Current Issue Highlights

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    Remimazolam versus sevoflurane for general anaesthesia

    November 2026: 43(11):901-912

    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.

    ELIGIBILITY CRITERIA

    RCTs comparing intraoperative use of remimazolam and sevoflurane with reported intraoperative or postoperative outcomes. Conference abstracts were excluded.

    RESULTS

    Twelve RCTs (n = 739 patients; mean age 61.6 years; 36.8% laparoscopic procedures) were included. Remimazolam significantly reduced the risk of intraoperative hypotension (as a binary event) compared with sevoflurane [risk ratio (RR) 0.38, 95% confidence interval (CI) 0.25 to 0.57; P < 0.001]. Mean arterial pressure (MAP) was higher with remimazolam at 30 min after start of surgery (mean difference 6.05 mmHg, P < 0.03). Heart rate (HR) was consistently higher with remimazolam at 30 min (P = 0.04), at the end of surgery (P < 0.01) and in the postanaesthesia care unit (P < 0.01). Analyses suggested a reduction in PONV incidence up to 24 h with remimazolam [RR 0.65 (95% CI, 0.47 to 0.90); P = 0.01] and 72 h [RR 0.66 (95% CI, 0.50 to 0.89)]. TSA just confirmed favouring remimazolam in reducing intraoperative hypotension.

    CONCLUSIONS

    Remimazolam was associated with a lower incidence of intraoperative hypotension compared with sevoflurane, while differences in MAP and HR were limited to specific time points. Sensitivity analyses suggested a potential reduction in PONV; however, these findings were not statistically significant in the primary analysis and should be interpreted with caution.

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    Prospective clinical evaluation of the Eleveld pharmacokinetic and pharmacodynamic model of propofol for moderate-to-deep sedation in adults

    November 2026: 43(11):892-900

    BACKGROUND

    Target-controlled infusion (TCI) based on pharmacokinetic- and pharmacodynamic (PKPD) models is widely used for procedural moderate to deep sedation (MDS) outside of the operating room. Recently, PKPD models developed for broad populations such as the Eleveld model have become commercially available and are thought to be suitable for TCI during MDS. As clinical experience and guidelines are lacking, we aimed to evaluate the Eleveld propofol model for MDS and to find normative values of propofol effect-site target concentrations for MDS.

    METHODS

    We considered three patient groups: adult, elderly, and obese, with 25 patients for each group. Primary outcomes were maintaining adequate respiratory and haemodynamic parameters and successful completion of the planned procedures. Secondary outcomes were clinically relevant endpoints on the procedure timeline and the occurrence of adverse events.

    RESULTS

    We found that targets with the Eleveld propofol model are generally between 2–3 μg ml−1 for adults and nearer to 2 μg ml−1 for elderly and obese individuals, and do not require much adaptation during the procedure. Clinicians may observe slightly increased blood pressure and heart rate during the procedure and interpret this as a sign of patient stimulation, and in response increase target concentrations. Respiration rate and SpO2 decrease slightly with increased predicted drug effect.

    CONCLUSION

    The Eleveld propofol model can be used in TCI to achieve MDS while maintaining adequate respiratory and hemodynamic parameters, resulting in the safe completion of the planned procedures.

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    Incidence and predictors of new persistent benzodiazepine and Z-drug use after critical illness: a nationwide cohort study

    November 2026: 43(11):882-891

    BACKGROUND

    Benzodiazepines and Z-drugs (BZRA) are commonly prescribed sedative–hypnotics but carry risks of dependence and cognitive impairment when used long-term. Patterns of new persistent BZRA use among ICU survivors remain poorly characterised.

    OBJECTIVE

    To determine the 6-month incidence of new persistent BZRA use following ICU admission and to identify demographic, clinical and socioeconomic risk factors

    DESIGN

    A retrospective, population-based cohort study.

    SETTING

    National Health Insurance Service claims data, Republic of Korea; 1 January 2020 to 31 December 31, 2022.

    PATIENTS

    Adults (≥ 18 years) admitted to any ICU during the study period who were BZRA-naive in the 12 months before admission and survived at least 180 days (final n = 620 810).

    INTERVENTIONS

    None.

