#319 Four New Studies That Change Daily Anesthesia Safety Decisions

Ketamine for emergency intubation has a reputation for hemodynamic stability, but does the best evidence back that up when your patient is truly sick? Today, we walk through four fresh research summaries that sharpen day-to-day anesthesia patient safety decisions, from airway management in shock and sepsis to the way teams and technology shape outcomes in the OR.

First, we break down a large randomized controlled trial comparing ketamine versus etomidate for tracheal intubation in critically ill adults across U.S. emergency departments and ICUs. Mortality is similar, but ketamine shows more peri-intubation cardiovascular collapse, including hypotension and increased vasopressor use, especially in sicker patients. Our practical focus is how to choose an induction agent based on hemodynamic risk and how to prepare for peri-intubation instability.

Next, we head into the cardiac OR to explore why surgeon-anesthesiologist dyad familiarity may be a systems-level patient safety strategy. A large retrospective study links more consistent pairings with lower operative mortality and better perioperative outcomes, raising real questions about scheduling, teamwork, and communication under pressure. We also review evidence on BIS-guided closed-loop anesthesia systems that improve anesthetic depth control by reducing excessively deep anesthesia without increasing light anesthesia, and we close with perioperative brain health, highlighting why routine preoperative cognitive screening is still uncommon and what resources could finally make it standard practice.

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For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/319-four-new-studies-that-change-daily-anesthesia-safety-decisions/

© 2026, The Anesthesia Patient Safety Foundation

Transcript

Welcome And Key Takeaways

Alli 0:03

Hello and welcome back to the Anesthesia of Patient Safety podcast. I'm your host, Allie Bechtel. We are bringing you an in-the-literature show today. This is a great way to stay up to date on the latest in Anesthesia Patient Safety. We are bringing you the highlights from these recent studies, but as always, we encourage you to check out the full articles. Here are the big takeaways from today's show. Anesthesia professionals should focus on hemodynamic risk when choosing an induction agent. Etominate may offer greater cardiovascular stability, especially in patients with shock or sepsis, while ketamine may increase periintubation instability. Familiarity within the cardiac surgeon anesthesiologist diad may lead to improved communication, anticipation of critical events, shared decision-making under pressure and teamwork, and organizational approaches that support stable cardiac anesthesia surgery pairings may be a systems-level strategy to improve perioperative outcomes and reduce preventable harm. This guided closed-loop systems with automated hypnotic control outperformed standard anesthesia care when it comes to anesthetic depth control by reducing the incidence of excessively deep anesthesia without increasing light anesthesia. And finally, there is a knowledge action gap when it comes to perioperative brain health, since anesthesia professionals recognize the importance of preoperative cognitive screening, but additional resources are needed to expand to routine implementation.

Recognizing APSF Corporate Support

Alli 1:44

Before we dive further into the episode today, we'd like to recognize BD, a major corporate supporter of APSF. BD has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, BD. We wouldn't be able to do all that we do without you.

