Daily Anesthesiology Research Analysis
Three perioperative studies stand out today: a large registry analysis links higher intraoperative neuromuscular blockade exposure to increased postoperative delirium in older adults, with reversal agents mitigating this risk; ASRA-PM presents PRISMA-adherent, PROSPERO-registered practice recommendations for gastric POCUS to tailor aspiration risk assessment in medically complex patients; and an external validation/optimization of the TRACK model improves preoperative transfusion risk stratifica
Summary
Three perioperative studies stand out today: a large registry analysis links higher intraoperative neuromuscular blockade exposure to increased postoperative delirium in older adults, with reversal agents mitigating this risk; ASRA-PM presents PRISMA-adherent, PROSPERO-registered practice recommendations for gastric POCUS to tailor aspiration risk assessment in medically complex patients; and an external validation/optimization of the TRACK model improves preoperative transfusion risk stratification in low-transfusion-rate cardiac surgery.
Research Themes
- Perioperative neurocognitive disorders and neuromuscular blockade management
- Point-of-care ultrasound to personalize aspiration risk assessment
- Transfusion risk prediction and model updating in cardiac surgery
Selected Articles
1. Association Between Neuromuscular Blockade and Its Reversal With Postoperative Delirium in Older Patients: A Hospital Registry Study.
In a registry of 53,772 older adults, nondepolarizing neuromuscular blockade was dose-dependently associated with higher 7-day postoperative delirium risk. Reversal agents reduced impaired neuromuscular recovery and delirium, effectively neutralizing the adverse association; neostigmine and sugammadex showed no difference in delirium risk.
Impact: Identifies a modifiable perioperative risk pathway for delirium and supports routine reversal of neuromuscular blockade in older adults. Dose-response and mitigation data provide actionable targets for anesthesia quality improvement.
Clinical Implications: Use quantitative neuromuscular monitoring and administer reversal agents to older adults before extubation to reduce delirium risk; selection between neostigmine and sugammadex may be guided by other clinical factors since delirium risk did not differ.
Key Findings
- ND-NMBA exposure was dose-dependently associated with higher postoperative delirium (adjusted OR 1.15; and 1.09 per unit increase in ED95-equivalent dose).
- Reversal agents reduced both impaired neuromuscular recovery (preextubation TOF ratio <95; OR 0.60) and delirium (OR 0.73) versus no reversal.
- The adverse delirium association of ND-NMBAs disappeared with reversal (OR 1.07 with reversal vs 1.52 without).
- No difference in delirium risk between neostigmine and sugammadex (adjusted OR 0.91).
Methodological Strengths
- Very large single-network registry (N=53,772) with dose-response assessment
- Multisource delirium ascertainment (chart review keywords, CAM, ICD codes) and adjusted analyses
Limitations
- Observational design with potential residual confounding and confounding by indication
- Single health system limits generalizability; detailed intraoperative factors beyond NMBA may not be fully captured
Future Directions: Prospective trials to test delirium reduction with protocolized quantitative monitoring and universal reversal in older adults; investigate mechanistic links between residual neuromuscular weakness and neurocognitive outcomes.
2. ASRA pain medicine narrative review and expert practice recommendations for gastric point-of-care ultrasound to assess aspiration risk in medically complex patients undergoing regional anesthesia and pain procedures.
ASRA-PM provides PRISMA-adherent, PROSPERO-registered recommendations on when to use gastric POCUS to assess aspiration risk in medically complex patients. Strong support exists for active labor, urgent cesarean, and diabetes; conditional support for obesity, emergency care, enteral feeding, and GLP-1RA use; and routine use is not recommended in non-laboring pregnancy, elective cesarean, or GERD.
Impact: Offers pragmatic, condition-specific guidance where ASA fasting guidance does not fully apply, potentially reducing aspiration events by personalizing risk assessment in regional anesthesia and pain practices.
Clinical Implications: Incorporate targeted gastric POCUS in patients in labor, undergoing urgent cesarean, or with diabetes; consider conditional use in obesity, emergency care, enteral feeding, and GLP-1RA users; avoid routine use in non-laboring pregnancy, elective cesarean, and GERD. Training, workflow, and credentialing are critical for implementation.
Key Findings
- PRISMA-adherent, PROSPERO-registered narrative review with MMAT quality appraisal and expert consensus produced patient-group–specific recommendations.
- Gastric POCUS is supported in active labor, urgent cesarean, and diabetes; conditional in obesity, emergency care, enteral feeding, and GLP-1RA therapy.
- Routine gastric POCUS is not recommended in non-laboring pregnancy, elective cesarean, or GERD; clinical judgment remains paramount.
Methodological Strengths
- Registered review (PROSPERO) with PRISMA adherence and MMAT-based quality assessment
- Iterative expert consensus translating evidence into practice recommendations
Limitations
- Narrative review with heterogeneous evidence and limited high-quality comparative studies
- Implementation barriers include operator training and workflow constraints; external validation of recommendations is needed
Future Directions: Prospective comparative studies to test gastric POCUS–guided pathways on aspiration events and perioperative outcomes; curriculum development and competency metrics for broader implementation.
3. Validation and optimization of a blood transfusion prediction model for low transfusion rate adult cardiac surgery.
Among 4,072 adult cardiac surgery patients with a low transfusion rate, the original TRACK model showed good discrimination (AUC 0.76) but poor calibration. Updating coefficients via cross-validation and adding preoperative antiplatelet therapy yielded optimized versions (uTRACK and uTRACK+APT) tailored to contemporary practice.
Impact: Provides updated transfusion risk stratification in modern cardiac surgery where transfusion rates are low, enabling targeted blood conservation strategies.
Clinical Implications: Adopting an updated, locally calibrated risk model that incorporates antiplatelet therapy can better identify patients at transfusion risk and guide preoperative optimization, blood product planning, and intraoperative conservation measures.
Key Findings
- External validation in 4,072 adult cardiac surgery patients with 26% receiving RBC transfusion.
- Original TRACK model showed good discrimination (AUC 0.76; 95% CI 0.74–0.78) but inadequate calibration.
- Model updating via cross-validation (uTRACK) and inclusion of preoperative antiplatelet therapy (uTRACK+APT) produced optimized risk tools.
Methodological Strengths
- External validation in a contemporary, low-transfusion-rate cohort (N=4,072)
- Model updating with cross-validation and inclusion of clinically relevant variable (antiplatelet therapy)
Limitations
- Calibration of the original model was inadequate; performance of updated models needs external validation
- Single-region dataset; incomplete abstract reporting limits quantitative assessment of updated models
Future Directions: Prospective, multicenter validation and impact analysis of uTRACK and uTRACK+APT on transfusion rates, costs, and patient outcomes; exploration of additional predictors (e.g., antifibrinolytics, hemodilution strategies).