Anesthesiology

Driving pressure–guided high PEEP fails to reduce PPCs and increases hypotension

In 1,435 at-risk adults undergoing open abdominal surgery, driving pressure–guided high PEEP plus recruitment did not lower 5-day pulmonary complications vs standard low PEEP. Pulmonary complications occurred in 19.8% with high PEEP vs 17.4% with low PEEP (absolute difference 2.5%; 95% CI -1.5% to 6.4%; P=0.23). High PEEP increased intraoperative hypotension (54.0% vs 45.0%) and vasoactive use (32.0% vs 18.8%), but low PEEP had more desaturation episodes. With universal low tidal volumes, further PEEP escalation offered no clinical pulmonary benefit and worsened hemodynamic stability. 1

Liposomal and plain bupivacaine TAP blocks match saline in major abdominal surgery

This 261-patient RCT compared single-shot four-quadrant TAP blocks using liposomal bupivacaine, plain bupivacaine, or saline for major abdominal surgery. Median 24-hour opioid consumption was similar across groups, and geometric mean ratios vs placebo were nonsignificant for both active drugs. Opioid requirements from 24–48 and 48–72 hours and pain scores through 72 hours were also comparable. Findings argue against routine use of liposomal or plain bupivacaine TAP blocks solely to reduce opioids or pain in this setting. 2

Rocuronium doses rose after sugammadex; risk depended on monitoring and reversal

In 163,402 rocuronium-only anesthetics, cumulative dosing increased annually after sugammadex introduction, from 0.83 to 1.20 mg/kg by 2024. Overall, 8.4% of 108,317 evaluable cases experienced postoperative respiratory complications, which increased dose-dependently with higher rocuronium exposure. Without sugammadex or neuromuscular monitoring, each 1 mg/kg increase nearly doubled adjusted respiratory complication odds (OR 1.99; 95% CI 1.82–2.18). This association was attenuated with sugammadex (OR 1.08; 95% CI 1.01–1.16) and abolished with quantitative train-of-four monitoring (OR 0.94; 95% CI 0.85–1.03). Liberal deep blockade appears acceptable only when paired with quantitative monitoring and effective reversal, not qualitative assessment alone. 3

ICU fluid balance trajectories show heterogeneous patterns and link persistent positivity to mortality

Among 1,702 ICU patients with acute circulatory failure, latent modeling identified five distinct 7-day cumulative fluid balance trajectories. Only 33.3% followed a pattern consistent with the classic four-phase fluid concept, indicating substantial real-world heterogeneity. Trajectories characterized by sustained fluid accumulation at 2–3 days after ICU admission were associated with higher adjusted 180-day mortality. Fluid balance classes also differed in hemodynamics and inflammatory markers, suggesting differing underlying mechanisms. Results support moving from rigid phased fluid strategies toward trajectory-informed, individualized fluid management. 4