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Will we see fewer carotid cases for asymptomatic disease? 🤔

Our (Claude-assisted 🤓 🧠) take: yes, and probably more so for endarterectomy than for stenting. Here's why.

Two new JAMA analyses from CREST-2 tested something many patients have heard before surgery: that opening a tight carotid might also help memory and thinking. The answer:

"Among the 1078 participants included in the carotid artery stenting trial and 1087 participants included in the carotid endarterectomy trial, there was no convincing evidence that revascularization improved cognition or prevented cognitive decline compared with medical therapy."

A second, smaller study (CREST-H) looked at the patients most likely to benefit: 51 people with reduced cognition at baseline, graded by perfusion MRI for impaired blood flow to the brain. Revascularization gave no added cognitive benefit at 1 year, whatever their flow status.

The editorial draws a clear line: revascularization for asymptomatic stenosis may be justified to prevent stroke, but not to improve cognition.

With cognition off the table, stroke prevention is the only reason left to intervene. On that measure, the main CREST-2 results point in different directions for the two procedures. CREST-2 was two parallel trials, each adding a procedure to intensive medical management and comparing it with medical management alone. Over 4 years, stroke or death occurred in:

2.8% with stenting vs 6.0% with medical therapy alone, a statistically significant reduction
3.7% with endarterectomy vs 5.3% with medical therapy alone, not statistically significant

Stenting has trial evidence of stroke benefit over medical therapy alone; endarterectomy, in this trial, does not. That's why we expect asymptomatic CEA to decline more.

Important caveats:

The two trials weren't a head-to-head comparison of CEA and stenting.
CEA did lower events numerically.
Stenting's benefit was modest, and in the stenting trial all the early strokes and deaths occurred in the stenting arm.
Cognition was a secondary outcome, and CREST-H is small.

Vascular anesthesiologists: are you already seeing the shift? 👇

Perioperative brain health is on the agenda at Anesthesia Camp Grand Cayman 2027 with Dr. Stacie Deiner (Dartmouth).
📅 January 26–30, 2027 | The Ritz-Carlton, Grand Cayman
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Reference: Smith EE, Ganesh A. Asymptomatic Carotid Revascularization May Be Justified, But Not to Improve Cognition. JAMA. Published online September 16, 2026. doi:10.1001/jama.2026.14839

Article link in first comment 👇

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🫀💊 A new JAMA trial says one pill the day before heart surgery can cut kidney injury nearly in half. I'm not so sure it settles anything.

MERCURI-2 randomized 784 elective cardiac surgery patients in the Netherlands to dapagliflozin 10 mg or placebo, 4 doses starting the day before surgery. Acute kidney injury within 7 days: 28% with dapagliflozin vs 52% with placebo (relative risk 0.54, P < .001).

AKI was defined by KDIGO criteria: an increase in serum creatinine of 0.3 mg/dL (26.5 μmol/L) or greater within 48 hours, a 1.5-fold or greater increase within 7 days of surgery, or urine output less than 0.5 mL/kg/h for 6 to 12 hours after surgery.

My concerns:

These patients were SGLT2 inhibitor-naive. The drug was started de novo the day before surgery. Anyone already taking one was excluded, so this says nothing about whether to continue or hold the drug in the patients we actually see on it.
AKI went down, but no other outcome was different: severe (stage 3) AKI, major adverse kidney events, atrial fibrillation, ICU or hospital stay, quality of life. The authors say the study was underpowered to detect those differences.
Periop use of SGLT2 inhibitors is already contested because of euglycemic ketoacidosis risk and the recommendation to hold them 3–4 days before surgery. I think this trial will add to the controversy, not resolve it.

Do you think this will change cardiac anesthesia practice? I'd like to hear from my anesthesia, surgery, and nephrology colleagues.

Source: Oosterom-Eijmael MJP, Hulst AH, Monteiro de Oliveira NP, et al; MERCURI-2 Study Group. Dapagliflozin and Acute Kidney Injury Following Cardiac Surgery: A Randomized Clinical Trial. JAMA. 2026;336(9):765-773. doi:10.1001/jama.2026.9268

An ASA Open Forum thread on GLP-1s and SGLT2s is worth twenty minutes of your morning.

