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

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

Hello and welcome back to the Anesthesia Patient Safety Podcast. I’m your host, Alli 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 3 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 in patient 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 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 May 11, 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 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. 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 11-20.7%. Postop delirium is a big threat to anesthesia patient safety and is associated with increased length of hospital stay and healthcare costs and higher mortality, poor cognitive outcomes, and increased risk for dementia. In the past, studies have found that S-ketamine which is an enantiomer of ketamine, may blunt the neuroinflammatory response to surgery and may reduce postop cognitive decline after elective surgery under general anesthesia. Other studies have suggested that general anaesthetics may lessen the effects of S-ketamine 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-center prospective, randomized, double-blind, placebo-controlled trial of 372 elderly patients undergoing total hip or total knee arthroplasty under neuraxial anesthesia who received an infusion of S-ketamine 0.2mg/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 sufentanil and ondansetron. The placebo group received sufentanil and ondansetron in their PCAs. Patients received either a preoperative adductor canal or iliac fascia block with neuraxial anesthesia as selected by the anesthesia team. The primary outcome was incidence of postoperative delirium within the first 3 days postoperatively.  And now for the results, the postop delirium occurred in 15 patients in the S-ketamine group compared with 38 patients in the placebo group. That was a reduction from 20% in the placebo group down to 8% in the S-ketamine. The authors concluded that S-ketamine significantly reduces postop delirium risk in elderly patients undergoing total hip or total knee arthroplasty under neuraxial analgesia. What did you think of this study? Are you giving S-ketamine to elderly patients undergoing lower extremity joint replacements under neuraxial anesthesia?

Our next In the Literature summary is of “Association Between Dexmedetomidine Use and Duration of Invasive Mechanical Ventilation After Cardiac Surgery: a Hospital Registry Study” published online April 27, 2026 and written by Boateng and Peng. You can check out the article published in Anesthesia and Analgesia March 2026 by Ramishvili and colleagues.

Okay, this one is for all of our cardiac anesthesia colleagues. Why is this study important? Well, Dexmedetomidine 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 is a concern that dexmedetomidine infusions could lead to longer duration of mechanical ventilation. So, the investigators wanted to look at if dexmedetomidine infusions after cardiac surgery were associated with longer duration of postop mechanical ventilation. This is a retrospective cohort study in a single US academic center of 2,191 adult patients who had non-emergent CABG, valve, or combined CABG-valve procedures with cardiopulmonary bypass with postoperative mechanical ventilation. And what did they find?

The median duration of mechanical ventilation was 406 minutes with an interquartile range from 297-837 minutes. Now, drumroll please, the use of dexmedetomidine infusion 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 is where it gets interesting. For patients with a high sedation burden index who received Dexmedetomidine infusion, there was a significantly shorter duration of mechanical ventilation compared to patients with a high index and no dexmedetomidine. The adjusted average difference with 23 minutes less.

The conclusions from this study are:

• Dexmedetomidine administration is associated with a longer duration of mechanical ventilation after cardiac surgery.
• And for patients receiving multiple sedative medications, the use of dexmedetomidine may help to speed up the time until extubation which highlights the context-sensitive nature of the effects of dexmedetomidine when combined with other sedative medications.

What are you using for postop sedation following cardiac surgery?

Moving on to our next literature review of the day, we have the summary of “Incidence of Pain during Caesarean Delivery with Neuraxial Anesthesia: An International, Prospective Cohort Study” written by Paul Lefebvre and published online April 20^th 2026. The article by O’Carroll and colleagues was published in Anesthesiology April 2026.

We are moving from the cardiac OR’s to the labour and delivery ward for our next summary. This has been an important anesthesia patient safety topic – pain during caesarean delivery –that we have talked about on the show before and this is an important article to discuss.  Patients who experience pain during caesarean delivery are at risk for depression and post-traumatic stress disorder. This is a prospective, cohort study to evaluate the incidence of pain during caesarean delivery for patients who have neuraxial 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 of 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 1-10.

Now, for the results:

7.6% of patients reported experiencing pain during their caesarean deliveries.

Urgent and emergent procedures were associated with increased incidence of intraoperative pain and higher pain scores compared to elective caesarean deliveries.

There was a higher incidence of pain for patients with epidural top-ups compared to caesarean deliveries with spinal anesthesia.

Spanish speaking patients were more likely to report having experienced pain than other cohorts.

There were 282 patients who reported intraoperative pain and 10.3% of patients were not satisfied with how the anesthesia team managed their pain.

Here are the big takeaways:

The authors conclude that intraoperative pain during caesarean 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 caesarean delivery that include the following:

Preop, anesthesia professionals should have a comprehensive discussion with their patients regarding pain control during careen 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 intraoperative pain.

Good news, we have time for one more literature review. Let’s turn our attention to a new study on paediatric patients. This is the summary of EEG-Guided Titration of Sevoflurane and Paediatric Anesthesia Emergence Delirium: A Randomized Clinical Trial” by Jeffrey Huang and published online April 13, 2026. You can check out the article published in JAMA Paediatrics in April 2025 by Miyasaka and colleagues.

The background is that emergence delirium in paediatric patients is common. General anesthesia appears to be a risk factor and the etiology remains unknown. Postoperative 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 usual anesthetic care in adults. This study is a single-centre, parallel-group, 2-arm, superiority randomized clinical trial. Participants included 177 children aged 1-5 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 sevoflurane 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 sevoflurane delivered to 1.0 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 sevoflurane 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 4 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 sevoflurane 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 with sevoflurane.

With 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. 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 [email protected]. 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. 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 committed to safer patient care.

Until next time, stay vigilant and stay informed so that no one shall be harmed by anesthesia care.

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