Anesthesiology, February 2025 edition

In a multicentre randomized trial of approximately 984 adults with obesity undergoing sedated gastrointestinal endoscopy, HFNC reduced hypoxia from 21.2% to 2.0%. Severe hypoxia fell from 4.1% to 0%, and subclinical respiratory depression decreased from 36.3% to 5.6%, without an increase in other sedation-related adverse events. The magnitude and consistency of benefit support HFNC as an immediately actionable safety intervention in this high-risk procedural population.

Impact: This large multicentre randomized trial demonstrates a dramatic reduction in clinically important and subclinical respiratory events. It provides unusually strong evidence for changing procedural sedation practice in patients with obesity.

Clinical Implications: HFNC protocols should be considered for obese patients undergoing sedated endoscopy, with attention to device availability, flow and FiO2 settings, staff training, and rescue-escalation pathways.

In a double-blind randomized trial of 38 older adults undergoing joint replacement, perioperative infusion of a young-donor plasma protein fraction altered circulating proteomic signatures and single-cell immune signaling. The intervention attenuated JAK-STAT, NF-kB, and MAPK inflammatory pathways, with reported discrimination metrics of 0.796 and 0.904 for proteomic and cellular signatures. This first-in-human proof of principle supports further investigation of biologic perioperative immunomodulation but does not establish clinical outcome benefit.

Impact: The study provides randomized human evidence that a plasma-derived biologic can modify age-associated perioperative inflammatory signaling. It opens a novel therapeutic direction for geriatric perioperative care while clearly requiring larger studies focused on safety, dosing, mechanism, and patient-centered outcomes.

Clinical Implications: Routine clinical use is premature. Future trials should identify the active plasma factors, define dose and timing, monitor immunologic and transfusion-related safety, and determine whether molecular changes translate into lower morbidity or improved recovery.

PRIME-AIR was a multicentre phase 3 randomized trial in intermediate- and high-risk patients undergoing major open abdominal surgery. The individualized perioperative lung-expansion bundle achieved high implementation fidelity, with adherence ranging from 72% to 98%, and increased intraoperative mean PEEP to approximately 7.5 cmH2O. The study provides a robust implementation model for pulmonary-complication prevention, although the supplied report did not include the complete pulmonary outcome results.

Impact: This large, rigorously conducted trial demonstrates that a complex perioperative respiratory bundle can be delivered reliably across centres. It is highly relevant to ventilation protocol design, implementation science, and future guideline development for postoperative pulmonary-complication prevention.

Clinical Implications: Hospitals can consider adopting checklist-based lung-expansion pathways, individualized PEEP assessment, and implementation-support tools for high-risk open abdominal surgery while awaiting complete outcome reporting and external validation.

This multidisciplinary SCCM focused update recommends using critical care ultrasonography to guide management of septic shock, acute dyspnea or respiratory failure, and cardiogenic shock. It highlights evidence that CCUS-guided targeted volume management is associated with improved mortality compared with usual care. The guideline also emphasizes training, credentialing, quality assurance, and research priorities for safe implementation.

Impact: Guideline-level endorsement of CCUS with mortality-linked evidence is practice-shaping for anesthesiology-led ICU and perioperative critical care. It provides a framework for moving ultrasound from an optional examination to an integrated hemodynamic management pathway.

Clinical Implications: Institutions should consider incorporating CCUS into shock and respiratory-failure pathways, with structured training, credentialing, quality dashboards, and protocols that link ultrasound findings to fluid and vasoactive management.

COMET is a transfer-learning framework that pretrains on large observational EHR datasets and integrates clinical and omics data from smaller cohorts. Across two independent datasets, it outperformed omics-only approaches for prediction and biological discovery and enabled more granular patient stratification than binary case-control classification. The method could substantially improve biomarker discovery in perioperative and critical-care research where omics cohorts are often limited.

Impact: COMET is a strategic methodological advance for precision anesthesiology. By leveraging large EHR datasets to strengthen small omics cohorts, it may accelerate discovery of biomarkers and risk signatures for delirium, acute kidney injury, pulmonary complications, and other perioperative outcomes.

Clinical Implications: The framework is not yet a clinical decision tool, but it can improve discovery-stage modeling and help generate hypotheses for prospective validation of perioperative biomarkers and individualized risk prediction.