Anesthesiology, October 30 edition

This systematic review and meta-analysis included 87 randomized controlled trials involving 30,611 patients. pEEG-guided anesthesia reduced propofol and volatile anesthetic use, decreased postoperative delirium by 27% (RR 0.73), and modestly shortened extubation, awakening, orientation, and PACU times. Benefits were most consistently demonstrated with BIS, while evidence for Entropy and SEDLine was less precise.

Impact: The large randomized evidence base supports pEEG as more than a depth-monitoring technology, linking anesthetic titration with delirium prevention and operating-room efficiency. Its device-stratified analysis also identifies where evidence is strong and where further trials are needed.

Clinical Implications: pEEG-guided titration, particularly with BIS, may be considered to reduce excessive anesthetic exposure and postoperative delirium risk, especially in older or delirium-vulnerable patients. Clinicians should recognize that absolute benefits may vary by device, patient population, anesthetic technique, and baseline delirium-prevention practices.

Future Directions: Future trials should use standardized delirium definitions, report protocol adherence and anesthetic exposure in detail, and directly compare pEEG technologies in diverse surgical populations. Pragmatic studies should also assess cost-effectiveness and implementation across different monitoring environments.

This comparative review systematically identified and appraised five major perioperative GLP-1 receptor agonist guidelines published between 2023 and 2026. Four of five guidelines now favor continuation with modified fasting and individualized mitigation rather than routine cessation, although gastric ultrasound thresholds, fasting protocols, and management of high-risk patients remain inconsistent. The review highlights limited prospective outcome data and gaps in multidisciplinary guideline development.

Impact: GLP-1 receptor agonists are widely used for diabetes and obesity, making perioperative decisions relevant to a rapidly expanding patient population. This review directly addresses conflicting guidance and supports a transition from blanket drug cessation toward individualized, evidence-informed risk management.

Clinical Implications: Routine discontinuation of GLP-1 receptor agonists before anesthesia may no longer be appropriate for every patient. Anesthesia teams should assess gastrointestinal symptoms, dosing phase, dose escalation, comorbidities, glycemic risk, and procedure urgency; use modified fasting or gastric ultrasound selectively; and coordinate decisions with prescribing clinicians. SGLT2 inhibitor management should remain focused on preventing euglycemic diabetic ketoacidosis through preoperative discontinuation according to current guidance.

Future Directions: Prospective multicenter studies should compare continuation and temporary interruption strategies while measuring aspiration events, gastric contents, glycemic complications, and delays or cancellations of surgery. Future guidelines should include broader multidisciplinary representation and develop validated gastric ultrasound-based algorithms.

This systematic review synthesized 48 human studies, predominantly case reports and case series, examining plasma concentrations measured near the onset of local anesthetic systemic toxicity. Central nervous system toxicity generally occurred at lower concentrations than severe cardiovascular toxicity, and moderate neurologic symptoms occurred at lower concentrations than seizures or coma. Because of substantial heterogeneity, the authors appropriately presented clinically useful concentration ranges narratively rather than as absolute thresholds.

Impact: LAST is uncommon but potentially catastrophic, and clinicians often lack a reliable framework for interpreting measured local anesthetic concentrations. This review converts fragmented human evidence into practical reference ranges while explicitly preventing overinterpretation of concentration cutoffs.

Clinical Implications: Measured plasma concentrations may help contextualize suspected LAST, particularly when symptoms and timing are compatible, but treatment should never be delayed while awaiting laboratory results. Clinicians should interpret concentrations according to the specific local anesthetic, sampling site, timing, clinical phenotype, and severity; lipid emulsion therapy and standard resuscitation remain guided by clinical presentation rather than a numeric threshold.

Future Directions: Prospective registries and standardized pharmacokinetic studies should collect timed arterial and venous concentrations alongside detailed clinical phenotypes and treatment interventions. Future work should examine whether concentration-informed decision support improves recognition, resuscitation, and outcomes in suspected LAST.