Daily Anesthesiology Research Analysis
Three studies with direct perioperative and critical care relevance stood out: a large randomized trial showed that adding nasal clips to standard nasal cannula oxygen reduced hypoxemia during sedated gastrointestinal endoscopy; a double-blind randomized ICU trial found esketamine provides hemodynamically stable induction for emergency intubation and shortens ventilation and ICU stay; and a secondary analysis of a multicenter RCT suggested intravenous amino acids reduce acute kidney injury in ca
Summary
Three studies with direct perioperative and critical care relevance stood out: a large randomized trial showed that adding nasal clips to standard nasal cannula oxygen reduced hypoxemia during sedated gastrointestinal endoscopy; a double-blind randomized ICU trial found esketamine provides hemodynamically stable induction for emergency intubation and shortens ventilation and ICU stay; and a secondary analysis of a multicenter RCT suggested intravenous amino acids reduce acute kidney injury in cardiac surgery patients requiring temporary mechanical circulatory support.
Research Themes
- Peri-procedural oxygenation strategies in sedated endoscopy
- Hemodynamically stable induction agents for ICU intubation
- Renal protection strategies in high-risk cardiac surgery
Selected Articles
1. Efficacy and safety of esketamine for emergency endotracheal intubation in ICU patients: a double-blind, randomized controlled clinical trial.
In a double-blind RCT of 80 ICU patients requiring emergency intubation, esketamine maintained higher MAP during and after induction without increasing heart rate, reduced norepinephrine requirements, and significantly shortened ventilation duration and ICU length of stay. No difference in 28-day mortality or serious adverse events was observed.
Impact: Demonstrates a hemodynamically stable induction option that improves ICU resource outcomes in a high-risk scenario. Findings can immediately inform drug selection for rapid-sequence induction in critically ill adults.
Clinical Implications: Consider esketamine as an induction agent for emergency intubations in hemodynamically fragile ICU patients to reduce vasopressor requirements, ventilation duration, and ICU stay, while monitoring for standard ketamine class effects.
Key Findings
- Esketamine maintained higher MAP during induction and at 1, 5, and 10 minutes post-intubation compared with midazolam/sufentanil.
- Ventilation duration was reduced (median 105.3 vs 211.5 hours, P=0.002) and ICU length of stay shortened (median 7.0 vs 15.0 days, P=0.002).
- Norepinephrine requirements were lower with esketamine; heart rate and 28-day mortality were not different and no serious adverse events occurred.
Methodological Strengths
- Prospective, double-blind, randomized controlled design
- Clinically relevant outcomes (vasopressor use, ventilation duration, ICU LOS) with objective hemodynamic measures
Limitations
- Single-center study with modest sample size (n=80)
- No difference in 28-day mortality; not powered for hard endpoints
Future Directions: Larger multicenter RCTs comparing esketamine to etomidate/ketamine/propofol across phenotypes (shock, sepsis, TBI), with standardized co-induction and neuromuscular blockade, and longer-term neurologic and mortality outcomes.
Emergency endotracheal intubation in critically ill patients are dangerous procedures with a greater risk of severe hypotension The efficacy and safety of esketamine with sympathoexcitatory effects for rapid sequence induction in critically ill patients remain unclear. In this prospective double-blinded randomized controlled trial, adult patients were randomly assigned to receive either esketamine or midazolam/sufentanil admixture for induction. The primary outcomes were the effects of induction with esketamine or midazolam/sufentanil admixture on hemodynamic responses (heart rate (HR) and mean arterial pressure (MAP) during and after induction). Secondary outcomes were the duration of ventilation support, length of intensive care unit (ICU) stay, 28-day mortality. We enrolled 80 patients, of whom 38 were assigned to the esketamine group and 42 to the midazolam/sufentanil admixture group. The MAP in group esketamine was significantly higher than that in group midazolam/sufentanil admixture during the induction, and at 1 min, 5 min and 10 min after intubation. No significant differences in HR between groups were observed. The duration of ventilation support [105.3 (interquartile range (IQR) 40.9 - 248.3) hours vs. 211.5 (IQR 122.1 - 542.1) hours, P = 0.002] and the length of ICU stay [7.0 (IQR 4.0 - 16.3) days vs. 15.0 (IQR 8.0 - 26.0) days, P = 0.002] were significantly decreased in group esketamine, compared to that in group midazolam/sufentanil admixture. In group esketamine, less norepinephrine [0.00 (IQR 0.00 - 0.10) µg/kg/min vs. 0.09 (IQR 0.00 - 0.29) µg/kg/min, P = 0.016] was needed. There was no significant difference in 28-day mortality between the two groups. No serious adverse events occurred. In conclusion, esketamine is a hemodynamically stable induction agent in critically ill patients, which could reduce the length of ICU stay and the duration of ventilation support.Trial registration: clinicaltrials.gov (19/07/2022; NCT05464979).
2. Efficacy of nasal clips combined with nasal cannulas in preventing hypoxemia during gastrointestinal endoscopy with sedation: a randomized controlled trial.
In 600 sedated endoscopy patients, adding nasal clips to standard nasal cannula oxygen significantly reduced hypoxemia incidence versus cannula alone (17.7% vs 25%; RR 0.707). The lowest SpO2 improved and adverse events were tolerable, supporting a simple, low-cost intervention to enhance periprocedural oxygenation.
Impact: Large randomized evidence for a widely applicable, low-cost modification that improves safety during sedated endoscopy, a high-volume anesthetic practice.
