Monthly ReportJun 1–30, 2025
Anesthesiology, June 2025 edition
We read 82 papers and selected 5.
Summary
June 2025 anesthesiology research increasingly favored recovery-oriented, less invasive perioperative care supported by randomized evidence. Regional analgesia studies showed that intercostal nerve blocks can outperform erector spinae plane blocks for uniportal VATS and provide noninferior analgesia to thoracic epidurals while improving opioid exposure and recovery. Anesthetic selection also emerged as a modifiable determinant of postoperative delirium, with remimazolam reducing delirium and hemodynamic instability in frail older adults. Mechanistic and translational work advanced neuroprotection and hypoxic lung-injury therapies, while large-scale validation of machine-learning transfusion prediction demonstrated growing readiness for perioperative decision-support implementation.
Selected Articles
1. Ketamine-induced Sustained Modulation of γ-Aminobutyric Acid Type A Receptor Function in Mouse Hippocampal Neurons after Anesthesia.
In a preclinical mouse study, ketamine prevented anesthetic-induced sustained increases in tonic GABAA currents through BDNF–TrkB/GSK-3β signaling and reduced surface expression of α5-GABAA receptors. These effects were associated with protection against sevoflurane-related recognition and spatial memory deficits, suggesting a cognitive-sparing mechanism independent of NMDA receptor antagonism.
Impact: The work identifies a novel molecular mechanism by which ketamine may protect cognition after general anesthesia and provides a strong biological rationale for translational trials targeting postoperative cognitive dysfunction.
Clinical Implications: The findings support carefully designed clinical trials of perioperative ketamine for cognitive protection, particularly in patients at elevated risk of postoperative cognitive decline. They should not be interpreted as evidence for routine ketamine use solely to prevent cognitive impairment until human efficacy and safety are established.
Key Findings
- Ketamine prevented sustained tonic GABAA current increases induced by etomidate and sevoflurane.
- The protective effect involved BDNF–TrkB/GSK-3β signaling and was independent of NMDA antagonism.
- Ketamine reduced α5-GABAA receptor surface expression and prevented memory deficits in mice.
2. Identification of HIF1A as a therapeutic target during SARS-CoV-2-associated lung injury.
This translational study combined mechanistic, preclinical, and phase II clinical data on HIF1A stabilization during SARS-CoV-2-associated lung injury. In a multicenter randomized trial of 448 patients, vadadustat induced HIF target genes and produced a modest overall reduction in severe lung injury at day 14, with a striking signal in patients requiring baseline FiO2 of at least 80%.
Impact: The study connects a biologically plausible target with randomized clinical evidence and suggests a repurposed oral therapy for severe hypoxic viral lung injury, although the subgroup signal requires confirmation.
Clinical Implications: Vadadustat should not yet be used routinely for SARS-CoV-2-associated lung injury. The findings justify larger confirmatory trials enriched for patients with severe baseline hypoxemia and careful assessment of thrombotic, renal, and other HIF-pathway-related safety outcomes.
Key Findings
- Vadadustat induced HIF target genes and had safety broadly similar to placebo in the phase II trial.
- Severe lung injury at day 14 occurred in 13.3% with vadadustat versus 16.9% with placebo overall.
- The apparent benefit was greatest in patients with baseline FiO2 of at least 80%.
3. Remimazolam tosylate or propofol and delirium in frail elderly patients after hip surgery: A randomised controlled clinical trial.
In a single-center randomized trial of 136 frail elderly patients undergoing hip surgery, remimazolam-based total intravenous anesthesia reduced postoperative delirium compared with propofol, from 17.6% to 4.4%. Remimazolam also reduced induction hypotension, vasopressor requirements, and EEG burst-suppression duration, suggesting that both hemodynamic stability and gentler anesthetic neurophysiology may contribute to the observed benefit.
Impact: This randomized evidence identifies anesthetic choice as a potentially modifiable determinant of postoperative delirium in a highly vulnerable population and links the clinical outcome to EEG and hemodynamic mechanisms.
Clinical Implications: Remimazolam may be considered for selected frail older adults undergoing major surgery, particularly when delirium and induction hypotension are major concerns. Implementation should include EEG-based depth monitoring, standardized delirium assessment, and evaluation of cost, recovery quality, and external reproducibility.
Key Findings
- Postoperative delirium occurred in 4.4% with remimazolam versus 17.6% with propofol; relative risk was 0.25.
- Induction hypotension occurred less often with remimazolam, at 23.5% versus 47.1%.
- Remimazolam produced substantially less intraoperative EEG burst suppression.
4. Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery: A Randomized Noninferiority Trial.
This 11-center randomized noninferiority trial included 389 patients undergoing thoracoscopic anatomical lung resection. Single-shot intercostal nerve block was noninferior to thoracic epidural analgesia for pain over postoperative days 0 to 2, while reducing opioid use, improving recovery quality and mobilization, and shortening hospital stay. Continuous paravertebral block was inferior for pain despite opioid-sparing effects.
Impact: The study provides multicenter evidence that a simpler, less invasive regional technique can replace thoracic epidural analgesia for many VATS patients while improving recovery-related outcomes.
Clinical Implications: Single-shot intercostal nerve block should be considered a first-line regional analgesic option for appropriate thoracoscopic lung surgery patients within ERAS pathways. Patient selection, local anesthetic dose monitoring, and situations requiring prolonged or extensive analgesia remain important considerations.
Key Findings
- Intercostal nerve block was noninferior to thoracic epidural analgesia for pain across postoperative days 0 to 2.
- Intercostal nerve block reduced opioid consumption and improved Quality of Recovery-15 scores.
- Hospital stay was shorter, with fewer postoperative pulmonary and nausea/vomiting-related events.
5. Erector Spinae Plane Block versus Intercostal Nerve Blocks in Uniportal Videoscopic-assisted Thoracic Surgery: A Multicenter, Double-blind, Prospective Randomized Placebo-controlled Trial.
In a multicenter double-blind randomized trial of 100 patients undergoing uniportal VATS, surgeon-performed intercostal nerve blocks under direct thoracoscopic visualization reduced morphine consumption at 12 and 24 hours compared with ultrasound-guided erector spinae plane block. Intercostal blocks also improved early pain scores and reduced rescue analgesic use without a meaningful safety penalty.
Impact: The trial directly challenged widespread use of ESPB in uniportal thoracic surgery and provided a technically pragmatic alternative with objective opioid-sparing benefits.
Clinical Implications: Thoracoscopically guided intercostal nerve block may be prioritized for opioid-sparing analgesia in uniportal VATS when performed by appropriately trained teams. Protocols should standardize local anesthetic dosing, timing, and integration with multimodal ERAS analgesia.
Key Findings
- Twelve-hour morphine consumption was 10.9 mg with intercostal block versus 17.6 mg with ESPB.
- Twenty-four-hour morphine consumption was 18.7 mg versus 26.7 mg, respectively.
- Rescue analgesic use was lower with intercostal block, at 16% versus 40%.