Vetrix Anesthesiology

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Vetrix Anesthesiology is an AI-driven podcast that dissects contemporary anesthesiology papers, translating dense methods and statistics into clear, clinically focused insights for everyday practice.

  1. 2d ago

    Low-dose intrathecal morphine versus intrathecal fentanyl for post-caesarean analgesia in a resource-constrained setting: a pragmatic randomised trial

    Citation: Chetty S, Paruk F, Kamerman P. Low-dose intrathecal morphine versus intrathecal fentanyl for post-caesarean analgesia in a resource-constrained setting: a pragmatic randomised trial. BMC Anesthesiol. 2026. doi:10.1186/s12871-026-04034-0 This trial asked whether low-dose intrathecal morphine reduces rescue morphine use compared with intrathecal fentanyl after caesarean delivery. Intrathecal morphine probably reduced 24-hour rescue morphine use compared with fentanyl. The trial was single-centre, retrospectively registered, and mainly analysed per protocol. Study at a glance - Design and setting: Single-centre, participant- and outcome-assessor-blinded, parallel-group pragmatic randomised trial at Rahima Moosa Mother and Child Hospital, a tertiary public-sector maternity hospital in Johannesburg, South Africa, between July and September 2015. Randomisation was blocked in a 1:1:1 ratio with adequate allocation concealment; the attending anaesthetist preparing and administering the intrathecal solution was aware of allocation. - Population: 105 women were screened, 100 were randomised, and 93 were analysed: M100 32, M50 29, and F25 32. Eligible participants were women aged 18 years or older undergoing elective or emergency caesarean delivery under single-shot spinal anaesthesia; sex female was 100%. Age, mean (range), was 31 (21–40) years in M100, 30 (23–39) years in M50, and 30 (21–41) years in F25. - Interventions: M100 received hyperbaric bupivacaine 0.5% 1.8 ml plus preservative-free intrathecal morphine 100 μg; M50 received hyperbaric bupivacaine 0.5% 1.8 ml plus preservative-free intrathecal morphine 50 μg; F25 received hyperbaric bupivacaine 0.5% 1.8 ml plus intrathecal fentanyl 25 μg. Total intrathecal volume was standardised to 2.3 ml during single-shot spinal anaesthesia. Postoperative analgesia included intravenous morphine patient-controlled analgesia solution 1 mg.ml-1, 1 mg bolus, 5-minute lockout, maximum 10 mg.h-1, no background infusion, plus rectal indomethacin. - Primary outcome: Cumulative 24-hour intravenous patient-controlled analgesia morphine consumption probably was lower with intrathecal morphine versus fentanyl (moderate certainty): medians were M100 12.5 mg (interquartile range 6 to 20.25), M50 15 mg (interquartile range 9 to 25), and F25 26 mg (interquartile range 16.5 to 38.5); overall p=0.00078. Hodges-Lehmann estimates were M100 vs F25 -13 mg (95% CI -20 to -7; p=0.00081), M50 vs F25 -10.5 mg (95% CI -18 to -3; p=0.019), and M100 vs M50 -3 mg (95% CI -8 to 3; p=0.326). - Key secondary outcome: Intravenous patient-controlled analgesia morphine consumption during 0–12 h may have been lower with morphine: M100 8 mg (interquartile range 2.75 to 12), M50 8 mg (interquartile range 4 to 17), and F25 16 mg (interquartile range 11 to 25.5); overall p=0.0021. Pairwise point estimates and 95% confidence intervals were not reported (low certainty). - Safety: Respiratory depression, defined as respiratory rate 8 breaths/min, occurred in 0/32 M100, 0/29 M50, and 0/32 F25. Any nausea or vomiting occurred in 9/32, 9/29, and 9/32; severe nausea or vomiting in 5/32, 0/29, and 5/32; any pruritus in 12/32, 14/29, and 9/32; severe pruritus in 1/32, 1/29, and 1/32; and any sedation in 7/32, 7/29, and 10/32, respectively. Serious adverse events and withdrawals due to adverse events: Not reported; harms were descriptive and the study was powered for analgesic efficacy rather than uncommon adverse events. - Risk of bias and certainty: RoB 2 overall judgement was Some concerns. Low risk was judged for randomization process and measurement of outcome; Some concerns were judged for deviations from intended interventions, missing outcome data, and selection of reported result, including unblinded attending anaesthetist, per-protocol primary contrasts after post-randomisation exclusions, outcome data available for 93/100 randomised participants, and retrospective registration. Overall GRADE certainty was Moderate for the primary outcome and Low for secondary outcomes.

