Daily Anesthesiology Research Analysis
Three perioperative studies stand out today: a massive VA multicenter analysis shows that preoperative SGLT2 inhibitor use slightly raises euglycemic ketoacidosis risk but lowers acute kidney injury and 30-day mortality. A meta-analysis of 24 randomized trials supports intraoperative goal-directed fluid therapy in oncologic surgery to reduce complications and length of stay. A randomized trial finds ciprofol reduces respiratory adverse events versus propofol during gastroscopy in patients with o
Summary
Three perioperative studies stand out today: a massive VA multicenter analysis shows that preoperative SGLT2 inhibitor use slightly raises euglycemic ketoacidosis risk but lowers acute kidney injury and 30-day mortality. A meta-analysis of 24 randomized trials supports intraoperative goal-directed fluid therapy in oncologic surgery to reduce complications and length of stay. A randomized trial finds ciprofol reduces respiratory adverse events versus propofol during gastroscopy in patients with obesity.
Research Themes
- Perioperative medication safety and outcomes (SGLT2 inhibitors)
- Intraoperative fluid optimization (goal-directed fluid therapy)
- Sedation/anesthetic agent innovation for high-risk patients (ciprofol vs propofol)
Selected Articles
1. Postoperative Outcomes Among Sodium-Glucose Cotransporter 2 Inhibitor Users.
In a large, multicenter VA analysis with propensity matching, long-term preoperative SGLT2 inhibitor use was linked to a slight increase in postoperative euglycemic ketoacidosis but significantly lower risks of acute kidney injury and 30-day mortality. These findings suggest nuanced perioperative risk-benefit tradeoffs for SGLT2 inhibitors.
Impact: This is the most comprehensive perioperative assessment of SGLT2 inhibitors to date, directly informing anesthesia and surgical teams on balancing eKA risk against kidney and survival benefits.
Clinical Implications: Consider individualized SGLT2i management rather than universal discontinuation: ensure perioperative monitoring and readiness to detect/treat euglycemic ketoacidosis, while recognizing potential renal protection and survival benefits.
Key Findings
- After matching (n=7,439 SGLT2i vs 33,489 controls), SGLT2i use increased postoperative eKA risk (OR 1.11; 95% CI 1.05–1.17).
- SGLT2i use reduced perioperative AKI risk (OR 0.69; 95% CI 0.62–0.78).
- SGLT2i use reduced 30-day postoperative mortality (OR 0.70; 95% CI 0.55–0.88).
- Among eKA cases, median hospital stay increased by 3 days (6 vs 3 days).
Methodological Strengths
- Very large, multicenter dataset with rigorous propensity score matching.
- Clear clinical endpoints (eKA, AKI, 30-day mortality) with robust effect estimates.
Limitations
- Retrospective design with potential residual confounding.
- Predominantly male veteran population limits generalizability to broader surgical cohorts.
Future Directions: Prospective trials or pragmatic registries to refine perioperative SGLT2i continuation/hold strategies and define optimal timing with standardized eKA monitoring and mitigation protocols.
