This Week in Anesthesiology — May 21, 2026

Welcome to This Week in Anesthesiology. This week we're covering 10 notable papers spanning perioperative pharmacology, innovations in monitoring, and updates on procedural techniques. Let's dive in.

Pharmacology and Patient Outcomes

First, we’ll look at four papers that challenge our assumptions about common perioperative medications, from opioids and gabapentinoids to colloids.

We begin with a provocative study from the *Journal of Clinical Anesthesia* that questions the role of gabapentinoids in enhanced recovery protocols [6]. This nationwide, retrospective cohort study examined over 27,000 opioid-naïve patients undergoing below-knee amputation. The investigators looked for an association between new perioperative prescriptions for gabapentinoids and persistent opioid use at three and six months. What they found was surprising. After adjusting for confounders, patients who received gabapentinoids had roughly triple the odds of still using opioids at three months, and more than double the odds at six months, compared to those who did not receive them. This strong association held true for both gabapentin and pregabalin, and it didn't matter whether the drug was started before or after surgery. While this is an observational study and cannot prove causation, its findings directly undermine the common rationale of using gabapentinoids for their supposed protective and opioid-sparing effects, suggesting their role in multimodal regimens needs careful re-examination.

In contrast to that challenging finding, a paper in *Anesthesiology* offers a clear success story in reducing opioid prescribing [2]. Investigators used an interrupted time series design to evaluate a system-wide clinical decision support tool. The tool targeted adult surgical patients who were hospitalized for at least 24 hours but had not received any opioids in the 24 hours prior to discharge—a group where a new opioid prescription is likely unnecessary.

Results In the post-intervention period, the total amount of oxycodone prescribed per discharge dropped significantly, from 27.4 to 16.5 morphine milligram equivalents. The proportion of these patients receiving any opioid prescription fell from 21% to 18%. And for those who did get a prescription, the median dose was substantially lower. This study demonstrates that a simple, automated decision support tool integrated into the electronic health record can produce clinically significant reductions in unnecessary opioid prescribing at scale.

Shifting from pain management to patient comfort, a randomized clinical trial in *Anesthesiology* highlights a strategy to improve recovery after ambulatory surgery [8]. The study focused on post-discharge nausea and vomiting, which can severely impact patient experience. The trial enrolled 384 female patients aged 18 to 50, who received either a single 5 mg oral dose of olanzapine or a placebo before surgery, in addition to standard antiemetic prophylaxis with dexamethasone and ondansetron.

The Study The primary outcome was the Quality of Recovery-40 score on postoperative day one. The olanzapine group reported significantly higher QoR-40 scores, with a 9-point difference compared to placebo. This benefit persisted to postoperative day two. Olanzapine was also associated with substantially lower odds of any nausea and severe nausea on the first day after surgery. A key practical finding was that this lower dose of olanzapine did not increase the length of stay in the post-anesthesia care unit. This suggests that adding a small dose of preoperative olanzapine can meaningfully improve the global quality of recovery for ambulatory surgery patients.

Finally in this section, a major systematic review and meta-analysis from *Anesthesiology* revisits the safety of hydroxyethyl starch, or HES [9]. Regulatory agencies in both the United States and Europe have issued strong warnings against using HES, including in surgical patients, due to risks of acute kidney injury reported in trials of critically ill and septic patients. To assess the risk specifically in the perioperative setting, investigators conducted a new meta-analysis, adding 45 new trials to a previous review.

Conclusions The final analysis included 114 trials and nearly 14,000 surgical patients. The results were clear: the use of modern HES 130/0.4 solutions did not significantly increase the risk of acute kidney injury, with a relative risk of 1.02. It also did not worsen postoperative creatinine concentration. Trial sequential analysis confirmed that there was sufficient evidence to conclude non-inferiority for this outcome. The authors state that current hydroxyethyl starch solutions do not provoke renal injury in surgical patients, a conclusion that stands in direct opposition to current regulatory black box warnings.

Innovations in Monitoring

Next, a look at new and existing technologies for monitoring patients, from predicting cognitive dysfunction to noninvasively tracking pain and respiratory effort.

First, a study in the *Journal of Clinical Anesthesia* explored whether preoperative processed EEG could help identify elderly patients at risk for postoperative delirium [5]. In a cohort of 80 patients with a median age of 71, investigators recorded baseline pEEG indices before surgery and assessed for delirium afterwards using the brief Confusion Assessment Method. They found that the 24 patients who developed delirium had significantly lower baseline values on several pEEG indices—including the Bispectral Index or BIS, and the SEDLine Patient State Index or PSI—particularly when measured with their eyes closed. The strongest predictor was the PSI measured with eyes open, which had an area under the curve of 0.71 for discriminating between patients who did and did not develop delirium. While the effect sizes were modest, this work highlights the potential for using preoperative pEEG monitoring as part of a risk stratification strategy for postoperative neurocognitive disorders.

From predicting delirium to measuring pain, another paper in the *Journal of Clinical Anesthesia* introduces a novel technology for objective pain assessment [1]. The study tested a system called ROPA, which stands for Real-time Objective Pain Assessment. It uses wearable forehead sensors with optical spectrometry to capture continuous, objective pain measurements. The technology was assessed in a prospective study of 130 women in labor who were receiving neuraxial analgesia. Using the patient’s self-reported Numerical Rating Scale as the ground truth, the algorithm demonstrated excellent performance. For distinguishing no or mild pain from severe pain, two different sensor models achieved an area under the curve of 0.95 and 0.93. This technology represents a significant step toward noninvasive, continuous, and objective pain monitoring, which could overcome the limitations of subjective patient reports.

