#308 We Break Down The Latest Evidence On Safer Anesthesia Care

Delirium, pain, and prolonged ventilation can feel like “expected” bumps in perioperative care until you look closely at the data. We walk through four recent APSF In the Literature reviews and pull out what’s actually actionable for anesthesia patient safety right now, with clear numbers and real-world implications.

First, we dig into a randomized controlled trial of S-ketamine for elderly patients undergoing total hip or total knee arthroplasty under neuraxial anesthesia. With general anesthesia out of the equation, the study reports a notable drop in postoperative delirium, raising practical questions about when S-ketamine belongs in your plan and how you weigh neuroprotection alongside analgesia.

Next, we shift to the ICU after cardiac surgery and examine evidence on dexmedetomidine sedation and duration of invasive mechanical ventilation. We talk through the key nuance: dexmedetomidine is associated with longer ventilation overall, yet may shorten ventilation time in patients with a high “sedation burden,” highlighting how stacking sedatives can change the outcome you’re trying to optimize.

We then move to labor and delivery with a large prospective cohort on pain during cesarean delivery with neuraxial anesthesia, including higher risk with urgent cases and epidural top-ups, plus an important signal on language and the need for interpreters. We close with a pediatric trial where EEG-guided sevoflurane titration reduces emergence delirium and speeds recovery in the PACU.

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For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/308-we-break-down-the-latest-evidence-on-safer-anesthesia-care/

© 2026, The Anesthesia Patient Safety Foundation

Transcript

Rapid-Fire Questions And Setup

Alli 0:00

What is the effect of ketamine on elderly patients and postoperative delirium? Is there a role for dexmetatomidine for sedation for patients undergoing cardiac surgery? Is this the best option for fast track cardiac? What is the incidence of pain during cesarean delivery with spinal anesthesia? Do you need to update your practice?

What “In The Literature” Means

Alli 0:21

Hello and welcome back to the Anesthesia Patient Safety Podcast. I'm your host, Ellie Bechtel. We started with a lot of questions today, but don't worry because we also have some answers since this is an in the literature episode. We are covering the three or maybe four most recent APSF in-the-literature reviews. Please check out the show notes for links to the APSF articles and citations to the studies that we are discussing. We are making it really easy to stay up to date with the latest inpatient safety with summaries of the best medical journal articles from the APSF newsletter editorial board. Before we dive further into the episode today, we'd like to recognize Vertex, a major corporate supporter of APSF. Vertex has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Vertex. We wouldn't be able to do all that we do without you. First

S-Ketamine And Elderly Delirium

Alli 1:25

up, we have a summary of effect of S- ketamine on postoperative delirium in elderly patients undergoing arthroplasty, a randomized controlled trial, that was published online 11th of May 2026. To follow along with us, head over to apsf.org and click on the newsletter heading. The fourth one down is in the literature. Then you can scroll down until you get to our featured articles today. And I will include the links in the show notes as well. You can find this article in Anesthesiology from January 2026 by Zhu and colleagues. Here is the summary by Jeffrey Huang. Here's the background information to get us started. Elderly patients undergoing total hip arthroplasty and total knee arthroplasty with neuraxial anesthesia are at risk for postoperative delirium. There is a reported incidence of 11 to 20.7%. Post-op delirium is a big threat to anesthesia patient safety and is associated with increased length of hospital stay and health care costs, as well as higher mortality, poor cognitive outcomes, and increased risk for dementia. In the past, studies have found that sketamine, which is an enantiomer of ketamine, may blunt the neuroinflammatory response to surgery and may reduce post-stop cognitive decline after elective surgery under general anesthesia. Other studies have suggested that general anesthetics may lessen the effects of sketamine as a neuroprotective agent. For this study, the authors wanted to determine the full neuroprotective effects of S-ketamine when general anesthesia is taken out of the equation. This is a single-centered prospective randomized double-blind placebo-controlled trial of 372 elderly patients undergoing total hip or total knee arthoplasty under neuraxial anesthesia, who received an infusion of S-ketamine 0.2 milligrams per kg or placebo over one hour. Patients in the S. ketamine group also received S. ketamine in their postoperative patient-controlled analgesia infusions combined with sous fentanyl and onansitron. The placebo group received sous fentanyl and onancetron in their PCAs. Patients received either a preoperative adductor canal or iliac fascia block with noraxial anesthesia as selected by the anesthesia team. The primary outcome was incidence of postoperative delirium within the first three days postoperatively. And now for the results. The post-op delirium occurred in 15 patients in the eschetamine group compared with 38 patients in the placebo group. That was a reduction from 20% in the placebo group down to 8% in the eschetamine group. The authors concluded that eschetamine significantly reduces post-op delirium risk in elderly patients undergoing total hip or total knee arthroplasty under neuraxial anesthesia. What did you think of this study? Are you giving eschetamine to elderly patients undergoing lower extremity joint replacements under noraxial anesthesia? Our

