Anesthesiology, September 29 edition

Among 4,878 analyzed pediatric encounters with airway hyperresponsiveness, supraglottic airway device placement was associated with substantially lower risks of respiratory adverse events than tracheal intubation. The association remained strong for airway-management-related events and severe oxygen desaturation after propensity-based adjustment, supporting consideration of supraglottic devices when clinically appropriate.

Impact: This is one of the largest multicenter evaluations of airway strategy in children at increased respiratory risk and provides an actionable comparative estimate. It directly informs a common anesthetic decision while appropriately retaining the need for clinical selection and awareness of residual confounding.

Clinical Implications: For children with airway hyperresponsiveness, including recent upper respiratory infection, asthma exacerbation, or smoke exposure, clinicians may consider a supraglottic airway device during induction when surgical and patient factors permit. The result should not be interpreted as universal superiority because airway anatomy, aspiration risk, procedure type, ventilation requirements, and operator expertise remain decisive.

Future Directions: Prospective pragmatic studies should evaluate airway-device selection algorithms across specific procedures and risk strata, while recording aspiration, ventilation adequacy, conversion to tracheal intubation, and recovery outcomes. Comparative effectiveness research should also assess whether the observed association persists across institutions with different pediatric airway expertise.

In a clinically relevant ovine model, cardiopulmonary bypass reduced renal blood flow and medullary oxygenation in both healthy and heart-failure animals. Only animals with pre-existing heart failure developed persistent medullary hypoxia, lower urine output, and greater renal inflammation during recovery, supporting renal oxygenation and inflammation as mechanistic targets for cardiac-surgery-associated acute kidney injury.

Impact: This study addresses a major translational gap by modeling cardiopulmonary bypass in the presence of pre-existing heart failure rather than in otherwise healthy animals. The direct physiological and histopathological measurements identify persistent renal medullary hypoxia as a plausible, potentially modifiable mechanism of postoperative kidney injury.

Clinical Implications: Patients with pre-existing heart failure undergoing cardiopulmonary bypass may require intensified renal perfusion and oxygenation surveillance after surgery. The findings support future trials of strategies that preserve renal medullary oxygen delivery or reduce renal inflammation, but they do not yet establish a clinical intervention.

Future Directions: Future studies should test renal oxygenation-guided perfusion, hemodynamic, or anti-inflammatory interventions in this model and determine whether the physiological signals predict clinically relevant acute kidney injury. Translation will require validation using perioperative renal oxygenation monitoring and biomarker studies in high-risk cardiac-surgery patients.

In 341,199 adults undergoing sedation or general anesthesia, both medical and non-medical cannabis use were associated with modestly higher propofol and volatile anesthetic doses. The very large cohort provides more precise estimates than prior small studies, while the authors appropriately emphasize that the clinical significance of these dose differences remains uncertain.

Impact: This study substantially improves the precision of evidence regarding a common perioperative question: whether cannabis exposure changes anesthetic requirements. Its large sample and distinction between medical and non-medical use help replace anecdotal dose escalation with quantitatively grounded expectations.

Clinical Implications: Anesthesia teams should routinely ask about cannabis use and anticipate that some patients may require modestly higher propofol or volatile anesthetic doses. Dose titration should remain individualized using clinical effect and physiologic monitoring; the study does not justify automatic dose escalation or imply that cannabis use alone predicts difficult anesthesia.

Future Directions: Prospective multicenter studies should characterize dose-response relationships using verified cannabis exposure data and evaluate clinically meaningful outcomes. Future work should also examine whether chronicity, route, cannabinoid composition, and withdrawal or intoxication states modify anesthetic pharmacology and postoperative recovery.