Daily Anesthesiology Research Analysis
Three impactful studies in anesthesiology and perioperative care emerged: a network meta-analysis suggests late extubation after adult cardiac surgery reduces extubation failure compared with early or on-table strategies; a prospective study found that mean arterial pressure (MAP) alerts can match the hypotension prediction index (HPI) performance when time-dependence is added; and a large cohort of electroconvulsive therapy (ECT) patients showed that COVID-era anesthetic dose reduction decrease
Summary
Three impactful studies in anesthesiology and perioperative care emerged: a network meta-analysis suggests late extubation after adult cardiac surgery reduces extubation failure compared with early or on-table strategies; a prospective study found that mean arterial pressure (MAP) alerts can match the hypotension prediction index (HPI) performance when time-dependence is added; and a large cohort of electroconvulsive therapy (ECT) patients showed that COVID-era anesthetic dose reduction decreased bag-valve mask use but increased insufficient initial sedation and postictal agitation without harming clinical response or cognition.
Research Themes
- Airway and ventilation strategies after cardiac surgery
- Intraoperative hypotension prediction and monitoring
- Anesthetic dosing adaptations and outcomes in ECT
Selected Articles
1. Different extubation protocols for adult cardiac surgery: a systematic review and pairwise and network meta-analysis.
This systematic review and network meta-analysis (12 studies, n=1,454) found that late extubation after adult cardiac surgery was associated with higher success and lower extubation failure than early or on-table extubation. Despite this, early extubation may retain cost-effectiveness and safety advantages, underscoring the need for individualized strategy selection.
Impact: Challenges the prevailing paradigm of ultra-fast-track extubation by quantifying failure risk across strategies using NMA. Provides comparative evidence to guide protocol design and personalization in cardiac anesthesia and ICU care.
Clinical Implications: Consider late extubation as the default in patients at high risk of extubation failure, while weighing resource and cost advantages of early extubation for low-risk patients. Develop risk-stratified extubation pathways and monitor quality metrics (extubation failure, reintubation).
Key Findings
- Pairwise meta-analysis: late extubation outperformed on-table immediate extubation for protocol success (RR 1.52, 95% CI 1.21–1.91).
- Network meta-analysis: late extubation showed lower failure risk than early extubation and on-table extubation (RR 0.76 and 0.22, respectively).
- SUCRA ranking favored late extubation (94%) as most effective for minimizing extubation failure.
- Early extubation may still be advantageous for cost-effectiveness and safety, highlighting the need for individualized decisions.
Methodological Strengths
- Prospero-registered, PRISMA-adherent systematic review with both pairwise and network meta-analysis.
- Comparative effectiveness framework across multiple extubation strategies.
Limitations
- Heterogeneity in definitions and timing windows for early vs late extubation across studies.
- Limited number of studies and potential selection/publication bias; variable adjustment for confounders.
Future Directions: Prospective, multicenter RCTs with standardized extubation definitions and risk stratification are needed to balance failure risk against resource utilization and patient-centered outcomes.
BACKGROUND: With the advancement of ultra-fast track anesthesia, early extubation following cardiac surgery has become a prevailing trend. While there are significant benefits associated with early extubation, its high failure rate warrants further investigation, and the effectiveness of various extubation strategies in cardiac surgery still requires validation. METHODS: An extensive literature search was performed in the PubMed, Scopus, Embase, and Web of Science databases, encompassing studies without language restrictions. Eligible studies were those that compared the outcomes of various extubation strategies. RESULTS: Primary outcome was the success rate of the extubation protocol. Secondary outcomes were time to extubation, intensive care unit (ICU) length of stay (LOS), complications and mortality rate. Data from 12 studies, which included a total of 1454 participants, were included in the analysis. The pairwise meta-analysis revealed that late extubation was significantly more effective than immediate extubation strategies (relative risk [RR] = 1.52, 95% confidence interval [CI] = 1.21-1.91, P = 0.0001). In the network meta-analysis (NMA), the late extubation protocol was associated with a significantly lower risk of extubation failure compared to early extubation and extubation on the table (RR = 0.76, 95% CI: 0.5-1.16; RR = 0.22, 95% CI: 0.05-0.91). Furthermore, according to the SUCRA plot, late extubation was ranked as the most effective strategy for reducing extubation failure (94%). CONCLUSIONS: Our findings indicate that a late extubation strategy, as opposed to early (within a specified time frame) or immediate extubation, is correlate with a substantially higher rate of successful extubation. Despite this, the early extubation strategy seems to offer better cost-effectiveness and safety profiles. The selection of an appropriate extubation strategy should be personalized, taking into account the patient's preoperative characteristics and the circumstances encountered during surgery. TRIAL REGISTRATION: The study protocol adheres to the PRISMA statement and checklist. The protocol was registered at PROSPERO (CRD42024529051).
