Anesthesiology, August 2025 edition

An open-source AI clinical classifier identified hyperinflammatory and hypoinflammatory ARDS phenotypes using routine clinical variables. Target trial emulation suggested corticosteroids reduced 30-day mortality in hyperinflammatory ARDS but increased mortality in hypoinflammatory ARDS, with benefit dependent on persistence of the hyperinflammatory phenotype at day 3.

Impact: The study converts routine bedside data into an actionable precision-medicine tool and demonstrates that corticosteroid effects may differ substantially by inflammatory phenotype and its temporal evolution.

Clinical Implications: Phenotype-guided corticosteroid treatment may be considered in ARDS research and specialized critical care settings, with repeat classification around 72 hours; routine adoption should await prospective validation.

In a single-center randomized, sham-controlled trial of 156 women undergoing elective cesarean delivery, daily 30-minute taVNS sessions on the day of surgery and postoperative days 1–2 reduced moderate-to-severe uterine contraction pain on postoperative day 3 from 28.2% to 5.1%. The intervention also improved incision pain, depression, anxiety, recovery quality, and sleep without major safety concerns.

Impact: This sham-controlled randomized trial provides strong evidence for a scalable, nonpharmacologic intervention that improves several patient-centered postpartum outcomes and may reduce reliance on opioids.

Clinical Implications: taVNS could be considered as an adjunct to standard analgesia after cesarean delivery, particularly within enhanced recovery pathways, provided device availability, staff training, and patient selection are addressed.

In a pragmatic multicenter randomized trial involving approximately 2,143 adults, lateral positioning during procedural sedation reduced the incidence and severity of hypoxaemia and decreased airway rescue interventions compared with supine positioning. Benefits were consistent across centers without an apparent safety trade-off.

Impact: This large pragmatic trial supports a low-cost, immediately implementable change in sedation practice that addresses a common and potentially dangerous complication.

Clinical Implications: Use lateral positioning as the default when feasible for procedural sedation in adults, while maintaining standard oxygenation, airway readiness, and monitoring protocols.

In a double-blind, placebo-controlled randomized trial of 204 women with baseline sleep disturbance undergoing surgical abortion, a single intravenous esketamine dose of 0.2 mg/kg reduced first-night postoperative sleep disturbance from 71.6% to 47.1%. No treatment-related serious adverse events were observed.

Impact: It demonstrates that a simple, low-dose intraoperative pharmacologic intervention can improve an important patient-centered recovery outcome with randomized evidence and a favorable short-term safety profile.

Clinical Implications: Low-dose intraoperative esketamine may be considered for selected patients with pre-existing sleep disturbance undergoing short procedures, after assessment of psychiatric, cardiovascular, and dissociative adverse-effect risks.

Spatial and single-cell transcriptomics with isotope tracing identified the outer medullary thick ascending limb as a metabolically vulnerable region dependent on oxidative phosphorylation and fatty acid oxidation. Propofol impaired oxidative phosphorylation in this region, worsened tubular injury in mice, and higher intraoperative exposure in transplant recipients was associated with worse renal metabolic and long-term outcomes.

Impact: The study bridges detailed renal metabolic mechanisms with a commonly used anesthetic and human perioperative observations, raising a clinically important hypothesis about anesthetic-related kidney injury.

Clinical Implications: In patients at very high risk for AKI, clinicians should consider minimizing unnecessary propofol exposure and intensifying renal monitoring, while recognizing that causal clinical evidence and prospective comparative trials are still needed.