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10/19/2026

Ketamine slows cancer cells in a dish. Does giving it on the day of surgery help your patient live longer? 🧪

A new study in the British Journal of Anaesthesia looked at 176,149 adults having major solid-tumor resections in US health systems (TriNetX records, 2014 to 2023). About 1 in 6 (29,649) had ketamine recorded on the day of surgery. The investigators matched 29,547 of them to 29,547 similar patients who had none.

What they found:

3-year mortality: 16.7% with ketamine vs 16.0% without (HR 1.04; 95% CI, 1.00 to 1.09). Not significant after correction for multiple comparisons (q = 0.187). If anything, the lean was toward ketamine doing slightly worse.
5-year mortality: 21.2% vs 20.8% (HR 1.04; 95% CI, 1.00 to 1.08).
No survival benefit in any of the 14 operations studied, from mastectomy to esophagectomy.

Now the catch, and it is a big one. The database recorded ketamine as yes or no. It could not tell a small bolus at induction from an infusion. No dose, no timing, no duration. So no dose-response analysis was possible.

That matters because of the biology. In one lab study the antitumor effect began at about 5 µg/mL for 4 hours. Analgesic plasma levels run roughly 0.1 to 0.2 µg/mL and hypnotic levels 1 to 2. The doses we give may never reach the range where the effect was seen.

Other limits: the data held no cancer stage, ketamine patients had more chronic pain and opioid-related disorders before matching, and this is association, not causation.

One exploratory signal pointed the other way. Among 3-year survivors, fewer ketamine patients had markers of progression such as new chemotherapy, radiation or palliative care (3.4% vs 4.1%; HR 0.82; 95% CI, 0.74 to 0.92). The marker was never validated, and the authors call it hypothesis-generating.

The practical reading: use ketamine for analgesia or hemodynamics on its merits. This study gives no reason to add it for the cancer.

How often do you use ketamine in your cancer cases? Bolus, infusion, or not at all?

What large databases can and cannot tell us is home ground for Dr. Sachin Kheterpal (University of Michigan), who joins us at Anesthesia Camp Grand Cayman, January 27–30, 2027, at The Ritz-Carlton. Registration at destinationCME.com.

Talmy T, Ledot S, Cohen B, et al. Ketamine administration and postoperative mortality after major cancer surgery: a propensity-matched population-based study. Br J Anaesth. 2026;137(4):1051-1060. doi:10.1016/j.bja.2026.06.033

10/19/2026

Does ketamine on the day of cancer surgery improve survival? A new propensity-matched study of about 59,000 adults found no benefit: 3-year mortality 16.7% vs. 16.0%, 5-year 21.2% vs. 20.8%, neither statistically significant.

The catch is what the database couldn't see. Ketamine was recorded only as yes or no, with no dose or timing, and the antitumor effect seen in the lab came from a single cell study at concentrations above hypnotic levels. Association, not causation.

Dr. Sachin Kheterpal of the University of Michigan, who lectures on database research in anesthesia, joins us at Anesthesia Camp Grand Cayman, January 27–30, 2027.

Learn more: https://destinationcme.com

Talmy T, et al. Br J Anaesth. 2026;137(4):1051-1060.

10/19/2026

10/18/2026

Anesthesia Camp Grand Cayman at The Ritz-Carlton Resort. Up to 28 hr CME/CE. 😎🌞🩴👙🏖️🤿🇰🇾🏌🏽‍♀️🎾

🗓️1/27/2027 - 1/30/2027

10/17/2026

AI infographic has a few errors! 😝
Clinical Briefing: Anesthetic Care for Pope Leo XIV’s Thoracic Case
Medical updates out of Gemelli Hospital confirm that Pope Leo XIV is recovering as expected following a VATS right lower lobectomy on October 13.
From an anesthesia perspective, this operation is typically performed under general anesthesia with single-lung ventilation to ensure an immobile surgical field. The Vatican has officially recognized the attending anesthesia faculty—Prof. Massimo Antonelli, Dr. Giovanni Punzo, and Dr. Giuseppe Bello—but has not described the anesthetic technique.
To date, no specific data regarding the chosen anesthetic agents or post-operative analgesic regimens have been made available to the public or the wider medical community.
See the accompanying infographic for the structural layout of the case.
DLT or bronchial blocker for a right lower lobectomy — what’s your go-to?

Source: Holy See Press Office medical bulletin, October 13, 2026 (link in first comment)

10/17/2026

Not only do we have excellent speakers, but we don't skimp on the AV.🎙️ 🔊 📽️ 🎬
The AV crew at the Ritz, no surprise, is first-rate. Everyone should see and hear well, and we walk around the audience with microphones so participants can ask questions and everyone can hear them.

Anesthesia Camp Grand Cayman at The Ritz-Carlton Resort. Up to 28 hr CME/CE. 😎🌞🩴👙🏖️🤿🇰🇾🏌🏽‍♀️🎾
destinationCME.com
🗓️1/27/2027 - 1/30/2027
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10/16/2026

I gave an amp of bicarb before aortic unclamping more times than I can count.

Open AAA repair, 1980s and 90s. The clamp comes off, the lactate-laden blood from two ischemic legs washes back, the pressure drops, the pH drops. So you drew a gas, you had bicarb and calcium chloride ready on the table, and you pushed. Everyone did. It felt like physiology.

NEJM has now published SODa-BIC, and when I first read the summaries I filed it as an ICU trial — interesting, but not my operating room.