    9 min

  2. Jun 21

    Residual gastric content after holding of glucagon-like peptide-1 receptor agonists before elective surgery: a cross-sectional study - The RESIDUAL study

    Citation: Boudreau C, Couture M, Rousseau-Saine N, Laferrière-Langlois P, Roy-Renaud É, Burey J, et al. Residual gastric content after holding of glucagon-like peptide-1 receptor agonists before elective surgery: a cross-sectional study - The RESIDUAL study. BMC Anesthesiol. 2026. doi:10.1186/s12871-026-03999-2 This episode asks whether fasted elective-surgery patients who held weekly injectable glucagon-like peptide-1 receptor agonists for at least 7 days still had more residual gastric content. Evidence is very uncertain whether use was associated with increased residual gastric content; aspiration outcomes were not collected. Study at a glance - Design and setting: Prospective cross-sectional study of fasted adults scheduled for elective surgery under anesthetic care at two university-affiliated hospitals in Montreal, Quebec, Canada, from October 2024 through February 2025; registered at ClinicalTrials.gov, NCT06500143. - Population: 94 patients undergoing elective procedures were included; 1 patient in the GLP-1 RA group was excluded after gastric ultrasound because the last dose was less than 7 days before surgery. 93 patients were analyzed: 52 in the GLP-1 RA group and 41 controls. Female sex was 40.9%. Inclusion required age at least 18 years, American Society of Anesthesiologists physical status I to IV, and fasting according to Canadian guidelines. In the exposure group, 50/52 (96%) received semaglutide, one patient received tirzepatide, one patient received dulaglutide, 45/52 (87%) had diabetes as the treatment indication, and median time since last dose was 11 days (IQR 9 to 13). - Exposure and comparator: Exposure was weekly injectable semaglutide, tirzepatide or dulaglutide use for more than 4 weeks, regardless of indication, with the last dose at least 7 days before surgery. The comparator group was not receiving any GLP-1 RA. Specific drug, dose in milligrams, and day of last injection were collected. - Primary outcome: Increased residual gastric content on preoperative gastric ultrasound after guideline-concordant fasting was defined as thick liquid, solid content, or more than 1.5 mL/kg clear liquid. It is very uncertain whether GLP-1 RA use was associated with increased residual gastric content: 22/52 (42.3) in the GLP-1 RA group versus 10/41 (24.4) in controls; unadjusted prevalence ratio 1.73, 95% CI 0.96 to 3.75; adjusted prevalence ratio 1.65, 95% CI 0.7 to 3.7; adjusted average treatment effect 15.4%, 95% CI -10 to 35.6; p-value not reported (very low certainty). - Key secondary outcome: Exploratory analyses were also very uncertain. For increased residual gastric content, the adjusted odds ratio per additional day since last GLP-1 RA injection was 1.08, 95% CI 0.86 to 1.39; per hour since last oral intake was 1.12, 95% CI 0.9 to 1.46; and per mg semaglutide dose was 2.19, 95% CI 0.47 to 12.7. p-values were not reported (very low certainty). - Confounding: The primary adjusted analysis used propensity-score overlap weighting for age, sex, American Society of Anesthesiologists physical status classification, BMI, diabetes, opioid use, moderate to severe preoperative pain (> 3 on the verbal rating scale), and time since last oral intake; balance threshold was 0.1 with no variables imbalanced. The planned augmented inverse probability weighting estimator was changed because of inadequate covariate balancing. Sensitivity analysis with augmented inverse probability weighting showed prevalence ratio 1.84, 95% CI 0.74 to 4.24, and average treatment effect 18.1%, 95% CI -10.2 to 38.7. Residual confounding by unmeasured diabetes-related factors remained a serious concern. - Risk of bias and certainty: ROBINS-I overall risk of bias was Serious, driven mainly by serious bias due to confounding. Selection of participants, exposure classification, deviations from intended exposure, and selection of reported result were Moderate; missing data and outcome measurement were Low. Overall GRADE certainty for increased residual gastric content was very low because of residual confounding, indirectness for clinical aspiration risk, and imprecision.

