Anesthesiology

Routine high-flow nasal oxygen after high-risk cardiac surgery offers no outcome benefit

In 1,280 adults at increased pulmonary risk after nonemergent cardiac surgery, prophylactic high-flow nasal oxygen (HFNOT) was compared with standard oxygen therapy (SOT). HFNOT or SOT was provided for at least 16 hours immediately after postoperative extubation, reflecting real-world ICU practice. Days alive and at home without increased support over 90 days were identical between groups (median difference 0; P=.75). Other clinical outcomes, including days alive at home ignoring additional support, were also similar. These findings do not support routine prophylactic HFNOT after cardiac surgery and favor selective use based on clinical deterioration. 1

Ketamine is less hemodynamically stable than etomidate for emergency intubation

This systematic review and meta-analysis included 10 randomized trials (4,673 adults) undergoing emergency tracheal intubation in EDs and ICUs. Compared with etomidate (nine trials), ketamine increased postinduction hemodynamic instability (risk ratio 1.28; 95% CI, 1.13–1.45). In the single trial using midazolam plus sufentanil, ketamine instead reduced hemodynamic instability (risk ratio 0.51; 95% CI, 0.29–0.89). There were no differences between ketamine and comparators in mortality, ventilator-free days, or ICU-free days. Clinicians should not assume ketamine is more hemodynamically stable than etomidate in critically ill adults. 2

Deep spinal infection after outpatient single-shot epidural injection is rare but predictable

Using Korean national claims data, investigators analyzed 12,049,555 outpatient single-shot epidural injections in 3,769,014 pain patients over 10 years. Deep spinal infection requiring hospitalization and prolonged antibiotics occurred after 2,422 injections, an incidence of 0.020% per injection. Risk increased with age ≥65 years, several comorbidities, recent immunosuppressant or systemic steroid use, ≥3 injections in 90 days, and lumbosacral-level injections. Selective nerve root block was associated with substantially lower infection risk (OR 0.49; 95% CI, 0.37–0.64). These results support explicit risk stratification, limiting clustered injections, and highlighting lumbosacral approaches during informed consent. 3

Growing perioperative gabapentin use in adolescents fails to spare opioids

This national private-insurance claims study included 181,225 opioid- and gabapentin-naive adolescents (11–21 years) undergoing seven common or high-risk procedures from 2012–2022. Overall, 32.1% filled a new perioperative prescription; 1.1% received gabapentin, and 2.2% received both gabapentin and opioids. Gabapentin prescribing with or without opioids increased over time, often with long initial supplies and frequent refills. Adolescents receiving both gabapentin and opioids had higher adjusted probability of opioid refill than opioid-only patients (40.7% vs 21.6%). Gabapentin did not reduce initial opioid quantities or refill likelihood, questioning its opioid-sparing role in this population. 4