Daily ReportSep 4, 2026
Anesthesiology, September 4 edition
We read 27 papers and selected 3.
Summary
Today's most impactful studies focused on evidence synthesis for safer anesthesia and perioperative care. Remimazolam was associated with less intraoperative hypotension than sevoflurane, perioperative esketamine showed a possible reduction in postoperative delirium, and a large systematic review demonstrated that reported burnout prevalence among anesthesia providers is highly dependent on measurement criteria.
Research Themes
- Hemodynamic safety of newer anesthetic agents
- Perioperative neurocognitive protection
- Measurement validity and workforce well-being in anesthesiology
Selected Articles
1. Remimazolam versus sevoflurane for general anaesthesia: A meta-analysis with trial sequential analysis of haemodynamic and clinical outcomes.
This systematic review and meta-analysis included 12 randomized controlled trials involving 739 patients. Remimazolam reduced intraoperative hypotension compared with sevoflurane (risk ratio 0.38, 95% CI 0.25-0.57) and was associated with higher mean arterial pressure at a prespecified time point. Possible reductions in postoperative nausea and vomiting were observed in sensitivity analyses, but the primary analysis did not provide definitive evidence.
Impact: The study synthesizes comparative evidence for a newer intravenous anesthetic and identifies a clinically important hemodynamic advantage over sevoflurane. Trial sequential analysis strengthens interpretation by assessing whether the accumulated evidence is sufficient, although uncertainty remains for several secondary outcomes.
Clinical Implications: Remimazolam may be considered when minimizing intraoperative hypotension is a priority, particularly in patients vulnerable to hemodynamic instability. Its use should be guided by local experience, recovery characteristics, cost, and patient-specific risks because evidence for postoperative nausea and vomiting remains less certain.
Key Findings
- Twelve randomized controlled trials with 739 patients were included.
- Remimazolam significantly reduced intraoperative hypotension compared with sevoflurane (RR 0.38, 95% CI 0.25-0.57; P<0.001).
- Trial sequential analysis supported the finding favoring remimazolam for intraoperative hypotension, whereas evidence for reduced postoperative nausea and vomiting was less definitive.
Methodological Strengths
- Systematic review and meta-analysis restricted to randomized controlled trials.
- Use of trial sequential analysis and prespecified sensitivity analyses to assess robustness.
Limitations
- Only 12 trials and 739 patients were available, limiting precision for less frequent outcomes.
- Variation in procedures, dosing, sedation depth, and outcome definitions may contribute to heterogeneity.
- Evidence for postoperative nausea and vomiting was not consistently statistically significant in the primary analysis.
Future Directions: Large, pragmatic, multicenter randomized trials should compare remimazolam and sevoflurane using standardized hypotension definitions, patient-centered recovery outcomes, cost-effectiveness, and clinically important subgroups such as older adults and patients with cardiovascular disease.
BACKGROUND: Remimazolam is a novel ultra-short-acting intravenous benzodiazepine, while sevoflurane is a widely used inhalational anaesthetic for general anaesthesia (GA). Both agents are associated with risks of haemodynamic instability and postoperative nausea and vomiting (PONV), which can affect patient safety and recovery. OBJECTIVE: To compare the efficacy and safety of remimazolam versus sevoflurane in terms of intraoperative haemodynamic stability during the maintenance phase of GA or deep sedation, and the incidence of PONV. DESIGN: Systematic review of randomised controlled trials (RCTs) and meta-analysis, with trial sequential analysis (TSA). DATA SOURCES: PubMed/MEDLINE, Embase, Cochrane CENTRAL, Web of Science and Scopus were systematically searched from inception to April 2025.
2. Effects of esketamine on postoperative delirium in adult patients: a systematic review and meta-analysis of randomized controlled trials.
This systematic review and meta-analysis included 22 randomized controlled trials involving 2,860 patients. Perioperative esketamine significantly reduced postoperative delirium incidence (RR 0.57, 95% CI 0.43-0.75) and was also associated with reductions in delayed neurocognitive recovery, postoperative neuroinflammation, neuronal injury, and agitation. However, the evidence was geographically concentrated in Chinese populations, heterogeneous, and judged to have low certainty.
Impact: The analysis addresses a major perioperative safety problem and integrates clinical and biological neurocognitive outcomes. Its favorable signal could support future delirium-prevention trials, but the low certainty of evidence prevents immediate broad adoption as standard care.
Clinical Implications: Esketamine may be investigated as part of multimodal strategies for preventing postoperative delirium, especially in high-risk adults. Routine use should await internationally diverse, adequately powered trials with standardized delirium assessment and systematic evaluation of psychotomimetic and cardiovascular adverse effects.
