patients undergoing laparoscopic hysterectomy, intraoperative alveolar recruitment improved dynamic lung compliance, arterial oxygenation, and the PaO2/FiO2 ratio. Recruitment also produced transient changes in mean arterial pressure, cardiac index, stroke volume index, and vascular-resistance variables, but did not increase inotrope use or cause clinically significant hemodynamic instability.
Impact: The study addresses a common anesthetic problem created by pneumoperitoneum and Trendelenburg positioning and links recruitment maneuvers to both respiratory and advanced hemodynamic measurements. It supports physiologic feasibility but does not yet establish improvement in patient-centered postoperative outcomes.
Clinical Implications: A structured alveolar recruitment maneuver may be incorporated during laparoscopic procedures in appropriately selected patients to improve intraoperative compliance and oxygenation. Clinicians should anticipate transient pressure-related hemodynamic changes and individualize the maneuver in patients with limited cardiovascular reserve.
Key Findings
- Recruitment maneuver significantly increased dynamic lung compliance, PaO2, and PaO2/FiO2 ratios.
- Mean arterial pressure, cardiac index, and stroke volume index were higher during recruitment, while stroke volume variation, pulse pressure variation, and systemic vascular resistance index were lower.
- The hemodynamic effects were transient, with no increase in inotrope requirements or clinically relevant instability.
Methodological Strengths
- Prospective randomized controlled design with invasive arterial pressure monitoring and arterial waveform-derived cardiac output assessment.
- The study assessed respiratory mechanics, arterial blood gases, hemodynamic variables, vasopressor or inotrope use, and postoperative pulmonary complications.
Limitations
- The sample was small and restricted to relatively healthy American Society of Anesthesiologists I-II patients undergoing laparoscopic hysterectomy.
- The study evaluated surrogate intraoperative outcomes and was not powered to determine effects on postoperative pulmonary complications, length of stay, or recovery.
Future Directions: Future multicenter trials should compare standardized recruitment protocols with individualized pressure-guided strategies and examine postoperative atelectasis, pulmonary complications, patient-reported recovery, and outcomes in patients with obesity or cardiovascular disease.
BACKGROUND: Pneumoperitoneum and the Trendelenburg position during laparoscopic hysterectomy (LH) increase intra-abdominal and intrathoracic pressure, reducing lung compliance and predisposing patients to atelectasis. This study evaluated the effects of alveolar recruitment maneuver (RM) on intraoperative hemodynamics, lung compliance, and oxygenation. METHODS: Following ethics committee approval, 70 American Society of Anesthesiologists I-II patients scheduled for elective LH were enrolled prospectively. Standard anesthesia monitoring was supplemented with radial arterial cannulation to assess cardiac output via arterial waveform analysis. After anesthesia induction and tracheal intubation, patients were randomly divided into 2 groups: Group I (RM) and Group II (Control).