Daily Anesthesiology Research Analysis
Three anesthesiology-relevant studies stood out today: a meta-analysis suggests sugammadex reduces postoperative nausea versus neostigmine, a post hoc analysis of TTM2 shows intravascular devices achieve better hypothermia performance than surface cooling after cardiac arrest, and a large pediatric ICU cohort links benzodiazepine sedation with fewer ventilator-free days and more delirium. These findings inform perioperative antiemesis strategy, post–cardiac arrest temperature management, and ped
Summary
Three anesthesiology-relevant studies stood out today: a meta-analysis suggests sugammadex reduces postoperative nausea versus neostigmine, a post hoc analysis of TTM2 shows intravascular devices achieve better hypothermia performance than surface cooling after cardiac arrest, and a large pediatric ICU cohort links benzodiazepine sedation with fewer ventilator-free days and more delirium. These findings inform perioperative antiemesis strategy, post–cardiac arrest temperature management, and pediatric sedation practices.
Research Themes
- Perioperative neuromuscular reversal and PONV mitigation
- Post–cardiac arrest targeted temperature management device performance
- Pediatric ICU sedation strategies and outcomes
Selected Articles
1. Comparative efficacy of sugammadex and neostigmine in postoperative nausea and vomiting management: a meta-analysis of randomized controlled trials.
Across 20 RCTs (n=3,248), sugammadex reduced postoperative nausea versus neostigmine (RR 0.65, 95% CI 0.48–0.88). Some analyses suggested lower opioid use with sugammadex depending on administration timing, though estimates were imprecise.
Impact: This synthesis directly informs a common perioperative decision—choice of neuromuscular reversal—linking sugammadex with lower postoperative nausea, a patient-centered outcome.
Clinical Implications: When PONV risk is a priority, selecting sugammadex for reversal may reduce postoperative nausea versus neostigmine; consider cost, availability, and patient-specific PONV risk stratification.
Key Findings
- Meta-analysis of 20 RCTs (3,248 participants) comparing sugammadex vs neostigmine for PONV.
- Sugammadex reduced postoperative nausea (RR 0.65, 95% CI 0.48–0.88).
- Signals toward reduced opioid consumption with sugammadex were noted but with imprecision.
- Comprehensive search across PubMed, Embase, and Cochrane with independent screening.
Methodological Strengths
- Included only randomized controlled trials with dual independent review
- Broad database search and quantitative synthesis
Limitations
- Heterogeneity and some imprecision (e.g., opioid use estimate with wide CI)
- Abstract does not report granular PONV time-windows or emesis outcomes
Future Directions: Prospective head-to-head RCTs stratified by PONV risk and standardized antiemetic prophylaxis to quantify absolute benefit, cost-effectiveness analyses, and safety endpoints.
Postoperative nausea and vomiting (PONV) are frequent complications that can occur after surgical procedures. Sugammadex, known for its effectiveness as a muscle relaxant antagonist, offers several advantages over neostigmine, however, there is still insufficient evidence to demonstrate its superiority in reducing PONV. This meta-analysis sought to assess the efficacy of sugammadex versus neostigmine in the management of PONV. Two independent investigators conducted a comprehensive review of randomized controlled trials (RCTs) across PubMed, Embase, and the Cochrane Library. The meta-analysis was performed using Review Manager software. Our meta-analysis scrutinized twenty studies that included 3248 participants. The results showed that sugammadex was effective in reducing postoperative nausea (RR = 0.65, 95% CI 0.48 to 0.88) versus neostigmine. Sugammadex reduced the dosage of opioids (SMD = 0.55, 95% CI -0.18 to 1.27) compared with neostigmine when the time of administration is T
2. Intravascular vs. surface cooling in out-of-hospital cardiac arrest patients receiving hypothermia after hospital arrival: a post hoc analysis of the TTM2 trial.
Intravascular devices achieved faster target temperature attainment (69.6% within 4 h vs 49.2%) and tighter temperature control with less post-TTM fever than surface devices in OHCA patients receiving hypothermia in TTM2. Exploratory IPTW analyses did not show significant differences in 6-month survival or good functional outcome.
Impact: Device selection materially affects TTM performance metrics that matter for protocol adherence and physiologic control after cardiac arrest, informing ICU practice even absent proven clinical outcome differences.
Clinical Implications: When implementing hypothermia, intravascular cooling may be preferred to achieve faster and more stable temperature control; outcome benefits remain unproven and require shared decision-making and alignment with contemporary TTM strategies.
Key Findings
- Post hoc analysis of TTM2 hypothermia arm (n=876 devices analyzed).
- Intravascular cooling reached target <33.5 °C within 4 h more often than surface (69.6% vs 49.2%).
- Less time outside target ranges and less post-TTM fever with intravascular devices.
- No statistically significant differences in 6-month survival or good functional outcomes in IPTW exploratory analyses.
Methodological Strengths
- Large sample embedded within a multicenter RCT framework
- Robust temperature performance metrics and IPTW exploratory analyses
Limitations
- Post hoc design; device allocation was not randomized
- Clinical outcomes exploratory and potentially underpowered for device comparisons
Future Directions: Prospective randomized comparisons of cooling modalities with standardized TTM protocols and pragmatic outcomes; device performance–to–outcome mediation analyses.
