Weekly Anesthesiology Research Analysis
This week’s anesthesiology literature emphasizes pragmatic, practice-changing trials and large-scale decision-support validation. High-quality randomized trials show anesthetic choice and regional techniques can reduce postoperative delirium and improve recovery after thoracic and orthopedic procedures. Large multicenter validation of an ML transfusion-risk model and point-of-care diagnostic/triage innovations underscore rapid implementation opportunities for perioperative decision support.
Summary
This week’s anesthesiology literature emphasizes pragmatic, practice-changing trials and large-scale decision-support validation. High-quality randomized trials show anesthetic choice and regional techniques can reduce postoperative delirium and improve recovery after thoracic and orthopedic procedures. Large multicenter validation of an ML transfusion-risk model and point-of-care diagnostic/triage innovations underscore rapid implementation opportunities for perioperative decision support.
Selected Articles
1. Remimazolam tosylate or propofol and delirium in frail elderly patients after hip surgery: A randomised controlled clinical trial.
In a single-centre randomized trial of 136 frail elderly hip surgery patients, remimazolam for TIVA reduced postoperative delirium compared with propofol (4.4% vs 17.6%; RR 0.25) and lowered induction hypotension and vasopressor needs. EEG burst suppression time was markedly less with remimazolam, suggesting gentler neurophysiologic effects that may mediate the delirium benefit.
Impact: Provides high-quality randomized evidence that choice of intravenous anesthetic reduces delirium in a high-risk, frail elderly population and links EEG physiology (burst suppression) and hemodynamics to clinical outcomes.
Clinical Implications: Consider remimazolam for frail elderly undergoing major surgery to reduce delirium and induction hypotension; implement EEG-based depth monitoring and protocols to minimize burst suppression and manage hemodynamics perioperatively.
Key Findings
- Postoperative delirium: remimazolam 4.4% vs propofol 17.6% (RR 0.25; NNT ~8).
- Induction hypotension lower with remimazolam (23.5% vs 47.1%) and fewer vasopressor requirements.
- Significantly less intraoperative EEG burst suppression with remimazolam (shorter duration and proportion).
2. Intercostal or Paravertebral Block vs Thoracic Epidural in Lung Surgery: A Randomized Noninferiority Trial.
In an 11-centre randomized noninferiority trial (n=389 ITT) of thoracoscopic anatomical lung resections, single-shot intercostal nerve block (ICNB) was noninferior to thoracic epidural analgesia for pain over POD0–2, while reducing opioid consumption, improving mobilization, and shortening hospital stay. Continuous paravertebral block was inferior for pain but also reduced opioid use.
Impact: High-quality multicentre RCT demonstrating that a simpler, less invasive regional technique (ICNB) can replace epidural analgesia for VATS with better recovery metrics, supporting ERAS pathway simplification.
Clinical Implications: Adopt ICNB as a first-line regional analgesic option in appropriate VATS patients to reduce opioid exposure, facilitate mobilization, and shorten hospitalization; tailor choices when epidural is indicated.
Key Findings
- ICNB noninferior to TEA for pain (pain NRS AUC POD0–2; noninferiority achieved).
- ICNB associated with reduced opioid consumption and improved QoR-15 at 24 and 48 h.
- ICNB group had shorter hospital stay and fewer postoperative pulmonary and PONV-related events.
3. Multicenter Validation of a Machine Learning Model for Surgical Transfusion Risk at 45 US Hospitals.
Across 3,275,956 surgical cases at 45 hospitals, the S-PATH ML model achieved median AUROC 0.929 and, at 96% sensitivity, reduced median type-and-screen recommendations from 51.6% (MSBOS) to 32.5% (median absolute reduction 17.9 percentage points), demonstrating external validity and potential to reduce unnecessary pretransfusion testing.
Impact: Massive multicenter external validation demonstrates robust generalizability and practical benefit (fewer unnecessary tests) at maintained sensitivity, a key step toward clinical adoption of ML decision support in perioperative workflows.
Clinical Implications: Integrate S-PATH into perioperative EHR decision support to personalize type-and-screen ordering, reduce lab workload and costs, and monitor calibration locally; run prospective implementation studies to confirm downstream safety and resource impacts.
Key Findings
- S-PATH AUROC median 0.929 across 45 hospitals vs MSBOS 0.857.
- At 96% sensitivity, S-PATH recommended type-and-screen for median 32.5% vs MSBOS 51.6% (median absolute reduction 17.9 percentage points).
- Validation performed without local retraining across diverse centers and 3.28M cases.