Anesthesiology, April 2025 edition

This randomized, placebo-controlled crossover study of 92 healthy adults used 7T fMRI and painful stimulation to compare common sedatives. Propofol most strongly impaired next-day recollection and reduced hippocampal and amygdala encoding activity, dexmedetomidine relatively preserved memory, and fentanyl produced a distinct pattern of somatosensory and limbic activation.

Impact: High-resolution neuroimaging offers mechanistic evidence for choosing sedatives according to the desired balance among amnesia, memory preservation, and analgesia.

Clinical Implications: Sedative selection may be individualized according to the clinical goal: propofol when robust amnesia is desired, dexmedetomidine when memory preservation is prioritized, and fentanyl when targeted nociceptive modulation is needed. Translation to older or surgical populations should remain cautious.

In 136 patients with chronic kidney disease undergoing cardiac surgery with cardiopulmonary bypass, perioperative inhaled nitric oxide at 80 ppm intraoperatively and for 6 postoperative hours reduced 7-day acute kidney injury from 39.7% to 23.5%. The intervention also improved 6-month GFR without significant methemoglobinemia, nitrogen dioxide toxicity, bleeding, or transfusion signals.

Impact: This randomized trial demonstrates both short-term AKI reduction and longer-term renal benefit from a protocolized intraoperative intervention in a high-risk population.

Clinical Implications: Perioperative inhaled nitric oxide may be considered for selected chronic kidney disease patients undergoing cardiopulmonary bypass, provided that delivery capability and monitoring for methemoglobin and nitrogen dioxide are available.

This PRISMA-compliant, PROSPERO-registered meta-analysis of 18 studies involving 2,625 patients found that enhanced recovery or fast-track programs reduced hospital stay by 1.40 days, ICU stay by 13.22 hours, and ventilation time by 4.68 hours compared with usual care. Comprehensive enhanced recovery programs provided additional benefit beyond fast-track-only strategies, particularly for hospital length of stay.

Impact: The study quantifies the incremental benefit of comprehensive enhanced recovery programs over isolated fast-track measures and directly informs cardiac anesthesia program design and resource allocation.

Clinical Implications: Cardiac surgery programs should consider standardized multimodal enhanced recovery pathways spanning the preoperative, intraoperative, and postoperative phases rather than relying solely on intraoperative fast-track measures.

In a randomized study of 48 patients undergoing laparoscopic cholecystectomy, remimazolam produced higher theta and alpha power, reduced functional connectivity, lower PACU PSI values, and slower achievement of an Aldrete score of 9 than propofol. Alpha-band connectivity metrics were strongly correlated with recovery time, suggesting a potential EEG-based approach to identifying delayed emergence.

Impact: The study links agent-specific EEG signatures to a clinically meaningful recovery outcome and provides a practical framework for monitoring patients receiving remimazolam.

Clinical Implications: When remimazolam is used, clinicians should anticipate potentially slower emergence and may consider EEG-informed titration and recovery planning, particularly in patients at risk for prolonged PACU care.

The TRANSFUSE model was developed and externally validated in 816,618 surgical cases using 24 preoperative variables, including ASA status, INR, emergency or redo surgery, anemia, and expected duration. It achieved an AUC of 0.93 and a negative predictive value of 99.7%, outperforming an established clinical score and supporting targeted crossmatching and blood conservation.

Impact: The model offers a highly discriminative and potentially transportable method for improving preoperative blood-product ordering across diverse surgical services.

Clinical Implications: Integration into preoperative EHR workflows could reduce unnecessary crossmatching, prioritize conservation strategies for high-risk patients, and improve blood-product stewardship. Prospective implementation and local recalibration remain necessary.