Daily Anesthesiology Research Analysis
Three perioperative/critical care studies stand out today: a multicenter randomized trial shows Del Nido cardioplegia improves intraoperative rhythm stability and glycemic control versus Buckberg in isolated AVR without biomarker differences; a translational porcine study demonstrates individualized PEEP (via EIT or esophageal pressure) can simultaneously optimize lung mechanics and pulmonary hemodynamics; and a retrospective ICU study links dexmedetomidine sedation to lower mortality in sepsis-
Summary
Three perioperative/critical care studies stand out today: a multicenter randomized trial shows Del Nido cardioplegia improves intraoperative rhythm stability and glycemic control versus Buckberg in isolated AVR without biomarker differences; a translational porcine study demonstrates individualized PEEP (via EIT or esophageal pressure) can simultaneously optimize lung mechanics and pulmonary hemodynamics; and a retrospective ICU study links dexmedetomidine sedation to lower mortality in sepsis-induced ARDS.
Research Themes
- Optimization of cardioplegia strategies in adult cardiac surgery
- Individualized mechanical ventilation integrating cardiopulmonary coupling
- Sedation choices and outcomes in sepsis-induced ARDS
Selected Articles
1. Buckberg versus Del Nido in isolated aortic valve replacement: a prospective, two-centre, randomized trial.
In 311 adults undergoing isolated AVR, Del Nido cardioplegia yielded higher spontaneous rhythm and less defibrillation for ventricular fibrillation after cross-clamp removal, as well as lower intraoperative glucose and insulin use, compared with Buckberg, while postoperative CK and hs-TnT peaks were similar.
Impact: This RCT directly informs cardioplegia selection in adult valve surgery, indicating process-of-care advantages for Del Nido without compromising myocardial injury biomarkers.
Clinical Implications: Del Nido cardioplegia may be preferred for isolated AVR to enhance rhythm stability and glycemic control and streamline workflow, though longer-term outcomes appear similar; centers may update perfusion/anesthesia protocols accordingly.
Key Findings
- No difference in postoperative peak CK or hs-TnT between Buckberg and Del Nido.
- Del Nido increased spontaneous rhythm after cross-clamp removal (66.7% vs 43.1%) and reduced ventricular fibrillation requiring defibrillation (23.6% vs 49.7%).
- Del Nido had lower peak intraoperative glucose (128 vs 198 mg/dL) and less insulin administration (18.1% vs 51.0%).
- Total cardioplegia volume was higher with Del Nido (1000 mL vs 374.5 mL).
Methodological Strengths
- Prospective, multicenter randomized design with clinical registration.
- Adequate sample size (n=311) and prespecified biochemical endpoints with clinically relevant intraoperative outcomes.
Limitations
- Limited to isolated AVR; not powered for long-term clinical endpoints.
- Blinding unlikely; potential performance bias on workflow-related outcomes.
Future Directions: Evaluate longer-term outcomes (e.g., myocardial function, arrhythmias, resource use) and generalizability to other adult cardiac procedures and higher-risk populations.
OBJECTIVES: Interest in Del Nido solution is increasing in adult cardiac surgery. This study compared Del Nido with Buckberg cardioplegia in patients undergoing isolated aortic valve replacement. METHODS: A prospective, two-centre, randomized trial was conducted from July 2019 to August 2023, with adult patients undergoing first-time isolated aortic valve replacement, and were randomized to receive Buckberg (n = 159) or Del Nido (n = 152) solution. Primary end-point was Creatine Kinase and ultrasensitive Troponin T postoperative peak level. RESULTS: A total of 311 patients were recruited. Total cardioplegia volume was higher in Del Nido group (1000 ml vs 374.5 ml, P < 0.001). No differences were observed in peak Creatine Kinase or Troponin T levels (422 vs 407 U/L and 282 vs 258 ng/L for Buckberg and Del Nido, respectively) or during postoperative days 1-5. After cross-clamp removal, patients in Del Nido group showed higher rates of spontaneous rhythm (66.7% vs 43.1%, P < 0.001) and less ventricular fibrillation requiring defibrillation (23.6% vs 49.7%, P < 0.001). Peak intraoperative glucose levels (128 mg/dl vs 198 mg/dl, P < 0.001) and insulin administration (18.1% vs 51.0%, P < 0.001) were lower in the Del Nido group. No other differences were found. CONCLUSIONS: No differences between Del Nido and Buckberg solutions were detected. Del Nido presents better intraoperative glycaemic control, higher spontaneous rhythm, less ventricular fibrillation requiring defibrillation after cross-clamp removal, and more comfortable surgical workflow due to less re-dose interruptions. CLINICAL REGISTRATION NUMBER: EU-CTR number: 2018-002701-59.
2. Individualized PEEP can improve both pulmonary hemodynamics and lung function in acute lung injury.
In two porcine ALI models with differing recruitability, both low and high PEEP impaired pulmonary hemodynamics. Individualizing PEEP based on respiratory mechanics—particularly using EIT or esophageal pressure—allowed simultaneous optimization of lung mechanics and pulmonary hemodynamics.
Impact: Demonstrates cardiopulmonary trade-offs of PEEP and provides a mechanistic basis for EIT/pressure-guided individualized PEEP to balance gas exchange and right ventricular afterload.
