Daily Anesthesiology Research Analysis
Three impactful anesthesiology/critical care studies stood out today: a protocol for the INCEPT adaptive platform trial promises faster, Bayesian, multi-domain evidence generation in ICU care; a 43-hospital cohort links higher adherence to patient blood management with fewer complications, shorter stays, and fewer transfusions after joint arthroplasty; and a multicenter pilot RCT suggests low-intensity anticoagulation during venovenous ECMO may be feasible with signals toward less bleeding.
Summary
Three impactful anesthesiology/critical care studies stood out today: a protocol for the INCEPT adaptive platform trial promises faster, Bayesian, multi-domain evidence generation in ICU care; a 43-hospital cohort links higher adherence to patient blood management with fewer complications, shorter stays, and fewer transfusions after joint arthroplasty; and a multicenter pilot RCT suggests low-intensity anticoagulation during venovenous ECMO may be feasible with signals toward less bleeding.
Research Themes
- Adaptive platform trials and Bayesian methods in critical care
- Patient Blood Management and perioperative outcomes
- Anticoagulation strategies during venovenous ECMO
Selected Articles
1. INCEPT: The Intensive Care Platform Trial-Design and protocol.
INCEPT is a pragmatic, Bayesian adaptive platform RCT infrastructure for ICU patients, organized into domains that evaluate commonly used but uncertain interventions. It defines core outcomes, uses response-adaptive randomization and pre-specified stopping rules, and aims to deliver faster, high-certainty evidence across multiple questions within one platform.
Impact: Methodological innovation enabling continuous, efficient, and high-certainty ICU evidence generation can reshape critical care research and practice.
Clinical Implications: If implemented as designed, INCEPT can shorten time-to-evidence for ICU practices, allow early adoption or de-implementation of interventions, and standardize outcome measures across trials.
Key Findings
- Investigator-initiated, pragmatic, randomized, embedded, multifactorial adaptive platform for adult ICU patients.
- Bayesian analyses with neutral/skeptical priors, adjustment for prognostic variables, and ITT effect estimates.
- Core outcomes include mortality, days alive without life support/out of hospital/free of delirium, HRQoL, cognition, and safety.
- Response-adaptive randomization and pre-specified stopping for superiority, inferiority, equivalence, or futility.
Methodological Strengths
- Adaptive platform architecture allowing multiple domains and perpetual trial conduct
- Bayesian framework with stakeholder-defined core outcomes and prespecified decision rules
Limitations
- Protocol paper without outcome data to date
- Complex implementation requiring robust infrastructure and governance
Future Directions: Activate domains across priority ICU questions, share platform tools and code, and evaluate scalability, equity, and global generalizability.
2. Association between Adherence to Patient Blood Management Recommendations and Postoperative Complications in Hip and Knee Arthroplasty.
In 30,926 arthroplasty patients across 43 hospitals, higher adherence to a nine-component PBM pathway was associated with 57% lower odds of 30-day complications, shorter length of stay, and dramatically reduced transfusion use. Associations persisted in sensitivity analyses, supporting PBM as a broader quality and safety strategy beyond transfusion avoidance.
Impact: Large, multicenter evidence linking PBM adherence to clinically meaningful outcomes can drive system-level perioperative quality improvement.
Clinical Implications: Integrate PBM bundles into perioperative pathways for arthroplasty patients; monitor adherence and outcomes; target components with the highest yield for complication reduction.
Key Findings
- Median PBM adherence was 60% across 43 hospitals for 30,926 arthroplasty patients.
- Higher PBM adherence associated with fewer 30-day complications (adjusted OR 0.43; 95% CI 0.32–0.58; P<0.001).
- Major adverse cardiac events reduced by ~65% and infections by ~45% with higher adherence.
- Higher adherence linked to shorter length of stay (adjusted IRR 0.77; 95% CI 0.76–0.79) and lower transfusion rates (adjusted OR 0.11; 95% CI 0.09–0.14).
Methodological Strengths
- Very large multicenter cohort with multilevel, multivariable modeling accounting for hospital-level effects
- Composite quality indicator capturing nine guideline-recommended PBM interventions; sensitivity analyses performed
Limitations
- Retrospective observational design cannot establish causality; residual confounding possible
- Composite adherence measure may obscure which PBM components drive benefits
Future Directions: Prospective implementation trials to test causality, component-level analyses to identify high-impact PBM elements, and cost-effectiveness and equity evaluations.
3. Low-Intensity vs Moderate-Intensity Anticoagulation for Venovenous Extracorporeal Membrane Oxygenation: The Strategies for Anticoagulation During Venovenous Extracorporeal Membrane Oxygenation Pilot Trial.
This three-center pilot RCT randomized 26 VV-ECMO patients to low- or moderate-intensity anticoagulation and demonstrated feasibility with full adherence and group separation. Major bleeding occurred less often in the low-intensity group (8.3% vs 28.6%), with no clear increase in thromboembolism; mortality favored the low-intensity group, but the study was not powered for outcomes.
Impact: Provides feasibility data and a signal that may reduce bleeding risk on VV-ECMO, informing the design of a definitive multicenter RCT.
Clinical Implications: Pending larger trials, clinicians may consider protocolized evaluation of anticoagulation intensity on VV-ECMO, balancing bleeding and thrombosis risks and participating in multicenter studies.
Key Findings
- Multicenter randomized pilot enrolled 26 VV-ECMO patients with 100% adherence to assigned anticoagulation intensity.
- Major bleeding occurred in 8.3% (1/12) with low-intensity vs 28.6% (4/14) with moderate-intensity anticoagulation (ARD −20.2 pp; P=0.33).
- Thromboembolic events were 8.3% vs 0%, respectively; in-hospital mortality was 0% vs 14.3% (both deaths followed major bleeding).
- Feasibility for a larger definitive trial was demonstrated.
Methodological Strengths
- Randomized, multicenter design with clear feasibility metrics and clinically meaningful outcomes
- Good protocol adherence and group separation
Limitations
- Small sample size limits statistical power and precision of effect estimates
- Pilot nature precludes definitive efficacy and safety conclusions
Future Directions: Proceed to a fully powered multicenter RCT with prespecified anticoagulation targets, standardized bleeding/thrombosis definitions, and patient-centered outcomes.