Daily ReportOct 11, 2026
Anesthesiology, October 11 edition
We read 45 papers and selected 3.
Summary
Today's most impactful studies addressed opioid-sparing analgesia, individualized pediatric sedation dosing, and prevention of cardiac surgery-associated acute kidney injury. The strongest evidence came from a registered network meta-analysis of 45 randomized trials and a large systematic review of 207 randomized trials, while a prospective dose-finding study provided clinically useful pharmacologic estimates for children with obstructive sleep apnea.
Research Themes
- Opioid-sparing perioperative analgesia
- Pharmacologically individualized pediatric sedation
- Prevention of cardiac surgery-associated acute kidney injury
Selected Articles
1. Bridging evidence gaps in opioid-sparing postoperative pain control for percutaneous nephrolithotomy: a network meta-analysis identifying optimal strategies.
This PROSPERO-registered Bayesian network meta-analysis included 45 randomized trials involving 2,626 adults undergoing percutaneous nephrolithotomy. Levobupivacaine-based techniques and non-opioid analgesics generally performed favorably, with intravenous paracetamol plus local-infiltrated levobupivacaine ranking highest in benefit-risk analysis, although safety estimates were sparse and imprecise.
Impact: The study directly addresses opioid minimization in a common endourologic procedure and compares multiple analgesic modalities within a unified framework. Its conclusions can inform multimodal analgesia protocols while clearly identifying the uncertainty surrounding comparative safety.
Clinical Implications: Clinicians may consider intravenous paracetamol, NSAIDs when appropriate, and levobupivacaine-based local or fascial-plane techniques as components of opioid-sparing analgesia after percutaneous nephrolithotomy. Individual renal, bleeding, cardiovascular, and gastrointestinal risks must be assessed, and the ranking should not be interpreted as proof of superior safety.
Key Findings
- The network included 45 randomized controlled trials and 2,626 patients without significant inconsistency or heterogeneity.
- Levobupivacaine outperformed bupivacaine or ropivacaine for pain reduction in selected erector spinae plane block or local infiltration comparisons.
- Intravenous paracetamol plus local-infiltrated levobupivacaine ranked highest in the multicriteria benefit-risk analysis, but complication data were sparse and imprecise.
Methodological Strengths
- Bayesian network meta-analysis enabled indirect comparison of diverse analgesic strategies.
- The protocol was registered in PROSPERO, and consistency, heterogeneity, and benefit-risk ranking were assessed.
Limitations
- Twenty-one trials had moderate risk of bias, and analgesic protocols and pain-assessment methods varied.
- Comparative safety could not be established because complication data were sparse and highly imprecise, with limited representation of high-risk patients.
Future Directions: Future adequately powered, standardized randomized trials should compare levobupivacaine-based strategies with NSAID-paracetamol regimens using patient-centered outcomes, opioid consumption, adverse events, and predefined high-risk subgroups.
Percutaneous nephrolithotomy (PCNL) is the gold standard for large renal calculi, yet postoperative pain from tract dilation, capsule injury, and inflammation often delays recovery, prolongs hospital stays, and reduces patient satisfaction. Amid the opioid crisis, reliance on opioids for pain control raises concerns over adverse effects like respiratory depression, nausea, and dependence. This has spurred interest in opioid-sparing multimodal strategies, with recent studies suggesting feasibility of opioid-free discharge and comparable relief from NSAIDs with fewer side effects.
2. Acute Kidney Injury After Cardiac Surgery: A Systematic Review of Pharmacological and Non-Pharmacological Interventions.
This systematic review identified 207 randomized controlled trials involving 63,785 patients and 55 interventions for prevention of cardiac surgery-associated acute kidney injury. Signals of lower odds of acute kidney injury were observed with dexmedetomidine, fenoldopam, nitric oxide, and remote ischemic preconditioning, but most trials were small, single-center, and neutral, requiring cautious interpretation.
Impact: The review provides the broadest contemporary synthesis of preventive interventions for a frequent and clinically important complication of cardiac surgery. Its major contribution is not only identifying promising interventions but also demonstrating that the overall evidence base remains fragmented and insufficient for definitive recommendations.
Clinical Implications: Dexmedetomidine, fenoldopam, nitric oxide, and remote ischemic preconditioning may be considered investigational or selectively applicable strategies for cardiac surgery-associated acute kidney injury prevention. Current evidence does not justify routine adoption of any single intervention without consideration of patient risk, institutional protocols, adverse effects, and local expertise.
