Daily Anesthesiology Research Analysis

BACKGROUND: Opioids are effective for treating acute pain but have safety, tolerability, and addiction concerns while nonopioid analgesics have limited efficacy. Suzetrigine, an oral, nonopioid small molecule, selectively inhibits the voltage-gated sodium channel 1.8 (NaV1.8) and has potential to provide efficacious and safe relief for acute pain without addiction concerns. METHODS: To evaluate suzetrigine for treatment of acute pain, two phase 3, randomized, double-blind, placebo- and active-controlled trials were conducted in adults with moderate-to-severe acute pain on the verbal categorical rating scale and 4 or greater on the numeric pain rating scale after abdominoplasty (n = 1,118) or bunionectomy (n = 1,073). After surgery, participants were randomized to suzetrigine (100 mg, then 50 mg every 12 h), hydrocodone bitartrate/acetaminophen (5/325 mg every 6 h), or placebo for 48 h. The primary endpoint was time-weighted sum of the pain intensity difference in numeric pain rating scale from 0 to 48 h (SPID48) versus placebo. Key secondary endpoints were SPID48 versus hydrocodone bitartrate/acetaminophen and time to 2-point or greater reduction in numeric pain rating scale from baseline versus placebo. RESULTS: The primary endpoint was achieved in both trials with suzetrigine demonstrating statistically significant and clinically meaningful reduction in pain versus placebo. The least squares mean difference in SPID48 between suzetrigine and placebo was 48.4 (95% CI, 33.6 to 63.1; P < 0.0001) after abdominoplasty and 29.3 (95% CI, 14.0 to 44.6; P = 0.0002) after bunionectomy. Neither trial achieved the first key secondary endpoint of superiority of suzetrigine versus hydrocodone bitartrate/acetaminophen on SPID48. For the second key secondary endpoint of time to 2-point or greater reduction in numeric pain rating scale, suzetrigine had a more rapid onset of clinically meaningful pain relief versus placebo after abdominoplasty (119 min vs. 480 min; nominal P < 0.0001) and bunionectomy (240 min vs. 480 min; nominal P = 0.0016). Adverse events were similar to those seen in postsurgical settings. CONCLUSIONS: As compared with placebo, suzetrigine reduced moderate-to-severe acute pain over 48 h after abdominoplasty or bunionectomy. Pain reduction with suzetrigine was similar to that with hydrocodone bitartrate/acetaminophen. Suzetrigine was associated with adverse events that were mild to moderate in severity.

INTRODUCTION: Flexible bronchoscopy is the gold standard for difficult airway management. Clinicians are using videolaryngoscopy increasingly because it is perceived to be easier to use with high success rates. We conducted this study to compare the success rates of the two techniques when used after failed direct laryngoscopy in children with difficult tracheal intubations. METHODS: We identified cases where initial attempts at direct laryngoscopy failed in the multicentre Pediatric Difficult Intubation Registry from August 2012-September 2023. After propensity score matching, we compared success rates and complications when videolaryngoscopy and flexible bronchoscopy were used as rescue techniques in the matched cohort and in matched patients weighing < 5 kg. RESULTS: Clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy when direct laryngoscopy failed (64.7%, 1426/2281 vs. 7.3%, 156/2281, p < 0.001). Propensity score matched cohorts did not differ with respect to first-attempt success, eventual success and complications. For the subgroup of infants < 5 kg, clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy to rescue failed direct laryngoscopy (54.3%, 295/543 vs. 8.9%, 44/543, p < 0.001). First-attempt success was 43% (62/145) with videolaryngoscopy and 62% (18/29) with flexible bronchoscopy (odds ratio 2.19, 95%CI 0.96-4.98, p = 0.061). Eventual success was 71% (103/145) with videolaryngoscopy and 90% (26/29) with flexible bronchoscopy (odds ratio 3.53, 95%CI 1.03-12.2, p = 0.046). Complications did not differ between the techniques. DISCUSSION: Videolaryngoscopy was chosen more frequently than flexible bronchoscopy as a rescue technique in a cohort of children with difficult direct laryngoscopy, with similar success and complication rates. For small infants, flexible bronchoscopy had a higher eventual success rate, underscoring the importance of maintaining proficiency with flexible bronchoscopy.

BACKGROUND: Perioperative stroke is a serious and potentially fatal complication following non-cardiac surgery. Thus, it is important to identify the risk factors and develop an effective prognostic model to predict the incidence of perioperative stroke following non-cardiac surgery. METHODS AND FINDINGS: We identified potential risk factors and built a model to predict the incidence of perioperative stroke using logistic regression derived from hospital registry data of adult patients that underwent non-cardiac surgery from 2008 to 2019 at The First Medical Center of Chinese PLA General Hospital. Our model was then validated using the records of two additional hospitals to demonstrate its clinical applicability. In our hospital cohorts, 223,415 patients undergoing non-cardiac surgery were included in this study with 525 (0.23%) patients experiencing a perioperative stroke. Thirty-three indicators including several intraoperative variables had been identified as potential risk factors. After multi-variate analysis and stepwise elimination (P < 0.05), 13 variables including age, American Society of Anesthesiologists (ASA) classification, hypertension, previous stroke, valvular heart disease, preoperative steroid hormones, preoperative β-blockers, preoperative mean arterial pressure, preoperative fibrinogen to albumin ratio, preoperative fasting plasma glucose, emergency surgery, surgery type and surgery length were screened as independent risk factors and incorporated to construct the final prediction model. Areas under the curve were 0.893 (95% confidence interval (CI) [0.879, 0.908]; P < 0.001) and 0.878 (95% CI [0.848, 0.909]; P < 0.001) in the development and internal validation cohorts. In the external validation cohorts derived from two other independent hospitals, the areas under the curve were 0.897 and 0.895. In addition, our model outperformed currently available prediction tools in discriminative power and positive net benefits. To increase the accessibility of our predictive model to doctors and patients evaluating perioperative stroke, we published an online prognostic software platform, 301 Perioperative Stroke Risk Calculator (301PSRC). The main limitations of this study included that we excluded surgical patients with an operation duration of less than one hour and that the construction and external validation of our model were from three independent retrospective databases without validation from prospective databases and non-Chinese databases. CONCLUSIONS: In this work, we identified 13 independent risk factors for perioperative stroke and constructed an effective prediction model with well-supported external validation in Chinese patients undergoing non-cardiac surgery. The model may provide potential intervention targets and help to screen high-risk patients for perioperative stroke prevention.