Daily Anesthesiology Research Analysis
Among 31 anesthesiology-related papers, the three most impactful advance environmental sustainability in anesthesia, infection prevention in regional analgesia for immunocompromised patients, and patient safety regarding solvent exposure in pediatric intensive care. A 35,242-case multicenter analysis shows total intravenous anesthesia (TIVA) has the lowest greenhouse gas emissions, a 196,711-catheter registry refines antibiotic use for catheter infection prophylaxis, and a prospective neonatal/p
Summary
Among 31 anesthesiology-related papers, the three most impactful advance environmental sustainability in anesthesia, infection prevention in regional analgesia for immunocompromised patients, and patient safety regarding solvent exposure in pediatric intensive care. A 35,242-case multicenter analysis shows total intravenous anesthesia (TIVA) has the lowest greenhouse gas emissions, a 196,711-catheter registry refines antibiotic use for catheter infection prophylaxis, and a prospective neonatal/pediatric study reveals pervasive cyclohexanone exposure from IV devices.
Research Themes
- Environmental sustainability in anesthesia practice
- Infection prevention for regional analgesia in immunocompromised patients
- Medical device-related solvent exposure in pediatric critical care
Selected Articles
1. Cyclohexanone and metabolites exposure in critically Ill neonates and children.
Prospective pediatric ICU and multicenter neonatal data show cyclohexanone is present in all tested IV solutions and detectable in every patient sample, with higher levels in urine than plasma. In preterm neonates, parent compound peaks on day 1, whereas metabolites peak on days 7–14, indicating sustained biotransformation. Findings highlight an urgent need for device/material substitution and mitigation strategies.
Impact: Reveals widespread, likely unavoidable solvent exposure from IV delivery systems in highly vulnerable ICU populations, with clear temporal kinetics. This can catalyze regulatory changes and safer device innovation.
Clinical Implications: Clinicians should minimize unnecessary IV tubing/line changes, prefer non-solvent bonding technologies where available, and advocate for vendor transparency on solvent content. Risk-benefit discussions are warranted in neonatal/pediatric ICU, and institutions should engage in procurement that prioritizes low-exposure devices.
Key Findings
- Cyclohexanone was detected in all tested IV solutions used in standard ICU care (fluids, medications, dialysate, RBC bags).
- Cyclohexanone and its metabolites were present in every plasma and urine sample; urine concentrations exceeded plasma in both cohorts.
- In preterm neonates, parent compound peaked on day 1, while metabolite levels peaked on days 7–14, indicating ongoing metabolism/exposure.
Methodological Strengths
- Prospective enrollment with serial measurements of parent compound and metabolites.
- Inclusion of both patient biospecimens and diverse medical fluid sources across cohorts.
Limitations
- Single-center pediatric ICU and secondary analysis for neonates may limit generalizability.
- No direct linkage to clinical outcomes or long-term neurodevelopmental effects.
Future Directions: Develop and test solvent-free or low-leach device technologies; quantify dose–response and clinical outcomes; conduct multicenter regulatory-grade exposure assessments to guide standards.