    8 min

  3. Jun 14

    Prospective Evaluation of Routine Extubation Criteria in Children with Upper Respiratory Symptoms Undergoing Elective Surgery

    Citation: Templeton TW, Smith LD, Mosher T, Saha AK, Hodges AS, Vishneski SR, et al. A Prospective Evaluation of Routine Extubation Criteria in Children with Upper Respiratory Symptoms Undergoing Elective Surgery. Anesthesiology. 2026. doi:10.1097/ALN.0000000000006197 This episode asks whether routine awake-extubation readiness criteria remain reassuring in children with upper respiratory infection symptoms undergoing elective surgery. The primary comparison is very uncertain: observed success was 94.7% without symptoms versus 93.9% with symptoms. Symptomatic children may have more desaturation, and unadjusted confounding limits causal conclusions. Study at a glance - Design and setting: Prospective observational cohort at a single center in the United States, conducted between November 20, 2019 and June 24, 2025, in elective outpatient or day-hospital pediatric surgery with planned general endotracheal anesthesia and awake extubation. Registered at ClinicalTrials.gov as NCT04155892 and prepared using Strengthening the Reporting of Observational Studies in Epidemiology guidelines. - Population: 927 subjects were screened; 799 were enrolled and extubated with one or more of the five extubation criteria; 756 patients were analyzed in the primary cohorts, including 379 in the non-upper respiratory infection symptom group and 377 in the upper respiratory infection symptom group. Inclusion criteria were children aged ≤9 years presenting for elective outpatient or day-hospital surgery with anticipated discharge on the day of surgery or postoperative day 1 and planned general endotracheal anesthesia; primary analysis required at least 3 of the Big Five extubation criteria. Female sex was 31.1%; age was 31.0 ± 26.4 months in the non-upper respiratory infection group and 37.9 ± 25.0 months in the upper respiratory infection group. - Exposure and comparator: Primary exposure was preoperative upper respiratory infection symptom status based on a parent or caregiver questionnaire: scores ≥3 defined the upper respiratory infection symptom group; scores 0 or 1 defined the non-upper respiratory infection reference group; score 2 was excluded as indeterminate. The questionnaire gave one point for each positive response plus a parent or caregiver sickness assessment scored 0 to 3; in the upper respiratory infection group, the median survey score was 4 (IQR 3 to 6). At emergence and extubation, an independent observer recorded the Big Five criteria: tidal volume >5 mL/kg, conjugate gaze, facial grimace, purposeful movement, and eye opening. - Primary outcome: Successful awake extubation at extubation occurred in 359/379 patients in the non-upper respiratory infection group, 94.7% (95% CI 92.5% to 97.0%), versus 354/377 patients in the upper respiratory infection group, 93.9% (95% CI 91.5% to 96.3%). Adjusted effect estimate not reported; unadjusted risk difference for non-upper respiratory infection versus upper respiratory infection was 0.8% (95% CI -2.6% to 4.2%); p-value not reported. The observed estimate fell within the study’s 5% clinical equivalence margin, but causal equivalence is very uncertain (very low certainty). - Key secondary outcome: At least one peri-extubation desaturation event occurred in 103/377 patients in the upper respiratory infection group, 27.3% (95% CI 22.8% to 31.8%), versus 62/379 in the non-upper respiratory infection group, 16.4% (95% CI 12.6% to 20.1%). Adjusted effect estimate not reported; unadjusted risk difference was 10.9% (95% CI 5.1% to 16.0%); p-value not reported, so upper respiratory infection symptoms may be associated with more desaturation (low certainty). Other secondary contrasts included visible endotracheal tube secretions, risk difference 43.3% (95% CI 37.1% to 49.5%, low certainty); major intervention, risk difference 1.0% (95% CI -1.1% to 3.2%, very low certainty); laryngospasm, risk difference 0.0% (95% CI -1.5% to 1.5%, very low certainty); postdischarge respiratory healthcare, risk difference 1.6% (95% CI -0.2% to 3.4%, very low certainty); and postanesthesia care unit oxygen saturation nadir, 96% (IQR 94 to 98) versus 95% (IQR 92 to 97), p-value 0.001 (very low certainty). - Confounding: No multivariable regression, propensity score, g-method, instrumental-variable, or other formal confounding adjustment was reported; group contrasts were unadjusted. Baseline prognostic factors differed between groups, including age, American Society of Anesthesiologists physical status, sleep-disordered breathing, and surgery type, and clinician experience was not accounted for. Clinicians were not blinded to questionnaire score, and albuterol administration differed as printed: 5/377 (1.3%) in the non-upper respiratory infection group versus 31/379 (8.2%) in the upper respiratory infection group, with printed denominators differing from final cohort sizes. - Risk of bias and certainty: ROBINS-E overall risk of bias was Serious. The main concern was serious confounding; moderate concerns included selection of participants, exposure classification, deviations from intended exposure, missing data, and selection of reported results, while outcome measurement was Low primarily for standardized observer-graded peri-extubation outcomes. Overall certainty was very low for successful awake extubation, low for peri-extubation desaturation and visible secretions, and very low for most other outcomes.