2. The hypotension prediction index versus mean arterial pressure in predicting intraoperative hypotension: A clinical perspective.
In a prospective cohort (n=91), HPI-85 alerts provided slightly earlier warning than MAP-70 but mainly excelled by higher PPV, while missed-event rates were similar. When a 40-second time condition was added, MAP alerts matched HPI across key metrics, suggesting time-dependent MAP thresholds could be a simpler alternative pending trials.
Impact: Directly informs the contentious question of whether proprietary HPI adds actionable value beyond MAP in predicting intraoperative hypotension. Offers a pragmatic modification (time-dependent MAP) that could democratize prediction without specialized algorithms.
Clinical Implications: If validated, implementing time-dependent MAP alerts (e.g., sustained MAP <72–75 mmHg for 40 s) may offer similar prediction with fewer false positives than instantaneous thresholds, while HPI remains useful where available for higher PPV.
Key Findings
- HPI-85 popups offered a mean 0.58-minute earlier alert than MAP-70, but differences narrowed at higher MAP thresholds.
- Positive predictive value was higher for HPI (≈56%) than MAP-75 (≈21%); missed-event proportions were similar (1–3%).
- Adding a 40-second time dependence to MAP alerts eliminated differences versus HPI across key metrics.
Methodological Strengths
- Prospective observational design with predefined alert definitions and multiple clinically relevant metrics (time-to-event, PPV, missed events).
- Trial registration and systematic comparison of instantaneous versus time-dependent alerts.
Limitations
- Single-center, modest sample size; device- and threshold-specific findings may limit generalizability.
- Observational design cannot assess downstream clinical outcomes or treatment algorithms triggered by alerts.
Future Directions: Randomized trials comparing HPI-driven management versus time-dependent MAP protocols should assess hypotension burden, organ injury, and overtreatment to define clinical equivalence or superiority.
BACKGROUND: The hypotension prediction index (HPI) predicts hypotension, with randomised trials showing a significant reduction in hypotension-related metrics. However, the reliability of previous validation studies is debated, and it's unclear if mean arterial pressure (MAP) can be used interchangeably with HPI. OBJECTIVES: This study compared the effectiveness of HPI versus MAP thresholds in predicting intraoperative hypotension, focusing on three clinically relevant metrics: time from alert to event, positive predictive value (PPV), and proportion of missed hypotensive events. DESIGN: Prospective observational study conducted between 2018 and 2020. SETTING: Single-centre, academic hospital in the Netherlands. PARTICIPANTS: Adults scheduled for elective non-cardiac surgery lasting over two hours. Of the 105 eligible patients, 91 had sufficient data for analysis. MAIN OUTCOME MEASURES: The primary outcome was the time-to-hypotensive event intervals predicted by HPI popup alerts (≥85 for ≥40 s) and MAP-alerts (70-75 mmHg). Secondary analyses examined differences between these predictors regarding the PPV and missed event rates, as well as the difference in these metrics between instant HPI-85 alerts and the six MAP-alerts. RESULTS: The largest time-to-event difference was seen between HPI-85 popup and MAP-70 alerts, with a gain of 0.58 (95% confidence interval (CI), 0.57 to 0.58) min, favouring HPI. Higher MAP thresholds reduced this time difference, but worsened PPV values, with 20.5 (95% CI, 20.3 to 20.6)% at MAP-75 compared to 55.6 (95% CI, 55.4 to 55.8)% for HPI-85 popups. Missed event proportions were similar: between one to three percent. Instant HPI-85 and MAP-72 alerts showed comparable performance, but both had suboptimal PPV values around 30%. However, adding a 40-s time-dependence to MAP's alert definition levelled the differences across the three evaluated metrics, aligning more closely with HPI-85 popup alerts. CONCLUSIONS: Using HPI-85 popup alerts does not provide additional prediction time over MAP-alerts in the 70 to 75 mmHg range, but they may be preferred due to higher PPV values. Instant HPI-85 and MAP-alerts perform similarly, with MAP-72 being closest, though these alerts more frequently occur regardless of subsequent hypotension with the potential to introduce unnecessary treatment. Adding a 40-s time-dependence to MAP-alerts to match the HPI popup characteristic eliminates distinctions between prediction time and missed events, while maintaining the higher PPV. However, whether 40sec-MAP-alerts are clinically equivalent remains to be determined in prospective clinical trials. TRIAL REGISTRATION: Clinicaltrials.gov NCT03795831 on 10 January 2019.
