Daily Anesthesiology Research Analysis

BACKGROUNDS: Post-induction hypotension (PIH) is prevalent in elderly surgical patients and associated with adverse outcomes; however, predicting PIH remains challenging. We aimed to develop a feasible and practical PIH prediction model for elderly patients undergoing non-cardiac surgery. METHODS: In this single-center prospective cohort study, 938 elderly patients undergoing non-cardiac surgery were enrolled from December 2022 to May 2023 (n = 657 in the development cohort) and from June 2023 to August 2023 (n = 281 in the temporal validation cohort), respectively. The study outcome was the occurrence of PIH, defined as hypotension during the first 15 min after anesthesia induction or until skin incision (whichever occurred first). Predictors were determined based on LASSO and logistic regression analyses. A nomogram and a dynamic application were used for model visualization. The internal and temporal validation were performed to evaluate the discriminability, calibration and clinical utility. RESULTS: The median age was 71 years in both cohorts. The incidence of PIH was 51.6% and 50.5% in the development and validation cohorts, respectively. Cardiac function, baseline mean arterial pressure in the ward, etomidate use, and pre-induction mean arterial pressure were determined as predictors. The PIH prediction model was visualized as a nomogram and a dynamic application. The area under the receiver operating characteristic curve was 0.680 (95% confidence interval [CI]: 0.639 to 0.720) in internal validation and 0.697 (95% CI: 0.635 to 0.759) in temporal validation. The mean absolute errors were 0.012 and 0.029 for the internal and temporal validation calibration curves, respectively. The Brier score was 0.223. The decision curve analysis indicated that the model had a gain in predicting PIH. CONCLUSION: A PIH prediction model with four predictors was developed and validated for elderly patients undergoing non-cardiac surgery. This model provides a foundation for future refinements to enhance its value of assisting clinical decision-making across diverse healthcare settings. TRIAL REGISTRATION: This study was registered at the Chinese Clinical Trial Registry (ChiCTR2200066201).

OBJECTIVES: Our primary objective was to quantify the effect of a clinical decision support system (CDSS) informed by inadequate delivery of oxygen index (ID o2 ), an algorithm that estimates the probability of inadequate oxygen delivery on inotropes and vasoactive infusions (IVAI) postoperatively. DESIGN: Multicenter before-and-after study conducted between June 01, 2020, and December 31, 2022. SETTING: Three pediatric cardiac ICUs (CICUs) at tertiary academic children's hospitals. PATIENTS: Infants older than 36 weeks estimated gestational age and 2 kg following cardiac surgery with cardiopulmonary bypass, treated with IVAI greater than or equal to 6 hours. INTERVENTIONS: Clinicians committed to consider data from a CDSS informed by 6 hours rolling ID o2 average in their plan to wean IVAI postoperatively. Within the system, documentation of decisions incorporating these data prompted patient inclusion in the intervention arm. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was IVAI duration. Secondary outcomes were CICU length of stay (LOS), rate of cardiac arrest (CA), and rate of IVAI weaning failure. Negative binomial and logistic regression models were used to assess differences between intervention and control groups. Age, sex, Society of Thoracic Surgeons-European association for Cardio-Thoracic Surgery (STAT) category, site, admit time, single-ventricle diagnosis, Vasoactive-Inotropic Score, and trial group were tested as input covariates. Three hundred forty-three and 432 patients were enrolled in the intervention and control groups, respectively. The intervention group included a higher proportion of STAT 4 patients and a lower proportion of STAT 1 patients (81 vs. 62; p < 0.01 and 43 vs. 108; p < 0.01, respectively). A risk-adjusted negative binomial regression model showed 29% shorter vasoactive infusion duration in the intervention group (95% CI, 14-42%; p < 0.01). There were no significant trends observed in CICU LOS, or occurrence rate of CA or weaning failure. CONCLUSIONS: A CDSS informed by ID o2 significantly decreased vasoactive infusions duration. There was no discernible change in ICU LOS, CA rate, or weaning failure rate.

BACKGROUND: Remimazolam (Rm) is a novel ultra-short-acting benzodiazepine used in general anesthesia. However, its application in pediatric general anesthesia remains limited. This study aims to compare the efficacy, safety, and postoperative emergence profiles of remimazolam and propofol (Pf) in pediatric surgical anesthesia. METHODS: Children (aged 3-12 years) undergoing strabismus correction surgery were randomly assigned to the Group Rm or the Group Pf. The Group Rm and Group Pf received an induction dose of 0.3 mg/kg and 2 mg/kg, respectively. For emergence, the Group Rm was administered flumazenil 0.2-0.3 mg. The primary outcome was the time from the discontinuation of anesthetic agents to the first eye opening. Secondary outcomes included the time from the end of surgery to laryngeal mask airway (LMA) removal, the time to achieve a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of 5 after LMA removal, and Aldrete scores during the postanesthetic care unit (PACU) stay. Additionally, the changes of vital signs before and after anesthesia were compared between the two groups. RESULTS: In all patients, both remimazolam and propofol induced anesthesia successfully. Regarding emergence profiles, the Group Rm had significantly shorter times to first eye opening, LMA removal, and achieving an MOAA/S score of 5 post-LMA removal compared to the Group Pf (p < 0.001). Upon arrival at the PACU, the number of patients with Aldrete scores ≥ 9 was significantly higher in the Group Rm (p < 0.001). Following injection, the reduction in DBP was significantly greater in the Group Pf compared to the Group Rm (p < 0.001). The Group Rm maintained a more stable HR compared to the Group Pf. CONCLUSION: Remimazolam provides more stable hemodynamic characteristics and significantly shorter postoperative emergence time in pediatric patients compared to propofol. This suggests that remimazolam may be more suitable than propofol for pediatric general anesthesia, though larger scale clinical trials are needed for further validation. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2400083265.