The edition · Anaesthesiology
A pre-induction crystalloid bolus does not prevent post-induction hypotension
A 504-patient blinded trial retires a common habit, pre-2023 data find no extra aspiration with GLP-1 receptor agonists, and the trials behind perioperative guidelines turn out to hinge on about four events.
The edition in brief
An Austrian two-centre randomised trial of 504 patients aged 45 and over with cardiovascular risk factors found that a crystalloid bolus given within an hour before induction did not reduce the time-weighted average of mean arterial pressure below 65 mmHg in the first 20 minutes (median 0.0 in both groups, P = 0.37). Pre-loading does not prevent post-induction hypotension; vasopressor readiness and induction technique matter more. A propensity-matched TriNetX analysis of type 2 diabetes patients from before the 2023 ASA advice to hold GLP-1 receptor agonists found no increase in aspiration pneumonitis with these drugs, and lower 14-day mortality than with metformin (RR 0.44) or DPP-4 inhibitors (RR 0.63); this is observational and does not justify ignoring gastric-emptying precautions. A meta-analysis of 17 trials in patients aged 60 and over associated esketamine-containing regimens with less postoperative delirium (OR 0.57) and less nausea and vomiting, on limited-certainty evidence. The PUMA group published guidelines on the organisational foundation for airway management. A survey of 161 superiority trials cited in perioperative guidelines found a median fragility index of 4.
GLP-1 receptor agonists before surgery: no excess aspiration in pre-2023 data
Aspiration risk with GLP-1 receptor agonists looked no higher in this database, but keep assessing gastric contents patient by patient.
PUMA guidelines: safe airway management starts with the system, not the laryngoscope
Audit the environment, equipment, training and culture around airway management, not just individual skill.
Esketamine-containing regimens were associated with less delirium in older surgical patients
Esketamine may reduce delirium in older surgical patients, but the evidence is not yet strong enough to use it for that reason alone.
The trials behind perioperative guidelines typically hinge on four events
Many perioperative guideline recommendations rest on fragile trials; weigh them with that in mind.
Draw up the vasopressor before the induction agent
Plan for post-induction hypotension with a ready vasopressor and titrated induction, not a pre-induction fluid bolus.
A crystalloid bolus before induction does not prevent post-induction hypotension
Do not use a pre-induction crystalloid bolus to prevent post-induction hypotension; plan vasopressor support instead.
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