Daily ReportNov 4, 2026
Anesthesiology, November 4 edition
We read 40 papers and selected 3.
Summary
The strongest paper was a multicentre randomized trial showing that laryngeal mask airway ventilation substantially reduced perioperative respiratory adverse events compared with endotracheal intubation in young children undergoing adenotonsillectomy. Two systematic reviews also provided clinically useful evidence: remifentanil effect-site concentrations for emergence cough suppression were estimated, although certainty was very low, and dexmedetomidine was associated with lower early postoperative cognitive dysfunction after abdominal surgery, with important heterogeneity and limited long-term data.
Research Themes
- Airway management and pediatric perioperative safety
- Pharmacologic control of emergence from general anesthesia
- Prevention of postoperative cognitive dysfunction
Selected Articles
1. Perioperative respiratory adverse events in children undergoing adenotonsillectomy with laryngeal mask airway versus endotracheal tube ventilation: multicentre, randomised controlled trial
In this multicentre randomized trial of 400 children, perioperative respiratory adverse events occurred in 22.5% of children ventilated with a laryngeal mask airway versus 57.5% with an endotracheal tube. The absolute risk reduction was 35.0 percentage points, with fewer intraoperative and postoperative events and no serious adverse events in either group.
Impact: This directly addresses a common pediatric anesthesia decision with a large treatment effect and patient-centred safety outcome. The multicentre randomized design and intention-to-treat analysis provide stronger evidence than the largely observational literature in this area.
Clinical Implications: In experienced hands, laryngeal mask airway ventilation may be considered an alternative to endotracheal intubation for selected children undergoing adenotonsillectomy, particularly when the surgical and aspiration-risk profile is appropriate. Local expertise, airway access, surgical exposure, and rescue-conversion capability remain essential.
Key Findings
- Perioperative respiratory adverse events occurred in 22.5% with laryngeal mask airway ventilation versus 57.5% with endotracheal tube ventilation.
- The absolute risk difference was -35.0 percentage points, with fewer intraoperative and postoperative events in the laryngeal mask group.
- Laryngeal mask ventilation reduced laryngospasm, desaturation, airway obstruction, and severe cough without serious adverse events.
Methodological Strengths
- Multicentre randomized parallel-group design with 400 participants.
- Clearly defined composite respiratory outcome and intention-to-treat analysis.
Limitations
- The findings may not generalize to inexperienced operators, other age groups, or children with substantially increased aspiration risk.
- The abstract does not provide detailed information on allocation concealment, blinding, or longer-term postoperative outcomes.
Future Directions: Future trials should evaluate patient subgroups with obstructive sleep apnea, difficult airways, or higher aspiration risk, and should assess operator experience, conversion rates, airway contamination, recovery quality, and longer-term respiratory outcomes.
OBJECTIVE: To assess the effect of ventilation with a laryngeal mask airway (LMA) compared with endotracheal tube (ETT) on perioperative respiratory adverse events (PRAEs) in children undergoing adenotonsillectomy. DESIGN: Multicentre, randomised, parallel group trial. SETTING: Four tertiary hospitals in China, 2023-24. PARTICIPANTS: 400 children aged ≥2 years and <7 years who were scheduled for adenotonsillectomy under general anaesthesia. INTERVENTIONS: Participants were randomised 1:1 to receive ventilation with a laryngeal mask airway (n=200) or an endotracheal tube (n=200) during adenotonsillectomy. MAIN OUTCOME MEASURE: The primary outcome was the proportion of participants who developed any perioperative respiratory adverse event (PRAE): laryngospasm, bronchospasm, desaturation, airway obstruction, severe cough, or stridor in the intention-to-treat population.
2. Effect-site concentrations of remifentanil to suppress coughing during emergence from general anesthesia in adults: a systematic review and meta-analysis
This PROSPERO-registered systematic review and meta-analysis included 22 prospective studies and 857 adults. The pooled remifentanil effect-site concentration was approximately 2.0 ng/mL for EC50 and 2.7 ng/mL for EC95, but heterogeneity was substantial and GRADE certainty was very low for all outcomes.
Impact: The study provides a practical pharmacodynamic reference for titrating remifentanil during emergence while explicitly quantifying uncertainty. Its value lies in synthesizing dose-response evidence and identifying sex and surgical-type differences rather than presenting a single universal target.
Clinical Implications: A target near 2.0 ng/mL may be a starting reference for suppressing emergence cough, while approximately 2.7 ng/mL may suppress cough in 95% of patients in the pooled data. Clinicians should individualize dosing and monitor for delayed awakening, hypoventilation, and context-specific differences, because certainty is very low and heterogeneity is substantial.
Key Findings
- Twenty-two prospective studies involving 857 adults were included, with no study judged to have high risk of bias or low methodological quality.
