Daily Anesthesiology Research Analysis
Context-specific evidence refines how the end-expiratory occlusion test (EEOT) should be used to predict fluid responsiveness, performing best in ICU settings. A randomized trial shows dexmedetomidine improves postoperative sleep and stress hormone profiles in older intestinal surgery patients. A large obstetric cohort finds lumbar epidural analgesia is not independently associated with postpartum depression, highlighting psychosocial determinants of epidural use.
Summary
Context-specific evidence refines how the end-expiratory occlusion test (EEOT) should be used to predict fluid responsiveness, performing best in ICU settings. A randomized trial shows dexmedetomidine improves postoperative sleep and stress hormone profiles in older intestinal surgery patients. A large obstetric cohort finds lumbar epidural analgesia is not independently associated with postpartum depression, highlighting psychosocial determinants of epidural use.
Research Themes
- Hemodynamic monitoring and fluid responsiveness
- Perioperative sleep and neuropsychological outcomes
- Obstetric anesthesia and maternal mental health
Selected Articles
1. Context-specific clinical applicability of the end-expiratory occlusion test to predict fluid responsiveness in mechanically ventilated patients: A systematic review and meta-analysis.
Across 24 studies (n=1073), EEOT showed pooled sensitivity 0.87 and specificity 0.90 to predict fluid responsiveness, with a typical cardiac index threshold of a 5% increase. Performance was substantially better in ICU (LR+≈14, LR−≈0.12) than in the operating room (LR+≈3.1, LR−≈0.21); heterogeneity was driven by context and monitoring methods. The overall certainty was very low, but findings support EEOT as a confirmatory test in critical care.
Impact: This meta-analysis clarifies when and how EEOT is most reliable, directly informing bedside fluid management strategies in ICU versus OR settings.
Clinical Implications: Use EEOT primarily as a confirmatory test in ICU patients on mechanical ventilation; interpret cautiously in the OR where performance drops. Align device averaging times and monitoring methods with occlusion duration, and integrate EEOT into multimodal, context-specific fluid responsiveness assessment.
Key Findings
- Pooled diagnostic performance: sensitivity 0.87 and specificity 0.90; median cardiac index threshold for positivity ≈5% increase.
- Marked context effect: ICU performance (LR+ ~14; LR− ~0.12) exceeded OR performance (LR+ ~3.1; LR− ~0.21).
- Heterogeneity sources included clinical context, monitoring method, averaging-time/occlusion-time ratio, PEEP level, and cardiac output marker; occlusion duration and tidal volume did not affect performance.
- Overall evidence quality rated very low; no publication bias detected.
Methodological Strengths
- Comprehensive systematic search with meta-analysis across 24 studies (22 meta-analyzed).
- Context- and method-specific subgroup and heterogeneity analyses with likelihood ratios.
Limitations
- Very low overall certainty due to heterogeneity and risk of bias in included observational diagnostic studies.
- Limited standardization of EEOT protocols and monitoring averaging settings across studies; few OR data with high quality.
Future Directions: Prospective, standardized EEOT protocols comparing ICU vs. OR with unified monitoring averaging windows; integration with dynamic indices and outcome-linked decision algorithms.
