This Month in Anesthesiology

Postoperative nausea and vomiting is a common complication after surgery that decreases patient satisfaction and can lead to unplanned admission. Known risk factors only partially explain interindividual variation in risk, suggesting that genetics may play a role. Genetic variants associated with postoperative nausea and vomiting were identified with a genome-wide association study. Based on this study, a polygenic risk score for postoperative nausea and vomiting was created and associations between the risk score and postoperative nausea and vomiting were assessed in a validation cohort. Genetic contributions to known clinical risks for postoperative nausea and vomiting were then compared. See the accompanying Editorial on page 3.Postoperative pulmonary complications frequently occur. High positive end-expiratory pressure (PEEP) with recruitment maneuvers can protect the lungs against repetitive tidal recruitment but can potentially cause lung overdistension. A recent individual patient data meta-analysis pooling the information from three large randomized clinical trials found that subjects ventilated with high PEEP with recruitment maneuvers were less likely to develop postoperative pulmonary complications; however, this result was not significant at the standard P value threshold. This post hoc Bayesian reanalysis of individual patient data from three large randomized clinical trials was conducted to gain further insights. See the accompanying Editorial on page 6.Heparin is used in cardiac surgical patients to provide anticoagulation during cardiopulmonary bypass. After cardiopulmonary bypass, patients are given protamine to reverse the effects of heparin to avoid postoperative bleeding. There is considerable between-institution variability in how much protamine is administered after cardiopulmonary bypass. Although protamine is very effective in reversing the bleeding effects of heparin, administering too much or too little protamine can cause postoperative bleeding. The objective of this single-center randomized trial of cardiac surgical patients was to compare adequacy of heparin reversal in patients given protamine after cardiopulmonary bypass using two different approaches to protamine dosing: a “fixed” approach (250-mg protamine dose) and a “ratio-based” approach (1 mg protamine: 100 U heparin dose). See the accompanying Editorial on page 9.Anesthesiologists frequently administer calcium chloride or calcium gluconate intravenously to patients for a variety of approved as well as off-label indications. Misunderstanding of the relative bioequivalence (dose ratio) of calcium gluconate to calcium chloride may lead to incorrect dosing and adverse patient outcomes. A bioequivalence (dose ratio) study of calcium gluconate and calcium chloride was conducted in parturients randomly assigned to receive intravenous infusions of one or the other after umbilical cord clamping.Regional anesthesia reduces chronic postsurgical pain after various surgical procedures. This randomized, blinded, placebo-controlled trial assessed superficial cervical plexus block for prevention of persistent incisional pain in 292 patients having suboccipital craniotomies. See the accompanying Editorial on page 19.Acute kidney injury (AKI) after surgery has been consistently associated with long-term morbidity, mortality, and healthcare costs, even among patients with complete renal recovery. The mechanism, pathogenesis, and risk factors for postoperative AKI vary significantly by surgical type and corresponding perioperative stressors. Treatment options for postoperative AKI are limited, so perioperative management has traditionally focused on prevention and diagnosis. This review defines AKI in the perioperative setting, describes the epidemiologic burden, discusses procedure-specific risk factors, details principles of management, and highlights areas of ongoing controversy and research.Continuous improvement of quality and safety is a professional obligation of anesthesiologists and an ongoing activity of all academic departments and private practices. Although serious adverse outcomes are now rare when compared to previous eras, infinite opportunities still exist to improve patient outcomes, especially if multiple dimensions of quality are considered. This review discusses current definitions and thinking in anesthesia quality improvement, outlines recommended efforts at the local department level, and makes suggestions for the projects and activities most likely to benefit the anesthesia patients and clinicians of the future.Practice advisories are systematically developed recommendations that assist anesthesiologists and patients in making decisions about health care. The 2025 American Society of Anesthesiologists Practice Advisory for Perioperative Care of Older Adults Scheduled for Inpatient Surgery provides evidence-based recommendations regarding the management of older adults undergoing inpatient surgery. Recommendations concerning care of ambulatory surgical patients were not made as the scientific evidence focused only on inpatient surgery. The focus of this advisory includes aspects of preoperative, intraoperative, and postoperative care of specific relevance to older adults, i.e., 65 yr or older. The advisory addresses approaches to minimizing complications of anesthesia common among older patients.