    8 min

  4. Jun 7

    Environmental and economic impacts of anaesthesia: A simulation study comparing total intravenous anaesthesia versus sevoflurane for maintenance of anaesthesia in 11 909 adult patients of a Belgian tertiary hospital

    Citation: Van Belleghem F, Rex S, Teunkens A, Vereecke H, Kalmar AF. Environmental and economic impacts of anaesthesia: A simulation study comparing total intravenous anaesthesia versus sevoflurane for maintenance of anaesthesia in 11 909 adult patients of a Belgian tertiary hospital. Eur J Anaesthesiol. 2026;43:567-574. doi:10.1097/EJA.0000000000002342 This study simulated total intravenous anaesthesia versus sevoflurane for maintenance and compared carbon dioxide equivalent emissions and costs. Low-certainty evidence suggests total intravenous anaesthesia has much lower emissions; cost savings are very uncertain. Internal numerical discrepancies and no uncertainty analysis limit exact estimates. Study at a glance - Design and setting: Retrospective simulation-based observational cohort study using electronic records from a single Belgian hospital, Sint-Jan Hospital, Bruges, Belgium. Anaesthesia time was defined as start of induction to end of surgery; results were standardised per 1000 procedures. - Population: 11909 cases were analysed. Inclusion criteria were all general anaesthesia procedures lasting more than 10 min in patients older than 5 years from 1 April to 30 November 2022. Baseline characteristics: 49.9% female, 50.1% male, mean age 55 ± 21 years, anaesthesia time 92 ± 73 min, height 169 ± 12 cm, weight 77 ± 20 kg. - Exposure and comparator: Each procedure was simulated under four maintenance scenarios with FiO2 50%: sevoflurane with minimal fresh gas flow using automatic gas control with a Flow-I ventilator; sevoflurane with 2 l min-1 fresh gas flow; total intravenous anaesthesia using 1% propofol vials and 6 l fresh gas flow; and total intravenous anaesthesia using 2% propofol vials and 6 l fresh gas flow. All scenarios used induction with propofol 2 mg kg-1 and maintenance with either volatile anaesthetic or propofol 6 mg kg-1 h-1. - Primary outcome: CO2-equivalent emissions per 1000 procedures: 25593 kg for minimal-flow sevoflurane, 59489 kg for sevoflurane 2 l min-1 fresh gas flow, 1271 kg for total intravenous anaesthesia with 1% propofol, and 812 kg for total intravenous anaesthesia with 2% propofol. The article reported minimal-flow sevoflurane as 26.5 times more CO2e than total intravenous anaesthesia and sevoflurane 2 l min-1 fresh gas flow as 61.8 times more; this suggests lower emissions with total intravenous anaesthesia. No adjusted effect estimate, 95% CI, or p-value reported (low certainty). - Key secondary outcome: Economic cost per 1000 procedures: €6805 for minimal-flow sevoflurane, €11961 for sevoflurane 2 l min-1 fresh gas flow, €5666 for total intravenous anaesthesia with 1% propofol, and €4264 for total intravenous anaesthesia with 2% propofol. The article reported total intravenous anaesthesia as 16.7 to 52.63% less expensive than sevoflurane, and as costing 36% and 63% of sevoflurane anaesthesia costs with minimal flow and 2 l min-1 fresh gas flow, respectively; exact cost savings are very uncertain. No adjusted effect estimate, 95% CI, or p-value reported (very low certainty). - Confounding: Patient-level confounding by indication was partly avoided because the same 11909 recorded cases were simulated under each anaesthesia scenario. No causal DAG, covariate-adjusted analysis, propensity score diagnostics, formal validation, or sensitivity analysis was reported; residual concerns depend on fixed assumptions for dosing, fresh gas flow, equipment, vial use, resource use, lifecycle emissions, and local prices. - Risk of bias and certainty: Overall ROBINS-I risk of bias was Serious. Key concerns were serious bias in selection of the reported result, moderate concerns for confounding, exposure classification, deviations from intended interventions, and outcome measurement, no information for missing data, and low concern for participant selection. Overall GRADE certainty for the primary CO2-equivalent emissions outcome was low; cost outcomes were very low certainty.

