Version August 2025
The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
ACUTE AND CHRONIC PAIN
Suzetrigine, a first-in-class nonopioid analgesic, now available for acute pain (March 2025)
Suzetrigine, a first-in-class nonopioid oral analgesic, has been approved by the US Food and Drug Administration for management of acute pain in adults and is now available. Suzetrigine is a selective inhibitor of the Nav 1.8 voltage-gated sodium channel, which is expressed in the dorsal root ganglia and is involved in transmission of nociceptive signals to the spinal cord. In randomized trials of 303 patients who had acute pain after abdominoplasty and 274 patients after bunionectomy, suzetrigine (100 mg orally followed by 50 mg orally every 12 hours) reduced pain scores compared with hydrocodone/acetaminophen (5 mg/325 mg orally every six hours) or placebo [1]. Further study is required to determine the role of suzetrigine in acute pain management. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Suzetrigine, a novel Nav1.8 inhibitor'.)
Lack of benefit from perioperative intravenous lidocaine infusion (February 2025)
Although intravenous lidocaine has been used to treat acute and chronic pain, its benefit in the perioperative setting is unknown. In a randomized trial of over 500 patients undergoing elective minimally invasive colorectal surgery, perioperative intravenous administration of lidocaine (1.5 mg/kg bolus at induction of anesthesia followed by 1.5 mg/kg/hour for 6 or 12 hours) did not improve return of gut function at 72 hours or postoperative pain control compared with placebo [2]. Given its potential toxicity, intravenous lidocaine should be used judiciously, rather than routinely in the perioperative setting. (See "Measures to prevent prolonged postoperative ileus", section on 'Local anesthetics'.)
CARDIOVASCULAR AND THORACIC ANESTHESIA
Prothrombin complex concentrate versus Fresh Frozen Plasma for coagulopathic bleeding after cardiopulmonary bypass (April 2025)
The optimal treatment for coagulopathic bleeding after cardiac surgery with cardiopulmonary bypass (CPB) is unclear. In a trial that randomly assigned 538 patients with post-CPB bleeding to receive unactivated prothrombin complex concentrate (PCC) or Fresh Frozen Plasma (FFP), those in the PCC group were less likely to require hemostatic intervention within 24 hours of therapy, received fewer transfusions, and had fewer serious adverse events [3]. If available, we use PCC rather than FFP to treat bleeding after CPB. (See "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)
Protamine dosing to reverse heparin anticoagulation after cardiopulmonary bypass (February 2025)
A European multidisciplinary taskforce has updated their guidelines for managing cardiopulmonary bypass (CPB) [4]. These guidelines suggest using point-of-care (POC) heparin-protamine titration assay or viscoelastic testing to guide protamine dosing to neutralize heparin and avoid excess protamine after weaning from CPB. If POC testing is unavailable, the protamine dose is based on the amount of heparin administered. Regardless of dosing strategy, the protamine-to-heparin dosing ratio should not be >1.0. We agree with this guidance. (See "Protamine reversal of heparin anticoagulation after cardiopulmonary bypass", section on 'Initial protamine dosing strategies'.)
Prophylactic use of inotropic agents during cardiac surgery in adults (January 2025)
Patients with low ejection fraction undergoing cardiac surgery often receive inotropic agents prophylactically, but whether patients benefit from this practice isn't clear. A 2024 systematic review of randomized trials of prophylactic administration of an inotropic agent during cardiac surgery found inadequate data to suggest any benefit (or harm) for most inotropic agents (ie, milrinone, amrinone, dobutamine, and dopamine) compared with placebo [5]. However, low certainty evidence suggested that prophylactic levosimendan infusion reduces the incidence of low cardiac output syndrome and mortality compared with placebo (risk ratio 0.43 and 0.65, respectively). Levosimendan is not available in the United States, and we do not prophylactically administer any inotropic agent during cardiac surgery. (See "Intraoperative problems after cardiopulmonary bypass", section on 'Vasoactive drug therapy'.)
Updated multidisciplinary guidelines for perioperative blood management during cardiac surgery (November 2024)
European multidisciplinary perioperative guidelines to minimize blood loss and the need for transfusion during adult cardiac surgery have been updated [6]. Given that cardiopulmonary bypass (CPB) affects hemostasis, preoperative strategies now emphasize timely management of preoperative anemia and medications affecting hemostasis. Before and during CPB, anticoagulation management, administration of antifibrinolytics, and strategies to avoid excessive hemodilution and unnecessary transfusion are addressed. The approach to achieving hemostasis after CPB has been revised to include updates on procoagulant interventions and utilization of blood products. New guidance on postoperative management covers chest tubes, re-exploration, and transfusion triggers. We generally agree with this guidance. (See "Anticoagulation and blood management strategies during cardiac surgery with cardiopulmonary bypass", section on 'Effects of cardiopulmonary bypass on hemostasis' and "Achieving hemostasis after cardiac surgery with cardiopulmonary bypass".)