    MAIN OUTCOME MEASURES

    New persistent BZRA use was defined as at least 4 consecutive weeks of BZRA prescriptions within 6 months after the index ICU admission, permitting refill gaps of 7 days or less. We estimated cumulative incidence and used multivariable logistic regression to evaluate predictors.

    RESULTS

    By 6 months, 94 293 patients (15.2%) met criteria for new persistent BZRA use. In the updated multivariable model, the odds ratios (ORs) for pre-ICU admission selective serotonin reuptake inhibitor (SSRI) use was 1.78 [95% confidence interval (CI), 1.74 to 1.82] and for opioid use 1.41 (95% CI, 1.38 to 1.43) (both P < 0.001). Even after adjusting for these, pre-existing psychiatric disorders remained the strongest predictors: ORs insomnia = 2.06 (95% CI, 2.00 to 2.11), anxiety = 1.55 (95% CI, 1.51 to 1.59), depression = 1.32 (95% CI, 1.28 to 1.36) and bipolar disorder = 1.27 (95% CI, 1.23 to 1.30), all P values < 0.001. Female sex, socioeconomic disadvantage (as indicated by Medical Aid status) and extracorporeal membrane oxygenation support also independently increased the risk: ORs were 1.23 (95% CI, 1.21 to 1.24), 1.06 (95% CI, 1.03 to 1.10) and 1.07 (95% CI, 1.03 to 1.12), respectively.

    CONCLUSIONS

    Nearly one in six ICU survivors developed new persistent BZRA use. Along with psychiatric comorbidities and female sex, pre-ICU exposure to SSRIs and opioids identified patients at particularly high risk.

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    Real-time peri-operative data integration and clinical decision support: an open interoperable platform for patient data

    November 2026: 43(11):875-881

    INTRODUCTION

    Modern intensive care units (ICU) and operating rooms (OR) generate vast quantities of physiological data, yet this information is often underused due to architectural barriers and lack of interoperability, a failure to integrate data from multiple devices. While imaging data has achieved global standardisation, continuous physiological time series remain fragmented and inaccessible for scientific use, limiting multicentric collaboration and the development of robust artificial intelligence (AI) models.

    METHODS

    We developed an open, interoperable peri-operative data platform compliant with General Data Protection Regulation. The platform integrates data from multiple sources, including patient monitors, syringe pumps, ventilators, EEG systems, and laboratory values, using Apache Kafka for real-time data streaming and a hybrid long-term storage architecture. Data governance was ensured through on-premise storage, anonymisation protocols, and ethical approvals.

    RESULTS

    Since March 2019, the platform has recorded data from 118 915 patients across 77 OR and ICU beds, encompassing waveform and numeric channels. The database includes data from various clinical specialties, such as bowel surgery, otolaryngology, neurosurgery, gynaecology, interventional neuroradiology, and orthopaedics. It encompasses cardiac output monitoring (3458 patients), ventilation data (56 212 patients), advanced ECG analysis (78 091 patients), and EEG recordings (9862 patients). Syringe pump data, collected since February 2023, includes 7096 cases.

    DISCUSSION

    The platform demonstrates the feasibility of creating a scalable, vendor-neutral infrastructure for peri-operative data, enabling both real-time clinical applications and long-term research. By adhering to open standards, it supports secure, cross-institutional collaboration while preserving data integrity. However, challenges remain in standardising data quality and expanding data volume to improve model generalisability.

    CONCLUSIONS

    This work provides a reproducible blueprint for building interoperable peri-operative data platforms, enabling both real-time clinical decision support and large-scale research. By combining real-time acquisition with durable storage and open standards, the platform transforms fragmented physiological data into a shared resource for precision medicine and clinical equity.

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    Clinical effectiveness of transversus abdominis plane block versus local anaesthesia wound infiltration for postoperative pain relief after laparoscopic appendicectomy in children

    October 2026: 43(10):842-850

    BACKGROUND

    Postoperative pain relief after laparoscopic appendicectomy in children provided by transversus abdominis plane (TAP) block and local anaesthesia wound infiltration (LAWI) of trocar insertion sites has never been compared.

    OBJECTIVE

    To investigate whether TAP block could decrease postoperative opioid requirements after laparoscopic appendicectomy in children compared with LAWI.

    DESIGN

    Multicentre, double-blind, phase III randomised trial.

