Daily Anesthesiology Research Analysis
Three studies likely to influence anesthetic practice emerged today: a large prospective cohort shows point-of-care haemoglobin devices lack sufficient agreement for transfusion decisions in surgery; a PROSPERO-registered meta-analysis identifies prophylactic lidocaine and dexmedetomidine as effective in reducing pediatric perioperative respiratory adverse events; and a multi-center cohort suggests adjunctive cryoprecipitate may be associated with better outcomes than fresh frozen plasma in blee
Summary
Three studies likely to influence anesthetic practice emerged today: a large prospective cohort shows point-of-care haemoglobin devices lack sufficient agreement for transfusion decisions in surgery; a PROSPERO-registered meta-analysis identifies prophylactic lidocaine and dexmedetomidine as effective in reducing pediatric perioperative respiratory adverse events; and a multi-center cohort suggests adjunctive cryoprecipitate may be associated with better outcomes than fresh frozen plasma in bleeding cardiac surgery patients receiving platelets.
Research Themes
- Perioperative monitoring accuracy and transfusion decision-making
- Prevention of pediatric perioperative respiratory adverse events
- Blood product strategy in cardiac surgery bleeding
Selected Articles
1. Evaluation of point-of-care haemoglobin measurement accuracy in surgery (PREMISE) and implications for transfusion practice: a prospective cohort study.
In a two-centre prospective cohort (1139 patients; 1735 intraoperative samples), none of the point-of-care haemoglobin devices achieved agreement within ±4 g/L of laboratory values in the clinically crucial 60–100 g/L range. These findings question reliance on point-of-care haemoglobin for transfusion decisions during noncardiac surgery.
Impact: Transfusion decisions hinge on small haemoglobin differences near thresholds; demonstrating inadequate agreement can directly change intraoperative transfusion workflows and device selection.
Clinical Implications: Avoid sole reliance on point-of-care haemoglobin for transfusion decisions near thresholds; confirm with laboratory measurements or use decision strategies that incorporate uncertainty. Reassess institutional patient blood management algorithms and device procurement.
Key Findings
- Prospective two-centre cohort with 1139 patients and 1735 intraoperative samples assessed three point-of-care haemoglobin devices.
- No device achieved limits of agreement within ±4 g/L compared to laboratory haemoglobin, including in 680 samples with lab Hgb <100 g/L.
- Findings specifically challenge device accuracy in the 60–100 g/L range where transfusion decisions are most sensitive.
Methodological Strengths
- Prospective diagnostic cohort with concurrent paired comparisons to laboratory standards at two academic centres.
- Predefined agreement threshold (±4 g/L) focusing on clinically relevant haemoglobin ranges (60–100 g/L).
Limitations
- Did not evaluate downstream patient outcomes based on transfusion decisions altered by device readings.
- Potential variation by sampling site and device-specific performance was not fully detailed in the abstract.
Future Directions: Conduct outcome-focused trials integrating device uncertainty into transfusion algorithms; evaluate device-specific calibration or hybrid strategies combining point-of-care and lab measurements.
BACKGROUND: Point-of-care testing devices to measure haemoglobin (Hgb) frequently inform transfusion decision-making in surgery. This study aimed to examine their accuracy in surgery, focusing on Hgb concentrations of 60-100 g L METHODS: This was a prospective diagnostic cohort study focused on method comparison, conducted at two academic hospitals. Consecutive patients undergoing noncardiac surgery and requiring point-of-care Hgb measurements were eligible. Hgb concentrations from arterial and central venous blood samples were measured concurrently using three devices and compared with laboratory Hgb. The primary outcome was individual pairwise comparisons between point-of-care and laboratory Hgb values; agreement was determined based on a threshold of within 4 g L RESULTS: A total of 1735 intraoperative blood samples were collected (1139 participants); 680 samples had a laboratory Hgb <100 g L CONCLUSIONS: No point-of-care Hgb device demonstrated limits of agreement that were smaller than the agreement difference of 4 g L
2. Prophylactic pharmacological interventions against perioperative respiratory adverse events in children undergoing noncardiac surgery: a systematic review and meta-analysis.
Across 29 RCTs (n=4452), prophylactic lidocaine and dexmedetomidine significantly reduced overall perioperative respiratory adverse events in children, with reductions observed for laryngospasm, coughing, and oxygen desaturation versus placebo. Findings support structured prophylactic strategies in high-risk pediatric anesthesia.
Impact: PRAE are common and preventable drivers of pediatric perioperative morbidity; synthesizing RCT evidence for specific agents can inform guideline updates and standardized prophylaxis protocols.
Clinical Implications: Consider prophylactic lidocaine or dexmedetomidine in children at high risk of PRAE, integrating dosing and monitoring protocols within multimodal airway safety pathways. Tailor to surgical context and comorbidities.
Key Findings
- Included 29 randomized controlled trials with 4452 pediatric patients undergoing noncardiac surgery.
- Lidocaine reduced overall PRAE (OR 0.27, 95% CI 0.17–0.42) and laryngospasm (OR 0.38, 95% CI 0.22–0.67) versus placebo.
- Dexmedetomidine reduced overall PRAE (OR 0.31, 95% CI 0.12–0.76), laryngospasm (OR 0.31, 95% CI 0.10–0.91), coughing (OR 0.24, 95% CI 0.14–0.41), and oxygen desaturation (OR 0.54, 95% CI 0.35–0.84).
Methodological Strengths
- PROSPERO-registered systematic review with Cochrane risk-of-bias assessment and pairwise meta-analyses.
- Focused on clinically relevant PRAE subtypes (e.g., laryngospasm, bronchospasm, desaturation) in randomized trials.
