Anesthesiology

Propofol vs volatile anesthesia in major cancer surgery: no survival benefit and possible harm

GA-CARES randomized 1,763 adults undergoing high-risk cancer resections to propofol- or volatile-only maintenance anesthesia. Two-year mortality did not improve with propofol in the intention-to-treat analysis (26.1% vs 22.9%; hazard ratio 1.16; 95% CI 0.96–1.41). Per-protocol analysis showed higher mortality with propofol (25.5% vs 20%; hazard ratio 1.31; 95% CI 1.05–1.64). Disease-free survival similarly showed no benefit for propofol across multiple subgroups. These results argue against selecting propofol maintenance solely to improve cancer-related outcomes. 1

ASA 2026 guideline elevates fascial plane blocks for thoracic, breast, and abdominal surgery

The ASA guideline strongly recommends fascial plane blocks in adults to reduce early pain and/or opioid use for open cardiothoracic, abdominal, retroperitoneal, pelvic surgery, and mastectomy. They are also recommended for minimally invasive abdominal procedures and conditionally for minimally invasive cardiothoracic surgery and open hernia repair. In children, fascial plane blocks are strongly recommended after open cardiac or thoracic surgery and conditionally for open hernia repair. The Task Force notes pervasive limitations in existing trials, including low methodological quality, inconsistent outcomes, and small single-center samples. Clinicians should incorporate fascial plane blocks into multimodal strategies while recognizing the underlying evidence remains imperfect. 2

Noncardiac surgery in aortic stenosis: high absolute and relative perioperative risk

This systematic review and meta-analysis included 19 studies with 100,486 patients with aortic stenosis undergoing noncardiac surgery. Estimated short-term mortality was 3.8% for any aortic stenosis and 9.6% for severe aortic stenosis. Across 14 comparative studies including over 2.8 million patients, aortic stenosis increased mortality versus no aortic stenosis (relative risk 1.58; 95% CI 1.18–2.12). Risks of postoperative myocardial infarction (relative risk 1.79) and heart failure (relative risk 2.06) were also significantly higher. These quantified risks support intensified preoperative assessment, invasive monitoring consideration, and careful discussion of timing and necessity of surgery. 3

Closed-loop ventilation improves physiologic control but not ventilator-free days

This international trial randomized 1,201 invasively ventilated adults early after intubation to INTELLiVENT closed-loop or protocolized conventional ventilation. Ventilator-free days at day 28 were similar between groups, about 16 days, with no difference in mortality or ventilation duration among survivors. Closed-loop ventilation achieved higher ventilation quality and fewer episodes of severe hypercapnia and hypoxemia. Fewer patients required rescue therapies, mainly prone positioning, although this was not statistically significant after multiplicity correction. Closed-loop systems appear safe and physiologically advantageous but have not yet improved key patient-centered outcomes. 4