Aug 2026· Journal of the American Medical Association (JAMA)· 1 citation· 41 references
Medicine
TL;DR
Among older adults undergoing major noncardiac surgery, TIVA did not improve days alive and at home at 30 days compared with inhalational anesthesia, and there were no differences in days alive and at home at 90 days; mortality at 30 days, 90 days, or 6 months; or Quality of Recovery-15 score at day 3.
Abstract
Importance
Older adults undergoing major noncardiac surgery experience substantial postoperative morbidity and health care use. The comparative effectiveness of total intravenous anesthesia (TIVA) vs volatile-based inhalational anesthesia on recovery and safety remains uncertain.
Objectives
To determine whether TIVA improves days alive and at home at 30 days compared with inhalational anesthesia and to evaluate differences in patient-centered outcomes and recovery.
Design, Setting, and Participants
Pragmatic, multicenter, open-label randomized clinical trial conducted in 49 UK National Health Service hospitals from January 2022 to April 2024 (final follow-up, October 2024) among patients aged 50 years or older scheduled for elective major noncardiac surgery.
Interventions
Participants were randomized 1:1 to receive maintenance of general anesthesia with either TIVA (propofol infusion) (n = 1254) or volatile-based inhalational agents (n = 1254). All other perioperative care was at clinician discretion.
Main Outcomes and Measures
The primary outcome was days alive and at home at 30 days. Secondary outcomes included days alive and at home at 90 days; mortality at 30 days, 90 days, and 6 months; Quality of Recovery-15 score at day 3; patient satisfaction (Bauer Patient Satisfaction Questionnaire) at day 1; delirium (4 As Test [4AT]) at day 3; unintentional awareness under anesthesia; and major postoperative complications within 30 days.
Results
Among the 2508 randomized participants, the mean age was 67 (SD, 8.9) years, and 55% were male. Characteristics were balanced across randomized groups. Days alive and at home at 30 days were similar between groups (mean, 22.5 [SD, 6.8] days vs 22.4 [SD, 6.6] days for TIVA vs inhalational anesthesia, respectively; incidence rate ratio, 1.00; 95% CI, 0.99-1.02; adjusted P = .68). There were no differences in days alive and at home at 90 days; mortality at 30 days, 90 days, or 6 months; or Quality of Recovery-15 score at day 3. Lower rates of thirst, hoarseness, and nausea and vomiting were reported in the TIVA group. Levels of delirium were similar between groups, with the majority (87.6%) having no delirium at day 3. Major complications occurred in 12.4% of patients overall, with no significant between-group differences. Two cases of certain or probable unintentional awareness under anesthesia were reported, both in the TIVA group.
Conclusions and Relevance
Among older adults undergoing major noncardiac surgery, TIVA did not improve days alive and at home at 30 days compared with inhalational anesthesia.
Trial Registration
ISRCTN.org Identifier: ISRCTN62903453.
In this selected population of older patients undergoing ERCP, the remimazolam-esketamine regimen was associated with fewer composite SRAEs than propofol-fentanyl while achieving a similar anesthetic regimen success rate.
Yong-Bo Yu, Jiyuan Wang, Qian-Qian Zhang et al.· Drug Design, Development and...· 0 citations
Thoracic surgery is associated with substantial postoperative pain, and opioid-based analgesia is often limited by adverse effects. This study evaluated whether subpleural continuous local anesthetic infusion (Sp-CLAI) using the On-Q system improves outcomes compared with intravenous patient-controlled analgesia (IV-PCA) after video-assisted thoracoscopic surgery (VATS) lung resection.
In this prospective randomized trial, 180 patients undergoing elective multiport VATS were randomized to receive either ropivacaine-based On-Q infusion or fentanyl-based IV-PCA. After exclusions, 136 patients were analyzed. The primary endpoint was the postoperative pain trajectory over time, assessed using repeated-measures analysis of Numerical Rating Scale (NRS) scores. Secondary outcomes included opioid use, adverse events, and timepoint-specific pain differences. Longitudinal trends were assessed using repeated-measures ANOVA, and adjusted between-group differences at postoperative day (POD) 1, POD 3, and discharge were quantified using estimated marginal means.
Early postoperative pain (PODs 1–3) was comparable between groups. The IV-PCA group had higher rates of nausea or vomiting (
P
= 0.007), antiemetic use (
P
= 0.004), rescue opioid use (
P
< 0.001), and early discontinuation (
P
= 0.015). At discharge, activity-related pain was lower in the On-Q group (adjusted difference, 0.52 NRS points;
P
= 0.038), although this did not reach the predefined minimal clinically important difference. Resting pain was similar. Opioid prescriptions at discharge were less frequent in the On-Q group (9 vs. 23;
P
= 0.002).
Sp-CLAI using the On-Q system delivers analgesia equivalent to IV-PCA in the immediate postoperative period but provides superior activity-evoked pain control during recovery while substantially reducing opioid exposure and related side effects. These findings support Sp-CLAI using the On-Q system as a safe, effective, and opioid-sparing analgesic strategy that aligns with enhanced recovery after surgery (ERAS) principles and may facilitate early mobilization and functional recovery after VATS lung resection.
