Daily Anesthesiology Research Analysis
Three high-impact perioperative studies stand out today: an international RCT shows early noninvasive ventilation on general wards reduces progression to severe respiratory failure; a secondary analysis of two large cohorts identifies preoperative eGFR as a top predictor of 30-day cardiac events; and a real-world, EHR-embedded closed-loop CDSS slashes low-value preoperative testing without harming outcomes.
Summary
Three high-impact perioperative studies stand out today: an international RCT shows early noninvasive ventilation on general wards reduces progression to severe respiratory failure; a secondary analysis of two large cohorts identifies preoperative eGFR as a top predictor of 30-day cardiac events; and a real-world, EHR-embedded closed-loop CDSS slashes low-value preoperative testing without harming outcomes.
Research Themes
- Perioperative risk stratification and prediction
- Digital health decision support and de-implementation of low-value care
- Respiratory support strategies outside the ICU
Selected Articles
1. Early noninvasive ventilation in general wards for acute respiratory failure: an international, multicentre, open-label, randomised trial.
In a multinational open-label RCT of 524 adults with mild acute respiratory failure on general wards, early NIV reduced progression to severe respiratory failure (18.5% vs 28.3%; RR 0.65) without differences in 28-day mortality, respiratory complications, or adverse events. Length of stay was similar.
Impact: This pragmatic RCT provides high-level evidence that ward-based early NIV prevents deterioration, informing resource-appropriate respiratory support strategies beyond ICUs.
Clinical Implications: Hospitals can implement protocolized, monitored early NIV on general wards for mild acute respiratory failure to reduce deterioration, with appropriate staff training and escalation pathways.
Key Findings
- Early NIV reduced progression to severe acute respiratory failure (18.5% vs 28.3%; RR 0.65, 95% CI 0.48-0.90, P=0.008).
- No differences in 28-day mortality, respiratory complications, or adverse events between groups.
- Hospital length of stay was similar (median 10 vs 9 days; P=0.30).
Methodological Strengths
- International, multicentre randomized controlled design with intention-to-treat analysis.
- Clinically meaningful, pragmatic endpoints applicable to real-world wards.
Limitations
- Open-label design may introduce performance bias.
- Study powered for progression outcome; mortality effects remain uncertain.
Future Directions: Evaluate implementation strategies, cost-effectiveness, and patient selection criteria for ward-based NIV; assess impacts on ICU admission and long-term outcomes.
BACKGROUND: The impact of noninvasive ventilation (NIV) managed outside the intensive care unit in patients with early acute respiratory failure remains unclear. We aimed to determine whether adding early NIV prevents the progression to severe respiratory failure. METHODS: In this multinational, randomised, open-label controlled trial, adults with mild acute respiratory failure (arterial oxygen partial pressure/fraction of inspiratory oxygen [Pao RESULTS: Between May 6, 2012, and July 18, 2023, we randomised 524 patients (44.8% female; median age 73 yr, interquartile range [IQR] 63-83 yr). One patient withdrew consent. Progression to severe acute respiratory failure occurred in 49/265 (18.5%) patients randomised to early NIV, compared with 73/258 (28.3%) patients receiving usual care (relative risk 0.65, 95% confidence interval 0.48-0.90, P=0.0080). Median length of hospital stay was 10 (IQR 6-16) days in the early NIV group and 9 (IQR 5-16) days in the usual care group (P=0.30). Respiratory complications, 28-day mortality, and adverse events were not different between early NIV and usual care. CONCLUSIONS: In patients with mild acute respiratory failure treated in nonintensive care wards, early NIV reduced the progression to severe acute respiratory failure. CLINICAL TRIAL REGISTRATION: NCT01572337.
2. Implementing a closed loop clinical decision support system for sustainable preoperative care.
A fully EHR-integrated closed-loop CDSS for preprocedural testing reduced chest X-rays by ~83%, ECGs by ~54%, blood typing by ~50%, and preop blood test panels by ~29% across 228,671 procedures, with €1.0M in savings and no increase in cancellations or adverse postoperative outcomes.
Impact: Demonstrates scalable de-implementation of low-value preoperative testing using an automated, closed-loop CDSS with substantial cost savings and safety preservation.
Clinical Implications: Health systems can embed closed-loop CDSS within EHRs to automate appropriate test ordering, reduce unnecessary preop testing, and cut costs without compromising safety.
Key Findings
- Chest X-ray orders decreased by ~83% after CDSS implementation (p<0.001).
