Anesthesiology, week 39 edition

This translational study combined human proteomics, a prospective surgical cohort, and mechanistic cellular and murine experiments. Lower or altered 14-3-3γ was associated with postoperative cognitive dysfunction and delirium, while surgery and anesthesia reduced hippocampal 14-3-3γ, increased Tau Thr205 phosphorylation, and impaired synaptic function in mice. Genetic overexpression or pharmacological stabilization of the 14-3-3γ–Tau interaction improved cognition and synaptic integrity.

Impact: The study moves postoperative cognitive dysfunction research from epidemiologic association toward a biologically defined and potentially druggable pathway. Its integration of human findings with genetic and pharmacological rescue experiments provides unusually strong mechanistic support for future biomarker and therapeutic development.

Clinical Implications: Circulating 14-3-3γ is not ready for clinical risk stratification, and targeted stabilizers are not yet available for patient care. However, the findings support future perioperative biomarker studies and therapeutic trials for patients at high risk of postoperative cognitive dysfunction or delirium.

PROTECT-CS is a multicenter, double-blind, placebo-controlled randomized trial protocol testing perioperative recombinant human brain natriuretic peptide in 694 high-risk patients undergoing elective on-pump cardiac surgery. The primary endpoint is KDIGO-defined acute kidney injury within 7 days, with renal replacement therapy, MAKE-30, MAKE-90, mortality, and length of stay as important secondary outcomes. The protocol directly addresses the lack of proven pharmacological prevention for cardiac-surgery acute kidney injury.

Impact: Although it reports a protocol rather than efficacy results, the study is designed to answer a major unresolved perioperative question with adequate multicenter randomization, blinding, and patient-important renal outcomes. A positive or negative result could directly influence cardiac-anesthesia renal-protection practice.

Clinical Implications: Routine prophylactic rhBNP should not be adopted before trial results are available. If effective and safe, rhBNP could become a targeted renal-protection strategy for selected high-risk cardiac-surgery patients; if ineffective, the trial will help prevent unsupported pharmacological use.

This international multidisciplinary consensus used systematic evidence review, GRADE assessment, and a three-stage Delphi process involving 68 stakeholders. It supports six-hour fasting for solid food and non-clear liquids while endorsing institutional protocols that permit clear liquids until two hours before anesthesia or sedation, with earlier postoperative oral intake when clinically feasible. Selective gastric ultrasound is recommended when aspiration risk remains uncertain.

Impact: The statement challenges the entrenched practice of unnecessarily prolonged clear-liquid fasting and provides an internationally developed, evidence-graded framework for safer and more patient-centered protocol reform. Its recommendations could reduce thirst, dehydration, metabolic stress, and delays in enhanced recovery pathways.

Clinical Implications: Hospitals should consider updating fasting orders to permit clear liquids closer to anesthesia while preserving appropriate restrictions for solids and non-clear liquids. Implementation should include standardized electronic orders, explicit exceptions for aspiration-risk conditions, staff education, auditing, and access to gastric ultrasound where appropriate.