Younggi Jung, E. Yi, Sungho Lee et al.· International Journal of Sur...· 0 citations
BACKGROUND
Post-induction hypotension in major non-cardiac surgery is common and a modifiable risk factor for adverse outcomes. There is an ongoing debate whether pre-operative crystalloid fluid administration can reduce the incidence or severity of post-induction hypotension. This study aims to assess whether a pre-operative intravenous crystalloid bolus reduces post-induction hypotension in high-risk patients under general anesthesia.
METHODS
This was a prospective, randomized, single-blind clinical trial conducted at two centers in Austria (Medical University of Graz, Medical University of Vienna). Adult patients aged 45 years and older with cardiovascular risk factors undergoing major surgery were enrolled and randomly assigned to receive a pre-operative crystalloid bolus within 60 ± 15 minutes before anesthetic induction, or to receive standard care. The primary outcome was the time-weighted average mean arterial pressure of <65 mmHg within the first 20 minutes after induction or until surgical incision.
RESULTS
Of the 504 patients analyzed (247 in the intervention group and 257 in the control group), no statistically significant difference in median time-weighted average of the mean arterial pressure <65 mmHg was observed (Intervention group: 0.0 mmHg (IQR 0.0-0.56); Standard of Care group: 0.0 mmHg (IQR 0.0-0.84, p=0.368).
CONCLUSIONS
In this blinded randomized clinical trial, administering a crystalloid fluid bolus within 60 minutes before surgery did not significantly reduce the time-weighted average of a mean arterial pressure less than 65 mmHg compared to standard care in patients with cardiovascular risk factors undergoing major non-cardiac surgery. Our study suggests that administering crystalloids before surgery does not prevent post-induction hypotension.
Michael Eichinger, C. Reiterer, Michael Eichlseder et al.· Anesthesiology· 0 citations
Intravenous sedation is optimal for profound anxiolysis in complex cases, while nitrous oxide is ideal for routine procedures, prioritizing rapid recovery and fewer side effects.
M. Nahar, Md Toufiqur Rahman, Mohammad Ataul Hasan et al.· Community Based Medical Jour...· 0 citations
This trial is expected to provide prospective, randomized evidence to compare continuous intraoperative blood-pressure trajectories between remimazolam- and propofol-based TIVA during robotic gynecologic surgery and clarify the relative hemodynamic stability of these anesthetic agents under the combined physiological challenges of Trendelenburg positioning and pneumoperitoneum.
Jung-Min Lee, Joohyun Lee, S. Kang et al.· Frontiers in Pharmacology· 0 citations
Importance
Two percent to 50% of patients undergoing elective cardiac surgery experience acute kidney injury (AKI) postoperatively. Medications to prevent AKI after elective cardiac surgery have not been identified.
Objective
In patients undergoing elective cardiac surgery, to evaluate whether initiating dapagliflozin 1 day prior to surgery reduces the incidence of AKI at 7 days after cardiac surgery, compared with placebo.
Design, Setting, and Participants
Multicenter, double-blind, placebo-controlled randomized clinical trial conducted at 2 academic medical centers and 5 nonacademic hospitals in the Netherlands. Eligible participants were adults undergoing elective cardiac surgery. Enrollment occurred between June 8, 2023, and January 27, 2025. Final follow-up occurred May 16, 2025.
Intervention
Patients were randomized 1:1 to receive either dapagliflozin (10 mg orally; n = 392) or placebo once daily (n = 392), beginning on the day before surgery and continuing through the second postoperative day (total of 4 doses).
Main Outcome and Measure
The primary outcome was the between-group difference in AKI (defined as an increase in serum creatinine level by at least 0.3 mg/dL [26.5 µmol/L] within 48 hours after surgery, a 1.5-fold creatinine increase within 7 days of surgery, or urine output less than 0.5 mL/kg/h for 6 to 12 hours according to Kidney Disease: Improving Global Outcomes criteria) during the first 7 postoperative days.
Results
Of 784 participants enrolled, 778 (99%) completed follow-up testing (median age, 68 [61-74] years; 76% male; 97% White; median body mass index, 27 [IQR, 25-30]; and median estimated glomerular filtration rate, 80 [IQR, 67-89] mL/min/1.73 m2). Compared with placebo, dapagliflozin reduced the incidence of AKI (28% vs 52%; relative risk, 0.54 [95% CI, 0.45-0.65]; P < .001) over 7-day follow-up after surgery. Atrial fibrillation and reoperation were the most frequent adverse events. The incidence of atrial fibrillation was 45% (176/392) in the dapagliflozin group vs 45% (176/392) in the placebo group, and the incidence of reoperation was 11% (43/392) vs 10% (39/392), respectively.
Conclusions and Relevance
In patients undergoing elective cardiac surgery, 4 doses of dapagliflozin, beginning the day before surgery, reduced the incidence of AKI during the 7-day postoperative period.
Trial Registration
ClinicalTrials.gov Identifier: NCT05590143.
M. Oosterom-Eijmael, A. Hulst, Nelson P. Monteiro de Oliveira et al.· Journal of the American Medi...· 1 citation
We use cookies to run the site and, with your consent, for analytics and to show ads.
See our Cookie Policy.
