Daily Anesthesiology Research Analysis
Three impactful studies shape perioperative anesthesia practice this cycle: (1) the fifth edition ASRA guidelines update regional anesthesia management in patients on antithrombotic/thrombolytic therapy with pragmatic, safety-focused recommendations; (2) a Bayesian network meta-analysis compares pediatric cardiothoracic regional analgesia techniques, highlighting opioid-sparing benefits; and (3) a multicenter observational study links intraoperative ulinastatin to lower postoperative delirium af
Summary
Three impactful studies shape perioperative anesthesia practice this cycle: (1) the fifth edition ASRA guidelines update regional anesthesia management in patients on antithrombotic/thrombolytic therapy with pragmatic, safety-focused recommendations; (2) a Bayesian network meta-analysis compares pediatric cardiothoracic regional analgesia techniques, highlighting opioid-sparing benefits; and (3) a multicenter observational study links intraoperative ulinastatin to lower postoperative delirium after cardiac surgery, with mechanistic support via endothelial glycocalyx preservation.
Research Themes
- Regional anesthesia safety with antithrombotic therapy
- Opioid-sparing pediatric cardiothoracic analgesia
- Delirium prevention via endothelial glycocalyx protection in cardiac surgery
Selected Articles
1. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (fifth edition).
This fifth edition provides safety-focused, evidence-based recommendations for regional and neuraxial anesthesia in patients receiving antithrombotic or thrombolytic therapy. Notable updates include adopting ‘low-dose’/‘high-dose’ terminology, conservative interruption intervals, and guidance on when drug-specific assays can inform timing of blocks and catheter management.
Impact: These guidelines directly influence perioperative decision-making globally and reduce the risk of neuraxial hematoma in anticoagulated patients. The reframed dosing and lab testing approach offers practical clarity for complex antithrombotic regimens.
Clinical Implications: Clinicians can align block timing and catheter management with conservative interruption intervals, stratified by low/high dose categories and complemented by drug-specific assays when available. This supports safer regional/neuraxial techniques in patients on DOACs, heparins, antiplatelets, and fibrinolytics.
Key Findings
- Terminology shift to ‘low dose’ and ‘high dose’ replaces ‘prophylactic/therapeutic’ to better reflect clinical dosing contexts.
- Conservative, safety-first interruption intervals are maintained to minimize neuraxial bleeding risk in rare but catastrophic events.
- Drug-specific assays (e.g., anti-Xa, direct oral anticoagulant levels) are suggested in select scenarios to guide timing of neuraxial procedures.
- Guideline is reorganized and condensed while clearly indicating changes from prior editions.
Methodological Strengths
- Evidence-based synthesis spanning multiple antithrombotic classes with explicit recommendations.
- Clear operational guidance on laboratory assays and timing, enhancing applicability.
Limitations
- True incidence of neuraxial hemorrhage is extremely low, limiting high-quality randomized evidence.
- Conservative intervals may delay care in certain scenarios and require local adaptation to resources and assays.
Future Directions: Prospective registries and pharmacodynamic studies to validate lab thresholds and refine safe intervals for newer agents; evaluation of outcomes with assay-guided neuraxial strategies.
2. Regional Analgesia in Pediatric Cardiothoracic Surgery: A Bayesian Network Meta-Analysis.
Across 24 RCTs (n=1602), all 13 regional techniques reduced 24-hour opioid consumption after pediatric cardiothoracic surgery. Thoracic retrolaminar block had the largest opioid-sparing effect; time to first rescue was longest with pectoral nerve blocks, and PONV incidence was lowest with epidural and transversus thoracis muscle plane blocks. Heterogeneity limits indirect comparisons.
Impact: This analysis provides comparative efficacy data to guide block selection in a high-stakes pediatric population where opioid minimization and recovery optimization are critical.
Clinical Implications: Consider thoracic retrolaminar block for maximal opioid-sparing and pectoral nerve blocks for prolonged analgesia; epidural and transversus thoracis muscle plane blocks may lower PONV. Individualize technique based on surgical approach, expertise, and risk profile, and standardize outcome tracking.
Key Findings
- Network meta-analysis of 24 RCTs (n=1602) across 13 regional techniques showed universal reduction in 24-hour opioid use.
- Thoracic retrolaminar block ranked best for opioid consumption reduction; pain score advantages were modest except immediately postoperative.
- Time to first rescue analgesic was longest with pectoral nerve blocks; PONV incidence was lowest with epidural and transversus thoracis muscle plane blocks.
- Indirect comparisons were limited by heterogeneity across studies.
Methodological Strengths
- Bayesian network meta-analysis enabling comparative ranking across multiple techniques.
- Restriction to randomized trials enhances internal validity.
Limitations
- Heterogeneity in block techniques, dosing, and outcome measures limits precision of indirect comparisons.
- Sparse head-to-head trials between certain blocks; safety outcomes variably reported.
Future Directions: Conduct adequately powered head-to-head RCTs with standardized dosing, sedation, and safety outcomes; evaluate long-term recovery metrics and enhanced recovery pathways.
3. Ulinastatin treatment mitigates glycocalyx degradation and associated with lower postoperative delirium risk in patients undergoing cardiac surgery: a multicentre observational study.
Across a large retrospective cohort (n=6522) with propensity matching and a validating prospective cohort (n=241), intraoperative ulinastatin use was associated with reduced postoperative delirium after cardiac surgery (prospective adjusted OR 0.392). In vitro, ulinastatin mitigated endothelial glycocalyx degradation, providing a biologic mechanism.
Impact: Links a feasible intraoperative intervention to lower delirium risk and identifies endothelial glycocalyx preservation as a mechanistic target in cardiac surgery.
Clinical Implications: Ulinastatin may be considered within multimodal delirium prevention strategies in cardiac surgery, pending randomized trials. Monitoring and targeting endothelial glycocalyx integrity could inform perioperative anti-inflammatory protocols.
Key Findings
- Intraoperative ulinastatin administration was associated with significantly lower postoperative delirium in a 6,522-patient retrospective cohort (supported by propensity score matching).
- A 241-patient prospective cohort validated the association (adjusted OR 0.392, 95% CI 0.157–0.977).
- In vitro assays showed ulinastatin mitigates endothelial glycocalyx degradation after ischemia-reperfusion stress, suggesting a mechanistic basis.
Methodological Strengths
- Large multicenter retrospective cohort with multivariable analysis and propensity score matching.
- Prospective cohort validation plus mechanistic in vitro experiments.
Limitations
- Observational design cannot exclude residual confounding; dosing and timing heterogeneity likely.
- Delirium ascertainment methods and generalizability outside study settings may vary.
Future Directions: Randomized controlled trials to confirm causality and define optimal dosing/timing; biomarker-driven strategies (e.g., syndecan-1) to monitor glycocalyx and personalize therapy; assess long-term cognitive outcomes.