Dexmedetomidine After Cardiac Surgery

Alli 4:45

next in the literature summary is Association Between Dexmenatomin Use and Duration of Invasive Mechanical Ventilation After Cardiac Surgery, a hospital registry study published online April 27, 2026, and written by Boetang and Peng. You can check out the article published in Anesthesia and Analgesia from March 2026 by Ramishvili and colleagues. Okay, this one is for all of our cardiac anesthesia colleagues. Why is this study important? Well, dexmenatominine is an alpha-2 adrenergic receptor agonist that can be used for sedation following cardiac surgery. It takes a long time to get to steady state levels, so there's a concern that dexmenatomidine infusions could lead to longer duration of mechanical ventilation. So the investigators wanted to look at if dexmenatomidine infusions after cardiac surgery were associated with longer duration of post-op mechanical ventilation. This is a retrospective cohort study in a single U.S. academic center of 2,191 adult patients who had non-emergent cabbage, valve, or combined cabbage valve procedures with cardiopulmonary bypassed with postoperative mechanical ventilation. And what did they find? The median duration of mechanical ventilation was 406 minutes with an interquartile range from 297 to 837 minutes. Now, drum roll, please. The use of dexmenatominine infusions in the ICU was associated with longer duration of mechanical ventilation with an adjusted average difference of 45 minutes. The authors also looked at whether a higher all-cause sedation burden index, which accounts for additional medications like propofol, opioids, and benzodiazepines, was associated with longer duration of mechanical ventilation. It is not surprising that patients with a high sedation burden index had significantly longer durations with an average adjusted difference of 71 minutes. Here's where it gets interesting. For patients with a high sedation burden index who received dexmenatomatine infusions, there was a significantly shorter duration of mechanical ventilation compared to patients with a high index and no DEX Menatomidine. The adjusted average difference was 23 minutes less. The conclusions from the study are DEXMETON administration is associated with a longer duration of mechanical ventilation after cardiac surgery. And for patients receiving multiple sedative medications, the use of dexmenatomidine may help to speed up the time until extubation, which highlights the context-sensitive nature of the effects of DEXMedatomidine when combined with other sedative medications. What are you using for post-oxidation following cardiac surgery? Moving