It starts with a familiar problem: a private group wrote hold guidelines, had a run of cancellations, and got asked by administrators to match the more liberal standards used by sister hospitals in the same system. Treat GLP-1 patients under standard 2/4/6/8 NPO. If they didn't hold it, do an RSI instead of an LMA and proceed. If they didn't hold the SGLT2, warn them about acidosis, hydrate, proceed. Don't cancel.

The replies are where it gets good.

Almost everyone landed on the same practical point: 24 hours of clear liquids does more work than the hold does. One large health system concluded that both the older ASA document and the newer SPAQI consensus were defensible, and cared mainly that instructions be consistent across every site in a market so patients aren't told one thing at the ASC and another at the hospital.

The real fight was about RSI. Is an airway-protective anesthetic an acceptable substitute for postponing an elective case in someone likely to have retained gastric contents? One camp says no — aspiration risk is modifiable, and we make people wait 8 hours after solid food for exactly that reason. The other camp says a flat cancel rule ignores how much gray there is, and that a documented shared decision-making conversation is the better process.

On SGLT2s, the consensus was more comfortable: the risk isn't really the drug, it's how long the patient will be NPO afterward. Screening colonoscopy followed by lunch is not the same as a bowel resection.

Then someone posted the OCULUS randomized trial. Sixty patients on stable GLP-1/GIP therapy, randomized to continue or hold one dose before upper endoscopy. Clinically significant retained gastric contents: 25.0% who continued vs. 3.1% who held. In the endoscopy-only group who ate normally the day before: 46.7% vs. 5.0%. And none of the patients with retained contents had GI symptoms — meaning asking "any nausea or bloating?" doesn't find them. (very small, though; n=60)

Read the whole thread: https://community.asahq.org/discussion/glp-1s-sglt2s

We built the infographic above from the two 2025 consensus statements — mechanism of action on the left, what it actually means in your room on the right.

These are the conversations that happen between lectures on Seven Mile Beach. Anesthesia Camp Grand Cayman 2027 registration is open at destinationCME.com

We've produced Anesthesia Camps for 20 years. Flashback to the 2012 and 2013 meetings.

Few topics in anesthesia ignite as passionate a debate as using the LMA in the prone position.

In a massive 48-post thread recently taking over the ASA Open Forum, clinicians from across the country weighed in (anonymized comments at bit.ly/ProneLMA ) : On one side are providers who have safely used 2nd-generation supraglottic airways for decades in highly selected ambulatory patients—such as healthy, normal-BMI individuals undergoing short Achilles tendon repairs or minor lumbar cases. They point out real clinical benefits: avoiding neuromuscular blockers, eliminating coughing and bucking upon emergence, and providing significantly better airway control and positive-pressure ventilation than heavy sedation with a natural airway ("prone MAC").

On the other side, many colleagues caution that when an airway emergency happens in the prone position—whether laryngospasm, dislodgement, or silent aspiration—it is an absolute, high-stakes nightmare. Turning an unstable, desaturating patient supine in the middle of a sterile field is chaotic, and defending an adverse outcome in court can be extraordinarily difficult.

Perhaps the most important takeaway from the discussion was about our culture and teamwork in the OR. Anesthesia is an interprofessional effort built on mutual trust. Our CRNA partners and physician colleagues bring deep clinical wisdom to the table. Several contributors rightly emphasized that no clinician—whether an attending, resident, or CRNA—should ever be pressured into an airway technique they are uncomfortable with to shave five minutes off turnover time. True patient safety lives where open communication and clinical discretion are always respected.

Read the full discussion on the ASA Community Forum:
https://community.asahq.org/discussion/using-lma-in-a-prone-position -091a-439d-abb7-01a0821c42ee

Where does your department stand on prone LMAs? Let us know in the comments below!

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🗓️1/27/2027 - 1/30/2027

Med School graduation pic 1982. Lots of folks have clicked on my reminisces of starting residency without pulse oximetry etc. https://bit.ly/BP-2minvs5min