Anesthesiology, week 35 edition

In a prospective randomized double-blind trial of 140 healthy ASA I-II children, drinking 3 mL/kg of carbohydrate-rich clear fluid 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 also improved comfort and produced no observed aspiration events, supporting evolving pediatric fasting recommendations in appropriately selected patients.

Impact: This is high-quality randomized evidence directly testing a liberalized pediatric fasting interval with objective gastric ultrasound rather than historical convention alone. It has immediate implications for patient comfort and peri-induction workflow while appropriately remaining limited to healthy elective-surgery children.

Clinical Implications: For healthy children undergoing elective non-gastrointestinal surgery, 3 mL/kg of carbohydrate-rich clear fluid one hour before induction may be feasible when oxygenation and aspiration risk are carefully assessed. The finding should not be extrapolated automatically to emergency surgery, gastrointestinal disease, or children with elevated aspiration risk.

In a single-center randomized double-blind trial of 160 adults aged 65–89 years, titrated ciprofol induction reduced post-intubation hypotension compared with propofol. Hypotension occurred in 36.3% versus 67.0% of patients, with lower hypotension burden and rescue norepinephrine use and no apparent worsening of early postoperative recovery.

Impact: Peri-intubation hypotension is common in older adults and may contribute to organ injury. The large relative reduction in a randomized trial supports further evaluation of ciprofol as a potentially hemodynamically safer induction agent, although effects on organ outcomes and cost remain uncertain.

Clinical Implications: Ciprofol may be considered for carefully titrated induction in older adults at risk of hemodynamic instability. Broad adoption should await multicenter confirmation and evaluation of acute kidney injury, myocardial injury, cerebral outcomes, mortality, availability, and cost-effectiveness.

In 7,145 adults undergoing thyroidectomy, higher cumulative thermal exposure within a 2-mm nerve-dense zone was associated with recurrent laryngeal nerve injury in an approximately linear dose-response pattern. In an independent test cohort, a low-exposure strategy was projected to reduce injury from 2.3% to 0.8%, a 65.9% relative reduction, although the thresholds remain hypothesis-generating.

Impact: This large multicentre study introduces a clinically interpretable exposure metric and applies target trial emulation, doubly robust estimation, and causal machine learning to individualize nerve-protection strategies. It could enable precision-guided energy use during thyroid surgery, but prospective validation is essential before implementation.

Clinical Implications: The thermal accumulation index may eventually support real-time monitoring of cumulative energy exposure near the recurrent laryngeal nerve and individualized surgical decision-making. It should not yet be used as a routine threshold because residual confounding, measurement error, and device-specific effects remain possible.