Anesthesiology

Individualised PEEP during minimally invasive surgery reduces pulmonary complications and driving pressure

Across 30 studies including 3295 patients undergoing minimally invasive thoracic or abdominal surgery, individualised PEEP reduced postoperative pulmonary complications versus standard lung-protective ventilation. The pooled risk ratio for pulmonary complications was 0.67 (95% CI 0.56–0.79), with low heterogeneity and moderate-certainty evidence. Individualised PEEP lowered driving pressure by about 3 cmH2O compared with fixed PEEP strategies. Benefits were consistent across thoracic and abdominal procedures, but causality and optimal individualisation methods still require confirmation. 1

Prophylactic NIV plus HFNC after extubation lowers reintubation in high-risk, non-hypercapnic adults

This post hoc analysis of two multicenter trials examined 829 high-risk adults without hypercapnia at extubation. Patients received either prophylactic NIV alternating with high-flow nasal cannula or high-flow nasal cannula alone after extubation. Seven-day reintubation was lower with NIV plus HFNC than HFNC alone (11.8% vs 17.6%; absolute difference -5.8%, p=0.021). G-computation confirmed a similar absolute risk reduction, and benefits persisted through ICU discharge. These data support routine consideration of prophylactic NIV plus HFNC for high-risk, non-hypercapnic patients at planned extubation. 2

PACU frontal EEG identifies older adults at increased risk of postoperative delirium

This prospective study recorded frontal EEG in the recovery room in 184 older adults, of whom 31% developed postoperative delirium. Patients who later developed delirium showed significantly reduced alpha- and beta-band power compared with those without delirium. Cumulative 10–20 Hz power discriminated delirium risk with an AUC of 0.69 (95% CI 0.60–0.77). Non-delirious patients demonstrated increased 8–20 Hz power versus baseline, whereas delirious patients failed to augment these oscillations. Recovery-room EEG could enable early identification of a “vulnerable brain” phenotype and targeted delirium-prevention strategies. 3

Inhaled volatile sedation in ARDS shortens ICU stay and improves oxygenation but increases AKI risk

This meta-analysis of eight studies including 1440 adults with ARDS compared inhaled sevoflurane or isoflurane with intravenous sedatives during mechanical ventilation. Short-term mortality and duration of mechanical ventilation were similar between inhaled and IV sedation groups. Inhaled sedation shortened ICU length of stay by about 2.3 days and improved PaO2/FiO2, largely in sevoflurane-based studies. Sevoflurane use was associated with a higher risk of acute kidney injury (OR 1.68; 95% CI 1.25–2.24). Clinicians adopting volatile sedation for ARDS should balance potential oxygenation and ICU-stay benefits against increased AKI risk and monitor kidneys closely. 4