Weekly ReportDec 1–7, 2025
Anesthesiology, week 49 edition
We read 21 papers and selected 3.
Summary
This week’s anesthesiology literature was dominated by high-quality negative trials that challenge routine use of aggressive or costly perioperative interventions. Intraoperative driving pressure-guided high PEEP with recruitment maneuvers did not reduce pulmonary complications and increased hypotension, while single-shot TAP blocks and several specialized airway devices showed limited benefit in selected settings. Conversely, adjunct systemic corticosteroids reduced short-term mortality in severe pneumonia and ARDS without clearly increasing hospital-acquired infections. Additional advances included quantitative neuromuscular monitoring, objective delirium prediction, novel malignant hyperthermia diagnostics, and improved airway and bronchoscopy techniques.
Selected Articles
1. Intraoperative Driving Pressure-Guided High PEEP vs Standard Low PEEP for Postoperative Pulmonary Complications.
In a 29-site randomized trial of 1,435 adults undergoing open abdominal surgery, driving pressure-guided high PEEP with recruitment maneuvers did not reduce postoperative pulmonary complications compared with standard low PEEP. Pulmonary complications occurred in 19.8% versus 17.4%, respectively, while high PEEP increased intraoperative hypotension and vasoactive drug use.
Impact: This large international RCT provides definitive evidence against routine use of high PEEP and recruitment maneuvers solely to prevent postoperative pulmonary complications in open abdominal surgery.
Clinical Implications: Use low-tidal-volume ventilation as a foundation, but avoid routine high PEEP with recruitment maneuvers when hemodynamic tolerance is limited. Reserve higher PEEP for physiologically selected patients rather than applying it universally.
Key Findings
- Postoperative pulmonary complications occurred in 19.8% with high PEEP versus 17.4% with low PEEP; P=0.23.
- High PEEP increased intraoperative hypotension: 54.0% versus 45.0%.
- Vasoactive drug use was higher with high PEEP: 32.0% versus 18.8%.
2. Systemic Corticosteroids, Mortality, and Infections in Pneumonia and Acute Respiratory Distress Syndrome: A Systematic Review and Meta-analysis.
This systematic review and meta-analysis of 20 randomized trials involving 3,459 patients found that low-dose, short-course systemic corticosteroids probably reduce short-term mortality in severe pneumonia and ARDS. In severe pneumonia, steroids may also reduce secondary shock, with little or no effect on hospital-acquired infections.
Impact: The synthesis addresses a longstanding controversy and provides high-level evidence that can influence ICU guidelines and adjunctive treatment decisions for non-COVID severe pneumonia and ARDS.
Clinical Implications: Consider low-dose, short-course systemic corticosteroids for appropriately selected patients with severe pneumonia or ARDS, while continuing clinical surveillance for infection and recognizing uncertainty in dose, duration, and ARDS-specific effects.
Key Findings
- Twenty randomized trials included 3,459 participants; 15 trials addressed severe pneumonia and 5 addressed ARDS.
- In severe pneumonia, corticosteroids reduced short-term mortality: RR 0.73, 95% CI 0.57-0.93.
- Hospital-acquired infections were little changed or not increased across severe pneumonia and ARDS.
3. Hospital mortality, withdrawal of life-sustaining therapy decisions and early secondary brain insults for critically ill traumatic brain injury patients in England, Wales and Northern Ireland (2009-2024): an observational cohort study.
In a 15-year cohort of 45,684 critically ill traumatic brain injury patients across 235 ICUs, hospital mortality increased from 25.6% to 35.0% and withdrawal of life-sustaining therapy decisions increased from 7.5% to 19.7%. Hypoxemia and other early secondary brain insults were common and, in the case of hypoxemia, increased substantially over time.
Impact: This large national analysis identifies concerning TBI-specific trends in mortality, life-sustaining treatment decisions, and preventable physiologic insults, raising major quality-of-care and ethical questions for neurocritical care.
Clinical Implications: Strengthen protocolized prevention of hypoxemia, hypotension, and abnormal carbon dioxide or glucose levels. Use transparent multidisciplinary prognostication and withdrawal-of-treatment frameworks to reduce bias and avoid premature decisions.
Key Findings
- Hospital mortality increased from 25.6% to 35.0% between 2009 and 2024.
- Withdrawal of life-sustaining therapy decisions increased from 7.5% to 19.7%.
- Hypoxemia exposure increased from 36.9% to 61.2%, while similar trends were not observed in comparator ICU cohorts.