Ketamine Vs Etomidate For Intubation

Alli 2:09

Our first featured article is a summary of an article from the New England Journal of Medicine published in April 2026. The article is Ketamine Oritominate for Tracheal Intubation of Critically Ill Adults by Casey and colleagues. The APSF summary was written by JW Beard and published online May 18, 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 article, and I will include a link in the show notes to all of the articles that we're talking about today. This first article highlights considerations for the choice of induction agent to use during emergency intubation for critically ill adults and evaluates the risk of death and peri-intubation hemodynamic instability. Past observational studies have suggested that using autominate may increase the risk of death, but data from randomized controlled trials are lacking. Which brings us to this trial. It is a multi-center randomized control trial to evaluate whether ketamine reduces mortality compared to autominate administration. There were over 2,000 critically ill adult patients in the United States emergency departments and ICUs who were assigned to receive either ketamine or automatate prior to tracheal intubation. The primary and secondary outcomes were 28-day in-hospital mortality and cardiovascular collapse during intubation, respectively. And now for some results. There was no significant difference in 28-day in-hospital mortality between ketamine and automatic, and the mortality findings were consistent across subgroups, including patients with sepsis. In the ketamine group, there was a higher incidence of cardiovascular collapse during intubation compared to automatic, including increased hypotension and increased vasopressor use, especially in sicker patients. In addition, patients who received ketamine had lower periintubation blood pressure and higher rates of hypotension with systolic blood pressures of less than 80 millimeters of mercury. Other clinical outcomes were similar between the two groups. The results from the study do not support the use of ketamine to help reduce mortality and challenge the perception that it offers superior hemodynamic stability. Anesthesia professionals need to consider hemodynamic risk for critically ill patients requiring emergency intubation. And automated may offer greater cardiovascular stability, especially in patients with shock and sepsis. Ketamine may lead to increased risk for cardiovascular instability, so you need to be prepared to treat hypotension following intubation.

Surgeon Anesthesiologist Familiarity Matters

Alli 5:06

For our next literature review, we are heading into the cardiac ORs. This is an APSF summary of a March 2026 article in anesthesia and analgesia, the association between surgeon anesthesiologist diet familiarity and operative mortality, a retrospective study at a large academic cardiac surgery program by LACA and colleagues. This summary was written by JW Beard and published online June 8th, 2026. We are very excited to talk about this article because we first covered the anesthesiologist surgeon dyad for episode number six of this podcast, all the way back on August 11th, 2020. And we talked about why healthy relationships between anesthesia professionals and surgeons are important for patient safety and how to strengthen this relationship. Let's see what we already know and what's new when it comes to this classic duo. This is a particularly important during cardiac surgery when teamwork between the surgeon and the anesthesiologist is critical to optimize patient outcomes. This study is a retrospective cohort study that looked at how often a surgeon and anesthesiologist work together and the differences in operative mortality and other perioperative outcomes. It included almost 17,000 adult cardiac surgical procedures between 2011 and 2024 at a single academic center with 481 unique surgeon anesthesiologist pairings. Team familiarity was quantified as the number of cases a specific surgeon-anesthesiologist pair completed together in the prior year stratified into quintiles. The primary endpoint was operative mortality, defined as death before hospital discharge or within 30 days of surgery. Secondary endpoints included procedure duration, ICU and hospital length of stay, reoperation, readmission, transfusion, and major postoperative complications. And now for some findings. The mortality rate decreased as team familiarity increased, with the diets performing the fewest surgeries together having the highest mortality, and the diads that worked together the most demonstrating the lowest. This is pretty impressive, since after risk adjustment, patients cared for by the least familiar diets had nearly twice the odds of operative death compared to those treated by the most familiar teams. In addition, less familiar teams were associated with longer operations, extended ICU and hospital stays, higher transfusion rates, and increased pulmonary and neurologic complications. These associations persisted in sensitivity analyses that accounted for individual clinician experience and excluded the highest volume surgeons. This is an important study for anesthesia professionals and surgeons that highlights the potential safety benefits of consistent collaboration with surgical colleagues. Familiarity within this diad may lead to better communication, anticipation of critical events like during separation from cardiopulmonary bypass, shared decision making under pressure, and teamwork. The authors suggest that organizational approaches that support stable cardiac anesthesia surgery pairings may be a modifiable systems-level strategy to improve perioperative outcomes and reduce preventable harm. We

