Anesthesiology

Closed-loop BIS-guided hypnotic delivery improves depth control and limits deep anaesthesia

Across 17 RCTs including 1,898 adults, BIS-guided closed-loop hypnotic delivery increased time within 10 BIS units of target by 17.6%. Closed-loop systems significantly reduced time with BIS <40 without increasing time with BIS >60, decreasing deep but not increasing light anaesthesia. Controller performance metrics favoured automation, and time to extubation was shorter by about 1.7 minutes versus manual control. Propofol consumption and vasopressor use were similar, supporting closed-loop BIS-guided delivery as a safe way to optimise hypnotic depth. 1

Biomarker-enriched KDIGO kidney protection bundles reduce moderate–severe postoperative AKI

This IPD meta-analysis pooled four RCTs, including 1,851 biomarker-selected high-risk patients undergoing major surgery. A KDIGO-based kidney protection strategy reduced moderate or severe AKI within 72 hours from 27.1% to 17.7% (OR 0.55, 95% CI 0.44-0.70). The bundle included haemodynamic and fluid optimisation, nephrotoxin and contrast avoidance, kidney function monitoring, and glycaemic control versus standard care. Persistent AKI and tubular stress biomarkers tended to improve, while other secondary endpoints showed no major group differences. Results support adopting structured kidney protection protocols in biomarker-enriched high-risk postoperative patients. 2

Extended-release opioid use after arthroplasty is common and practice-pattern driven

In this population-based study of 229,995 primary hip or knee arthroplasties, 12.1% of patients filled a new extended-release opioid prescription within seven days of discharge. Male sex, higher preoperative opioid exposure, and ASA 3 increased odds of extended-release opioid dispensing. Neuraxial anaesthesia, peripheral nerve blocks, and acute pain service involvement were associated with lower extended-release prescribing. Variation was large across hospitals and surgeons with minimal anaesthetist-level variation, indicating institutional and surgical practices predominantly drive prescribing. Extended-release opioids after arthroplasty remain a clear target for stewardship and standardised discharge analgesia pathways. 3

Sevoflurane versus propofol and later ADHD after a single paediatric anaesthetic

This multinational retrospective cohort compared sevoflurane versus propofol as the main anaesthetic in 54,102 children with a single general anaesthesia exposure. Cumulative ADHD incidence was 5.63% after sevoflurane and 2.95% after propofol, with higher incidence rates after sevoflurane. Sevoflurane exposure was associated with increased ADHD risk (hazard ratio 1.21, 95% CI 1.11-1.31), robust across subgroup and sensitivity analyses. Mortality was rare and similar between groups, suggesting a specific neurobehavioral signal. Findings raise concern that anaesthetic choice may influence long-term ADHD risk and warrant prospective confirmation before practice change. 4