Key Findings
- Twenty-two randomized controlled trials involving 2,860 patients were included.
- Perioperative esketamine reduced postoperative delirium incidence (RR 0.57, 95% CI 0.43-0.75).
- Additional favorable effects were reported for delayed neurocognitive recovery, postoperative neuroinflammation, neuronal injury, and agitation, but overall evidence certainty was low.
Methodological Strengths
- Systematic review and meta-analysis of randomized controlled trials.
- Risk of bias was assessed with RoB 2.0 and certainty was graded using the GRADE framework.
- The review was prospectively registered in PROSPERO.
Limitations
- Most included participants were from Chinese surgical populations, limiting generalizability.
- Substantial clinical and methodological heterogeneity was present across trials.
- The overall certainty of evidence was low, and adverse-event definitions and delirium assessment methods may have varied.
Future Directions: Future studies should be large, multicenter, internationally representative randomized trials using standardized diagnostic criteria for postoperative delirium, consistent esketamine dosing, long-term neurocognitive outcomes, and prespecified safety monitoring.
BACKGROUND: Postoperative delirium (POD) is a common perioperative complication linked to poor prognosis. As the S-enantiomer of racemic ketamine, esketamine exhibits neuroprotective potential, yet its overall efficacy and safety for perioperative neurocognitive protection await systematic confirmation. METHODS: PubMed, Embase, Cochrane Library, and Web of Science were searched from inception to November 8, 2025, for randomized controlled trials (RCTs) examining esketamine's effect on POD in patients under elective general anesthesia. Meta-analyses were conducted via Stata/MP 18.0: risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data, and mean differences (MD) or standardized mean differences (Cohen's d) with 95% CIs for continuous outcomes.
3. Prevalence of burnout among practising anaesthesia providers: a systematic review.
This systematic review included 50 studies involving 35,599 qualified anesthesia providers, including physicians and non-physicians. The median reported burnout prevalence was 42%, but estimates ranged from 9% to 99%; reanalysis of five datasets produced prevalence estimates from 3.1% to 69.9% for the same populations depending on the diagnostic criteria. Most studies had non-random sampling and unclear or high risk of bias.
Impact: This paper challenges the apparent precision of commonly cited burnout prevalence estimates and shows that measurement choices can dominate the result. It provides a methodological basis for improving workforce surveillance, intervention targeting, and interpretation of patient-safety risks.
Clinical Implications: Healthcare organizations should avoid comparing burnout prevalence across services or countries without examining definitions, instruments, sampling, and response rates. Workforce programs should use standardized reporting, validated classification tools, and organizational interventions rather than relying only on individual resilience training.
Key Findings
- Fifty studies including 35,599 qualified anesthesia providers were reviewed.
- The median burnout prevalence was 42%, with a reported range of 9%-99%.
- Reanalysis of five datasets showed prevalence estimates ranging from 3.1% to 69.9% for the same populations depending on the criteria used.
- Most studies used non-random sampling and had unclear or high risk of bias.
Methodological Strengths
- Large evidence base encompassing more than 35,000 anesthesia providers.
- Explicit examination of burnout definitions, measurement instruments, sampling methods, and risk of bias.
- Reanalysis directly demonstrated how classification criteria alter prevalence estimates.
Limitations
- The underlying studies were predominantly observational and often used non-random sampling.
- Substantial variation in burnout definitions and Maslach Burnout Inventory thresholds prevents direct prevalence comparisons.
- The review synthesized prevalence narratively rather than providing a pooled estimate suitable for causal inference.
Future Directions: Future research should adopt standardized burnout definitions, report continuous subscale scores, use validated binary classification tools, improve sampling representativeness, and prospectively evaluate organizational interventions with workforce and patient-safety outcomes.
INTRODUCTION: Burnout is characterised by emotional exhaustion, depersonalisation and reduced personal accomplishment. Anaesthesia providers are at particular risk of experiencing burnout, with implications for workforce well-being and patient safety. We aimed to quantify the prevalence of burnout among practising anaesthesia providers and critically appraise the methodological quality of the underlying evidence. METHODS: Databases were searched for English-language studies reporting prevalence of burnout in anaesthesia providers. Definitions of burnout, measurement tools used and prevalence estimates were narratively synthesised. RESULTS: We included 50 studies, encompassing 35,599 fully qualified anaesthesia providers (31,500 physicians and 4099 non-physicians); 43 (86%) studies used the Maslach Burnout Inventory.