Daily Anesthesiology Research Analysis
Network meta-analysis shows non-invasive ventilation best prevents hypoxemia during intubation in critically ill adults, outperforming high-flow nasal oxygen and facemask oxygen. A meta-analysis of randomized trials supports minimally invasive extracorporeal circulation reducing mortality and major complications in cardiac surgery, while a large randomized trial finds no benefit of NIRS-guided tissue oxygenation management during off-pump CABG.
Summary
Network meta-analysis shows non-invasive ventilation best prevents hypoxemia during intubation in critically ill adults, outperforming high-flow nasal oxygen and facemask oxygen. A meta-analysis of randomized trials supports minimally invasive extracorporeal circulation reducing mortality and major complications in cardiac surgery, while a large randomized trial finds no benefit of NIRS-guided tissue oxygenation management during off-pump CABG.
Research Themes
- Airway management and preoxygenation strategies
- Cardiopulmonary bypass/perfusion innovation
- Perioperative monitoring and outcomes
Selected Articles
1. Preoxygenation strategies for intubation of patients who are critically ill: a systematic review and network meta-analysis of randomised trials.
Across 15 randomized trials (n=3420), preoxygenation with NIPPV probably reduces hypoxemia during intubation compared with HFNC (RR 0.73, 95% CI 0.55–0.98) and reduces hypoxemia versus facemask oxygen (RR 0.51, 0.39–0.65). HFNC also reduces hypoxemia versus facemask (RR 0.69, 0.54–0.88). First-pass success and all-cause mortality were not different; NIPPV likely lowers serious adverse events versus facemask and possibly versus HFNC.
Impact: Clarifies the comparative effectiveness of widely used preoxygenation strategies and will inform airway management guidelines in the ICU and ED.
Clinical Implications: When feasible, use NIPPV for preoxygenation of critically ill adults requiring intubation; HFNC is preferable to facemask oxygen when NIPPV is unavailable or contraindicated. Protocols should prioritize staff training and equipment availability.
Key Findings
- NIPPV reduced hypoxemia versus HFNC (RR 0.73, 95% CI 0.55–0.98) and versus facemask oxygen (RR 0.51, 0.39–0.65).
- HFNC reduced hypoxemia versus facemask oxygen (RR 0.69, 0.54–0.88).
- No differences were found in first-attempt intubation success or all-cause mortality among strategies.
- NIPPV probably reduced serious adverse events versus facemask oxygen and may reduce them versus HFNC.
Methodological Strengths
- Frequentist network meta-analysis of randomized trials with risk of bias and GRADE assessment
- Comprehensive search across multiple databases with no language restriction
Limitations
- Heterogeneity in trial protocols and definitions of serious adverse events and mortality
- No observed effects on first-pass success or mortality despite reductions in hypoxemia
Future Directions: Head-to-head pragmatic RCTs in high-risk subgroups (e.g., severe hypoxemia, obesity), evaluation of combined strategies (NIPPV+HFNC), and cost-effectiveness and implementation studies.
2. Minimal invasive extracorporeal circulation versus conventional cardiopulmonary bypass in cardiac surgery: a contemporary systematic review and meta-analysis.
Across 36 randomized controlled trials (n=4849), MiECC was associated with lower mortality (OR 0.66, 95% CI 0.53–0.81; I2=0%), reduced postoperative myocardial infarction (OR 0.42, 0.26–0.68) and cerebrovascular events (OR 0.55, 0.37–0.80). MiECC also decreased RBC transfusion, blood loss, re-exploration for bleeding, atrial fibrillation, and shortened ventilation, ICU, and hospital stay.
Impact: Provides robust RCT-level synthesis indicating MiECC improves hard outcomes, supporting wider adoption and potential perfusion strategy change in cardiac surgery.
Clinical Implications: Cardiac anesthesia and perfusion teams should consider implementing MiECC circuits where expertise and resources permit, with protocols for anticoagulation, hemodilution, and circuit management standardized to MiECC criteria.
Key Findings
- MiECC reduced mortality versus cCPB (OR 0.66, 95% CI 0.53–0.81; I2=0%).
- Lower risk of postoperative myocardial infarction (OR 0.42) and cerebrovascular events (OR 0.55) with MiECC.
- MiECC decreased RBC transfusions, blood loss, re-exploration for bleeding, atrial fibrillation, and reduced ventilation, ICU and hospital length of stay.
Methodological Strengths
- Inclusion limited to RCTs meeting pre-defined MiECC criteria
- Low heterogeneity (I2=0% for primary outcomes) with Cochrane RoB 2 assessment
Limitations
- Variability in MiECC platforms and surgical techniques across trials
- Potential publication bias and limited reporting on long-term outcomes
Future Directions: Pragmatic multicenter implementation trials, standardized MiECC protocols, cost-effectiveness analyses, and registries to monitor real-world outcomes.
3. Care guided by tissue oxygenation and haemodynamic monitoring in off-pump coronary artery bypass grafting (Bottomline-CS): assessor blind, single centre, randomised controlled trial.
In 1960 older adults undergoing off-pump CABG, guided care using multisite NIRS and haemodynamic monitoring kept tissue oxygenation near baseline but did not reduce the 30-day composite of major complications (47.3% vs 47.8%; RR 0.99, P=0.83). No secondary outcomes differed significantly after multiplicity adjustment; pneumonia was numerically lower with guided care.
Impact: A large, well-conducted randomized trial provides definitive evidence that routine NIRS-guided oxygenation targets during off-pump CABG do not improve clinical outcomes.
Clinical Implications: Routine use of NIRS-guided tissue oxygenation targeting during off-pump CABG is not supported to reduce complications; resources may be better allocated to interventions with proven benefit.
Key Findings
- Guided care significantly reduced time outside ±10% of baseline tissue oxygenation across forehead and forearm sites.
- No reduction in 30-day composite complications (47.3% vs 47.8%; RR 0.99, 95% CI 0.90–1.08; P=0.83).
- Secondary outcomes, including mortality and atrial fibrillation, showed no significant differences; pneumonia was numerically lower with guided care.
Methodological Strengths
- Assessor-blinded randomized design with large sample size (n=1960)
- Standardized multisite NIRS monitoring and concealed data in control group
Limitations
- Single-centre trial limits generalizability
- Restricted to off-pump CABG and patients aged ≥60 years
Future Directions: Multicentre trials to test targeted NIRS strategies in high-risk subgroups and cost-effectiveness analyses; exploration of combined neuromonitoring approaches.