    9 min

  5. May 17

    An interpretable machine learning model for predicting emergence agitation in children: a multicenter development and validation study

    Citation: Zhao Q, Zhang Y, An R, Yi B, Huang G. An interpretable machine learning model for predicting emergence agitation in children: a multicenter development and validation study. BMC Anesthesiol. 2026;[epub ahead of print]. This multicenter retrospective study from two Chinese hospitals developed and externally validated several machine learning models to predict emergence agitation in children after general anesthesia. Using five routine perioperative predictors, a compact multilayer perceptron model showed excellent discrimination internally but only moderate performance and suboptimal calibration in an external cohort. Because variable selection, model choice, and key predictors are highly data- and center-dependent, the tool is best seen as a proof-of-concept rather than a ready-made decision aid for routine paediatric anesthesia practice. Study at a glance - Design and setting: Retrospective multicenter prediction-model study using electronic records from two tertiary hospitals in China: Center I (Third Affiliated Hospital of Zunyi Medical University) for model development and internal validation, and Center II (First Affiliated Hospital of Army Medical University) as an independent external validation cohort. Children aged 3–12 years with American Society of Anesthesiologists physical status I–II undergoing elective surgery under general anesthesia were included. - Participants and primary outcome: A total of 445 pediatric patients were analyzed (321 in the development center, 124 in the external validation center). In Center I, emergence agitation occurred in 95 children, an incidence of 29.6%; in Center II, the reported incidence was about 25.8% (32–33 events, with slight inconsistencies across sections). The primary outcome was emergence agitation within 30 minutes after post-anesthesia care unit admission, defined as Pediatric Anesthesia Emergence Delirium (PAED) score >10, after pain was assessed and treated using the FLACC scale to limit misclassification from pain-related distress. - Predictors and main model: From 63 perioperative variables, the authors used univariable screening followed by least absolute shrinkage and selection operator (LASSO) regression to select predictors, then trained six algorithms (logistic regression, support vector machine, multilayer perceptron, random forest, extreme gradient boosting, and Light Gradient Boosting Machine). The final five-variable clinical model used parental educational level, preoperative alanine aminotransferase (ALT), postoperative patient-controlled analgesia (PCA) pump use, postoperative antagonist (reversal agent) use, and extubation suctioning frequency. A multilayer perceptron (MLP) was chosen as the primary clinical model because it performed best in external validation; a support vector machine was used for detailed interpretability analyses with SHAP values. - Key performance results: In internal holdout validation at Center I, discrimination was high across models, with area under the receiver operating curve (AUC) around 0.87–0.92; the support vector machine achieved AUC 0.918 (95% confidence interval 0.844–0.973, Brier score 0.098), and logistic regression AUC 0.915. In external validation at Center II, performance dropped noticeably. The primary clinical MLP model achieved AUC 0.705 (95% confidence interval 0.59–0.804) with a Brier score of 0.190, reflecting only moderate discrimination and imperfect calibration; other models performed worse (e.g., logistic regression AUC 0.587, LightGBM AUC 0.494). No decision-curve or net benefit analyses were reported. - Risk of bias and applicability: Using a structured prediction-model appraisal, overall risk of bias was judged high, mainly due to the analysis domain. Concerns include data-driven predictor selection from many candidates, testing and informally selecting among six algorithms, limited optimism correction (formally reported only for the support vector machine), and a relatively small, case-mix–different external validation cohort. Applicability is further constrained because three of the five final predictors (PCA pump use, antagonist use, suctioning frequency) are early postoperative management decisions that vary by center and over time, rather than stable baseline risk factors. - Practice implications: For practising clinicians, this study underscores that emergence agitation after pediatric anesthesia is common and potentially predictable, and it highlights perioperative features—such as parental education, preoperative ALT, and postoperative analgesia and reversal strategies—that may correlate with risk. However, the current models should not be used as stand-alone decision aids: external performance is only moderate, calibration is imperfect, and the models depend strongly on center-specific management choices. At present, these tools are best viewed as research prototypes and a stimulus for locally developed and rigorously validated prediction models, rather than as ready-to-implement clinical calculators.