Pain During Cesarean Under Neuraxial

Alli 7:43

on to our next literature review of the day, we have the summary of incidence of pain during cesarean delivery with neuraxial anesthesia, an international prospective cohort study written by Paul LeFebre and published online April 20th, 2026. The article by O'Carroll and colleagues was published in Anesthesiology in April 2026. We are moving from the cardiac ORs to the Labor and Delivery Ward for our next summary. This has been an important anesthesia patient safety topic, pain during cesarean delivery that we have talked about on the show before, and this is an important article to discuss. Patients who experience pain during cesarean delivery are at risk for depression and post-traumatic stress disorder. This is a prospective cohort study to evaluate the incidence of pain during cesarean delivery for patients who have neuroxial anesthesia. Here are the details. 3,693 patients from 15 academic centers in the United States and Canada were included in the study. 45% were elective deliveries, and 54% were urgent or emergent. At 24 hours postpartum, patients were asked whether they experienced pain during their delivery, and if so, how severe was their pain on a scale from 1 to 10? And now for the results. Urgent and emergent procedures were associated with increased incidence of interoperative pain and higher pain scores compared to elective cesarean deliveries. There was a higher incidence of pain for patients with epidural top-ups compared to cesarean deliveries with spinal anesthesia. Spanish-speaking patients were more likely to report having experienced pain than other cohorts. There were 282 patients who reported interoperative pain, and 10.3% of patients were not satisfied with how the anesthesia team managed their pain. Here are the big takeaways from this study. The authors conclude that intraoperative pain during cesarean delivery with neuraxial anesthesia is fairly common, and further work is needed to address this issue. The authors provide potential interventions to reduce the rate, severity, and long-term impact of pain during cesarean delivery that include the following. Pre-op. Anesthesia professionals should have a comprehensive discussion with their patients regarding pain control during the cesarean delivery, with a goal of reaching a shared decision about the anesthesia plan and pain management options. Interpreters should be used for patients whose preferred language is not English. In the operating room, anesthesia professionals need to be vigilant and perform careful block assessment for non-elective cases, especially when epidural top-up is the planned mode of anesthesia, since these variables are associated with an elevated risk of interoperative pain. Good news. We have time for one more literature review. Let's turn

EEG-Guided Sevoflurane In Kids

Alli 10:45

our attention to a new study on pediatric patients. This is the summary of EEG guided titration of sevofluorine and pediatric anesthesia emergence delirium, a randomized clinical trial, by Jeffrey Wong and published online April 13, 2026. You can check out the article published in JAMA Pediatrics in April 2025 by Miyasaka and colleagues. The background is that emergence delirium in pediatric patients is common. General anesthesia appears to be a risk factor and the etiology remains unknown. Post-op delirium in adults has been studied, and EEG guided anesthesia with the goal of minimizing EEG suppression did not reduce the incidence of postoperative delirium compared to the usual anesthetic care in these adults. This study is a single-centered parallel group two-arm superiority randomized clinical trial. Participants included 177 children aged 1 to 5 years old, scheduled for elective surgery with a duration of general anesthesia of 30 minutes or longer. The two groups were the EEG guided group with sevofluorine titrated to the lowest concentration required to maintain EEG patterns consistent with unconsciousness, or stable continuous alpha and slow delta EEG patterns, or the control group with sevofluorine delivered to one MAC. Delirium was assessed in the PACU on arrival and at 5, 10, 15, and 30 minutes, or until full emergence and recovery from the anesthesia. Here are the results. EEG guided management reduced sevofluorine exposure by 4 MAC hours. Emergence delirium occurred in 35% of children in the control group compared with 21% of children in the EEG guided group. Full emergence occurred four minutes earlier, and PACU discharge was 16.5 minutes earlier in the EEG guided group. The authors of the study concluded that in children, EEG guided general anesthesia reduced sebofluorine exposure and the incidence of emergence delirium combined with faster emergence and shorter PACU stays. This is such an interesting study that uses EEG monitoring to potentially provide safer and faster anesthesia care when sevofluorine is used. With

Key Takeaways And How To Engage

Alli 13:13

that, we have made it to the end of our literature review. We hope you enjoyed catching up on the latest in perioperative patient safety, and we'll be back next week to talk about a new APSF article. If you have any questions or comments from today's show, please email us at podcast at APSF.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apsf.org for detailed information and check out the show notes for links to all the topics we discussed today. Thank you for joining us for another episode of the Anesthesia Patient Safety Podcast. Here at the APSF, we believe that patient safety is everyone's responsibility and every conversation helps move our specialty forward. If you enjoyed this episode, please subscribe, leave a review, and share the podcast with your colleagues, trainees, and anesthesia professionals and other perioperative providers committed to safer patient care. Until next time, stay vigilant and stay informed so that no one shall be harmed by anesthesia care.