Anesthesiology, October 2025 edition

This international, multicenter randomized trial enrolled 1,467 patients with early septic shock across 86 centers in 19 countries. A personalized resuscitation algorithm targeting capillary refill time, together with blood pressure, pulse pressure, fluid responsiveness, and echocardiographic information, improved a 28-day hierarchical composite outcome compared with usual care. The principal benefit was a reduction in the duration of vasopressor therapy, mechanical ventilation, and kidney replacement therapy rather than a clearly demonstrated mortality reduction.

Impact: This large pragmatic trial provides high-level evidence that a simple bedside perfusion marker can be integrated into individualized resuscitation and improve clinically meaningful support-related outcomes.

Clinical Implications: Institutions may consider structured CRT assessment alongside fluid responsiveness and echocardiography when tailoring fluids, vasopressors, and inotropes in early septic shock. Implementation requires staff training, reproducible measurement, and attention to whether the effect is maintained across different healthcare systems and patient phenotypes.

This placebo-controlled randomized trial enrolled 372 elderly patients undergoing hip or knee arthroplasty under neuraxial anesthesia. Perioperative S-ketamine reduced delirium within three postoperative days from 20.43% to 8.06%, and also reduced activity-related pain and rescue analgesic use on postoperative day one. Hallucinations, dizziness, and nightmares were more frequent, requiring appropriate monitoring and patient selection.

Impact: It is a large, clinically actionable randomized trial showing a substantial reduction in postoperative delirium, a complication associated with prolonged recovery, morbidity, and resource use.

Clinical Implications: S-ketamine may be considered as part of multimodal care for selected elderly arthroplasty patients under neuraxial anesthesia. Clinicians should balance potential delirium and analgesic benefits against psychotomimetic adverse effects, contraindications, staffing requirements, and local monitoring capacity.

This multinational cluster-randomized trial evaluated a four-week, low-cost positive communication intervention across 370 ICUs in 60 countries. Burnout prevalence decreased from 63.3% in control ICUs to 52.2% in intervention ICUs, with improvements in emotional exhaustion, depersonalization, personal accomplishment, job satisfaction, perceived safety, and ethical climate. The intervention offers a scalable organizational approach to workforce resilience.

Impact: The study demonstrates at unusually large scale that a brief, inexpensive communication intervention can improve staff well-being and multiple dimensions of ICU organizational safety.

Clinical Implications: ICUs and perioperative departments should consider incorporating structured positive communication into staff-support programs, while monitoring durability, local cultural fit, participation, and downstream effects on patient safety and staff retention.

This international cluster-randomized crossover trial included 9,289 randomized patients and an ecological assessment involving 10,711 patients. Selective digestive decontamination did not reduce 90-day in-hospital mortality compared with standard care, although patient-level bloodstream infections and cultured resistant organisms were reduced. However, the ecological noninferiority criterion for new antibiotic-resistant organisms was not met, leaving a major antimicrobial stewardship concern unresolved.

Impact: This definitive trial addresses a long-standing ICU policy debate by showing no mortality advantage while demonstrating that ecological antibiotic-resistance safety cannot be assumed.

Clinical Implications: Routine adoption of selective digestive decontamination to reduce mortality is not supported. If used in selected settings, it should be accompanied by unit-level resistance surveillance, antimicrobial stewardship review, and explicit consideration of local microbiology and ecological risks.

PHOENICS was a multicenter, double-blind randomized trial of 1,985 patients undergoing major abdominal surgery. In-label 6% HES 130/0.4 was noninferior to crystalloids for short-term cystatin C–based estimated GFR decline and a 90-day composite of mortality and major complications. Renal function at 90 days and one-year mortality were also not clinically different between groups, supporting carefully protocolized use in selected patients.

Impact: This large double-blind phase-level perioperative fluid trial directly informs a controversial area of anesthesiology and may influence institutional fluid stewardship policies.

Clinical Implications: In-label, dose-limited, protocolized HES may be considered as an alternative to crystalloids for selected major abdominal surgery patients, but this evidence should not be generalized to off-label use, high-risk renal populations, sepsis, or unrestricted dosing.