    11 min

  6. May 10

    Clinical Performance in Critical Care Simulation Under Sleep Deprivation: Effects of Power Napping in the R-NAP Randomized Controlled Trial

    Citation: Schmidt L, Genty F, Delaire T, Valero B, Rey I, Galan L, Mairet-Mabboux S, Douplat M, Schlatter S, Rimmele T, Mazza S, Lilot M. Clinical Performance in Critical Care Simulation Under Sleep Deprivation: Effects of Power Napping in the R-NAP Randomized Controlled Trial. Anesthesiology. 2026; doi:10.1097/ALN.0000000000006135. In this single-centre randomized controlled trial, anesthesia and intensive care residents finishing an overnight on-site shift were assigned either to a brief supervised nap opportunity or to quiet wakefulness before a high-fidelity critical care simulation. The nap group achieved higher overall and non-technical performance scores without reported harms, but the trial is small, uses simulation rather than real patient outcomes, and has some missing data, so confidence in the size of benefit is moderate and the findings mainly support, rather than replace, broader fatigue management strategies. Study at a glance - Design and setting: Prospective individually randomized parallel-group behavioural trial conducted in a single French university simulation centre, comparing a supervised thirty-minute nap opportunity versus quiet wakefulness after an overnight on-site shift in anesthesia and intensive care residents. - Participants: Thirty-five second to fifth year anesthesia and intensive care residents were randomized (nineteen to nap, sixteen to no nap); twenty-seven with complete actigraphy sleep data were included in the primary adjusted analysis, with similar baseline characteristics between groups. - Primary outcome: Overall simulated clinical performance (sum of technical and non-technical scores, range zero to two hundred) after the overnight shift was higher with a nap; the adjusted mean difference was 14.84 points in favour of the nap group, with a ninety-five percent confidence interval from 2.8 to 26.88 and a P value of 0.018, yielding moderate certainty that a brief nap improves overall simulated performance. - Key secondary outcomes: Total non-technical skills score (zero to one hundred) was higher with a nap, with an adjusted mean difference of 11.03 points (ninety-five percent confidence interval 2.22 to 19.84; P value 0.016). Among Ottawa Global Rating Scale subscales, Overall performance (mean difference 0.77; ninety-five percent confidence interval 0.05 to 1.48; P value 0.036), Leadership (0.73; ninety-five percent confidence interval 0.05 to 1.41; P value 0.037), and Resource utilization (1.02; ninety-five percent confidence interval 0.03 to 2.00; P value 0.043) favoured the nap group, whereas purely technical checklist scores showed smaller, imprecise differences. - Harms and safety: No intervention-related adverse events or harms were reported in either the nap group (zero of nineteen) or the control group (zero of sixteen) during or after the brief nap or quiet wakefulness periods. - Risk of bias and certainty: Overall risk of bias was judged as having some concerns, mainly due to missing outcome data (eight of thirty-five randomized residents excluded from the primary model because of missing actigraphy) and lack of participant blinding, although assessors were blinded and outcomes were structured and video-based. Using this and the reasonably precise effect estimate, certainty in the primary outcome was rated as Moderate. - Applicability and limitations: Findings apply most directly to anesthesia and intensive care residents in similar academic settings and to high-fidelity simulation; they are indirect for attending physicians, other specialties, or real-world patient outcomes. The trial is small and single-centre, with multiple secondary and exploratory analyses without adjustment for multiplicity, so apparent benefits on individual subscales should be interpreted cautiously and used to support, not replace, broader fatigue risk management policies.

    10 min

  7. May 3

    Outcome Differences Between General and Neuraxial Anesthesia for Hip Fracture by Frailty and Age in the Elderly: A Retrospective Cohort Study