BACKGROUND: The emergence of context-specific clinical evidence from the end-expiratory occlusion test (EEOT) may change the perception of its operative performance to predict fluid responsiveness. OBJECTIVES: Assessment of predictive performance of the EEOT in the intensive care unit (ICU) and operating room. DESIGN: Systematic review of observational diagnostic test accuracy studies with meta-analysis. DATA SOURCES: MEDLINE, Embase and Scopus were used as data sources for relevant publications until February 2024. ELIGIBILITY CRITERIA: Prospective clinical studies in which the EEOT was used to predict fluid responsiveness in mechanically ventilated adults, regardless of the clinical care context. The operative performance characteristics must also have been reported. RESULTS: Twenty-four studies involving 1073 adult patients (588 receiving intensive care and 485 in the operating room) were systematically reviewed, and 22 studies comprising 1049 volume expansions were meta-analysed. The pooled sensitivity [95% confidence interval (CI)] of the EEOT was 0.87 (0.81 to 0.92), and the pooled specificity was 0.90 (0.85 to 0.94); the median [interquartile range] cardiac index ( CI ) threshold for a positive test was a 5.0 [3.3 to 5.3] increase. The clinical context, the method used for haemodynamic monitoring, the ratio of the averaging time of the monitoring method to the occlusion time, the levels of positive end-expiratory pressure and the choice of cardiac output marker were identified as significant sources of heterogeneity. However, the occlusion duration and tidal volume did not significantly affect its performance. A novel insight is that performance was notably lower in the operating room setting. The likelihood ratios were 14 (positive) and 0.12 (negative) for the ICU, both better than 3.1 and 0.21 for the operating room. The overall quality of the evidence was assessed to be very low, mainly due to high heterogeneity and risk of bias; however, no publication bias was detected. CONCLUSION: The EEOT for predicting fluid responsiveness in critical care performs acceptably well
2. Correlation between dexmedetomidine and postoperative sleep quality in older patients undergoing intestinal surgery.
In a randomized study of 112 older patients undergoing intestinal surgery, dexmedetomidine improved postoperative sleep quality, reduced early sleep disorder incidence (days 1–3), lowered cortisol, increased melatonin, and decreased pain relative to saline. Logistic models identified dexmedetomidine dose, sex, and 24-hour pain as significant determinants of postoperative sleep quality.
Impact: Links a commonly used anesthetic adjunct to patient-centered sleep outcomes with supportive biomarker changes, suggesting a modifiable perioperative target.
Clinical Implications: Consider dexmedetomidine to enhance early postoperative sleep quality in older abdominal surgery patients, alongside multimodal analgesia. Monitor dosing and sedation, and individualize use based on sex and pain profiles.
Key Findings
- Dexmedetomidine reduced early postoperative sleep disorders (days 1–3) and improved PSQI versus saline.
- Biomarker shifts favored dexmedetomidine: higher urinary melatonin and lower cortisol postoperatively.
- Pain scores were lower with dexmedetomidine; dose, sex, and 24-hour VAS independently predicted sleep quality.
Methodological Strengths
- Randomized allocation with serial measurements across 30 days.
- Objective hormonal biomarkers (melatonin, cortisol) complement patient-reported PSQI.
Limitations
- Single-center trial with modest sample size; blinding procedures not detailed.
- PSQI is subjective; urinary biomarker levels can be affected by perioperative factors beyond the intervention.
Future Directions: Multicenter, blinded RCTs comparing dosing regimens, timing (intra- vs. postoperative), and interactions with multimodal analgesia on sleep and delirium outcomes.
OBJECTIVE: This study examined the correlation between dexmedetomidine and postoperative sleep quality in older patients following intestinal surgery. METHODS: A total of 112 older patients were randomly assigned to receive either saline (Group A) or dexmedetomidine (Group B). Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI) before surgery and on postoperative days 1, 3, 7 and 30. Urinary melatonin and cortisol levels were measured, and pain intensity was assessed using the Visual Analogue Scale (VAS) at various time points. Logistic regression analysis identified factors influencing postoperative sleep quality. RESULTS: Both groups showed increased PSQI scores postoperatively, with Group A scoring higher than Group B. Group B exhibited a significantly lower incidence of sleep disorders on Days 1 and 3. Urinary melatonin levels decreased in both groups, with Group A showing lower levels, while cortisol concentrations increased, particularly in Group A. Higher VAS scores were also noted in Group A. Patients not receiving dexmedetomidine had a greater prevalence of sleep disorders. Logistic regression revealed dexmedetomidine dosage, gender and VAS scores at 24 h as significant factors affecting sleep quality. CONCLUSIONS: Dexmedetomidine enhances postoperative sleep quality in older patients undergoing intestinal surgery by reducing cortisol levels, increasing melatonin production and effectively alleviating pain, thereby supporting better recovery outcomes.
