Anesthesiology, October 23 edition

The FRAGILE study prospectively enrolled 1,472 adults undergoing elective or emergency surgery at 64 centres in 10 European countries. Preoperative frailty prevalence varied by instrument, and 11.9% of initially nonfrail patients became frail within 30 days. Preoperative frailty independently predicted postoperative complications, mortality, and postoperative cognitive impairment.

Impact: This is one of the largest prospective multicentre European evaluations showing that frailty is not merely a baseline trait but can emerge or worsen rapidly after surgery. The findings support routine preoperative assessment and postoperative surveillance for frailty as part of perioperative risk management.

Clinical Implications: Frailty assessment should be incorporated into preoperative counselling, shared decision-making, perioperative optimisation, discharge planning, and postoperative cognitive and functional follow-up. Reassessment after surgery is important because newly developed frailty may identify patients requiring rehabilitation, nutritional support, and enhanced care transitions.

Future Directions: Future research should compare frailty instruments prospectively, develop intervention pathways for patients with newly emerging postoperative frailty, and test whether prehabilitation, geriatric co-management, rehabilitation, and nutritional interventions improve outcomes.

In this prospective exploratory study of elderly patients receiving sevoflurane anesthesia, patients who developed postoperative delirium showed minimal alpha-power amplification immediately before loss of responsiveness, unlike patients without delirium. During maintenance, the delirium group had lower alpha power across nearly all EEG channels and longer characteristic path lengths, indicating reduced functional network efficiency.

Impact: The study links specific neurophysiological transitions during induction and maintenance anesthesia with postoperative delirium, moving beyond postoperative clinical screening toward a potentially real-time perioperative susceptibility biomarker. Its network analysis also provides a mechanistic perspective on impaired brain integration during anesthesia.

Clinical Implications: Perioperative EEG monitoring may eventually help identify patients at high risk for postoperative delirium before surgery is completed, enabling individualized anesthetic depth, medication review, enhanced monitoring, and targeted delirium-prevention strategies. The findings are not yet sufficient to justify routine EEG-based delirium prediction.

Future Directions: Multicentre studies should externally validate the EEG signatures, establish thresholds and timing for prospective prediction, and determine whether EEG-guided anesthetic management can reduce delirium incidence or severity.

This preregistered systematic review synthesized 10 randomized studies of fospropofol, including six procedural-sedation trials and four ICU-sedation trials. Fospropofol 6.5 mg/kg produced higher endoscopic sedation success than 2 mg/kg, while hypotension risk in mechanically ventilated ICU patients was not clearly different from propofol. Paresthesia and pruritus were common, and no consistent cardiorespiratory safety advantage was established.

Impact: The review addresses an important translational question: whether a water-soluble propofol prodrug offers meaningful clinical advantages across procedural and ICU sedation. By separating dose, setting, comparator, and evidence certainty, it prevents overinterpretation of promising pharmacologic properties and identifies the need for adequately powered comparative trials.

Clinical Implications: Fospropofol may be considered an effective alternative for selected procedural or ICU sedation settings, but clinicians should not assume superior cardiopulmonary safety compared with propofol or other sedatives. Dose selection should account for the setting and the increased risk of adverse effects at higher doses, particularly paresthesia and pruritus.

Future Directions: Large, prospectively registered randomized trials should compare fospropofol with propofol and other sedatives using standardized sedation targets, cardiorespiratory endpoints, patient-centered recovery outcomes, and dose-stratified adverse-event reporting across procedural and ICU populations.