    Citation: Giannakis P, Restrepo M, Stone AB, Zhuang ST, Wang J, Cozowicz C, et al. Outcome Differences Between General and Neuraxial Anesthesia for Hip Fracture by Frailty and Age in the Elderly: A Retrospective Cohort Study. Anesth Analg. 2026;XXX(00):00–300. doi:10.1213/ANE.0000000000008062 Using a large United States hospital claims database, Giannakis and colleagues compared neuraxial versus general anesthesia for more than six hundred thousand hip fracture surgeries across age and frailty strata. Neuraxial anesthesia was associated with very small differences in in-hospital mortality and a composite of major complications, a clearer reduction in high opioid use, and slightly more discharges home, but also small increases in some complications and intensive care admissions. Because anesthesia type was not randomized and key clinical confounders and outcomes were captured only through billing codes, overall certainty is very low and the results should inform, not dictate, anesthetic choice. Study at a glance - Design and setting: Retrospective cohort study using the Premier Healthcare Database, including 623,122 adults undergoing surgical treatment of hip fracture in United States hospitals between 2016 and 2023. Exposure was anesthesia type (general vs neuraxial) coded from billing data; outcomes (in-hospital mortality, major complications, intensive care unit admission, length of stay, opioid use, discharge disposition) were defined from ICD-10-CM diagnosis codes and billing records. Associations were estimated with mixed-effects multivariable logistic regression adjusted for demographics, comorbidities, hospital characteristics, procedure type, peripheral nerve block use, fracture type, and time to surgery. - Primary outcome – composite of death and major complications: The prespecified primary endpoint was a composite of in-hospital mortality, respiratory complications, cardiac complications, acute renal failure, and delirium. Overall, neuraxial anesthesia versus general anesthesia was associated with an adjusted odds ratio (OR) of 0.97 (95% confidence interval [CI] 0.94–0.997; p=0.053), a very small relative difference compatible with little to no effect. Given the nonrandomized, claims-based design and serious residual confounding, GRADE certainty for this outcome is Very Low; the apparent benefit could easily be due to unmeasured differences between patients selected for each technique. - In-hospital mortality: In-hospital death was lower in the neuraxial group overall, with an adjusted OR of 0.83 (95% CI 0.74–0.93; p=0.003), and a more pronounced association in older, more frail subgroups (for example, OR 0.77, 95% CI 0.65–0.91 in patients aged ≥87 years with intermediate/high frailty). However, choice of anesthesia is strongly confounded by clinical status, cognitive function, and hemodynamic reserve, which are incompletely measured in claims. With Serious overall risk of bias and no advanced causal methods, GRADE certainty for any mortality benefit is Very Low. - Key secondary outcomes – opioid use, discharge home, length of stay: Neuraxial anesthesia was associated with a moderate reduction in high postoperative opioid use (overall adjusted OR 0.69, 95% CI 0.66–0.72; p0.001), consistent across age and frailty strata, and with slightly higher odds of discharge to home among survivors (overall OR 1.08, 95% CI 1.04–1.12; p0.001). Prolonged length of stay (≥75th percentile) showed a very small reduction with neuraxial anesthesia (overall OR 0.97, 95% CI 0.94–0.998; p=0.046). High opioid use is a process measure rather than a direct patient-important endpoint, and discharge disposition and length of stay are influenced by social and system factors; all three outcomes are rated Very Low certainty due to serious confounding and, for opioid use, additional indirectness. - Potential harms – respiratory, cardiac, and ICU outcomes: Across the overall cohort, neuraxial anesthesia was associated with slightly higher rates of several coded complications and intensive care unit use: respiratory complications (OR 1.06, 95% CI 1.01–1.10; p=0.03), cardiac complications (OR 1.07, 95% CI 1.02–1.12; p=0.008), and intensive care unit admission (OR 1.07, 95% CI 1.03–1.12; p=0.002). Subgroup and sensitivity analyses showed some heterogeneity by age, frailty, and hospital neuraxial use, but effects remained small. Because these outcomes rely on diagnosis codes without validation and are highly susceptible to confounding by severity and practice patterns, GRADE certainty is Very Low, and the direction of true effect is uncertain. - Risk of bias, certainty, and practice implications: Overall risk of bias is judged Serious due to residual confounding by indication, selection related to coding completeness, and outcome misclassification from claims data. All appraised outcomes, including the primary composite, mortality, complications, length of stay, opioid use, intensive care unit admission, and discharge home, are rated Very Low certainty with GRADE. Clinically, the study suggests that neuraxial and general anesthesia for hip fracture have broadly similar in-hospital risks, with neuraxial associated with less high opioid use and more home discharges but also small increases in some complications, all very uncertain. These findings should not, on their own, drive a major practice shift; instead, anesthetic choice should remain individualized, and system-level improvements in timely surgery, hemodynamic management, multimodal analgesia, delirium prevention, and early mobilization are likely to have larger and more reliable impact than anesthesia type alone.

    11 min

  8. Apr 26

    Effect of low-dose propofol infusion with sevoflurane versus propofol-only total intravenous anesthesia on postoperative nausea and vomiting in high-risk patients: a single-blind randomized controlled clinical trial