Closed Loop Control Of Anesthetic Depth

Alli 8:47

are on to our third summary today: the John Icorn summary of closed loop systems for automated hypnotic drug delivery during general anesthesia, a systematic review and meta-analysis that was published online June 15, 2026. The article by Felipe and colleagues was published in the British Journal of Anesthesia in April of 2026. The focus of this article is on the challenge of maintaining an appropriate depth of anesthesia during surgery, keeping in mind that excessively deep anesthesia can lead to hemodynamic instability or postoperative cognitive dysfunction or delirium, while inadequate anesthesia puts patients at risk for excessive catecholamine stimulation, disruptive patient movement, and interoperative recall. There have been numerous studies that looked at the use of closed loop systems to automate the delivery of anesthetic agents while maintaining adequate depth of anesthesia based on continuous bispectral index or BIS monitoring, and computerized controller algorithms to adjust infusion rates in real time. And now for the details. This is a systematic review and meta-analysis of 17 trials and almost 2,000 patients that compared closed loop automated systems with standard care, that is, the anesthesia professional manually adjusting the anesthetic delivery. The primary outcome was proportion of time that BIS values were kept within 10 units of a target. And now for the results. The automated closed loop systems were better than standard care, with the time within target BIS range increased by 17% in patients managed with the closed loop system. There were additional benefits as well. The closed loop system significantly reduced the amount of time that patients spent with a BIS less than 40, and the time spent with BIS greater than 60 did not differ between the groups. The time to extivation was shorter in the closed loop system, and there were no differences in propofol consumption or vasopressor use. The big takeaway from this article is that BIS-guided closed loop systems with automated hypnotic control has a superior safety profile for anesthetic depth control by decreasing the incidence of excessively deep anesthesia without increasing the incidence of light anesthesia. And now it's time to discuss our final summary of the day.

Preop Cognitive Screening Implementation Gap

Alli 11:17

We are turning our attention to the summary of routine preoperative cognitive assessment to improve brain health in older surgical patients. Insights from an Anesthesia Patient Safety Foundation survey that was published online July 20th, 2026, and written by Jeffrey Wong. This summary covers the June 2026 Anesthesia and Analgesia article by Rangasami and colleagues. This is an important article since cognitive impairment is common in older surgical patients with estimated rates of 37 to 50% of this population. Even with this high prevalence, it may go unrecognized. And patients with cognitive impairment are at increased risk for peroperative neurocognitive disorders and postoperative delirium. There is a call from major professional organizations to complete preoperative cognitive assessment screening for older surgical patients, but routine screening is still uncommon in clinical practice. This study is a cross-section survey of participants in the Anesthesia Patient Safety Foundation, Patient Safety Advisory Group, and the broader APSF community. The authors looked at current cognitive screening practices, perceived importance of cognitive screening, barriers to implementation, and educational needs. The survey was distributed to 205 APSF participants with 113 responses for a 55% response rate. 57.5% were physician anesthesiologists, and nearly two-thirds had more than 10 years of clinical experience. And now for some results. And 28% rated it as moderately important. Even though there was a high perceived importance of preoperative screening, only 3.8% routinely screened all surgical patients, and only 27.6% performed any screening at all, even in selected populations like older patients. Barriers to performing these screenings included lack of institutional support or formal protocols, insufficient time during preoperative evaluation, inadequate resources or staffing, and lack of training on the screening tools. This survey reveals the substantial knowledge action gap when it comes to perioperative brain health. Anesthesia professionals recognize that cognitive screening is important, but the next step, routine implementation, has not been taken. The author suggests that to close this implementation gap, the following resources are needed: institutional support, standardized protocols, electronic health record integration, staff training, adequate resources, and clear clinical pathways for management of patients with positive cognitive screening results. And that's it for our literature review today.

Wrap Up And How To Connect

Alli 14:25

If you have any questions or comments from today's show, please email us at podcast atapsf.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 apf.org for detailed information and check out the show notes for links to all the topics we discussed today. We hope that you will subscribe to the Anesthesia Patient Safety Podcast for weekly, evidence-focused anesthesia insights. We hope that you'll also share this podcast with a colleague and leave her a review so that more clinicians can find the latest perioperative patient safety updates as we work towards our mission. Until next time, stay vigilant and stay informed so that no one shall be harmed by anesthesia care.