Daily Anesthesiology Research Analysis
Three impactful anesthesiology-related studies stood out today: a large multicenter RCT found that Hypotension Prediction Index–guided hemodynamic therapy did not reduce postoperative acute kidney injury after major abdominal surgery; a meta-analysis of randomized trials showed no survival advantage of intraosseous over intravenous access in adult cardiac arrest and suggested lower sustained ROSC with intraosseous; and an innovative biobank study leveraged perioperative anesthetic exposures to r
Summary
Three impactful anesthesiology-related studies stood out today: a large multicenter RCT found that Hypotension Prediction Index–guided hemodynamic therapy did not reduce postoperative acute kidney injury after major abdominal surgery; a meta-analysis of randomized trials showed no survival advantage of intraosseous over intravenous access in adult cardiac arrest and suggested lower sustained ROSC with intraosseous; and an innovative biobank study leveraged perioperative anesthetic exposures to reclassify many RYR1/CACNA1S variants linked to malignant hyperthermia.
Research Themes
- Hemodynamic monitoring and kidney outcomes in abdominal surgery
- Vascular access strategy and outcomes in adult cardiac arrest
- Perioperative genomics and malignant hyperthermia risk refinement
Selected Articles
1. Hemodynamic Management Guided by the Hypotension Prediction Index in Abdominal Surgery: A Multicenter Randomized Clinical Trial.
In a 28-center RCT of 917 moderate-to-high-risk elective abdominal surgery patients, HPI-triggered hemodynamic interventions did not lower the 7-day incidence of moderate-to-severe AKI versus standard care. There were no differences in overall complications, RRT, length of stay, or 30-day mortality.
Impact: This large, pragmatic RCT provides high-level evidence challenging the clinical utility of HPI-guided therapy to prevent postoperative AKI, informing device adoption and intraoperative management strategies.
Clinical Implications: Routine intraoperative use of HPI-guided algorithms to reduce postoperative AKI is not supported; clinicians should prioritize established hemodynamic strategies and individualized care rather than relying on HPI thresholds.
Key Findings
- Moderate-to-severe AKI within 7 days: 6.1% (HPI) vs 7.0% (standard); RR 0.89 (95% CI 0.54–1.49), P=0.66.
- No differences in overall complications (31.9% vs 29.7%), renal replacement therapy, hospital length of stay (median 6 days in both), or 30-day mortality (1.1% vs 0.9%).
- Interventions were triggered at HPI >80 using fluids and vasoactive agents, yet outcomes were unchanged versus real-world standard care.
Methodological Strengths
- Multicenter, randomized, intention-to-treat design with a large sample (n=917).
- Clinically relevant endpoints including KDIGO-based AKI, complications, and 30-day mortality.
Limitations
- Open-label design with heterogeneous standard-care comparators across 28 hospitals.
- Potentially underpowered to detect small absolute differences in relatively low AKI rates.
Future Directions: Evaluate refined hemodynamic algorithms (e.g., individualized blood pressure targets, microcirculatory/end-organ perfusion markers) and assess cost-effectiveness and patient-centered outcomes.
2. Intraosseous and intravenous vascular access during adult cardiac arrest: A systematic review and meta-analysis.
Across three randomized trials (n=9,332) in out-of-hospital cardiac arrest, initial intraosseous access did not improve 30-day survival or favorable neurological outcome compared with intravenous access and was associated with lower odds of sustained ROSC.
Impact: This meta-analysis of randomized trials provides high-level evidence to guide first-line vascular access choices during cardiac arrest, a frequent responsibility for anesthesiologists and resuscitation teams.
Clinical Implications: When feasible, prioritize rapid intravenous access for initial drug delivery during adult cardiac arrest; intraosseous remains an important backup but may be less likely to achieve sustained ROSC.
Key Findings
- 30-day survival: no difference IO vs IV (OR 0.99, 95% CI 0.84–1.17; moderate-certainty).
- Favorable neurological outcome: no difference (OR 1.07, 95% CI 0.88–1.30; low-certainty).
- Sustained ROSC was lower with IO (OR 0.89, 95% CI 0.80–0.99; moderate-certainty).
Methodological Strengths
- Randomized evidence synthesis with prespecified outcomes and GRADE assessment.
- Large cumulative sample size (n>9,000) enhancing precision for key outcomes.
Limitations
- Limited to out-of-hospital cardiac arrest; applicability to in-hospital settings uncertain.
- Heterogeneity in IO sites, timing, and concomitant interventions across trials.
Future Directions: Research should clarify optimal access sequences integrating ultrasound-guided IV, IO placement speed/quality, and pharmacokinetic consequences, and evaluate training/algorithm adherence in real-world resuscitation systems.
3. Updating probability of pathogenicity for RYR1 and CACNA1S exon variants in individuals without malignant hyperthermia after exposure to triggering anesthetics.
Linking biobank genotypes with real-world exposures to triggering anesthetics in 253 patients allowed Bayesian reclassification of many RYR1/CACNA1S variants, downgrading 45% overall and 72% of VUS to benign/likely benign when unique exposures were considered.
Impact: Introduces a pragmatic, data-driven approach to variant classification in malignant hyperthermia by incorporating anesthetic exposure outcomes, reducing uncertainty and improving perioperative risk assessment.
Clinical Implications: Genetic counseling and perioperative planning for suspected MH can be refined by incorporating anesthetic exposure history with biobank-linked evidence, potentially reducing unnecessary alerts and guiding testing.
Key Findings
- Among 107 variants assessed with exposure data, 48 (45%) were downgraded (9 to benign, 37 to likely benign, 2 to VUS).
- Of 57 variants of uncertain significance (VUS), 41 (72%) were downgraded to benign or likely benign with unique exposure evidence.
- Counting repeat anesthetics per individual as one exposure still led to 39% downgrading overall and 65% of VUS to likely benign.
Methodological Strengths
- Bayesian application of ACMG/AMP framework integrating real-world anesthetic exposure data.
- Use of biobank-scale genotyping enabling systematic variant reassessment.
Limitations
- Retrospective design with potential selection and exposure misclassification biases.
- Lack of functional validation for reclassified variants and limited generalizability beyond the biobank cohort.
Future Directions: Prospective validation combining in vitro functional assays, contracture testing, and multi-institutional anesthetic exposure registries to formalize evidence weighting in MH variant classification.