Coming Up Next on Improving Perioperative Medicine

Young May Cha, MD

Moderator Jessica Spence, MD, PhD, FRCPC, assistant professor of anesthesia at McMaster University, an investigator at the Population Health Research Institute, and an anesthesiologist and intensivist at Hamilton Health Sciences, introduced four exciting new studies in the International Clinical Trials Program, “Clinical Trials Late-Breaking Session,” on Saturday, May 2 at the 2026 Annual Meeting presented by IARS and SOCCA. Since not all data have been published, readers should stay tuned for all the results.

First, Daniel McIsaac, MD, MPH, FRCPC, professor and vice chair (research and innovation) of anesthesiology and pain medicine at the University of Ottawa, a scientist at the Ottawa Hospital Research Institute, senior scientist at the Institute for Clinical Evaluative Sciences (ICES) and an anesthesiologist at the Ottawa Hospital, presented findings from TRACTION (a phase IV trial of a hospital policy of tranexamic acid (TXA) to reduce transfusion in major noncardiac surgery). Prior studies have shown a reduced transfusion rate with TXA use in orthopedic and cardiac surgeries, but TXA is infrequently used for other major surgeries. This multicenter randomized controlled trial evaluated the benefit of TXA for nonorthopedic and noncardiac surgeries with a high risk of bleeding, which was defined as procedures with a greater than 5% transfusion rate based on historical data. Coprimary outcomes were effectiveness, which was measured by the proportion of patients requiring blood transfusion, and safety, which was measured by the incidence of thromboembolic events within 3 months of surgery. TXA successfully reduced transfusion rates without any increased thromboembolic complications and met criteria for noninferiority. Secondary outcomes of effectiveness and safety, such as length of stay and survival, were not different between the two groups. As a noninferior therapy compared to control conditions, use of TXA for these additional surgeries is estimated to potentially save 15 units of packed red blood cells for every 100 patients. 

Next, Joyce Yeung, MBChB, PhD, who leads the Emergency, Prehospital, Perioperative and Critical Care (EPPiC) Trials Group within the clinical trials unit at Warwick Medical School, and is a consultant in critical care and professor of anaesthesia and critical care medicine at the University of Warwick, director of the Centre for Research and Improvement at the Royal College of Anaesthetists and NIHR National Specialty lead for anaesthesia, perioperative medicine and pain management, discussed VITAL (Volatile vs Total intravenous Anaesthesia (TIVA) for major non-cardiac surgery: a pragmatic randomized triaL), which compared patient outcomes with volatile anesthesia or TIVA after elective, major noncardiac surgery in the United Kingdom. If anesthetic technique could reduce a patient’s hospital stay by half a day, then the National Health Service could save 170 million pounds per year.  With data from the Perioperative Quality Improvement Programme (PQIP registry), the VITAL study examined postoperative outcomes in adults aged 50 years and older. Primary outcomes measured were days alive and at home at 30 days after surgery, survival, and quality of recovery. Secondary outcomes included longer assessment intervals for days alive and at home, 6-month mortality, and patient satisfaction. The data are soon to be published and should provide interesting insights into this question. Additional studies are also ongoing to assess how anesthetic choice could impact other parameters, such as the trajectories of patient recovery in the THRIVE trial (Trajectories of Recovery after Intravenous propofol versus inhaled VolatilE anaesthesia), and glucose variability and insulin resistance in the GlucoVITAL study (Glucose variability and mode of anaesthesia in major noncardiac surgery).

C. David Mazer, MD, FRCPC, professor of anesthesia at the University of Toronto, discussed the EPOCH CardioLink-10 trial (efficacy of superficial parasternal intercostal plane (SPIP) block on postoperative pain control in patients undergoing cardiac surgery with median sternotomy). Inadequate pain control after sternotomy can cause persistent postoperative pain and opioid use, pulmonary complications, delayed mobilization, and prolonged hospitalization. This multicenter, double-blind, placebo-controlled randomized trial examined if SPIP blocks reduced opioid exposure in the 72 hours after cardiac surgery with median sternotomy. Catheters were placed under ultrasound guidance between the pectoralis major and intercostal muscles. The data are embargoed but results are favorable for the SPIP blocks without significant differences in safety outcomes and complication rates. Once published, the EPOCH CardioLink-10 trial could add to the evidence currently cited in the recently published 2026 ASA practice guideline on perioperative pain management using local and regional analgesia for cardiothoracic surgeries, mastectomy, and abdominal surgeries.

Lastly, Duminda Wijeysundera, MD, PhD, FCRPC, FAHA, professor, staff anesthesiologist, and the Elizabeth A. and Richard J. Currie, O.C. chair in translational anesthesia research at St. Michael’s Hospital – Unity Health Toronto and the University of Toronto, discussed results from the FIT After Surgery (Functional Improvement Trajectories After Surgery) study, which is a multicenter prospective cohort study of older adults 65 years old or older who had major elective noncardiac surgery. Traditional measures of perioperative outcomes focus on survival and hospital discharge times, but they do not paint the full picture of a patient’s functional recovery. When a patient returns to baseline, achieves independence, and returns to baseline cognitive function are important measures that have major impacts on the postoperative lives of older adults. Measurements included self-reported disability, medical complications, pain symptomology, depressive symptoms, and decisional regret. New disability or death occurred in 1 in 6 patients at 6 months, which increased to 1 in 5 patients at one year. There was a nadir risk of significant new disability at 3-6 months after surgery, which then showed gradual improvement but often persisted afterward. Risk factors for postoperative disability included factors that affected patient vulnerability, such as frailty, mobility limitations, and cognitive impairment, surgical factors, such as open surgical procedure, and contextual factors, such as recent smoking history and poor social support. Standard informed consent decisions often neglect these factors that can contribute significantly to the risk of new disability or death months after surgery and should be included as part of the development of more individualized risk prediction tools.