- ECG orders fell by ~54%, blood type testing by ~50%, and preop blood test panels by ~29%.
- Estimated cost savings were €1,013,666 with no increase in same-day cancellations or postoperative adverse events.
Methodological Strengths
- Large-scale interrupted time series across 69 months and two hospitals.
- Full EHR integration enabling automated, closed-loop ordering and robust pre/post comparisons.
Limitations
- Quasi-experimental design susceptible to secular trends and unmeasured confounding.
- Conducted in two teaching hospitals in one region, which may limit generalizability.
Future Directions: Multicentre deployments with randomized or stepped-wedge designs; assess patient-centred outcomes and sustainability metrics (e.g., carbon footprint) alongside cost and safety.
Unnecessary preoperative testing poses a risk to patient safety, causes surgical delays, and increases healthcare costs. We describe the effects of implementing a fully EHR-integrated closed-loop clinical decision support system (CDSS) for placing automatic preprocedural test orders at two teaching hospitals in Madrid, Spain. Interrupted time series analysis was performed to evaluate changes in rates of preoperative testing after CDSS implementation, which took place from September 2019 to December 2019. We included 228,671 surgical procedures during a 69-month period from January 1st, 2018, to October 1st, 2023, of which 78,388 were from the preintervention period and 150,283 from the postimplementation period. We observed a significant reduction (p < 0.001) of 83% (-83.4% to -83.1%) for chest X-ray orders, 54% (-54.7% to -54.2%) for ECG orders, 50% for blood type testing (-50.5% to -50.1%), and 29% (-29.5% to -29.0%) for preoperative blood test order sets, leading to overall cost-savings of €1,013,666. No increase in postoperative adverse events or same-day cancellations was observed. Our results demonstrate that an EHR-embedded closed-loop CDSS can reduce avoidable preoperative testing without increasing surgical cancelations, postoperative adverse events, or early re-interventions, thus improving the quality of care and healthcare expenditure.
3. Preoperative estimated glomerular filtration rate to predict cardiac events in major noncardiac surgery: a secondary analysis of two large international studies.
Across VISION (n=35,815) and POISE-2 (n=9,219), lower preoperative eGFR showed a strong, graded association with 30-day cardiac events, with attenuation at older ages. Adding continuous eGFR (and its age interaction) improved predictive information, discrimination, and net benefit in multivariable models.
Impact: Positions preoperative eGFR as a top-tier predictor for perioperative cardiac risk, enabling refinement of risk calculators used by anesthesiologists and surgeons.
Clinical Implications: Incorporate continuous eGFR (with age interaction) into preoperative risk assessments to improve identification of patients at cardiac risk and guide optimization and monitoring strategies.
Key Findings
- Lower preoperative eGFR had a strong, graded association with 30-day cardiac events in both VISION and POISE-2.
- The association was attenuated by older age, indicating an age interaction.
- Adding continuous eGFR improved predictive information, discrimination (C-statistic), and net benefit in multivariable models.
Methodological Strengths
- Large combined sample from two independent international cohorts/trials.
- Modeling of eGFR as a continuous, nonlinear variable with interaction testing.
Limitations
- Secondary analysis; residual confounding cannot be excluded.
- Generalizability to urgent or outpatient procedures requires confirmation.
Future Directions: External validation and integration of continuous eGFR with age interaction into perioperative risk calculators; evaluate effects on clinical decision-making and outcomes.
BACKGROUND: Optimised use of kidney function information might improve cardiac risk prediction in noncardiac surgery. METHODS: In 35,815 patients from the VISION cohort study and 9219 patients from the POISE-2 trial who were ≥45 yr old and underwent nonurgent inpatient noncardiac surgery, we examined (by age and sex) the association between continuous nonlinear preoperative estimated glomerular filtration rate (eGFR) and the composite of myocardial injury after noncardiac surgery, nonfatal cardiac arrest, or death owing to a cardiac cause within 30 days after surgery. We estimated contributions of predictive information, C-statistic, and net benefit from eGFR and other common patient and surgical characteristics to large multivariable models. RESULTS: The primary composite occurred in 4725 (13.2%) patients in VISION and 1903 (20.6%) in POISE-2; in both studies cardiac events had a strong, graded association with lower preoperative eGFR that was attenuated by older age (P CONCLUSIONS: Continuous preoperative eGFR is among the best cardiac risk predictors in noncardiac surgery of the large set examined. Along with its interaction with age, preoperative eGFR would improve risk calculators. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00512109 (VISION) and NCT01082874 (POISE-2).