BACKGROUND: Cyclohexanone is a volatile organic compound known to be toxic to humans and animals, used in the medical setting as a solvent sealer for intravenous (IV) fluid administration devices. We aimed to determine exposure sources as well as plasma and urine levels of cyclohexanone and metabolites in critically ill infants and children. METHODS: We prospectively enrolled children in a single center pediatric intensive care unit (ICU) (n = 66), and conducted a secondary analysis of a multicenter trial in premature neonates (n = 69). Cyclohexanone and its predominant metabolites, trans-1,2-cyclohexanediol and trans-1,4-cyclohexanediol, were measured serially in medical fluids, plasma, and urine. RESULTS: Cyclohexanone was detected in all IV solutions used in standard ICU care (IV fluids, medications, dialysate and red blood cell bags, n = 53 fluid samples). Cyclohexanone and metabolites were higher in urine versus plasma in both cohorts. In premature neonates, plasma and urine cyclohexanone concentrations were highest on day of randomization, while metabolite concentrations were highest on days 7-14. CONCLUSIONS: Currently, cyclohexanone may represent an inevitable exposure to children who require intensive care inclusive of IV fluid and medication administration devices. Further studies are needed to develop replacement or mitigation strategies for cyclohexanone exposure in the vulnerable neonatal and pediatric ICU populations. IMPACT: Direct bloodstream exposure to cyclohexanone in the hospital environment has been poorly described in the healthcare setting. Cyclohexanone was present in all tested types of intravenous solutions used in standard intensive care (intravenous fluids, medications, dialysate and stored red blood cell bags). In a single center pediatric intensive care unit cohort and a multicenter neonatal intensive care unit cohort, cyclohexanone and its metabolites were detected in every blood and urine sample tested. In a multicenter neonatal intensive care unit cohort, plasma and urine cyclohexanone concentrations were highest on day 1 of admission and metabolite concentrations were highest on days 7-14.
2. The carbon footprint of general anaesthesia in adult patients: a multicentre observational comparison of intravenous and inhalation anaesthetic strategies in 35,242 procedures.
Across 35,242 anesthetics at three hospitals, drug-related greenhouse gas emissions per hour were lowest with propofol TIVA (0.4 kg CO2e/h) versus TCIA sevoflurane (0.9) and manually optimized low-flow sevoflurane (1.4). While TIVA minimizes GHG emissions, the authors caution about supply, plastic waste, and water contamination if universally adopted.
Impact: Provides large-scale, modern benchmark data comparing environmentally optimized inhalational techniques to TIVA, guiding anesthesia departments’ sustainability strategies.
Clinical Implications: When clinically appropriate, prefer TIVA to reduce GHG. If inhalation is used, adopt TCIA or low-flow sevoflurane and eliminate desflurane and N2O. Incorporate full life-cycle considerations (plastic waste/effluents) into departmental sustainability policies.
Key Findings
- Per-hour anesthetic drug-related emissions: TIVA 0.4 kg CO2e/h, TCIA sevoflurane 0.9 kg CO2e/h, manually optimized sevoflurane 1.4 kg CO2e/h.
- Real-world multicenter procurement data enabled robust comparison across 35,242 adult procedures.
- Exclusive global TIVA use could have unintended environmental trade-offs (stock depletion, plastic pollution, water contamination).
Methodological Strengths
- Very large multicenter sample with pharmacy-procurement based quantification.
- Comparison against modern optimized inhalational techniques (TCIA, low-flow).
Limitations
- Each site used a single strategy, introducing potential center-level confounding.
- Lifecycle impacts beyond drug emissions (plastic waste, effluents) were not fully quantified.
Future Directions: Integrate full life-cycle assessment (drug, devices, waste) and conduct within-center randomized or crossover implementation studies to minimize confounding.
BACKGROUND: General anaesthesia is a significant contributor to healthcare-related greenhouse gas (GHG) emissions. Previous studies have compared non-optimised anaesthesia strategies (desflurane, nitrous oxide, or both) to evaluate the impact of green initiatives on reducing the carbon footprint of anaesthesia. However, modern halogenated anaesthesia techniques, including low fresh gas flow and target-controlled inhalation anaesthesia (TCIA), offer potentially more environmentally friendly alternatives. Thus, we aimed to compare the GHG emissions of total intravenous anaesthesia (TIVA) with these newer techniques. METHODS: This multicentre study compared GHG emissions per hour of general anaesthesia in adult surgical patients between three anaesthetic strategies: TIVA with propofol, sevoflurane in TCIA mode, and manually optimised sevoflurane. The study was conducted in three French university hospitals, each using one anaesthesia strategy. The quantity of anaesthetic drugs used was obtained from pharmacy procurement records and converted to carbon dioxide equivalents (CO RESULTS: TCIA, manually optimised sevoflurane, and TIVA strategies were used in 7873, 15 461, and 10 717 anaesthetics, respectively. The carbon footprint of the principal anaesthetic drugs per hour of anaesthesia was significantly lower in the TIVA strategy, at 0.4 kg CO CONCLUSIONS: TIVA with propofol was the most effective approach for minimising greenhouse gas emissions in anaesthesia practices. However, if TIVA were used exclusively globally, it could lead to issues such as stock depletion, plastic pollution, and water contamination.