- The pooled EC50 was 2.0 ng/mL by the up-and-down method, and the model-based EC95 was 2.7 ng/mL.
- Heterogeneity was considerable, and GRADE certainty was very low for all outcomes; male patients and video-assisted thoracic surgery required higher estimated EC50 values.
Methodological Strengths
- PROSPERO registration, broad database searching, prespecified concentration outcomes, and formal risk-of-bias assessment.
- Random-effects meta-analysis with heterogeneity assessment, subgroup analyses, and GRADE certainty evaluation.
Limitations
- All outcomes had very low certainty, with substantial heterogeneity across study groups and estimation methods.
- Most included studies used up-and-down pharmacodynamic designs, which may not reliably define individualized dosing or long-term safety.
Future Directions: Prospective studies should validate concentration targets using patient-level pharmacokinetic-pharmacodynamic models and clinically relevant outcomes, including cough severity, hemodynamic effects, extubation quality, hypoventilation, and delayed recovery across diverse surgical populations.
PURPOSE: Remifentanil infusion titrated to effect-site concentration (Ce) is commonly used to suppress coughing during emergence from general anesthesia; nevertheless, the optimal Ce range remains unclear. We aimed to conduct a systematic review and meta-analysis to synthesize the existing evidence on the optimal Ce values of remifentanil for cough suppression during emergence. SOURCE: We performed a comprehensive literature search using PubMed®, Embase, Web of Science™, the Cochrane Library, and Google Scholar on 27 February 2025. We included prospective studies that used the up-and-down method to estimate the effective concentrations of remifentanil in 50% of patients (EC50) and 95% of patients (EC95) for suppressing coughing during emergence from general anesthesia with tracheal intubation in adult patients.
3. EXPRESS: Effect of Dexmedetomidine on Postoperative Cognitive Dysfunction in Elderly Patients Undergoing Abdominal Surgery: A Systematic Review with Meta-Analysis.
This systematic review and meta-analysis included 12 randomized controlled trials, 14 comparisons, and 1,361 elderly patients undergoing abdominal surgery. Dexmedetomidine reduced postoperative cognitive dysfunction on postoperative day 1 (RR 0.49) and day 3 (RR 0.29), but cognitive score analyses showed substantial heterogeneity and evidence beyond postoperative day 3 was sparse.
Impact: Postoperative cognitive dysfunction is clinically important in older adults, and this review evaluates a widely available anesthetic adjunct with a potentially modifiable neuroinflammatory mechanism. The findings are promising but appropriately support cautious interpretation rather than immediate universal adoption.
Clinical Implications: Perioperative dexmedetomidine may be considered as part of an individualized anesthetic strategy for older adults undergoing abdominal surgery, particularly when early cognitive outcomes and opioid-sparing effects are priorities. The evidence does not yet establish benefit for persistent cognitive decline, delirium, functional recovery, or long-term safety.
Key Findings
- Twelve randomized controlled trials comprising 1,361 patients were included.
- Dexmedetomidine reduced postoperative cognitive dysfunction on day 1 (RR 0.49, 95% CI 0.40-0.59) and day 3 (RR 0.29, 95% CI 0.21-0.41).
- Dexmedetomidine lowered TNF-α concentrations, but MMSE results had substantial heterogeneity and no trial reported robust postoperative cognitive dysfunction incidence beyond day 3.
Methodological Strengths
- Systematic synthesis restricted to randomized controlled trials with prespecified primary and secondary outcomes.
- Random-effects models used Hartung-Knapp-Sidik-Jonkman confidence intervals, with subgroup analyses and exploratory publication-bias assessment.
Limitations
- Risk of bias was assessed with the older Cochrane Risk of Bias 1 tool, and substantial heterogeneity affected cognitive score outcomes.
- Evidence was limited to early postoperative outcomes; persistent cognitive impairment, delirium, functional recovery, and long-term safety were not adequately evaluated.
Future Directions: Large, preregistered randomized trials should use standardized cognitive and delirium definitions, assess outcomes beyond hospital discharge, and evaluate patient-centred endpoints such as functional independence, quality of life, and long-term cognitive trajectory.
OBJECTIVE: To systematically evaluate whether perioperative intravenous dexmedetomidine (DEX) reduces postoperative cognitive dysfunction (POCD) in elderly patients undergoing abdominal surgery. METHODS: A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed using PubMed, Embase, Cochrane CENTRAL, and Web of Science from database inception to 15 April 2026. Eligible studies included patients aged ≥60 years undergoing abdominal surgery under general anesthesia and compared intraoperative DEX with placebo. The primary outcome was POCD incidence assessed by the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA). Secondary outcomes included MMSE scores, tumor necrosis factor-α (TNF-α), and visual analogue scale (VAS) pain scores; interleukin-6 (IL-6) was summarized narratively because only two trials reported it.