This week in Anesthesiology

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Welcome to This Week in Anesthesiology. This week we're covering 10 notable papers spanning airway management, blood pressure targets, and analgesia and recovery after surgery. Let's dive in.

Airway management dominates the week, with four papers examining how device choice, positioning and technique shape what happens at induction and afterwards. The highest-profile paper comes from the BMJ, where Han and colleagues randomised 400 children aged two to six years undergoing adenotonsillectomy at four Chinese tertiary hospitals to a laryngeal mask airway or an endotracheal tube [1]. Perioperative respiratory adverse events, a composite of laryngospasm, bronchospasm, desaturation, airway obstruction, severe cough and stridor, occurred in about 23 percent of children with the laryngeal mask versus about 58 percent with the tube, an absolute reduction of 35 percentage points. Most of that gap emerged after surgery, and severe cough fell from roughly four in ten children to one in ten. No child in the laryngeal mask group had laryngospasm, and the mask was converted to a tube in only three children. The authors stress that the airways were managed by experienced anaesthesiologists, which matters when weighing how far the result generalises; this is a single, well-sized trial in one surgical population, but the size of the effect is hard to ignore. In Anaesthesia, the VILARE trial led by Taboada tested videolaryngoscopy against direct laryngoscopy in just over a thousand adults intubated by supervised anaesthesia residents [2]. First-attempt success rose by about nine points, to just under 80 percent, with better glottic views, less operator-reported difficulty and procedural complications cut by more than half, without a meaningful difference in intubation time. For training programmes, this pragmatic multicentre evidence strengthens the case for videolaryngoscopy as a default for trainees, though it does not address whether direct laryngoscopy skills erode. A smaller single-centre trial in the Canadian Journal of Anesthesia by Zhang and colleagues examined video double-lumen tube intubation in a modified lateral position for unilateral thoracoscopic surgery [3]. In 62 patients with unremarkable airways, intubating in the lateral position shortened the time from room entry to incision by about 13 minutes, and tube malposition dropped from nearly half of patients intubated supine to one patient in the lateral group. The authors frame this as a feasible alternative, and with an unblinded operator and a highly selected population, it remains early evidence. Rounding out the theme, Cook and colleagues offer a narrative review of rapid sequence induction in Anaesthesia [4]. Their central message is that many elements of the technique lack robust evidence either way. Nasogastric tubes do not reliably empty the stomach, cricoid force works only when correctly located and applied, and may need removal for airway rescue, while videolaryngoscopy during rapid sequence induction is supported by evidence and gastric ultrasound remains of uncertain value. The review also highlights how common cardiovascular complications are in critically ill patients, and argues for acknowledging uncertainty rather than treating the technique as settled dogma.

Our second theme questions a long-held assumption that pushing blood pressure higher protects organs. In Anesthesiology, the OPTIPAM trial by Descamps and colleagues randomised cardiac surgical patients on cardiopulmonary bypass at ten French centres to an individualised mean arterial pressure within ten percent of their preoperative baseline, or to a standard target of at least 65 millimetres of mercury [5]. The trial was stopped early by its data and safety monitoring board after 172 patients because of increased bleeding in the individualised group, where haemorrhagic complications occurred in 18 percent versus 3 percent. The composite of death, acute kidney injury or neurologic complications at seven days was similar, at roughly 30 percent in both arms, so the trial could not show benefit. Adherence was limited too, with patients within target for only a third of intraoperative time despite more vasopressor use. In the British Journal of Anaesthesia, an editorial by D'Amico and Landoni offers a framework for interpreting this kind of result [6]. Commenting on a meta-analysis of nine noncardiac surgery trials involving more than fourteen thousand patients, they note that higher pressure targets did not reduce 30-day mortality, kidney injury or myocardial injury. Their argument is that low blood pressure may be a marker of vulnerability rather than a modifiable target, and that normalising a number may not remove the underlying risk. Taken together, these papers, from different surgical settings, weaken the case for routinely raising pressure targets, while the bleeding signal in OPTIPAM is a single early-stopped trial that the authors themselves say needs further study.

Our final theme covers analgesia and recovery, where several trials delivered neutral results that are nonetheless informative. In the BMJ, the TOPIC-2 trial led by Shelley randomised 770 thoracotomy patients across 15 United Kingdom centres to paravertebral blockade or thoracic epidural [7]. At six months, chronic post-thoracotomy pain affected about 22 percent of patients in the paravertebral group and 16 percent in the epidural group, a difference that was not statistically significant, so paravertebral blockade did not reduce chronic pain. The epidural gave marginally better pain relief on day one only. The side-effect profiles differed, with less hypotension and pruritus but roughly double the urinary retention after paravertebral blockade. The authors conclude that the findings support ongoing use of both techniques. Also in Anesthesiology, Östrand and colleagues tested intravenous lidocaine in 124 patients undergoing minor liver surgery, a setting where hepatic metabolism raises safety questions [8]. Lidocaine did not significantly reduce 24-hour opioid consumption, and quality of recovery was unchanged, although early pain scores were lower. Two patients had transient plasma levels above 5 micrograms per millilitre after the bolus without signs of toxicity, and the authors judged the regimen safe. In the European Journal of Anaesthesiology, Putzu and colleagues updated the Cochrane comparison of sugammadex and neostigmine, pooling 165 trials and over nineteen thousand adults [9]. Sugammadex at 2 milligrams per kilogram reversed blockade about ten minutes faster and probably reduced the proportion of patients with any adverse event by about a quarter, including residual blockade, desaturation, bradycardia and urinary retention. Certainty was moderate and risk of bias was often unclear or high, but with falling drug costs the authors argue broader use could improve outcomes. Finally, a single-centre Anesthesiology trial by Fu and colleagues asked whether simply blocking operating room noise affects nausea [10]. Among 192 women having gynaecological laparoscopy with dual antiemetic prophylaxis, passive earmuffs from induction to the end of surgery reduced nausea and vomiting within 48 hours from about half of patients to about a third. It is a cheap, low-risk intervention, but the evidence comes from one centre in one population and needs replication before it informs guidelines.

If you only have time for one paper this week, make it the BMJ trial comparing the laryngeal mask with the endotracheal tube in children having adenotonsillectomy [1]. It brings randomised multicentre evidence to a long-running debate in paediatric airway practice, and the size of the reduction in respiratory complications reopens the question of which device should be the default for this common operation.

That's your roundup for This Week in Anesthesiology. The full transcript and references are available on the episode page. See you next week.

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