Limitations
- Heterogeneity across dosing regimens, timing, and routes may limit direct protocol adoption.
- Abstract truncation precludes full appraisal of all intervention classes and comparative efficacy.
Future Directions: Standardize dosing and timing in future RCTs; perform network meta-analysis for head-to-head comparisons; evaluate safety profiles and long-term outcomes.
PURPOSE: Perioperative respiratory adverse event (PRAE) is one of the most common complications in pediatric anesthesia. We aimed to evaluate the efficacy of perioperative pharmacological interventions to prevent the development of PRAE in children undergoing noncardiac surgery. METHODS: PubMed, Embase, Cochrane Library and ClinicalTrials.gov were searched for randomized controlled trials (RCT) of prophylactic pharmacological interventions for PRAE among surgical children from inception to 5 August 2024. Pairwise meta-analyses were conducted to compare the effects of an intervention with placebo or another intervention on overall PRAE and their subtypes, including laryngospasm, bronchospasm, oxygen desaturation, airway obstruction, coughing and stridor. Risk of bias was assessed using the Cochrane Collaboration tool. RESULTS: Seven categories of prophylactic interventions were identified. Twenty-nine RCTs with 4452 children were included. Compared with placebo, lidocaine reduced the odds ratio (OR) of overall PRAE ( 0.27 [95% CI] [0.17, 0.42]) and laryngospasm (0.38 [0.22, 0.67]); dexmedetomidine reduced the OR of PRAE (0.31 [0.12, 0.76]), laryngospasm (0.31 [0.10, 0.91]), coughing (0.24 [0.14, 0.41]) and oxygen desaturation (0.54 [0.35, 0.84]); β CONCLUSIONS: The meta-analysis demonstrated prophylactic potential of lidocaine, dexmedetomidine, β TRIAL REGISTRATION: PROSPERO (CRD42020220028). Registered 11 December 2020. Updated 3 September 2024.
3. Adjunctive Fresh Frozen Plasma Versus Adjunctive Cryoprecipitate in Cardiac Surgery Patients Receiving Platelets for Perioperative Bleeding.
In 12,889 cardiac surgery patients receiving platelets for perioperative bleeding, adjunctive fresh frozen plasma (vs cryoprecipitate) was associated with higher operative and 1-year mortality, acute kidney injury, infection, and longer ICU stay after entropy balancing. Results suggest potential benefit of cryoprecipitate as adjunctive therapy.
Impact: Large multi-center evidence with advanced causal adjustment challenges common plasma-first strategies and could reshape cardiac surgical bleeding protocols.
Clinical Implications: When platelets are indicated for perioperative bleeding in cardiac surgery, consider cryoprecipitate as the adjunctive product of choice while awaiting prospective validation; embed product selection into goal-directed hemostasis algorithms.
Key Findings
- Multi-institutional cohort from 58 centers (2005–2021) included 12,889 platelet-transfused cardiac surgery patients.
- Compared with cryoprecipitate, adjunctive FFP was associated with higher operative mortality (RR 1.49) and 1-year mortality (RR 1.37) after entropy balancing.
- FFP use was also associated with increased acute kidney injury (RR 1.16), all-cause infection (RR 1.14), and longer ICU stay (mean +8.02 days).
Methodological Strengths
- Very large, multi-center cohort with contemporary practice trends and extensive covariate balancing (IPTW with entropy balancing).
- Multiple clinically meaningful endpoints including operative and 1-year mortality and organ complications.
Limitations
- Observational design with potential residual confounding and indication bias despite advanced weighting.
- Granular laboratory hemostasis metrics and product dosing details may be limited in registry data.
Future Directions: Prospective comparative effectiveness studies or pragmatic RCTs to validate product selection; integrate viscoelastic-guided algorithms to tailor adjunct choice.
OBJECTIVE(S): This study was designed to assess the relative association between adjunctive fresh frozen plasma (FFP) or adjunctive cryoprecipitate and morbidity and mortality in cardiac surgery patients receiving platelets for perioperative bleeding. DESIGN: Retrospective cohort study using inverse probability of treatment weighting with entropy balancing. SETTING: Multi-institutional study of 58 centers using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database from January 1, 2005, to December 31, 2021. PARTICIPANTS: Cardiac surgery patients who received platelets for perioperative bleeding. INTERVENTIONS: Adjunctive FFP versus adjunctive cryoprecipitate transfusion in the perioperative period. MEASUREMENTS AND MAIN RESULTS: A total of 12,889 platelet-transfused patients were assessed. Of these, 8,764 received adjunctive FFP and 4,125 received adjunctive cryoprecipitate, with cryoprecipitate increasing over time relative to FFP. After entropy balancing, compared with adjunctive cryoprecipitate, adjunctive FFP transfusion was associated with increased operative mortality (relative risk [RR]: 1.49, 95% confidence interval [CI]: 1.24, 1.79, p < 0.001); 1-year mortality (RR: 1.37, 95% CI: 1.13, 1.66, p = 0.001); increased risk of acute kidney injury (RR: 1.16, 95% CI: 1.02, 1.33, p = 0.024); all-cause infection (RR: 1.14, 95% CI: 1.02, 1.29, p = 0.026), and intensive care length of stay in days (adjusted mean difference: 8.02, 95% CI: 1.72, 14.33, p = 0.013). CONCLUSIONS: In cardiac surgery patients receiving platelets for perioperative bleeding, adjunctive FFP was independently associated with greater morbidity and mortality compared with adjunctive cryoprecipitate. These hypothesis-generating findings warrant further prospective investigation.