Key Findings
- The review included 207 randomized controlled trials, 63,785 patients, and 55 pharmacological or non-pharmacological interventions.
- Among interventions evaluated in at least four trials, dexmedetomidine, fenoldopam, nitric oxide, and remote ischemic preconditioning were associated with lower odds of cardiac surgery-associated acute kidney injury.
- Most studies were small and single-center, 149 of 206 reported neutral results, and the authors emphasized the need for adequately powered confirmatory trials.
Methodological Strengths
- The review comprehensively assembled randomized evidence across 55 distinct interventions and 207 trials.
- Interventions were qualitatively synthesized, and quantitative meta-analysis was performed when at least four randomized trials were available.
Limitations
- Many included trials were small, single-center studies, with substantial variation in definitions and ascertainment of acute kidney injury.
- The apparent benefits of several interventions may reflect between-study heterogeneity, selective reporting, or limited precision rather than definitive treatment effects.
Future Directions: Future trials should use standardized acute kidney injury definitions, clinically important kidney and mortality outcomes, transparent registration, and adequately powered multicenter designs. Comparative effectiveness studies should focus on high-risk cardiac surgery populations and evaluate intervention-related harms as rigorously as benefits.
OBJECTIVE: To identify and synthesize all randomized controlled trials (RCTs) evaluating pharmacological and non-pharmacological interventions for the prevention of cardiac surgery‒associated acute kidney injury (CSA-AKI). DESIGN: We performed a systematic review of RCTs evaluating pharmacological and non-pharmacological strategies. Interventions were qualitatively synthesized, and meta-analysis was performed when at least 4 RCTs were available. SETTING: Hospitals. PARTICIPANTS: Adults undergoing cardiac surgery.
3. Remimazolam ED95 for Preoperative Sedation in Children with Obstructive Sleep Apnea, with Obesity or a Reference-Range BMI: A Biased-Coin Dose-Finding Study.
This prospective biased-coin dose-finding study estimated protocol-specific remimazolam ED95 values in 80 children with obstructive sleep apnea undergoing adenotonsillar surgery. The ED95 was 0.38 mg/kg in children with obesity and 0.44 mg/kg in those with reference-range BMI, with similar confidence intervals and only limited transient respiratory or cardiovascular events.
Impact: Children with obstructive sleep apnea have a narrow respiratory safety margin, and dosing uncertainty is amplified by obesity. This study provides prospectively derived, subgroup-specific dosing estimates for a newer sedative in a clinically vulnerable population.
Clinical Implications: For protocol-defined preoperative sedation, total-body-weight remimazolam dosing produced similar ED95 estimates in children with obesity and reference-range BMI. These estimates should be applied cautiously with continuous respiratory monitoring, airway readiness, and local validation rather than used as universal dosing recommendations.
Key Findings
- The study enrolled 80 children aged 3 to 17 years with clinically diagnosed obstructive sleep apnea, including 40 with obesity and 40 with reference-range BMI.
- The ED95 was 0.38 mg/kg in the obesity group and 0.44 mg/kg in the reference-BMI group; the estimated difference was not clearly meaningful.
- One child in each group developed transient hypoxemia, and one reference-BMI child developed bradycardia; no child had a 30% or greater decrease in mean arterial pressure.
Methodological Strengths
- Prospective sequential dose-finding design with independent biased-coin sequences for the two BMI groups.
- ED95 estimates included bootstrap confidence intervals and used a prespecified sedation response at a defined time point.
Limitations
- The study was single-center, noncomparative, and focused on a protocol-specific sedation endpoint rather than clinical recovery or patient-centered outcomes.
- The sample size was modest, and the findings may not generalize to children without obstructive sleep apnea, other procedures, or alternative administration protocols.
Future Directions: Multicenter randomized or comparative pharmacokinetic-pharmacodynamic studies should evaluate remimazolam dosing using ideal or adjusted body weight, compare it with established sedatives, and assess respiratory events, recovery quality, and postoperative outcomes.
BACKGROUND: Obesity may alter total-body-weight dosing of remimazolam, whereas obstructive sleep apnea narrows the respiratory safety margin. We estimated the ED95 for protocol-defined preoperative sedation in children with obesity or a reference-range body mass index (BMI). METHODS: In this prospective, single-center sequential dose-finding study, 80 children aged 3-17 years with a clinical OSA diagnosis undergoing adenoidectomy and/or tonsillectomy entered study-defined obesity (BMI-for-age >95th percentile) or reference-BMI (25th-84th percentile) groups.