This Month in Anesthesiology

525 Impact of Preoperative Functional Capacity on Postoperative Mortality and Morbidity: A Prospective Cohort StudyImage: A. Johnson, Vivo Visuals Studio.Self-reported metabolic equivalents of task (METs) are widely used as a dichotomized variable (METs less than 4) to assess preoperative functional status as a component of preanesthetic risk assessments. Among 38,293 patients undergoing noncardiac surgery at two hospitals in Sweden, preoperative functional status, as determined by self-reported METs, divided into numerous graded categories, was associated with 30-day and 365-day mortality and the number of days spent alive and out of the hospital at 30 and 365 days after surgery. Compared to patients in the highest functional status groups (METs of 9 or greater), adjusted postoperative mortality was higher among patients in lower MET categories, and mortality risk increased progressively with decreasing MET scores, with distinct trajectories at 365 days. See the accompanying Editorial on page 503. 535 Mode of Anesthesia for Patients with Placenta Accreta Spectrum Undergoing Cesarean Hysterectomy: A Report from the Multicenter Perioperative Outcomes Group DatabaseImage: Adobe Stock.Placenta accreta spectrum frequently necessitates cesarean hysterectomy and poses substantial hemorrhage risk. Anesthetic management has traditionally favored general anesthesia, but neuraxial techniques are used in experienced centers. Across 1,257 placenta accreta spectrum cesarean hysterectomies at 43 U.S. hospitals (2015 to 2021), the most common approach was neuraxial anesthesia followed by conversion to general anesthesia (40.3%), with general anesthesia alone in 33.3% and neuraxial alone in 26.5%. In models of intended technique for suspected placenta accreta spectrum, increta/percreta, unscheduled cases, and higher American Society of Anesthesiologists Physical Status were associated with choosing general anesthesia. Anesthetic choice showed substantial between-institution variation, and use of neuraxial anesthesia increased over the time interval studied. See the accompanying Editorial on page 506. 546 Liposomal Bupivacaine, Plain Bupivacaine, and Saline for Transversus Abdominis Plane Blocks: The CLEVELAND Randomized TrialImage: J. P. Rathmell.Ultrasound-guided transversus abdominis plane (TAP) blocks have been associated with reduced pain and postoperative opioid requirement after open abdominal surgeries. As TAP blocks have been implemented more widely into Enhanced Recovery After Surgery (ERAS) pathways across a broader range of surgical procedures, some studies have shown no analgesic benefit. Single-shot TAP blocks placed before abdominal surgery in a group that includes both open and laparoscopic procedures using liposomal bupivacaine or plain bupivacaine did not reduce opioid consumption or pain scores for the first 72 h after surgery when compared with injection of normal saline. Absence of early benefit suggests that routine preincision, single-shot TAP blocks provide little analgesia in this surgical population with a mix of open and laparoscopic abdominal surgeries. Future studies designed to determine patient-level and surgical-level factors that may be associated with greater benefit from TAP blocks are needed. See the accompanying Editorial on page 509. 559 Preoperative Hypnosis versus Mindfulness for Reducing Postoperative Symptoms in Breast Surgery: A Randomized Clinical TrialImage: Adobe Stock.Preoperative anxiety is common and associated with worse postoperative outcomes. This single-center study enrolled 203 patients undergoing breast surgery, randomizing them to receive a single session of either preoperative hypnosis or mindfulness within 2 h before their scheduled surgery. Several postoperative outcomes (fatigue, emotional distress, and opioid use), assessed in the early recovery period, were lower in the group receiving hypnosis, although future larger studies are needed to verify these results. A moderation analysis revealed that effects of hypnosis on emotional distress were more prominent among individuals with higher baseline anxiety. See the accompanying Editorial on page 512. 570 Single Muscle Fiber Calcium Wave Frequency Assay for Malignant Hyperthermia Diagnosis: An Exploratory Validation StudyImage: Adobe Stock.The in vitro contracture test performed on muscle biopsy tissue is currently regarded as the accepted standard for determining malignant hyperthermia susceptibility. Given the inherent methodologic limitations of the in vitro contracture test, there is a need to develop less invasive tests aimed at reliably identifying malignant hyperthermia susceptibility. Using a calcium wave frequency assay, designed to determine distinct ryanodine receptor 1 activation thresholds within single muscle fiber preparations, the proportion of muscle fibers that responded with regenerative calcium waves to halothane was higher in muscle from malignant hyperthermia susceptible compared to non–malignant hyperthermia susceptible patients. The calcium wave frequency assay offered comparable sensitivity and specificity to the in vitro contracture test to discriminate malignant hyperthermia susceptible from non–malignant hyperthermia susceptible patients. See the accompanying Editorial on page 515. 634 Effects of Repeated Early-life Anesthesia Exposure on Visual System Development in MiceImage: J. P. Rathmell.In preclinical experimental studies, early-life exposure to general anesthetics have been shown to have a variety of both morphologic and functional effects on central nervous system development, but the translational relevance of these observations remains unclear. In newborn mice, repeated exposure during 7 consecutive days to 1.5 h of isoflurane anesthesia induced lasting visual function deficits that were associated with reduced retinal and visual cortical thickness, as well as with lower plasma levels of tissue plasminogen activator. Genetically modified mice lacking tissue plasminogen activator displayed a phenotype in the absence of anesthesia comparable to that of wild-type mice exposed to repeated anesthesia early in life. In contrast to wild-type counterparts, neonatal genetically modified mice lacking tissue plasminogen activator did not experience further impairment of the visual system after repeated isoflurane exposure. 670 Perioperative Vasopressor Management in Noncardiac Surgical PatientsImage: From original article.Vasopressors are central to the management of intraoperative hypotension, yet optimal agent selection, timing, and titration remain variable and incompletely defined. This review integrates evidence, physiology, and emerging technology to propose a framework for personalized vasopressor therapy. This review focuses on general surgical patients in the operating room and intensive care unit, and intentionally excludes cardiac and obstetric populations, which involve distinct physiologic considerations. 692 Leveraging the Multifaceted Platelet Storage Lesion to Advance Precision Platelet Transfusion MedicineImage: From original article.There is growing interest in transfusion medicine in leveraging functional differences among blood products to improve patient outcomes. The functional distinctions between cold-stored and room temperature–stored platelets have been studied for decades, yet clinical decision-making still relies largely on surrogate quality metrics such as platelet count and pH. This review argues for a shift toward assessment of platelet function, including properties beyond hemostatic capacity. Differences in collection, processing, and storage that contribute to the platelet storage lesion, with particular attention to cold storage, are discussed. The current clinical evidence supporting the use of cold-stored platelets is summarized, and remaining gaps in knowledge and priorities for the development of precision platelet transfusion are highlighted.