Anesthesiology

Regional anesthesia, not intra-op opioids, drives postoperative pain and PONV outcomes

This network meta-analysis pooled 885 randomized trials comparing opioid-free vs opioid-inclusive anesthesia, each with or without regional anesthesia, in adults. Strategies incorporating regional techniques consistently achieved the best postoperative pain scores and lowest opioid requirements at multiple time points. When regional anesthesia was used, outcomes differed little between opioid-free and opioid-inclusive intraoperative strategies. Without regional anesthesia, no consistent analgesic superiority emerged, but opioid-free techniques reduced postoperative nausea and vomiting. 1

Continuation of RAAS inhibitors shows patient-specific hypotension risk in major noncardiac surgery

This secondary STOP-or-NOT analysis assessed 2007 patients for heterogeneity in intraoperative hypotension with continued vs withheld RAAS inhibitors. Mean arterial pressure <60 mm Hg requiring vasopressors showed statistically significant heterogeneity of treatment effect between patients. Machine-learning–derived conditional average treatment effects defined a high-risk group with markedly increased hypotension when RAAS inhibitors were continued. High-risk patients were younger, more obese, with lower baseline systolic pressure, higher hemoglobin, and lower creatinine. 2

Preoperative sleep disturbance doubles long-term POCD risk in older surgical patients

This multicenter cohort followed 535 patients aged ≥60 years undergoing major noncardiac surgery for postoperative cognitive dysfunction up to 180 days. Patients with preoperative sleep disturbance (PSQI>7) had significantly higher POCD rates at all time points, with relative risks around 1.4–1.8. Sleep disturbance also increased delirium risk, worsened QoR-15 scores, and was linked to persistent insomnia at 180 days. A PSQI≥10 optimally predicted POCD risk, with sensitivity about 72% and specificity about 69%. 3

Postoperative delirium is high-risk and substantially under-screened in NSQIP data

This ACS-NSQIP analysis included 217,783 adults with documented delirium assessment and compared them with 2.7 million unscreened patients. Delirium screening occurred almost exclusively in patients ≥75 years and captured only a minority of that age group. Among screened patients, delirium incidence was 10.6%, rising to 12.8% in those aged ≥90 years. Delirium was strongly associated with dementia, recent falls, urgent or emergency surgery, and longer operative time. 4