    SETTING

    Two tertiary paediatric surgery centres.

    PATIENTS

    Children aged 3 to 15 years admitted for laparoscopic appendicectomy.

    MAIN OUTCOME MEASURES

    The primary outcome was the total dose of nalbuphine delivered within 24 h after surgery. Secondary outcomes were the Face Legs Activity Cry Consolability (FLACC) scale values at 1, 2, 6, 12 and 24 h, the time from levobupivacaine injection to the first dose of nalbuphine, and the time from the end of surgery to the first mobilisation. Patients received either ultrasound-guided TAP block (TAP group) or LAWI of trocar insertion sites (infiltration group) with 0.6 ml kg−1 of levobupivacaine 2.5 mg ml−1, combined with standardised systemic multimodal analgesia including paracetamol, ketoprofen, phloroglucinol and nalbuphine.

    RESULTS

    Forty-six and 50 patients were analysed in the TAP and infiltration groups, respectively [age: 10 [7 to 12] versus 10 [8 to 12] years; females: 16 (35%) versus 25 (50%); duration of surgery: 71 [64 to 90] versus 69 [56 to 89] min]. The primary outcome (total nalbuphine dose) was 0.2 [0.0 to 0.2] and 0.2 [0.0 to 0.2] mg kg−1 in the TAP and infiltration groups, respectively (P = 0.95). FLACC scale values did not significantly differ between the two groups (P = 0.78). Time to the first dose of nalbuphine or to first mobilisation was not significantly different between groups (P value for log-rank test = 0.095 and 0.18, respectively).

    CONCLUSION

    TAP block does not appear to provide a greater opioid-sparing effect than LAWI of trocar insertion sites after laparoscopic appendicectomy in children, when combined with systemic multimodal analgesia including nonsteroidal anti-inflammatory drugs.

    TRIAL REGISTRATION

    ClinicalTrials.gov NCT04969133.

Latest Articles

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    Frailty patterns in European surgical patients

    European Journal of Anaesthesiology | EJA. October 22, 2026

    BACKGROUND

    Frailty represents a multidimensional decline in physiological reserve that increases vulnerability to surgical stress. Its perioperative dynamics and association with outcomes across diverse surgical populations remain insufficiently characterised.

    OBJECTIVE

    This study aimed to describe the prevalence of frailty before and after surgery and to evaluate its association with postoperative complications, mortality, and hospital length of stay.

    METHODS

    We conducted a prospective, multicentre European cohort study including adults undergoing elective or emergency surgery under general or regional anaesthesia across 64 participating centres in 10 countries. Each centre contributed data from one to three predefined recruitment days between April 2021 and December 2022. Frailty was assessed preoperatively and at 30 days using the Rockwood Clinical Frailty Scale (CFS), the FRAIL questionnaire, and the Barthel Index. The primary outcome was the association between preoperative frailty and 30-day postoperative complications (Clavien–Dindo ≥ II); secondary outcomes included 30-day mortality, postoperative cognitive impairment, and new-onset frailty.

    RESULTS

    Among 1472 patients (mean age 60.9 years; 52.9% male), preoperative frailty prevalence was 14.6% (FRAIL), 10.4% (CFS), and 10.4% (Barthel). Within 30 days, 11.9% of nonfrail patients became frail, increasing overall frailty prevalence to 21.2%. Postoperative complications occurred in 19.2% and mortality in 1.7%. Preoperative frailty was independently associated with complications: adjusted odds ratio (OR) 2.35 [95% confidence interval (CI) 1.53 to 3.60], P < 0.001); 30-day mortality OR 10.9 (95% CI 1.28 to 93.0), P = 0.029). Frailty was also associated with postoperative cognitive impairment: OR 3.47 (95% CI 1.98 to 6.08), P < 0.001).

    CONCLUSIONS

    Frailty is common among surgical patients, increases after surgery, and independently predicts postoperative complications and mortality. These findings highlight frailty as a dynamic and potentially modifiable marker of surgical vulnerability that should be routinely assessed and integrated into perioperative care.

    TRIAL REGISTRATION

    ClinicalTrials.gov identifier: NCT04140370

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    Development and temporal validation of a simple CT-based body surface landmark approach for optimising central venous catheter tip position in the superior vena cava

    European Journal of Anaesthesiology | EJA. October 20, 2026

    BACKGROUND

    Accurate positioning of central venous catheter (CVC) tips is essential to avoid complications, yet consistent appropriate placement within the superior vena cava remains challenging without a simple method for depth adjustment.