3. Tolerability and Clinical Outcomes With Anesthesia Dose Reduction During Electroconvulsive Therapy.
Among 616 ECT patients, pandemic-era anesthetic dose reduction (lower methohexital and succinylcholine) reduced BVM use to 13.8% without worsening treatment response or cognitive outcomes, but increased insufficient initial sedation and postictal agitation. Findings support targeted strategies to prevent/mitigate postictal agitation when using dose-sparing anesthesia.
Impact: Provides large real-world evidence guiding ECT anesthesia during infectious risk scenarios and beyond—balancing aerosol mitigation with patient safety and tolerability.
Clinical Implications: When dose-sparing to minimize BVM ventilation, anticipate higher rates of insufficient initial sedation and postictal agitation; consider preemptive measures (e.g., adjuncts, dosing algorithms) and standardized PIA management protocols.
Key Findings
- COVID-era cohort received lower methohexital (0.82 vs 0.87 mg/kg) and succinylcholine (0.33 vs 0.53 mg/kg) than pre-COVID.
- BVM use decreased to 13.8% during COVID-era practice modifications.
- Insufficient initial sedation (OR 2.16) and postictal agitation (OR 2.81) increased; other complications were similar.
- Treatment response (~68–71%) and cognitive impairment (~19–21%) did not differ between eras.
Methodological Strengths
- Large single-center cohort with clear exposure periods and multivariable logistic regression.
- Clinically relevant outcomes spanning complications, efficacy, and cognition.
Limitations
- Retrospective design and single-center setting; potential confounding due to pandemic-related practice changes.
- Generalizability may be limited to methohexital–succinylcholine ECT protocols.
Future Directions: Prospective studies to optimize anesthesia dosing algorithms that minimize aerosolization while preventing insufficient sedation and postictal agitation; evaluation of adjuncts and airway strategies.
IMPORTANCE: Electroconvulsive therapy (ECT) practice during the COVID-19 pandemic necessitated restriction of bag-valve mask (BVM) ventilation to minimize disease transmission through aerosolization. To reduce BVM use, many sites decreased doses of anesthesia agents, but the associations of such dose reduction with clinical and tolerability outcomes are unknown. OBJECTIVES: To investigate the association of COVID-19 pandemic modifications in ECT, including reduction in anesthetic dosage and BVM use, with the rates of clinical complications and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study included data from patients receiving an index course of ECT for any clinical indication treated with methohexital and succinylcholine between March 16, 2017, and March 15, 2023, at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada. Data analysis occurred from February to December 2024. EXPOSURE: Participants were split into 2 cohorts: pre-COVID-19 (treated between March 2017 and March 2020) and COVID-19 (treated between June 2020 and March 2023). MAIN OUTCOMES AND MEASURES: The primary outcomes were BVM use and rates of complications (specifically, aspiration, bradycardia, insufficient initial sedation dosage, postictal agitation [PIA], residual weakness, and prolonged seizures). Secondary outcomes were rates of response and cognitive impairment. Multivariable logistic regression was used to assess associations of COVID-19 pandemic modifications with outcomes. RESULTS: A total of 616 individuals (median [IQR] age, 45.0 [31.0-59.0] years; 342 female [55.5%]) were included in the analysis, with 362 in the pre-COVID-19 group and 254 in the COVID-19 group. Demographic and clinical characteristics were similar. The COVID-19 group received lower median (IQR) methohexital dosages (0.82 [0.72-0.96] mg/kg vs 0.87 [0.78-1.00] mg/kg; P = .007) and succinylcholine (0.33 [0.27-0.39] mg/kg vs 0.53 [0.45-0.59] mg/kg; P < .001) than the pre-COVID-19 group. The COVID-19 group had higher odds of insufficient initial sedation dosage (odds ratio, 2.16, 95% CI, 1.09-4.38) and PIA (odds ratio, 2.81; 95% CI, 1.76-4.56), with no difference for other complications. BVM use was reduced from standard use to 13.8% (35 individuals) during COVID-19. Groups were similar in the rates of response (pre-COVID-19, 246 individuals [68.0%]; COVID-19, 181 individuals [71.3%]; P = .38) and cognitive impairment (pre-COVID-19, 75 individuals [20.7%]; COVID-19, 49 individuals [19.3%]; P = .66). CONCLUSIONS AND RELEVANCE: In this retrospective cohort study, reduction of anesthesia agents was associated with reduced BVM use, with similar clinical outcomes and tolerability other than increased rates of insufficient initial sedation dosage and PIA, suggesting that management of PIA with this anesthesia dosing strategy warrants further investigation.