Clinical Implications: Adopt nasal clips with nasal cannula oxygen during sedated endoscopy—especially in patients at risk of hypoxemia—to reduce desaturation events and improve nadir SpO2.
Key Findings
- Hypoxemia incidence decreased from 25.0% to 17.7% with nasal clips (RR 0.707, 95% CI 0.516–0.967, P=0.029).
- Lowest SpO2 during the procedure improved in the nasal clip group (median and IQR improved; details reported by authors).
- Adverse events were tolerable without excess complications compared to cannula alone.
Methodological Strengths
- Large sample size randomized controlled design (n=600)
- Intention-to-treat analysis with clinically meaningful primary endpoint
Limitations
- Single-country study; sedation regimens and oxygen flow settings may affect generalizability
- Blinding likely not feasible, which could influence ancillary care
Future Directions: Evaluate effectiveness across different sedation protocols, high-risk populations (OSA, obesity), and cost-effectiveness analyses to inform widespread adoption.
BACKGROUND: Gastrointestinal endoscopy with sedation is frequently complicated by hypoxemia. Nasal cannulas have limitations in eliminating hypoxemia. We hypothesized that the combination of nasal clips and nasal cannulas would improve the inspired oxygen concentrations and prevent hypoxemia compared with the use of nasal cannulas alone. METHODS: A total of 600 adult patients were randomly assigned to receive supplemental oxygen through single-lumen nasal cannulas or through the combination of nasal clips and nasal cannulas. The primary outcome was the incidence of hypoxemia. Additionally, subclinical respiratory depression and severe hypoxemia, duration of hypoxemia, lowest SpO RESULTS: Three hundred patients in the nasal clip group and 296 patients in the nasal cannula group were included in the intention-to-treat analysis. Nasal clips significantly decreased the incidence of hypoxemia from 25.0-17.7%(RR = 0.707, 95% CI = 0.516 to 0.967, P = 0.029). The median and interquartile range of lowest SpO CONCLUSIONS: The combination of nasal clips and cannulas reduces hypoxemia during gastrointestinal endoscopy with sedation, demonstrating a significant advantage over the sole use of nasal cannulas, with tolerable adverse events. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2200065407).
3. Intravenous amino acids for renal protection in patients receiving temporary mechanical circulatory support: a secondary subgroup analysis of the PROTECTION study.
In the tMCS subgroup (n=232) of a multicenter RCT in cardiac surgery, intravenous amino acids (up to 100 g/day) reduced AKI incidence versus placebo (44.6% vs 60.8%; RR 0.73; NNT=6) despite higher baseline creatinine in the AA group. Secondary outcomes did not differ.
Impact: Targets a high-risk cardiac anesthesia cohort where AKI is common and morbid; suggests a simple perioperative nutritional-pharmacologic intervention with favorable NNT.
Clinical Implications: For cardiac surgery patients on tMCS, consider perioperative intravenous amino acid infusion protocols to mitigate AKI risk, with attention to dosing limits and renal monitoring.
Key Findings
- AKI incidence lowered with AA infusion vs placebo in tMCS patients (44.6% vs 60.8%; RR 0.73; 95% CI 0.57–0.94; P=0.01; NNT=6).
- AA group had higher baseline serum creatinine yet showed reduced AKI risk.
- No significant differences in secondary outcomes; effect specific to AKI endpoint.
Methodological Strengths
- Derived from a large multicenter randomized trial with standardized intervention dosing
- Clinically meaningful primary endpoint (AKI) and prespecified subgroup of high-risk patients
Limitations
- Secondary subgroup analysis with potential for residual confounding and imbalance (baseline creatinine higher in AA group)
- Not powered for secondary outcomes; external validity depends on tMCS practices
Future Directions: Prospective confirmation in an a priori stratified tMCS cohort with renal biomarker panels, dose–response evaluation, and cost-effectiveness analyses.
OBJECTIVES: In cardiac surgery patients, acute kidney injury (AKI) frequently occurs in the setting of haemodynamic instability and treatment with temporary mechanical circulatory support (tMCS). Recent evidence suggests amino acids (AA) infusion may reduce AKI rate. However, the effect of AA infusion in patients requiring tMCS may be less effective. METHODS: We performed a secondary analysis of the PROTECTION multicentre randomized controlled trial including all patients treated with tMCS. Patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomized to receive 2 g/kg ideal body weight/day of intravenous AA to a maximum of 100 g/day or matching placebo from operating room admission until up to 3 days, receipt of renal-replacement therapy, discharge from ICU or death. The primary outcome of the PROTECTION study was the rate of AKI, as in this secondary analysis. A total of 3511 patients were randomized in the study. RESULTS: We studied 232 patients who received tMCS, 112 randomized to AA infusion and 120 to placebo. The median preoperative serum creatinine value was significantly higher among AA group patients (AA: 1.08, interquartile range 0.90-1.26; placebo: 0.98, interquartile range 0.85-1.15; P = 0.02). The rate of AKI, however, was lower in patients randomized to AA (44.6% vs 60.8%; relative risk 0.73; 95% confidence interval (0.57-0.94); P = 0.01; number needed to treat = 6). We found no significant differences in secondary outcomes. CONCLUSIONS: Short-term AA infusion appears to reduce rate of AKI among patients requiring tMCS. Use of AA in this population at high-risk for renal failure appears justified. CLINICAL TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03709264.