Anesthesiology, October 25 edition

This systematic review and meta-analysis included 33 studies involving 580,197 children. Pulmonary aspiration occurred at a pooled incidence of 0.03% under both conventional and liberal clear-fluid fasting policies, with no significant difference in risk ratio, although the certainty of evidence was very low.

Impact: The study directly evaluates a widely used pediatric anesthesia safety rule using an exceptionally large evidence base. Its findings support reconsideration of rigid two-hour clear-fluid fasting policies, while appropriately emphasizing uncertainty because aspiration is rare and the underlying evidence is low certainty.

Clinical Implications: Selected children may be allowed clear fluids closer to anesthesia than two hours before induction, potentially reducing thirst, discomfort, dehydration, and unnecessary cancellations. Local protocols should be updated cautiously, with attention to aspiration risk factors and the very low certainty of evidence.

Future Directions: Prospective multicenter surveillance and pragmatic trials should evaluate liberal fasting protocols in defined pediatric risk groups, including emergency procedures and children with delayed gastric emptying, while monitoring aspiration, comfort, cancellations, and recovery outcomes.

This systematic review and meta-analysis included 10 randomized controlled trials with 2,745 randomized women. Adjunct strategies increased external cephalic version success (risk ratio 1.53), with the largest effects for pharmacological tocolysis and neuraxial anesthesia, but did not significantly reduce cesarean delivery.

Impact: The study synthesizes randomized evidence on a clinically modifiable strategy that can increase the chance of avoiding persistent breech presentation. It also separates improvement in version success from the more consequential outcome of cesarean delivery, preventing overinterpretation of the intervention's benefits.

Clinical Implications: When external cephalic version is attempted in an appropriate setting, pharmacological tocolysis and neuraxial anesthesia or analgesia may be considered to improve procedural success. Counseling should clarify that a higher version success rate has not yet translated into a proven reduction in cesarean delivery.

Future Directions: Future trials should standardize tocolytic regimens, neuraxial techniques, timing, operator expertise, and definitions of success, and should be powered for cesarean delivery, maternal experience, neonatal outcomes, and adverse events.

This retrospective ACS-NSQIP cohort included 24,401 patients receiving general anesthesia and 6,193 receiving spinal anesthesia for hip-fracture fixation. After multivariable adjustment, general anesthesia remained independently associated with higher odds of 30-day mortality, unplanned readmission, and overall complications among frail and severely frail patients.

Impact: This is one of the largest analyses focused specifically on frailty rather than age alone, addressing a clinically important anesthetic decision in a high-risk surgical population. The findings support preferential consideration of spinal anesthesia or enhanced postoperative surveillance, while not proving causality because treatment allocation was observational.

Clinical Implications: Frailty should be incorporated into preoperative anesthetic planning for hip-fracture fixation. When clinically feasible, spinal anesthesia may be considered for frail patients, while patients requiring general anesthesia may warrant intensified postoperative monitoring and complication-prevention pathways.

Future Directions: Prospective comparative studies, pragmatic randomized trials where feasible, and target-trial emulation should evaluate anesthetic choice in predefined frailty strata while incorporating delirium, mobility, discharge destination, functional recovery, and patient-centered outcomes.