IMPORTANCE: Case reports and small retrospective studies have suggested that there is an increased risk of postoperative euglycemic ketoacidosis (eKA) and acute kidney injury (AKI) among patients using sodium-glucose cotransporter 2 inhibitors (SGLT2i) preoperatively. However, there has not been a representative assessment of the risks of these agents among patients undergoing surgery. OBJECTIVE: To evaluate the risk of postoperative eKA, AKI, and mortality within 30 days after surgery among preoperative long-term SGLT2i users compared with nonusers. DESIGN, SETTINGS, AND PARTICIPANTS: This is a multicenter, propensity-matched, retrospective case-control study from the Veterans Affairs Health Care System (VAHCS) National Registry performed from January 1, 2014, to December 31, 2022. Adult patients using SGLT2i preoperatively who underwent inpatient surgical procedures were compared with a 1:5 matched control group using propensity score matching, including the patient's demographic characteristics, comorbidities, and surgical characteristics. Data analysis was performed from June 2023 to August 2024. EXPOSURE: Long-term use of SGLT2i, defined as having more than 3 fills of outpatient prescription or less than a 180-day gap of the last fill according to the VAHCS pharmacy registries. MAIN OUTCOMES AND MEASURES: The primary outcome was the rate of postoperative eKA among SGLT2i users vs control patients. Secondary outcomes included postoperative AKI and 30-day mortality after surgery. RESULTS: Among 462 968 patients undergoing surgery, 7448 SGLT2i users (mean [SD] age, 67.7 [8.1] years; 7204 [96.7%] male) and 455 520 nonusers (mean [SD] age, 65.8 [11.0] years; 424 785 [93.3%] male) were identified. After propensity score matching, 7439 patients were identified as SGLT2i users and compared with 33 489 control patients. SGLT2i use was associated with an increased risk of eKA (odds ratio [OR], 1.11; 95% CI, 1.05-1.17) but reduced risks of perioperative AKI (OR, 0.69; 95% CI, 0.62-0.78) and 30-day mortality (OR, 0.70; 95% CI, 0.55-0.88). The mortality rate 30 days after surgery was 1.1% among SGLT2i users vs 1.6% among control patients. The median hospital length of stay among the patients presenting with eKA increased by 3 days (median [IQR], 6 [3-10] days for those with eKA vs 3 [2-6] days for those without eKA). CONCLUSIONS AND RELEVANCE: Patients treated with SGLT2i had a small but significantly higher risk of postoperative eKA but lower risks of postoperative AKI and 30-day mortality.
2. Intraoperative Goal-Directed Fluid Therapy and Outcomes After Oncologic Surgeries: A Systematic Review and Meta-Analysis.
Across 24 RCTs in oncologic surgery, intraoperative goal-directed fluid therapy reduced hospital length of stay by 1.57 days, lowered overall postoperative complications (RR 0.74), and accelerated bowel recovery. Certainty is limited by heterogeneity and risk of bias, and long-term cancer outcomes were not reported.
Impact: Synthesizes randomized evidence supporting GDFT as a perioperative optimization strategy in cancer surgery, with clinically meaningful reductions in complications and length of stay.
Clinical Implications: Implementing GDFT protocols (e.g., stroke volume/CO-guided) during oncologic surgery may reduce complications and expedite discharge, though local adoption should consider device availability, team training, and protocol standardization.
Key Findings
- Across 24 RCTs (GDFT n=1,172; control n=1,186), GDFT reduced hospital length of stay (MD −1.57 days; 95% CI −2.29 to −0.85; P<.01).
- GDFT lowered total postoperative complications (RR 0.74; 95% CI 0.56–0.97; P=.03).
- Time to bowel function recovery was shorter with GDFT (MD −0.58 days; 95% CI −1.02 to −0.14; P=.01).
- Trial sequential analysis suggests conclusions on length of stay are unlikely to change with more trials.
Methodological Strengths
- Meta-analysis restricted to randomized controlled trials.
- Predefined primary outcomes and use of trial sequential analysis to assess conclusiveness.
Limitations
- Between-study heterogeneity and risk of bias lowered certainty of evidence.
- No trial reported long-term oncologic outcomes, limiting assessment of downstream cancer care impact.
Future Directions: High-quality, standardized GDFT trials in specific cancer procedures, with harmonized protocols and long-term oncologic outcomes, to confirm durability and generalizability.
BACKGROUND: Surgery is the first-line curative treatment for most solid-organ malignancies. During major surgeries, fluid under- or over administration can have a significant impact on recovery and postoperative outcomes. For patients undergoing oncologic surgery, delayed recovery or complications could additionally impact subsequent oncologic treatment planning. This systematic review and meta-analysis aims to evaluate the impact of goal-directed fluid therapy (GDFT) on perioperative outcomes after oncologic surgeries. METHODS: We systematically searched PubMed, EMBASE, CINAHL, and Web of Science citation index for clinical trials comparing the GDFT to routine clinical care. The primary outcomes of interest are the hospital length of stay and the total incidence of postoperative complications. Secondary outcomes include organ-specific complications and recovery of bowel function. RESULTS: The literature search was last updated on February 17, 2024. We identified a total of 24 randomized controlled trials (RCTs) comparing GDFT to routine care with 1172 and 1186 patients, respectively. The GDFT arm had a significantly shorter length of hospital stay (mean difference [MD], 1.57 days, 95% confidence interval [CI], -2.29 to -0.85, P < .01), as well as lower incidence of complications (risk ratio, 0.74, 95% CI, 0.56-0.97, P = .03). The GDFT arm also had a shorter time to bowel function recovery (MD, 0.58 days, 95% CI, -1.02 to -0.14, P = .01). None of the included trials reported the longer-term oncologic outcomes. The overall certainty of evidence is low due to between-study variance and study risk of bias. Trial sequence analysis indicates that further studies are unlikely to alter the conclusion regarding postoperative length of stay but may provide further information on the postoperative complications. CONCLUSIONS: Our systematic review and meta-analysis suggests that in oncologic surgery, intraoperative GDFT significantly reduces the length of hospital stay, lowers the risk of complications, and facilitates bowel function recovery. Further studies are required to evaluate whether the improvement in early postoperative outcomes leads to better long-term oncologic outcomes.
