Anesthesiology, October 26 edition

In this double-blind randomized clinical trial of 328 adults, a single 40-IU intranasal oxytocin dose before anesthesia induction reduced the 3-day incidence of screening-positive probable acute stress disorder from 30.5% to 15.9%. The risk ratio was 0.52 and the adjusted hazard ratio was 0.45, while no serious adverse events were observed.

Impact: This is a clinically relevant randomized evaluation of a preventive perioperative strategy for a common psychological complication for which effective pharmacological prevention is limited. The magnitude of benefit supports further trials integrating psychological and biological outcomes.

Clinical Implications: Preoperative intranasal oxytocin could become a feasible preventive intervention for patients undergoing traumatic fracture surgery, but it should not yet be adopted routinely because the study was single-center, follow-up was short, and the outcome was a screening-positive probable diagnosis rather than a confirmed long-term disorder.

Future Directions: Multicenter trials should assess confirmed acute stress disorder and posttraumatic stress disorder over longer follow-up, examine dose-response relationships, identify patients most likely to benefit, and evaluate interactions with perioperative psychological support and analgesic strategies.

Among 356 men undergoing elective ureteroscopic surgery, prophylactic intravenous esketamine at 0.3 mg/kg reduced intraoperative penile erection from 21.9% with placebo to 6.2%. It also reduced clinically significant erections requiring rescue treatment, without clinically important impairment of hemodynamics, recovery, or adverse-event rates.

Impact: The study addresses an uncommon but procedure-disrupting anesthesia complication with a simple pre-induction intervention and reports a large absolute risk reduction. Its practical value is high because prevention may avoid reactive rescue measures and potential urethral injury.

Clinical Implications: Low-dose esketamine may be considered as a preventive option for selected men undergoing ureteroscopic surgery, particularly when intraoperative erection would be highly disruptive. Routine adoption requires confirmation of cardiovascular, neuropsychiatric, and urologic safety in broader populations and different anesthetic protocols.

Future Directions: Large multicenter trials should evaluate diverse surgical populations, compare esketamine with established rescue and prophylactic approaches, define optimal dosing, and systematically assess cardiovascular, neuropsychiatric, urinary, and recovery outcomes.

In 106 ambulatory surgery patients with moderate-to-severe preoperative anxiety, a single 20-minute immersive VR session produced an adjusted between-group reduction of 18.7 points in State-Trait Anxiety Inventory scores compared with standard care. Postanesthesia care unit morphine use was also lower in the VR group, whereas benzodiazepine use, postoperative pain, and overnight admission were comparable.

Impact: This trial demonstrates a large immediate anxiolytic effect from a brief, nonpharmacological intervention that is potentially scalable in ambulatory anesthesia. It also suggests possible downstream opioid-sparing effects, although secondary outcomes were not consistently improved.

Clinical Implications: A single preoperative VR session may be offered to appropriately selected anxious ambulatory surgery patients as an adjunct to standard care. Implementation should include screening for motion sickness, visual intolerance, cognitive impairment, and situations in which rapid communication or monitoring is essential.

Future Directions: Future multicenter pragmatic trials should compare different VR contents and delivery platforms, evaluate cost-effectiveness and workflow integration, and determine whether anxiety reduction translates into lower anesthetic, analgesic, and healthcare utilization over longer follow-up.