Anesthesiology, October 2026 edition

In a multicentre randomized trial of 673 evaluable infants undergoing cardiac procedures, first-attempt nasotracheal intubation success was higher with videolaryngoscopy than with direct laryngoscopy, 83% versus 75%, with an adjusted absolute improvement of 8.2%. First-attempt and cumulative complication rates were similar, and no cardiac arrest or death occurred in either group.

Impact: This high-quality multicentre randomized trial provides directly actionable evidence for a vulnerable pediatric population and demonstrates a clinically meaningful improvement in first-attempt airway success.

Clinical Implications: Videolaryngoscopy should be strongly considered as the initial device for nasotracheal intubation in infants undergoing elective cardiac procedures when appropriate equipment and trained operators are available. Generalization to emergency cases and non-specialist settings requires caution.

This multimodal study integrated neural recordings from humans, macaques, marmosets, mice, zebrafish, and nematodes and extracted more than 6,000 time-series features. Across species, anesthesia consistently shortened intrinsic neural timescales and reduced inter-regional synchrony, indicating spatiotemporal isolation of local brain activity. Centromedian thalamic stimulation in macaques reversed the anesthetic neural profile and restored behavioral responsiveness.

Impact: The study establishes a conserved dynamical framework for anesthesia across phylogeny and provides causal evidence that thalamic stimulation can reverse anesthetic brain-state features in a nonhuman primate model.

Clinical Implications: The conserved neural signature may support future biomarkers of anesthetic depth, emergence, delirium, and disorders of consciousness. Thalamic stimulation remains investigational because behavioral reversal was demonstrated only in macaques.

The fully blinded, cluster-randomized ORACLE trial evaluated supplemental operating-room air sterilization across 68 operating rooms and more than 110,000 surgeries. The intervention did not reduce the 30-day composite of surgical wound infection, infection-related complications, or death compared with sham treatment, and the trial stopped for futility.

Impact: This exceptionally large and rigorously blinded trial provides strong negative evidence against a biologically plausible but resource-intensive infection-control intervention.

Clinical Implications: Routine supplemental operating-room air purification should not be assumed to reduce surgical infections or mortality. Infection-control resources should instead prioritize measures that prevent direct wound contamination and have demonstrated clinical benefit.

In a single-centre, double-blind randomized noninferiority trial of 686 patients undergoing elective neurovascular surgery, postoperative delirium occurred in 12.8% of patients receiving remimazolam and 10.8% receiving propofol. Remimazolam met the prespecified noninferiority criterion and was associated with less hypotension and more frequent operating-room extubation.

Impact: This rigorous randomized trial addresses whether remimazolam can provide hemodynamic advantages in high-risk neurovascular surgery without an unacceptable increase in postoperative delirium.

Clinical Implications: Remimazolam-based anesthesia may be considered when minimizing hypotension, facilitating operating-room extubation, or enabling rapid reversal is important. Delirium surveillance and familiarity with flumazenil reversal remain necessary.

In this double-blind randomized clinical trial of 328 adults undergoing traumatic fracture surgery, a single 40-IU dose of intranasal oxytocin before anesthesia induction reduced the 3-day incidence of screening-positive probable acute stress disorder from 30.5% to 15.9%. The risk ratio was 0.52 and the adjusted hazard ratio was 0.45, with no serious adverse events observed.

Impact: The trial broadens anesthesiology outcomes beyond physiologic endpoints and demonstrates a large preventive effect on acute psychological morbidity using a simple, low-burden intervention.

Clinical Implications: Preoperative intranasal oxytocin is promising for preventing acute stress symptoms after traumatic fracture surgery, but routine adoption is premature because the trial was single-centre, follow-up was short, and the endpoint was a screening-positive probable disorder.