Anesthesiology, October 9 edition

In 181 patients undergoing elective percutaneous nephrolithotomy, lung ultrasound-guided protocolized fluid management was compared with conventional central venous pressure-based management. The lung ultrasound strategy reduced the incidence and severity of early postoperative extravascular lung water increase and postoperative hypoxemia, while also shortening extubation time and post-anaesthesia care unit stay.

Impact: This study links a noninvasive, real-time physiologic measure to predefined interventions and demonstrates clinically relevant respiratory benefits in a procedure with substantial irrigation-fluid exposure. It provides a practical framework for testing protocolized fluid management in other high-risk surgical settings.

Clinical Implications: Perioperative lung ultrasound may help detect early fluid-related pulmonary congestion more sensitively than central venous pressure alone. In selected patients undergoing percutaneous nephrolithotomy, integrating lung ultrasound findings with predefined diuretic and fluid-management thresholds could reduce postoperative hypoxemia, although external validation and confirmation of patient-centered outcomes are needed.

Future Directions: Multicentre trials should validate the protocol across different surgical procedures, compare lung ultrasound with other dynamic fluid-responsiveness measures, and evaluate major pulmonary complications, intensive care use, hospital length of stay, and cost-effectiveness.

In a pragmatic randomized trial of 7,294 patients with preoperative cognitive impairment, an AI-driven non-interruptive clinical decision support intervention was compared with routine care. Among the small subset with documented delirium assessments, postoperative delirium did not differ significantly between groups, and the intervention did not improve adherence to 12 perioperative best practices. Only 17.2% of randomized patients had documented delirium assessments, substantially limiting conclusions.

Impact: This is an important implementation-oriented negative trial: identifying high-risk patients and displaying AI-generated recommendations did not by itself improve care processes or measured delirium outcomes. The study highlights the difference between algorithmic detection, clinician behavior change, reliable outcome ascertainment, and actual patient benefit.

Clinical Implications: AI delirium tools should not be assumed to reduce postoperative delirium solely because they identify risk or provide electronic prompts. Successful implementation requires reliable delirium screening, workflow integration, clinician engagement, measurable adherence to prevention bundles, and evaluation of patient-centered outcomes.

Future Directions: Future trials should require standardized, near-complete delirium assessments; use interruptive or team-based implementation strategies when appropriate; monitor fidelity to prevention bundles; and prespecify patient-centered outcomes such as delirium duration, discharge disposition, functional recovery, and mortality.

This multicentre prospective cohort included 9,989 Caesarean deliveries from 361 centres in 31 European countries. General anesthesia was used in 54.0% of emergency cases compared with 10.9% of elective cases, and conversion from initial neuraxial anesthesia to general anesthesia occurred in 7.7% of cases, rising to 23.1% in emergency deliveries.

Impact: The study provides contemporary, large-scale European benchmarking data for Caesarean anesthesia and quantifies how urgency drives general anesthesia use and neuraxial-to-general conversion. These data can inform staffing, airway preparedness, and obstetric anesthesia service planning.

Clinical Implications: Obstetric anesthesia services should anticipate substantially higher general anesthesia and conversion rates in emergency Caesarean delivery. Adequate availability of airway expertise, rapid-sequence induction capability, difficult-airway equipment, and neuraxial rescue pathways is particularly important in high-acuity settings.

Future Directions: Future studies should examine institutional, maternal, fetal, and provider-level determinants of anesthesia choice, link anesthesia technique with maternal and neonatal outcomes, and assess whether standardized emergency pathways reduce avoidable general anesthesia and conversion.