Nothing new today — the ASA older adults advisory, IACTS on the CABG downgrade, and ESPEN's ICU guideline

No new guidelines from tracked societies today. Two sweeps, both empty with no query failures: the named-journal sweep across ten priority journals for 5–7 September, and — applying the lesson from today’s brief — a topic-wide guideline search across all journals for 4–7 September. Zero hits.

Three more off the landmark backlog, including the first document from IACTS to appear in this archive.

1. ASA Practice Advisory — perioperative care of older adults

Society · Published: American Society of Anesthesiologists, Anesthesiology 2025;142(1):22–51, January 2025 — ~20 months old Sieber, McIsaac, Deiner, Berger, Hughes, Leung, Neuman, Russell et al.

Access note: no abstract is deposited and the full text was not reachable. The recommendations below come from the ASA’s own summary and secondary coverage, not from the document. Flagged as such.

Scope: adults 65 or older undergoing inpatient surgery, across pre-, intra- and postoperative care, with the stated focus on mitigating cognitive complications — delirium and longer-term cognitive decline.

Reported recommendations:

• Engage a multidisciplinary care team
• Choose anaesthetic technique on patient-specific factors — both neuraxial and general anaesthesia are acceptable
• Consider dexmedetomidine for delirium prophylaxis, balancing benefit against cardiovascular risk
• Review all medications with CNS effects preoperatively to minimise delirium risk
• Incorporate frailty assessment, cognitive screening, and psychosocial or nutritional evaluation into routine preoperative workup

Interpretation. The neuraxial-versus-general line is the one that settles an old argument, and it settles it as a draw. That is the correct reading of REGAIN and RAGA — neither showed the delirium advantage for spinal anaesthesia that a generation of teaching assumed — and it is worth having a society document say so plainly rather than leaving the assumption in place.

Dexmedetomidine “with attention to cardiovascular risk” is a fair summary of a literature where SUPER-DEX and similar trials show delirium reduction alongside bradycardia and hypotension, and where the cardiac surgery population is precisely where both effects are largest.

Note how much of this advisory is preoperative and organisational rather than intraoperative — frailty, cognition, medication review, multidisciplinary teams. That places most of the work outside the operating theatre and outside a single anaesthetist’s control, which is realistic and also why such advisories are hard to implement.

Read the advisory · PMID 39655991 · ASA summary page

2. IACTS position statement on the ACC/AHA/SCAI revascularization guideline

Society · Published: Indian Association of Cardiovascular and Thoracic Surgeons. Indian Journal of Thoracic and Cardiovascular Surgery, 22 January 2022 — ~4.5 years old Yadava, Narayan, Padmanabhan, Sajja, Sarkar, Varma, Jawali

The first IACTS document to appear in this archive. A consensus position responding to section 7.1 of the 2021 ACC/AHA/SCAI coronary revascularization guideline.

From the statement itself:

The guidelines were the felt need of the fraternity and this single all-encompassing document, relegating the previous six guidelines on the subject to archives, is indeed welcome. However, the downgrading of coronary artery bypass surgery for stable multivessel coronary artery disease and its bracketing with percutaneous coronary interventions has caused a lot of anguish in the surgical fraternity. This document presents the official viewpoint of the Indian Association of Cardiovascular and Thoracic Surgeons on the matter.

Interpretation. Worth reading as a document about how guidelines get contested, which is a subject this archive has now circled three times.

The 2021 ACC/AHA/SCAI guideline downgraded CABG in stable multivessel disease from Class I to Class IIb — a change that drew formal objection from EACTS, which withdrew its endorsement, and from surgical societies internationally. This is the Indian society’s contribution to that response, and it is unusually direct about the emotion involved: “anguish in the surgical fraternity.”

Set it beside two more recent items here. The Annals of Thoracic Surgery Medicare analysis from 26 August reported CABG associated with a hazard ratio of 0.44 for survival in stable multivessel disease and explicitly urged “a reevaluation of recent guidelines” — the same argument, five years on, now with registry-scale data behind it. And the field lost David Taggart this month, whose ART trial and advocacy sat at the centre of it, noted in Saturday’s brief.

Whether the surgical case is right is a separate question — that Medicare hazard ratio is large enough to suspect residual confounding, as noted at the time. But the dispute is live, it is international, and it shapes what your heart team is arguing about.

Read the statement · PMID 35221551

3. ESPEN practical guideline — clinical nutrition in the intensive care unit

Society · Published: ESPEN, Clinical Nutrition, 15 July 2023 — ~3 years old Singer, Blaser, Berger, Calder, Casaer, Hiesmayr, Pichard, Preiser, Szczeklik et al.

The original located at last — a Spanish translation carrying a 2026 date had surfaced earlier and would have read as new. This is a shortened, flowchart-illustrated practical version of the 2019 ESPEN scientific guideline, revised under ESPEN’s new standard operating procedures, covering all items from the previous guideline plus special conditions. Its stated aim is implementation: “to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines.”

Interpretation. The abstract describes format rather than content, so this is a pointer to a document rather than a summary of it — but locating it matters, because it completes the nutrition picture this archive has been assembling.

Three documents now sit alongside each other: ESPEN in the ICU (this one), the ESPEN surgery guideline updated in 2025, and the AAST/ACS trauma nutrition protocol from 26 August. Between them they cover the elective surgical patient, the trauma patient and the general critically ill patient — and the AAST protocol’s flat rejection of immunonutrition, glutamine and probiotics is the sharpest statement of the three.

Also worth noting: the ESPEN ICU guideline attracted a published exchange about enteral glutamine in trauma patients in 2024, which is the same question REDOXS answered against a decade earlier. That argument has not gone away.

Read the guideline · PMID 37517372