Then I read the actual paper. Half these patients came from an operating room. 26% were emergency surgical admissions and 25% were elective. Postoperative state, hemorrhage, hypovolemia, cardiac arrest and vasoplegia are all listed as causes of the acidosis. And surgical versus medical admission was one of eight subgroups the investigators specified in advance, before they saw any data.

The trial: 500 adults on vasopressors with metabolic acidosis (pH under 7.30), randomized double-blind to a titrated sodium bicarbonate infusion or 5% dextrose placebo, 55 ICUs across 7 countries, median total dose 300 mmol — six of these vials.

The bicarbonate did exactly what we always believed. Recurrence of acidosis fell from 55.7% to 32.0%. Lowest pH 7.31 vs 7.26. The blood gas got better.

Nothing else did. Major adverse kidney events at 30 days: 40.2% vs 39.4%. Death: 25.4% vs 24.0%. No difference in AKI, vasopressor-free days, ICU-free days or hospital-free days. And in the surgical patients specifically: 27.2% vs 29.8%.

Fair caveats. The authors say it plainly — the trial was powered to detect moderate-to-large effects, and smaller clinically relevant differences cannot be ruled out. It was one 5-hour infusion. Patients with DKA, bicarbonate-losing states, severe CKD, planned dialysis and suspected poisoning were all excluded, and those uses are untouched by this.

One more thing worth noticing. The only adverse signal in the whole trial was hypokalemia requiring correction, 1.6% versus zero. Part of why we pushed bicarb at declamping was the potassium coming back from those legs. The drug moves potassium in both directions, and in a controlled setting the direction it moved was down.

Forty years of reflex, and the number was the only thing we were ever treating.

Did you learn the declamping amp? Do you still give it?

Dr. Vivek Moitra of Columbia teaches perioperative resuscitation at Anesthesia Camp Grand Cayman, January 27–30, 2027.

Reference: SODa-BIC Investigators & ANZICS CTG. Sodium Bicarbonate for Critically Ill Adults with Metabolic Acidosis and Shock. N Engl J Med 2026;395:1062-1074.

10/15/2026

The Holy Grail. I missed my college 25th reunion going to a meeting for a company called Biopure that had supposedly created a bovine polymerized hemoglobin that could sit on a shelf and be used like this. But the company they went bust and actually the stock went to zero when it turned out they lied to the FDA about their science and to the SEC about their finances. I'll believe it when I see it!

10/15/2026

When I was a resident at the University of Virginia, neurotrauma arrived by helicopter from all over the state. The teaching was simple: watch the ICP and treat the number.

Most of us don't do neurotrauma every day. But sooner or later a head-injured patient lands on your table for a craniectomy, a laparotomy or a femur. A new review in Intensive Care Medicine is a good reminder of how much of that patient's ICP is in the hands of whoever is at the head of the bed.

What the authors list as raising ICP:

• PaCO2 going up. Their first-tier target is 35–38 mmHg. Below 30 risks ischemia.
• Blood pressure going down. Below the autoregulation limit, vessels dilate and ICP rises.
• Pain, agitation, coughing. Uncontrolled pain can raise ICP significantly, and adequate sedation and analgesia are first-tier ICP therapy.
• Fever and hyponatremia.
• Anything that blocks venous drainage: a rotated head, a tight cervical collar, a tight tube tie, high PEEP, prone positioning.

The review's larger argument is that a single cutoff (22 mmHg) is not enough. An ICP of 18–20 for several hours may do as much harm as a brief, higher spike. Duration counts as much as the peak.

Worth knowing: this is a narrative review, not a trial. The authors say plainly that studies showing individualized ICP management improves outcomes are still lacking.

How do you secure the tube in a head-injured patient: tape, or a tie around the neck?

Anesthesia Camp Grand Cayman, January 27–30, 2027.

Reference: Taccone FS, Arabi Y, Baggiani M, Brasil S, Figaji A, Gouvea Bogossian E, Hawryluk G, McCredie V, Moller K, Puppo C, Robba C, Shrestha GS, Tokmak F, Udy A, Wong YL, Meyfroidt G. Intracranial pressure physiology, monitoring and individualized management in the acute brain injured patient. Intensive Care Med. 2026;52:2108–2128. doi:10.1007/s00134-026-08558-4

(Link in first comment)

10/14/2026

"Cuz folks ain't getting any smaller. Well, maybe a few with the GLP1s." 😄

Here's a good one to pass along to your trainees. Intensive Care Medicine just published an open-access review on ventilating ICU patients with obesity. Most of us know this physiology in our bones, but residents and SRNAs will find it all in one tidy place:

Set tidal volume by predicted body weight (6–8 mL/kg), not actual weight. The lungs don't grow with the waistline.
Higher pleural pressure and lower FRC mean more atelectasis, so these patients often need more PEEP.
A high plateau or driving pressure may be the chest wall talking, not the lung. Esophageal manometry and EIT can help sort that out.
Preoxygenate with positive pressure and reach for video laryngoscopy first.
Proning and ECMO are feasible, and BMI alone shouldn't disqualify anyone.

The authors are honest that most of this is extrapolated from general ICU trials. Among their future research questions: how GLP-1 RA–driven weight loss changes respiratory mechanics and drug handling.

Who's sharing this with their residents? 👇

Join us at Anesthesia Camp Grand Cayman, January 27–30, 2027 👉 destinationCME.com

Kitisin N, Caroli A, Carvalho Ferreira J, et al. Mechanical ventilation for ICU patient with obesity: current best practices and future directions. Intensive Care Med. 2026;52:1051–1065. doi:10.1007/s00134-026-08397-3