3. Regional analgesia catheter-related infections and the effectiveness of antibiotic prophylaxis in immunocompromised patients: A retrospective multicenter registry analysis.
In 196,711 regional analgesia catheters, immunocompromised patients had slightly earlier and more frequent infections. Antibiotic prophylaxis offered marginal benefit overall but was more effective in immunocompromised patients (OR 0.54 to prevent infection; NNT 55 vs 83), supporting selective, risk-based use rather than routine prophylaxis.
Impact: Largest multicenter analysis to date quantifying timing, severity, and antibiotic prophylaxis effectiveness for catheter infections in immunocompromised patients, informing stewardship and safety.
Clinical Implications: Avoid routine prophylactic antibiotics for all regional catheters; reserve prophylaxis for severely immunocompromised or special-risk patients, and emphasize meticulous asepsis and surveillance.
Key Findings
- Immunocompromised patients without antibiotics had 29% higher infection hazard (HR 1.29; p=0.1) and 91% higher odds of greater severity (OR 1.91; p<0.001).
- Antibiotic prophylaxis was more effective in immunocompromised patients (OR 0.54 to prevent infection; NNT 55 vs 83).
- Overall infection frequencies were low, but mild infections were more common in immunocompromised patients.
Methodological Strengths
- Very large multicenter registry with long time horizon (2007–2022).
- Appropriate multivariable Cox and ordinal regression to adjust for confounding.
Limitations
- Observational design with potential residual confounding and indication bias.
- Heterogeneity of catheter types, dwell times, and antibiotic regimens not fully standardized.
Future Directions: Prospective risk-stratified trials to refine prophylaxis criteria; standardized infection definitions and surveillance across catheter types; evaluate non-antibiotic preventive bundles.
BACKGROUND: The risk of regional analgesia catheter-related infections in immunocompromised patients remains uncertain. We therefore tested the hypotheses that catheter-related infections appear earlier and are more severe, and that antibiotic prophylaxis is more effective in immunocompromised than immunocompetent patients. METHODS: Data were extracted from the Network for Safety in Regional Anesthesia and Acute Pain Therapy (net-ra) registry from 2007 to 2022. We used multivariable cox and ordinal regression to assess the effect of immune function and antibiotic prophylaxis indicated by surgery on infection onset and severity. RESULTS: We analyzed data from 196,711 catheters, including 1347 in immunocompromised patients. Infection severities in immunocompetent patients were none (190,220 (97.4 %)), mild (4517 (2.3 %)), and moderate/severe (627 (0.3 %)). In immunocompromised patients, infection severities were none (1285 (95.4 %)), mild (58 (4.3 %)), and moderate/severe (4 (0.3 %)). Immunocompromised patients who were not given antibiotics had a 29 % greater infection hazard (HR 1.29 [95 %CI: 0.95, 1.76], p = 0.1) and 91 % greater odds of higher infection severities (OR 1.91 [95 %CI: 1.39, 2.63], p < 0.001). Antibiotics were more effective in delaying infection onset (HR 0.65 [95 %CI: 0.38, 1.12], p = 0.12) and preventing infection (OR 0.54 [95 %CI: 0.31, 0.94], p = 0.029) in immunocompromised than immunocompetent patients. The number of patients needed-to-treat to prevent an infection with antibiotics was 55 in immunocompromised patients versus 83 in immunocompetent patients. CONCLUSIONS: Regional analgesia catheter-related infections occur slightly earlier and are more frequent in immunocompromised patients. Antibiotics are marginally effective for catheter infection prophylaxis and should be restricted to patients who are severely immunocompromised with and at special risks.