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.
BACKGROUND: Preoxygenation is a crucial preparatory step for intubation. Several strategies for preoxygenation exist, including facemask oxygen, high-flow nasal cannula (HFNC), and non-invasive positive pressure ventilation (NIPPV). However, the comparative efficacy of these strategies remains largely uncertain. We aimed to compare the efficacy and safety of HFNC, NIPPV, and facemask oxygen for preoxygenation of patients who are critically ill requiring tracheal intubation. METHODS: In this systematic r
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.
OBJECTIVES: The question whether minimally invasive extracorporeal circulation (MiECC) represents the optimal perfusion strategy in cardiac surgery remains unanswered. We sought to systematically review the entire literature and thoroughly address the impact of MiECC versus conventional cardiopulmonary bypass (cCPB) on adverse clinical outcomes after cardiac surgery. METHODS: We searched PubMed, Scopus and Cochrane databases for appropriate articles as well as conference proceedings from major con
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.
OBJECTIVE: To assess whether perioperative management guided by near-infrared spectroscopy to determine tissue oxygen saturation and haemodynamic monitoring reduces postoperative complications after off-pump coronary artery bypass grafting. DESIGN: Assessor blinded, single centre, randomised controlled trial (Bottomline-CS trial). SETTING: A tertiary teaching hospital in China. PARTICIPANTS: 1960 patients aged 60 years or older who were scheduled for elective off-pump coronary artery bypass grafting. I