Anesthesiology

Updated PeRLS guidance for perioperative and ICU cardiac arrest

This PeRLS update reframes perioperative and ICU cardiac arrest as usually witnessed, often with an identifiable precipitant, enabling earlier causal therapy than ward or out-of-hospital arrests. Recommendations, developed with GRADE, focus on rapid physiologic assessment, dynamic diagnosis, and targeted treatment rather than purely algorithmic compressions and drugs. Algorithms are designed for use across the perioperative continuum, including OR, PACU, ICU, and emergency department settings. Anesthesiologists are positioned as leaders for recognizing impending collapse over minutes to hours and intervening before full arrest occurs. 1

Revised perioperative BP thresholds and management for elective noncardiac surgery

These guidelines recommend that secondary care teams accept referrals when clinic BP is <160/100 mmHg or ambulatory/home BP <155/95 mmHg in the past year. Patients without primary-care documentation may still proceed if clinic BP is <180/120 mmHg or ambulatory/home BP <175/115 mmHg. Guidance spans the full perioperative window, detailing how and when to measure BP and when to postpone planned surgery. The document emphasizes nuanced antihypertensive management, including omission and reintroduction strategies, and stresses clear communication with primary care to avoid conflicting advice. 2

PROSPECT 2025: first-line analgesia for open thoracotomy

This PROSPECT update recommends either thoracic epidural analgesia or paravertebral block as first-line regional techniques after open thoracotomy. Other regional options—erector spinae plane, rhomboid intercostal, or intercostal nerve blocks—are suggested only as second-line when epidural or paravertebral block is not feasible. All patients should receive basic systemic analgesia with paracetamol plus an NSAID or COX-2 inhibitor unless contraindicated. Acupuncture or cryoanalgesia is reserved for situations where regional anesthesia cannot be performed, with acknowledgment of the low supporting evidence level. 3

Remimazolam vs dexmedetomidine for short-term ICU sedation on mechanical ventilation

In this multicenter noninferiority trial of 314 ventilated adults, remimazolam achieved similar target sedation rates to dexmedetomidine over 8–48 hours. Sedation efficacy was comparable in both per-protocol and intention-to-treat analyses, meeting the predefined noninferiority margin. Bradycardia occurred less frequently with remimazolam than dexmedetomidine (4.7% vs 0.7%), with no major differences in other adverse events. These data support remimazolam as a viable alternative to dexmedetomidine when bradycardia or hemodynamic instability is a concern. 4