Continuing the theme of advanced monitoring, a study from *Critical Care Medicine* describes an artificial intelligence algorithm designed to noninvasively monitor a patient's breathing effort during mechanical ventilation [4]. Current methods to measure inspiratory muscle pressure, or Pmus, are either invasive, requiring an esophageal catheter, or require intermittent airway occlusion maneuvers. This new AI algorithm estimates the timing and amplitude of Pmus in real-time, using only data from the ventilator. In a study of 48 ICU patients, the AI-estimated Pmus showed good agreement with the gold standard of esophageal manometry and was comparable in accuracy to traditional occlusion-based techniques. Furthermore, the algorithm could automatically detect patient-ventilator dyssynchronies, like ineffective efforts, with 86% sensitivity. This noninvasive tool could enable continuous monitoring of patient work of breathing and ventilator synchrony at the bedside.

Finally, we look at a study that questions the need for high-tech monitoring in certain situations. A randomized noninferiority trial in the *Journal of Clinical Anesthesia* compared one-minute oscillometric blood pressure monitoring to a continuous invasive arterial line for managing hypotension during induction of anesthesia [7]. The study included relatively healthy patients scheduled for noncardiac surgery. The primary outcome was the area of mean arterial pressure below 65 millimeters of mercury during the first 15 minutes of induction. The results showed that monitoring with a cuff every minute was noninferior to the arterial line. An interesting secondary finding was that the group with continuous arterial monitoring received significantly more vasopressors, especially phenylephrine. The authors suggest that for low-risk patients, high-frequency oscillometric monitoring is a safe and pragmatic alternative to placing a pre-induction arterial line, potentially avoiding procedural delays and patient discomfort.

Procedural Techniques and Safety

Finally, we turn to two papers examining the finer points of procedural practice: one in the high-stakes setting of cardiac arrest, and another on a common question in labor analgesia.

First, a study from *Anesthesiology* used a swine model of cardiac arrest to investigate the importance of chest compression location [3]. Standard landmark-guided compressions often end up over the left ventricular outflow tract, or LVOT. The researchers hypothesized that this could obstruct blood flow. Using continuous transesophageal echocardiography, or TEE, they guided compressions to either the mid-left ventricle or the LVOT. The results were dramatic. TEE-guided compressions over the mid-LV generated significantly better hemodynamics. Coronary perfusion pressure was over 15 mmHg higher, systolic and diastolic aortic pressures were higher, and end-tidal CO2 was higher. M-mode imaging confirmed that LVOT-centered compressions led to significant outflow tract collapse, which correlated with worse perfusion. This animal study strongly suggests that using real-time TEE to target compressions over the ventricle and avoid the outflow tract can substantially improve the quality of CPR.

Our last paper, from *Anesthesia and Analgesia*, addresses a common clinical concern in obstetric anesthesia [10]. Dural puncture epidural, or DPE, and combined spinal-epidural, or CSE, techniques can improve labor analgesia compared to conventional epidurals. However, there's a worry that using the larger 24- or 25-gauge spinal needles required for these benefits might increase the risk of post-dural puncture headache. This systematic review and meta-analysis pooled data from 16 randomized controlled trials involving over 3,200 patients.

Results The overall rate of headache was very low in all groups. Just nine headaches were reported among more than 1,500 patients receiving a DPE or CSE, a rate of about 0.6%. In the conventional epidural group, six headaches were reported among more than 1,700 patients, a rate of about 0.3%. Although the point estimate favored the conventional epidural group as having fewer headaches, the number of events was so rare that the confidence interval for the difference was very wide and included the possibility of no difference, or even harm. The authors conclude that while these results are reassuring that both techniques are clinically safe, the data should be interpreted cautiously. A large, dedicated trial with headache as the primary outcome is still needed to definitively answer the question.

If you only have time for one paper this week, make it the study in the *Journal of Clinical Anesthesia* on the association between perioperative gabapentinoids and persistent opioid requirements [6]. Its findings from a large, nationwide database challenge the widespread practice of using these drugs for their presumed opioid-sparing effects and demand a critical re-evaluation of their role in multimodal analgesia protocols.

Here are the key takeaways from this week in Anesthesiology...

First, perioperative gabapentinoids may be associated with increased odds of long-term opioid use in opioid-naïve patients after major surgery like below-knee amputation, questioning their routine use for opioid-sparing.

Second, a simple automated clinical decision support tool can significantly and safely reduce unnecessary opioid prescribing at hospital discharge for surgical patients.

Third, a large new meta-analysis suggests that modern hydroxyethyl starch solutions do not cause acute kidney injury in the perioperative setting, which is in direct contrast to current FDA and EMA warnings.

Fourth, for low-risk patients, monitoring blood pressure with a cuff every minute during induction is a safe and non-inferior alternative to placing a pre-induction arterial line for managing hypotension.

And finally, a single preoperative 5 mg dose of olanzapine can improve overall quality of recovery and reduce nausea for patients undergoing ambulatory surgery, without prolonging PACU stay.

That's your roundup for This Week in Anesthesiology. The full transcript and references are available on the episode page in your AudioScholar library. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.

This is an automated summary generated by artificial intelligence, which can make mistakes. Always review the original source materials.