Clinical Implications: Supports integrating EIT and/or esophageal pressure monitoring to individualize PEEP, potentially reducing hemodynamic compromise while maintaining lung recruitment in ARDS/ALI patients.
Key Findings
- Different titration strategies yield different optimal PEEP levels in ALI models.
- Both excessively low and high PEEP levels impair pulmonary hemodynamics.
- EIT- and esophageal pressure–guided PEEP selection allowed concomitant optimization of respiratory mechanics and hemodynamics.
Methodological Strengths
- Translational large-animal models capturing high vs low recruitability.
- Concurrent monitoring of mechanics and hemodynamics with multiple PEEP titration strategies, including EIT and esophageal pressure.
Limitations
- Preclinical animal study; external validity to human ARDS requires clinical trials.
- Abstracted details on exact PEEP values and measured parameters are limited.
Future Directions: Prospective clinical trials incorporating EIT/esophageal pressure to test hemodynamic-respiratory co-optimization strategies and outcome effects in ARDS.
RATIONALE: There are several approaches to select the optimal positive end-expiratory pressure (PEEP), resulting in different PEEP levels. The impact of different PEEP settings may extend beyond respiratory mechanics, affecting pulmonary hemodynamics. OBJECTIVES: To compare PEEP levels obtained with three titration strategies-(i) highest respiratory system compliance (C METHODS: Experimental studies in two porcine models of acute lung injury: (I) bilateral injury induced in both lungs, generating a highly recruitable model (n = 37); (II) asymmetrical injury, generating a poorly recruitable model (n = 13). In all experiments, a decremental PEEP titration was performed monitoring P MEASUREMENTS AND MAIN RESULTS: PEEP titration methods resulted in different levels of median optimal PEEP in bilateral lung injury: 14(12-14) cmH CONCLUSIONS: In porcine models of acute lung injury with variable lung recruitability, both low and high levels of PEEP can impair pulmonary hemodynamics. Optimized ventilation and hemodynamics can be obtained simultaneously at PEEP levels individualized based on respiratory mechanics, especially by EIT and esophageal pressure.
3. Dexmedetomidine administration is associated with reduced mortality in patients with sepsis-induced acute respiratory distress syndrome: a retrospective study.
In a single-center cohort of 208 patients with sepsis-induced ARDS, dexmedetomidine sedation was associated with significantly lower MODS incidence and in-hospital mortality versus standard care, alongside improved ABG indices and inflammatory markers, despite similar baseline severity.
Impact: Adds clinically relevant evidence supporting dexmedetomidine in sepsis-induced ARDS, aligning with mechanistic benefits observed in preclinical ALI models.
Clinical Implications: ICUs may consider dexmedetomidine as a preferred sedative in sepsis-induced ARDS to potentially improve survival and organ dysfunction, pending confirmation by randomized trials.
Key Findings
- Baseline severity (e.g., APACHE II, predicted mortality) and ARDS etiologies were comparable between groups.
- DEX group had significantly lower incidence of MODS and lower in-hospital mortality compared with controls.
- DEX group showed improved ABG parameters (acid–base balance and oxygenation) and reduced inflammatory markers.
Methodological Strengths
- Consecutive ICU cohort with standardized ARDS care and comparative analyses.
- Multiple domains assessed (ABG, inflammatory markers, organ dysfunction, mortality).
Limitations
- Retrospective single-center design with potential confounding by indication and sedation dosing variability.
- Causality cannot be established; no randomization or protocolized sedation depth reporting.
Future Directions: Randomized controlled trials to test whether dexmedetomidine improves survival and organ failure in sepsis-induced ARDS and to define optimal dosing and sedation targets.
BACKGROUND: Although studies have revealed the benefits of using dexmedetomidine (DEX) in treating rodent models of acute lung injury (ALI) by improving their survival rates, clinical investigation on the effect of DEX on patients with acute respiratory distress syndrome (ARDS) remains scarce. Through this retrospective study, we aim to better understand the underlying mechanism of sepsis-induced ARDS and the effect of DEX on patients' standard treatment. METHODS: A total of 208 patients with sepsis-induced ARDS, admitted to the intensive care unit (ICU) at Affiliated Hospital of Jiangsu University, China, from January 2017 to December 2019, were included. The patients were divided into the control group (n = 102) and the DEX group (n = 106). Both groups of patients received mechanical ventilation and standard care; however, the DEX group was additionally treated with DEX as a sedative. Demographic information, baseline characteristics, laboratory parameters, arterial blood gas (ABG) analyses, and inflammatory indicators were compared between the two groups to evaluate the therapeutic outcomes of different treatment approaches. RESULTS: Age and male gender constituted risk factors for high ARDS incidence, and hypertension led in the list of patients' comorbidities. The baseline characteristics including primary diagnosis and ARDS causes, and prognostic values such as the Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality, were comparable between the two groups of patients. However, the multiple organ dysfunction syndrome (MODS) incidence and actual mortality rate were significantly lower in the DEX group compared to the control group. Additionally, the DEX group demonstrated improved ABG metrics, representing better acid-base balance and oxygenation, and enhanced inflammatory responses. CONCLUSIONS: Intravenous administration of DEX was associated with reduced in-hospital mortality, at least in part, by ameliorating ABG indices and inflammatory mediators.