3. Effects of ciprofol on respiratory-related adverse incidence in patients with obesity during painless gastroscopy: a prospective, randomized clinical trial.
In obese patients undergoing painless gastroscopy, ciprofol (0.4 mg/kg) significantly reduced respiratory-related adverse events and hypotension compared with propofol (2.0 mg/kg), while maintaining procedural success and satisfaction.
Impact: Addresses a high-risk population where sedation-related respiratory events are common, suggesting a viable alternative to propofol with improved safety profile.
Clinical Implications: For obese patients requiring endoscopic sedation, ciprofol may be preferred over propofol to mitigate respiratory events and hypotension, contingent on local availability and clinician familiarity.
Key Findings
- Respiratory-related adverse events were lower with ciprofol vs propofol (17.5% vs 57.5%; P<0.001).
- Ciprofol reduced intra-procedural hypotension (P=0.024) and movement (P=0.007).
- Procedure and anesthesia success rates and satisfaction were similar between groups.
- Ciprofol 0.4 mg/kg achieved sedation comparable to propofol 2.0 mg/kg.
Methodological Strengths
- Prospective randomized parallel-group design in a clearly defined high-risk (obese) population.
- Clinically meaningful primary endpoint focused on respiratory adverse events.
Limitations
- Single-center, modest sample size limits external validity.
- Blinding procedures not described; potential performance and detection bias.
Future Directions: Larger multicenter, double-blind trials across diverse endoscopic procedures and BMI strata; dose-finding and pharmacoeconomic analyses to guide implementation.
BACKGROUND: Ciprofol is an intravenous anesthetic agent which in low doses produces sedation. It was developed via structural modification of propofol. Ciprofol is claimed to reduce respiratory depression. The object of the present study was to investigate whether or not ciprofol did actually reduce respiratory depression or not in patients with obesity undergoing gastroscopy. METHODS: A total of 84 patients with obesity scheduled for gastroscopy were enrolled. The participants were randomly allocated to receive sedation with ciprofol (group C) or propofol (group P). The primary outcome was the incidence of respiratory-related adverse events (AEs), whereas the secondary outcomes were the incidence of further intraoperative and postoperative AEs; procedure and anesthesia success rates; Narcotrend index (NI); induction dosage; procedure time; recovery time; discharge time; and satisfaction ratings from the patients, anesthesiologists, and endoscopists. RESULTS: The incidence of respiratory-related AEs was significantly lower in group C than in group P (17.5% vs. 57.5%; P < 0.001). The occurrence of hypotension and movement during procedural events in group C was markedly reduced compared with that in group P (P = 0.024 and 0.007, respectively). No notable differences were observed in the occurrence of additional AEs or in the success rates of the procedure and anesthesia between the two groups (P > 0.05). The three-point satisfaction levels were comparable between the groups (P > 0.05). CONCLUSIONS: 0.4 mg/kg of ciprofol provides anesthesia comparable with 2.0 mg/kg of propofol. However, it is related to reduced respiratory-related AEs and hypotension during gastroscopy in patients with obesity; thus, ciprofol is preferred to propofol for anesthesia in obese patients. TRIAL REGISTRATION: This study was registered in the Chinese Clinical Trial Registry (KYLS20230625; first registration date: 29/06/2023).