PREOPERATIVE AND POSTOPERATIVE MANAGEMENT
Associations of preoperative anemia with frailty, cognitive dysfunction, and postoperative mortality (January 2025)
Anemia is common in older adults. In a retrospective study of more than 8500 patients older than 65 years who had elective surgery, preoperative mild anemia (hemoglobin 11 to 12 g/dL), moderate anemia (hemoglobin 8 to 11 g/dL), and severe anemia (hemoglobin <8 g/dL) were diagnosed in 17 percent, 10 percent, and 0.4 percent, respectively [7]. Lower preoperative hemoglobin values were associated with preoperative cognitive dysfunction and frailty and an increased risk of death within one year of surgery, compared with those who were not anemic. Since even mild anemia may have important perioperative ramifications, timely management of preoperative anemia is necessary. (See "Anesthesia for the older adult", section on 'Assessment for anemia'.)
REGIONAL ANESTHESIA
New ASRA guidelines for regional anesthesia in patients taking anticoagulants (April 2025)
The American Society of Regional Anesthesia and Pain Medicine (ASRA) has published updated guidelines for regional anesthesia in patients receiving antithrombotic or thrombolytic therapy [8]. Important changes from the prior edition include new recommendations on timing of needle placement or catheter removal for direct oral anticoagulants and fondaparinux, designation of high versus low doses for some medications, and new guidance on plasma levels of medications that should be used to determine whether regional anesthesia techniques are appropriate. Our recommendations are consistent with these guidelines and are shown in a table (table 1). (See "Neuraxial anesthesia/analgesia techniques in the patient receiving anticoagulant or antiplatelet medication".)
Crystallization of mixtures of drugs used for regional anesthesia (February 2025)
Regional anesthesia often involves the use of two different local anesthetics (with or without adjuvant drugs) to speed onset, improve block quality, and/or prolong the block effect. A new laboratory study found that even commonly used combinations may precipitate in the syringe; many of the tested combinations precipitated immediately, and most precipitated after one hour [9]. The safety of perineural injection of crystallized solutions and the potential for in situ crystallization after injection have not been determined. Whenever possible, compatibility of drug combinations should be confirmed prior to the use of admixtures. (See "Clinical use of local anesthetics in anesthesia", section on 'Combinations of local anesthetics'.)
SURGICAL CRITICAL CARE
Inhaled sevoflurane not beneficial in acute respiratory distress syndrome (April 2025)
Preliminary data suggested that the gaseous anesthetic sevoflurane may be efficacious as a sedative in mechanically ventilated patients. However, in a trial of 687 patients with early moderate to severe acute respiratory distress syndrome (ARDS), compared with patients treated with propofol, patients randomized to sevoflurane had fewer ventilator-free days (between-group difference -2.1, 95% CI -3.6 to -0.7) and lower 7- and 90-day survival (90.6 versus 86.5 percent; 47.1 versus 55.7 percent, respectively) [10]. In addition, patients receiving sevoflurane had higher lactate levels, acute kidney injury rates, and sevoflurane-specific adverse effects (eg, arginine vasopressin resistance and malignant hyperthermia). These findings do not support inhaled sevoflurane use as a sedative in patients with ARDS. (See "Sedative-analgesia in ventilated adults: Medication properties, dose regimens, and adverse effects", section on 'Sevoflurane'.)
OTHER ANESTHESIA
No role for tranexamic acid during open radical cystectomy (February 2025)
Radical cystectomy can result in significant blood loss and has the highest transfusion requirement among all non-cardiac operations. Prophylactic tranexamic acid (TXA) reduces blood loss during some types of surgery, but in a randomized trial of 386 patients undergoing open radical cystectomy for bladder cancer, TXA administered both before the incision and during surgery did not reduce 30-day blood transfusion rate, blood loss, or intraoperative blood transfusion rate compared with placebo [11]. Based on these findings, prophylactic TXA should not be used for open radical cystectomy. (See "Radical cystectomy", section on 'Operative morbidity and mortality'.)
Hypovolemic phlebotomy for liver resection (February 2025)
Hypovolemic phlebotomy before liver transection involves removing 7 to 10 mL/kg of whole blood from the patient without replacement with intravenous fluid before transection and then returning all of the blood after transection. In a randomized trial including 446 patients, hypovolemic phlebotomy reduced the 30-day transfusion rate compared with usual care (16 versus 8 percent), without significantly affecting severe or overall complication rates [12]. Hypovolemic phlebotomy should be considered a strategy to reduce blood loss during liver resection. (See "Overview of hepatic resection", section on 'Strategies to minimize blood loss'.)
Tranexamic acid does not reduce bleeding during hepatectomy (October 2024)
Tranexamic acid (TXA) is used routinely during some types of surgery to prevent excessive bleeding; however, its effect during hepatectomy is unclear. In a randomized trial of over 1200 patients undergoing hepatic resection for cancer, administration of an intravenous bolus of TXA followed by an eight-hour infusion did not reduce blood loss or the need for blood transfusion compared with placebo [13]. Patients receiving TXA had more postoperative complications (44 versus 38 percent), with the largest difference in major complications. Venous thromboembolism was similar in the two groups, though the study may have been too small to detect a large difference. These results support our practice of avoiding routine administration of TXA during hepatic resection. (See "Anesthesia for the patient with liver disease", section on 'Preparing for hemorrhage'.)