PURPOSE: To compare the performance of targeted temperature management (TTM) at 33 °C using intravascular (IC) vs. surface-cooling (SFC) devices after out-of-hospital cardiac arrest (OHCA). METHODS: A post hoc analysis including OHCA patients randomized to hypothermia in the TTM2-trial (NCT02908308) comparing hypothermia with normothermia. The main outcome was cooling performance, defined as the proportion of patients reaching target temperature < 33.5 °C within 4 h, time outside temperature ranges during maintenance, rewarming rate and post-TTM fever. Exploratory outcomes included survival and good functional outcome, defined as modified Rankin Scale (mRS) scores of 0-3 at 6 months, analyzed using Inverse Probability Treatment Weighting (IPTW). RESULTS: Among 930 patients randomized to hypothermia, 876 were treated with a cooling device and included in this study. Of those, 27.3% received IC devices, while 72.7% received SFC devices. The proportion reaching target temperature within 4 h was higher with IC (IC: 69.6% vs. SFC: 49.2%; p < 0.001). Temperature outside ranges during the cooling period and post-TTM fever were lower with IC compared to SFC (17.2% vs. 39.6%; p < 0.001 and 0% vs. 6.3%; p < 0.001, respectively). In the exploratory IPTW analysis, 6-month survival rates were 55.2% in the IC group and 50.2% in the SFC group (OR 1.22, 95% CI 0.89-1.68) and survival with good functional outcome at 6 months was 51.1% patients in the IC group and 44.9% in the SFC (OR 1.28, 95% CI 0.93-1.77). CONCLUSIONS: Among OHCA patients randomized to hypothermia in the TTM2 study, intravascular cooling, compared with surface cooling, was associated with better cooling performance.
3. Impact of Benzodiazepines on Outcomes of Mechanically Ventilated Pediatric Intensive Care Patients: A Retrospective Cohort Study.
Among 1,054 ventilated PICU patients, benzodiazepine-inclusive sedation was associated with fewer ventilator-free days (median 21.0 vs 26.7), fewer ICU- and hospital-free days, higher delirium scores, and more withdrawal-tapering medication use. Propensity-matched analyses supported these associations, but confounding by indication cannot be excluded.
Impact: Findings reinforce the movement toward benzodiazepine-sparing pediatric ICU sedation strategies by linking benzodiazepines with patient-centered harms.
Clinical Implications: Prefer non-benzodiazepine sedation strategies when feasible (e.g., dexmedetomidine, analgesia-first), enhance delirium surveillance, and implement structured withdrawal prevention/tapering protocols.
Key Findings
- Retrospective cohort of 1,054 ventilated PICU patients; 747 received benzodiazepines.
- Benzodiazepine use associated with fewer ventilator-free days (21.0 vs 26.7; p<0.001).
- Fewer ICU- and hospital-free days, higher delirium scores, and greater need for withdrawal-tapering medications.
- Associations persisted in intermittent-only benzodiazepine users; younger patients more likely to receive benzodiazepines.
Methodological Strengths
- Large sample size with multivariable regression and propensity-score matching
- Clinically meaningful, patient-centered outcomes (VFDs, delirium, LOS)
Limitations
- Single-center retrospective design with potential confounding by indication
- Medication exposure intensity and co-sedatives may vary and introduce bias
Future Directions: Prospective multicenter trials comparing benzodiazepine-sparing protocols vs standard care, integrating delirium prevention bundles and withdrawal mitigation.
IMPORTANCE: Benzodiazepines are the most frequently used sedatives in PICUs, but they are increasingly associated with negative outcomes. Understanding their impact on patient outcomes is critical to provide better sedative management for patients. OBJECTIVE: Our objective was to determine the impact of midazolam and lorazepam on clinical outcomes among subjects requiring mechanical ventilation in the PICU. We hypothesized that subjects receiving benzodiazepines for tolerance of mechanical ventilation will demonstrate worse clinical outcomes when compared with those not receiving benzodiazepines. DESIGN: Single-center, retrospective cohort study. SETTING AND PARTICIPANTS: PICU of a tertiary-care medical center. One thousand fifty-four pediatric participants requiring invasive mechanical ventilation between June 2018 and December 2022. Participants were categorized into those who received benzodiazepine-inclusive sedation regimens (n = 747) and those who received nonbenzodiazepine regimens (n = 307). INTERVENTIONS: None. MAIN OUTCOMES AND MEASURES: Subjects were sorted into groups of benzodiazepine-sedative regimens (midazolam and lorazepam, only lorazepam) or nonbenzodiazepine-sedation regimens. The primary outcome was ventilator-free days (VFDs). Statistical analysis was performed using multivariable linear regression and propensity-score matching. RESULTS: Subjects receiving continuous and/or intermittent benzodiazepines had fewer VFDs compared with the nonbenzodiazepine group (median 21.0 vs. 26.7; p < 0.001). The benzodiazepine group had fewer ICU-free and hospital-free days, higher delirium scores, and a greater need for withdrawal-tapering medications. This was redemonstrated in subjects only receiving intermittent benzodiazepines as well. Younger subjects were more likely to receive benzodiazepines. CONCLUSIONS AND RELEVANCE: Our study demonstrates an association between children receiving both continuous and intermittent benzodiazepine sedation and worse clinical outcomes. These patients have fewer VFDs and longer length of stay, higher doses of nonbenzodiazepine sedatives, and increased need for withdrawal tapering medications and antipsychotics. It is unclear in this retrospective study if the outcomes were worse because the subjects received benzodiazepines or because subjects receiving benzodiazepines were sicker and thus required benzodiazepines in their analgosedative regimen. Further investigation is warranted into the impact of benzodiazepines on patient outcomes, nonpharmacologic management of sedation, improvement in bedside assessment of analgosedation, and optimal balance between over- and under-sedation.