Anesthesiology

Delirium remains frequent in cognitively impaired patients despite perioperative best-practice adherence

Among 1,255 surgical patients with preoperative cognitive impairment, postoperative delirium occurred in 34%, despite implementation of 12 anesthesia-related best practices. Individually, intraoperative glucose <200 mg/dL, temperature monitoring, and maintaining temperature >36 °C were each associated with lower delirium odds in separate models. When all practices were analyzed together, no specific intraoperative practice remained protective, except that postoperative glucose monitoring was paradoxically associated with higher delirium odds. These findings suggest current perioperative bundles are foundational but insufficient for delirium prevention in cognitively impaired patients and highlight the need for novel, targeted strategies. 1

Sivelestat reduced ARDS and mortality after major cardiovascular surgery

In 424 randomized cardiovascular surgery patients, postoperative continuous IV sivelestat lowered ARDS incidence compared with placebo (16.8% vs 31.2%). Ninety-day mortality was also reduced with sivelestat (1.1% vs 5.2%), without an increase in monitored adverse events. Sivelestat attenuated postoperative inflammatory responses, including reductions in neutrophil elastase and interleukin-6 levels. This single-center trial suggests neutrophil elastase inhibition may provide clinically meaningful lung protection after major cardiovascular surgery but requires multicenter confirmation before routine adoption. 2

Individualized EIT-guided PEEP improved mechanics but not pulmonary complications after lung cancer surgery

In 400 patients ≥60 years undergoing lung cancer surgery, individualized PEEP (median 11 cmH2O during one-lung ventilation) was compared with fixed PEEP of 5 cmH2O. Individualized PEEP reduced driving pressures and improved intraoperative oxygenation during both one-lung and two-lung ventilation. Despite these physiologic benefits, postoperative pulmonary complication rates were similar between groups (28% individualized vs 25% fixed; risk ratio 1.09). These results indicate that EIT-guided PEEP optimization alone does not reduce pulmonary complications in this population and should not replace broader lung-protective strategies. 3

Subprophylactic anti-Xa levels on LMWH are common in ICU patients and linked to higher VTE risk

Across 39 studies including 7,124 critically ill adults on LMWH prophylaxis, only 47% achieved target anti-Xa levels. Subprophylactic anti-Xa levels were associated with a higher venous thromboembolism risk (unadjusted odds ratio 2.87; low-certainty evidence). Male sex, higher body weight, and elevated BMI were moderately associated with subprophylactic anti-Xa levels. These data suggest standard fixed-dose LMWH may underdose many ICU patients, particularly heavier males, and support consideration of anti-Xa monitoring or weight-adjusted regimens. 4