3. Factors influencing the choice of lumbar epidural analgesia and its association with postpartum depression risk.
In a longitudinal cohort of 4436 planned vaginal deliveries, 38% used epidural analgesia. Independent predictors of LEA choice included primiparity, prior cesarean, intimate partner violence, gestation ≥280 days, and fear of childbirth. Although LEA correlated with higher PPD risk in crude models, the association disappeared after adjustment, indicating no independent relationship.
Impact: Differentiates social/psychological drivers of epidural use from depression outcomes, providing reassurance that LEA is not an independent risk factor for postpartum depression.
Clinical Implications: Counseling should address social and psychological vulnerabilities (e.g., IPV, fear of childbirth) when discussing LEA. Clinicians can reassure patients that LEA does not independently increase PPD risk after accounting for confounders.
Key Findings
- Among 4436 women, 38% chose LEA; users were younger, more often primiparous, reported higher IPV, and had lower resilience.
- Independent predictors of LEA choice: primiparity, prior cesarean section, intimate partner violence, gestation ≥280 days, and fear of childbirth.
- LEA was associated with higher PPD in crude models but not after multivariable adjustment (no independent association).
Methodological Strengths
- Large longitudinal cohort with repeated measures and linkage to medical records.
- Bayesian multivariable modeling and use of validated PPD instruments at 6–8 weeks and 6 months.
Limitations
- Single-center Swedish cohort; residual confounding and selection bias possible.
- Study not registered at inception (2010); exclusions (e.g., induction) may limit generalizability.
Future Directions: Multi-center cohorts and quasi-experimental designs to test causality; integrate structured IPV screening and resilience-building interventions into peripartum care pathways.
BACKGROUND: The use of lumbar epidural analgesia (LEA) during childbirth varies significantly among women. Factors influencing a woman's choice of LEA and its possible effects on postpartum depression (PPD) remain underexplored. OBJECTIVES: To investigate factors influencing the choice of LEA among women with intended vaginal deliveries. A secondary objective was to explore the association between LEA use and PPD. STUDY DESIGN: A longitudinal cohort study. SETTING: Uppsala University Hospital, Sweden, 2010 to 2019. POPULATION: Women with an intended vaginal delivery. EXCLUSIONS: Twins, elective caesarean section, induction of labour. METHODS: Data were collected by web-based self-completed questionnaires at gestational weeks 17, 32 and at 6 weeks and 6 months postpartum. The exposures were sociodemographic, resilience-related, medical and obstetric characteristics of all participants from the BASIC (Biology, Affect, Stress, Imaging and Cognition) study. Information on the use of LEA was retrieved from medical records. PPD was assessed using either the Edinburgh Postnatal Depression Scale, or the Depression Self-Rating Scale, and/or the Mini-International Neuropsychiatric Interview at 6 to 8 weeks and 6 months postpartum. Bayesian models were applied to investigate the associations of multivariate factors with the choice for LEA, and the association between the use of LEA and PPD. RESULTS: Among 4436 participants, 38% opted for LEA, while 62% did not. LEA users were younger, primiparous, reported higher rates of intimate partner violence (IPV) and had lower resilience. The adjusted model revealed primiparity, previous caesarean section, IPV, pregnancy length at least 280 days and fear of childbirth as independent predictors of LEA use. While LEA use was associated with higher odds of PPD in the crude regression model, it was no longer statistically significant after adjusting for possible confounders and mediators. CONCLUSION: Social and psychological vulnerabilities influence a woman's decision to opt for LEA during childbirth. LEA was not associated with PPD in adjusted models. TRIAL REGISTRATION: This is a longitudinal study which was not registered in 2010.