    Citation: Keck WL, Deng E, Liu WM, Kanekar R, Lomivorotov V, Sharma S. Effect of low-dose propofol infusion with sevoflurane versus propofol-only total intravenous anesthesia on postoperative nausea and vomiting in high-risk patients: a single-blind randomized controlled clinical trial. BMC Anesthesiol. 2026;26:136. doi:10.1186/s12871-026-03649-7 Single-center randomized trial in high-risk adults undergoing elective laparoscopic surgery compared a hybrid anesthetic (low-dose propofol infusion plus sevoflurane) with propofol-only total intravenous anesthesia, with all patients receiving dexamethasone and ondansetron prophylaxis. Rates of postoperative nausea and vomiting over 24 hours and rescue antiemetic use were similar, and adjusted odds ratios had very wide confidence intervals spanning benefit and harm. Overall certainty for differences between techniques in postoperative nausea and vomiting or antiemetic use is very low, so these findings are best viewed as exploratory rather than practice-changing. Study at a glance - Design and setting: Prospective, single-blind, individually randomized controlled trial in a single United States academic medical center, enrolling high-risk adults undergoing elective laparoscopic general, gynecologic, or urologic surgery under general anesthesia. - Participants: Sixty-five adults aged 18 years or older with a history of postoperative nausea and vomiting and/or motion sickness, predominantly American Society of Anesthesiologists physical status II–III and mostly female, were randomized to hybrid anesthesia (n=32) or propofol-only total intravenous anesthesia (n=33). - Intervention and comparator: Hybrid group: induction with propofol plus opioids and neuromuscular blockade, then low-dose propofol infusion combined with sevoflurane for maintenance under bispectral index guidance. Comparator group: propofol-based total intravenous anesthesia for maintenance under bispectral index guidance without volatile agents. Both groups received standardized prophylaxis with dexamethasone 4 milligrams after induction and ondansetron 4 milligrams at closure, similar fluid and vasoactive management, and opioid-based analgesia. - Primary outcome: 24-hour postoperative nausea and vomiting: Cumulative postoperative nausea and vomiting (any nausea, retching, or vomiting within 24 hours after surgery) occurred in 19 of 32 patients (59%) in the hybrid group versus 14 of 33 (42%) in the propofol-only group. Adjusted odds ratio 1.59; 95% confidence interval 0.51 to 4.93; p=0.80. GRADE certainty for this outcome is rated Very Low due to some concerns about selective reporting and very serious imprecision. - Secondary outcomes: early postoperative nausea and vomiting and rescue antiemetics: Post-anesthesia care unit postoperative nausea and vomiting occurred in 9 of 32 (28%) hybrid versus 7 of 33 (21%) propofol-only patients; adjusted odds ratio 1.83; 95% confidence interval 0.52 to 6.48; p=0.34 (Very Low certainty). Rescue antiemetic use in the post-anesthesia care unit occurred in 9 of 32 (28%) versus 7 of 33 (21%); adjusted odds ratio 1.59; 95% confidence interval 0.51 to 4.92; p=0.48 (Very Low certainty). - Secondary outcomes: 24-hour rescue antiemetic use and overall antiemetic consumption: Within 24 hours, rescue antiemetics were used in 12 of 32 (38%) hybrid versus 8 of 33 (24%) propofol-only patients; adjusted odds ratio 1.84; 95% confidence interval 0.56 to 6.04; p=0.31 (Very Low certainty). Overall, any postoperative rescue antiemetic (post-anesthesia care unit or 24 hours) was given to 16 of 32 hybrid versus 13 of 33 propofol-only patients (no adjusted estimate reported; Very Low certainty). - Pain and opioid use: Visual analog scale pain scores in the post-anesthesia care unit and total perioperative morphine milligram equivalents did not differ meaningfully between groups (for example, median total morphine equivalents 20 vs 27.5, p=0.19), and no clear analgesic or opioid-sparing advantage of the hybrid technique was demonstrated; these outcomes were not formally graded for certainty in this appraisal. - Risk of bias and certainty: Randomization, protocol adherence, and outcome measurement were generally robust, with low risk of bias for most domains. However, incomplete visibility of the prespecified analysis plan and selective emphasis on adjusted models led to an overall risk-of-bias judgement of "some concerns." All key postoperative nausea and vomiting and antiemetic outcomes (24-hour and post-anesthesia care unit) were rated Very Low certainty by GRADE because of this risk-of-bias concern and very serious imprecision from the small sample and wide confidence intervals. - Bottom line for practice: In high-risk adults undergoing elective laparoscopic surgery with standardized dexamethasone and ondansetron prophylaxis, hybrid low-dose propofol plus sevoflurane did not clearly reduce 24-hour postoperative nausea and vomiting, early postoperative nausea and vomiting, or rescue antiemetic use compared with propofol-only total intravenous anesthesia. Given the Very Low certainty of evidence, these findings should not on their own drive a change in anesthetic technique for the purpose of postoperative nausea and vomiting prevention; choice of hybrid versus propofol-only anesthesia should instead be guided by other clinical considerations until larger, higher-certainty trials are available.

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Vetrix Anesthesiology is an AI-driven podcast that dissects contemporary anesthesiology papers, translating dense methods and statistics into clear, clinically focused insights for everyday practice.

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