Author: Young May Cha, MD
The Daily Dose
Four major studies presented during the late-breaking clinical trials session at the 2026 IARS and SOCCA Annual Meeting examined important questions involving tranexamic acid, anesthetic technique, regional analgesia after cardiac surgery, and long-term functional recovery in older surgical patients.
Because some of the results remain unpublished or under embargo, the findings should be considered preliminary until the complete studies undergo peer review and publication.
TRACTION: Tranexamic Acid in Major Noncardiac Surgery
Daniel McIsaac, MD, MPH, presented findings from TRACTION, a phase IV trial evaluating a hospital policy of using tranexamic acid in patients undergoing major noncardiac, nonorthopedic surgery.
Tranexamic acid is already commonly used in orthopedic and cardiac surgery because it can reduce surgical bleeding and the need for blood transfusion. However, it has been used less consistently during other major operations.
TRACTION included procedures considered to have a high risk of bleeding, defined as operations with a historical transfusion rate greater than 5%.
The trial examined two primary outcomes:
• Effectiveness, measured by the proportion of patients requiring a blood transfusion
• Safety, measured by thromboembolic events occurring within three months of surgery
Tranexamic acid reduced the need for blood transfusion without increasing thromboembolic complications. The treatment met the study’s criteria for noninferiority regarding safety.
There were no important differences between the treatment and control groups in secondary outcomes such as hospital length of stay and survival.
The investigators estimated that using tranexamic acid in these additional types of surgery could save approximately 15 units of packed red blood cells for every 100 patients treated.
These findings suggest that the appropriate use of tranexamic acid could conserve blood products and reduce transfusion exposure in a broader range of major surgical procedures without creating a measurable increase in thrombotic risk.
VITAL: Volatile Anesthesia Versus Total Intravenous Anesthesia
Joyce Yeung, MBChB, PhD, discussed the VITAL trial, a pragmatic randomized study comparing volatile anesthesia with total intravenous anesthesia for major elective noncardiac surgery in the United Kingdom.
The study included adults 50 years of age and older and used information from the Perioperative Quality Improvement Programme registry.
The primary outcomes included:
• Days alive and at home within 30 days after surgery
• Survival
• Quality of recovery
Secondary outcomes included longer-term measurements of days alive and at home, six-month mortality, and patient satisfaction.
The choice between inhaled anesthesia and propofol-based total intravenous anesthesia is often determined by clinician preference, institutional practice, equipment, environmental considerations, and patient-specific factors.
However, even a relatively small difference in recovery could have major implications across a national health system. Investigators estimated that reducing hospitalization by only half a day could potentially save the United Kingdom’s National Health Service approximately £170 million annually.
The complete VITAL results were not yet available for publication at the time of the presentation. The findings should provide valuable information about whether anesthetic technique meaningfully affects recovery, survival, patient satisfaction, or time spent at home after surgery.
Related Studies of Anesthetic Technique
Additional investigations are examining other potential differences between volatile anesthesia and total intravenous anesthesia.
The THRIVE trial is evaluating trajectories of recovery after intravenous propofol compared with inhaled volatile anesthesia.
The GlucoVITAL study is examining whether the mode of anesthesia affects glucose variability and insulin resistance during major noncardiac surgery.
Together, these studies may clarify whether anesthetic choice produces clinically meaningful effects beyond the immediate intraoperative period.
EPOCH CardioLink-10: Parasternal Blocks After Cardiac Surgery
C. David Mazer, MD, presented the EPOCH CardioLink-10 trial, which evaluated superficial parasternal intercostal plane blocks for pain control following cardiac surgery through a median sternotomy.
Poorly controlled pain after sternotomy can contribute to:
• Increased opioid use
• Persistent postoperative pain
• Impaired coughing and breathing
• Pulmonary complications
• Delayed mobilization
• Longer hospitalization
The multicenter, double-blind, placebo-controlled randomized trial examined whether superficial parasternal intercostal plane blocks could reduce opioid exposure during the first 72 hours following cardiac surgery.
Ultrasound-guided catheters were positioned between the pectoralis major and intercostal muscles to deliver regional analgesia to the anterior chest wall.
The complete data remained embargoed, but the investigators reported favorable results for the parasternal blocks without significant differences in safety outcomes or complication rates.
Once published, the results may strengthen the evidence supporting regional analgesia for patients undergoing cardiac surgery through a median sternotomy.
The study may also contribute to the evidence discussed in the 2026 ASA practice guideline addressing perioperative pain management with local and regional analgesia for cardiothoracic, breast, and abdominal surgery.
FIT After Surgery: Functional Recovery in Older Adults
Duminda Wijeysundera, MD, PhD, presented results from the Functional Improvement Trajectories After Surgery study.
This multicenter prospective cohort study followed adults 65 years of age and older undergoing major elective noncardiac surgery.
Traditional perioperative outcomes frequently emphasize mortality, complications, and hospital length of stay. Although these outcomes are important, they may not fully describe what matters most to older patients.
Patients may be more concerned about whether they will:
• Return to their previous level of independence
• Regain mobility
• Recover their cognitive function
• Resume normal daily activities
• Continue living at home
• Avoid persistent pain or disability
The study assessed self-reported disability, medical complications, pain, depressive symptoms, cognitive and functional recovery, and decisional regret.
New disability or death occurred in approximately one out of every six patients at six months after surgery. By one year, the rate had increased to approximately one out of every five patients.
The risk of significant new disability appeared to reach its lowest point between three and six months after surgery. Some patients subsequently improved, but disability frequently persisted.
Risk Factors for Postoperative Disability
Several categories of risk factors were associated with poorer functional outcomes.
Patient vulnerability factors included:
• Frailty
• Preexisting mobility limitations
• Cognitive impairment
Surgical factors included undergoing an open rather than a less-invasive surgical procedure.
Contextual factors included:
• Recent smoking
• Poor social support
These findings demonstrate that surviving surgery and leaving the hospital do not necessarily represent a complete recovery.
A patient may avoid a major medical complication but still experience long-lasting loss of independence, mobility, cognition, or quality of life.
Improving Informed Consent
Standard surgical consent discussions may focus heavily on immediate risks such as bleeding, infection, myocardial infarction, stroke, or death.
For many older adults, the possibility of permanent functional decline may be equally important—or more important—than the risk of a traditional postoperative complication.
Discussions before major surgery should therefore address:
• The likelihood of returning to baseline function
• The possibility of needing help with daily activities
• The potential for prolonged rehabilitation
• The risk of cognitive or mobility decline
• The patient’s available family and social support
• Whether the expected postoperative outcome is consistent with the patient’s goals
More individualized risk-prediction tools are needed to help patients understand their personal likelihood of disability, loss of independence, or death during the months following surgery.
The Future of Perioperative Research
These four studies demonstrate the expanding scope of perioperative medicine.
TRACTION suggests that tranexamic acid may safely reduce transfusions during a broader range of major operations.
VITAL and its related studies may determine whether volatile anesthesia or total intravenous anesthesia produces meaningful differences in recovery and health-care utilization.
EPOCH CardioLink-10 may strengthen the role of parasternal regional blocks in reducing opioid exposure following cardiac surgery.
The FIT After Surgery study demonstrates that perioperative success must be measured by more than survival and hospital discharge. Long-term independence, functional ability, cognition, pain, and quality of life are essential outcomes, particularly for older adults.
As the complete results are published, these studies may influence blood-management policies, anesthetic selection, postoperative pain protocols, preoperative counseling, and shared decision-making.
Thank you to The Daily Dose and the International Anesthesia Research Society for allowing us to summarize these important clinical studies.