Anesthesiology, August 2026 edition

In a pragmatic multicenter randomized trial of 2,508 adults aged 50 years or older, total intravenous anesthesia did not improve days alive and at home at 30 days compared with volatile anesthesia. Mortality, delirium, quality of recovery, and major postoperative complications were similar, although TIVA reduced thirst, hoarseness, and nausea and vomiting.

Impact: This is the largest pragmatic randomized comparison of TIVA and volatile anesthesia in major noncardiac surgery and directly challenges the assumption that TIVA universally improves recovery.

Clinical Implications: Anesthetic technique should be selected according to patient characteristics, postoperative nausea risk, airway symptoms, procedural requirements, expertise, and resources rather than an expectation of superior overall recovery with TIVA.

In the multicenter COVALENT randomized trial, first-pass success was 78.2% with direct laryngoscopy, 82.9% with Macintosh video laryngoscopy, and 87.6% with hyperangulated video laryngoscopy. Both video laryngoscopy approaches were superior to direct laryngoscopy, with the greatest success observed for hyperangulated devices.

Impact: This large pragmatic randomized trial directly addresses routine airway management and supports video laryngoscopy as a potential default first-line device rather than a tool reserved only for difficult airways.

Clinical Implications: Video laryngoscopy should be strongly considered for routine operating-room intubation, while direct-laryngoscopy skills should be maintained and blade geometry selected according to anatomy, expertise, and equipment.

In 140 healthy ASA I-II children, 3 mL/kg of carbohydrate-rich clear fluid given one hour before anesthesia increased gastric fluid volume compared with a two-hour interval, but no child exceeded the 1.5 mL/kg risk threshold. The one-hour regimen improved comfort without observed aspiration.

Impact: This randomized trial directly evaluates liberalized pediatric clear-fluid fasting using objective gastric ultrasound and provides clinically relevant evidence for improving comfort and peri-induction workflow.

Clinical Implications: In healthy children undergoing elective non-gastrointestinal surgery, 3 mL/kg of carbohydrate-rich clear fluid one hour before induction may be feasible when aspiration risk is carefully assessed. The findings should not be generalized to emergency surgery or children with gastrointestinal or aspiration-risk conditions.

In a double-blind, multicenter randomized trial of 1,210 patients undergoing elective curative digestive cancer surgery, preoperative methylprednisolone 20 mg/kg did not reduce major postoperative complications compared with placebo. Major complications occurred in 23% versus 20% of patients, with no benefit for infection, wound healing, or hospital length of stay.

Impact: This large, rigorous randomized trial provides practice-changing negative evidence against routine high-dose corticosteroids for complication prevention in elective digestive cancer surgery.

Clinical Implications: Routine methylprednisolone 20 mg/kg should not be used solely to reduce postoperative complications or inflammation in this population. Corticosteroids should be reserved for established indications and individualized risk-benefit assessment.

In 100 older adults undergoing lumbar spine fusion, EEG spectrogram-guided dexmedetomidine-ketamine anesthesia produced a smaller decline in 24-hour QoR-15 scores than conventional balanced anesthesia. It reduced sevoflurane, intraoperative fentanyl, and PACU morphine use, but increased norepinephrine and atropine requirements.

Impact: The study combines EEG-guided precision titration with multimodal opioid-sparing pharmacology and demonstrates a patient-reported recovery benefit in a high-pain surgical population.

Clinical Implications: This strategy may be considered for selected older adults undergoing lumbar spine fusion when opioid and volatile-agent reduction is desirable, but it requires close hemodynamic monitoring and confirmation in larger multicenter trials.