    OBJECTIVES

    To develop and temporally validate a simple computed tomography-based (CT-based) body surface landmark approach for estimating optimal insertion depth (OID) and to assess its impact on appropriate catheter tip positioning.

    DESIGN

    Single-centre prospective observational cohort study.

    SETTING

    Tertiary care hospital in Japan; February 2017 to June 2019.

    PATIENTS

    Adult patients undergoing surgery requiring CVC placement via the right internal jugular vein with preoperative chest CT. After exclusions, 86 patients were included in the derivation cohort and 100 in the validation cohort.

    INTERVENTION

    In the derivation cohort, insertion depth was determined by the attending anaesthesiologist; in the validation cohort, it was determined using a model derived from the derivation cohort.

    MAIN OUTCOME MEASURE

    The primary outcome was the proportion of appropriately placed catheter tips.

    RESULTS

    The final model retained the insertion point-to-body surface landmark distance (ILD), defined using a body surface landmark corresponding to the CT-identified midpoint of Zone B, as the sole predictor: OID (cm) = 0.64 × ILD + 3.64. The proportion of appropriately placed catheter tips was higher in the validation cohort than in the derivation cohort (92.0% (95% CI, 85.0 to 95.9%) vs. 73.3% (95% CI, 63.1 to 81.5%); P < 0.001). Model-guided placement was associated with increased likelihood of appropriate positioning (adjusted odds ratio 4.68 (95% CI, 1.97 to 12.27)). Model performance showed good calibration and moderate explanatory ability (R2 approximately 50%) in both cohorts.

    CONSLUSIONS

    A CT-based body surface landmark approach was associated with improved consistency of appropriate CVC tip placement and enables patient-specific estimation of insertion depth.

    TRIAL REGISTRY

    UMIN Clinical Trials Registry (UMIN000026252).

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    Postoperative delirium and 1-year functional decline, institutionalization and mortality

    European Journal of Anaesthesiology | EJA. October 20, 2026

    BACKGROUND

    Postoperative delirium is a common and serious complication in older surgical patients and has been associated with increased morbidity, healthcare costs, long-term functional decline and mortality.

    OBJECTIVE

    To determine whether postoperative delirium is associated with functional status, quality of life, institutionalisation and mortality at 1 year after surgery in a large multicentre surgical cohort.

    DESIGN

    Prospective multicentre observational study.

    SETTING

    Forty-three hospitals in Spain. Surgical patients were recruited in November 2023 and assessed for delirium 48 h after surgery, with follow-up at 1 year.

    PATIENTS, OTHER PARTICIPANTS

    A total of 2442 adult surgical patients undergoing elective or urgent procedures requiring hospital admission. Postoperative delirium was assessed using the Confusion Assessment Method (CAM), CAM for the Intensive Care Unit (CAM-ICU) or the telephone-administered 4AT according to clinical setting.

    INTERVENTIONS

    None.

    MAIN OUTCOME MEASURES

    Functional status and quality of life at 1 year assessed using the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0). Secondary outcomes included institutionalisation and mortality.

    RESULTS

    After excluding 81 deaths and 462 nonresponders, the 1-year telephone follow-up was completed for 1899 patients. Postoperative delirium within the first 48 h was independently associated with a 4.6-point higher WHODAS score at 1 year: adjusted mean difference = 4.60 [95% confidence interval (CI), 1.57 to 7.64, P = 0.003]. Delirium was also associated with increased institutionalisation and higher mortality: odds ratio (OR) 2.5 (95% CI, 1.07 to 5.84, P = 0.03), and (16.7 vs. 3.1%; P < 0.001), including 30-day, 60-day, and 365-day mortality (all P < 0.001), respectively.

    CONCLUSIONS

    Postoperative delirium is independently associated with long-term functional decline, loss of independence, institutionalisation and increased 1-year mortality. These findings highlight delirium as a key perioperative complication and support prevention strategies and structured long-term follow-up after surgery.

    TRIAL REGISTRATION

    ClinicalTrials.gov (identifier: NC-T06127901).

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