Anesthesiology, October 27 edition

In this multicentre randomized trial of 673 evaluable infants, first-attempt nasotracheal intubation success was significantly higher with videolaryngoscopy than with direct laryngoscopy: 83% versus 75%, with an adjusted risk difference of 8.2%. First-attempt and cumulative complication rates were similar, and no cardiac arrest or death occurred in either group.

Impact: This is high-quality randomized evidence addressing a clinically important and previously uncertain question in infant airway management. An 8.2% absolute improvement in first-attempt success may reduce repeated airway manipulation and supports videolaryngoscopy as a first-line technique in appropriately equipped pediatric cardiac settings.

Clinical Implications: Videolaryngoscopy should be strongly considered as the initial device for nasotracheal intubation in infants undergoing elective cardiac procedures, particularly where trained operators and appropriate equipment are available. The findings should not yet be generalized to anticipated difficult airways, emergency settings, or non-specialist centers.

Future Directions: Future studies should evaluate videolaryngoscopy in infants with anticipated difficult airways, urgent or emergency procedures, and lower-volume centers, while assessing device-specific performance, training requirements, and cost-effectiveness.

This meta-analysis included 22 randomized controlled trials involving 2,452 participants undergoing fiberoptic bronchoscopy. Compared with propofol, ciprofol had similar procedural success and recovery outcomes but significantly lower risks of hypotension, injection pain, hypoxemia, and respiratory depression.

Impact: The study quantitatively synthesizes the largest evidence base among the selected pharmacologic comparisons and identifies a consistent safety signal for a newer sedative. Its findings may support broader clinical evaluation of ciprofol, although implementation should await confirmation in standardized, multicentre trials and diverse patient populations.

Clinical Implications: Ciprofol may be considered an alternative to propofol for fiberoptic bronchoscopy when hypotension, injection pain, hypoxemia, or respiratory depression are major concerns. Choice of sedative should still account for local availability, cost, clinician experience, patient comorbidity, and monitoring and rescue capabilities.

Future Directions: Future research should use multicentre pragmatic trials with standardized dosing, sedation targets, monitoring protocols, rescue criteria, and patient-centered recovery outcomes, including cost-effectiveness and longer-term safety.

Among 101,531 patients undergoing surgery under general anesthesia, artificial intelligence-derived cardiomediastinal vascular border metrics from routine preoperative chest radiographs were independently associated with in-hospital postoperative major adverse cardiovascular events. Adding cardiothoracic ratio or a composite cardiovascular-border z-score to a clinical model increased the AUC from 0.894 to 0.906, with similar improvement in temporal validation.

Impact: This study demonstrates how routinely acquired, low-cost imaging may be transformed into quantitative perioperative risk information without additional patient burden. Its very large cohort and temporal validation strengthen the signal, while the modest incremental discrimination appropriately highlights that clinical utility still requires external validation.

Clinical Implications: Automated analysis of preoperative chest radiographs could eventually support cardiovascular risk stratification, particularly when radiographs are already obtained for routine care. It should currently be considered an adjunct to, rather than a replacement for, clinical assessment because external validation, calibration across institutions, and prospective impact studies are still required.

Future Directions: Future studies should externally validate the model across hospitals, imaging devices, patient populations, and surgical specialties; assess calibration and fairness; and determine whether AI-assisted alerts change perioperative management and patient outcomes.