Daily Anesthesiology Research Analysis
Three studies stand out in anesthesiology: a prospectively validated decision tool (Expect-It) markedly improved first-attempt tracheal intubation success and recognition of indications for camera-assisted and awake intubation; an ESAIC consensus statement provides pragmatic, evidence-informed recommendations for intra-operative hemodynamic monitoring and management; and a randomized trial shows remimazolam does not potentiate rocuronium-induced neuromuscular block beyond propofol, unlike sevofl
Summary
Three studies stand out in anesthesiology: a prospectively validated decision tool (Expect-It) markedly improved first-attempt tracheal intubation success and recognition of indications for camera-assisted and awake intubation; an ESAIC consensus statement provides pragmatic, evidence-informed recommendations for intra-operative hemodynamic monitoring and management; and a randomized trial shows remimazolam does not potentiate rocuronium-induced neuromuscular block beyond propofol, unlike sevoflurane.
Research Themes
- Airway management decision support and predictive planning
- Intra-operative hemodynamic monitoring and individualized goal-directed therapy
- Interactions between anesthetic maintenance agents and neuromuscular blockade
Selected Articles
1. Decision-Making Tool for Planning Camera-Assisted and Awake Intubation in Head and Neck Surgery.
A prospectively developed and validated airway decision tool (Expect-It) predicted when camera-assisted and awake intubation were appropriate with high accuracy, substantially outperforming non-algorithmic planning in sensitivity while maintaining specificity. Implementation was associated with higher first-attempt intubation success and fewer failed direct laryngoscopies.
Impact: It operationalizes multi-source airway risk data into a validated algorithm that improved real-world intubation outcomes, addressing a key patient safety domain in anesthesiology.
Clinical Implications: Use of Expect-It can guide preoperative airway planning, prompting camera-assisted and awake strategies when indicated to increase first-attempt success and reduce failed direct laryngoscopy. Integration into pre-op assessment workflows or EHRs may standardize difficult airway preparation.
Key Findings
- AUC 0.86 for predicting appropriate camera-assisted intubation and 0.97 for appropriate awake intubation.
- Sensitivity vs. clinical standard: 88% vs 35% (camera-assisted) and 97% vs 29% (awake); specificity noninferior (≥97%).
- Post-implementation: first-attempt success increased 73%→82% (OR 1.72), failed direct laryngoscopy decreased 8%→2% (OR 0.18).
Methodological Strengths
- Prospective two-stage development/validation with multivariable regularized regression.
- Objective performance metrics (AUC, sensitivity/specificity) and pre-post clinical outcome comparison.
Limitations
- Single-center study; external validation across diverse settings is needed.
- Before-after comparison may be susceptible to temporal and implementation biases.
Future Directions: External multicenter validation, integration into clinical decision support within EHRs, and evaluation of algorithm-driven training effects on airway management.
2. Intra-operative haemodynamic monitoring and management of adults having noncardiac surgery: A statement from the European Society of Anaesthesiology and Intensive Care.
ESAIC experts recommend maintaining intra-operative MAP ≥60 mmHg, identifying and treating causes of hypotension, selectively monitoring stroke volume/cardiac output in high-risk or high-risk surgery patients, avoiding routine maximization of flow variables, and administering fluids only when clinical/metabolic signs of hypovolemia or hypoperfusion exist. Depth of anesthesia monitoring and optimization are also advised.
Impact: Provides pragmatic, evidence-informed guidance to standardize intra-operative hemodynamic care, directly influencing broad anesthetic practice and patient safety.
Clinical Implications: Adopt MAP-based targets (≥60 mmHg), use cause-directed therapy for hypotension, selectively apply CO/SV monitoring to high-risk cases, avoid chasing maximal flow, and give fluids based on hypovolemia/perfusion evidence rather than fluid responsiveness alone. Incorporate depth of anesthesia monitoring to titrate hypnotics/analgesics.
Key Findings
- Maintain intra-operative MAP above 60 mmHg and treat underlying causes of hypotension.
- Selective CO/SV monitoring for high-risk patients or high-risk surgeries; avoid routine maximization of flow variables.
- Administer fluids based on clinical/metabolic signs of hypovolemia or hypoperfusion, not fluid responsiveness alone; optimize anesthetic depth.
Methodological Strengths
- Multidisciplinary international expert panel with transparent recommendations.
- Evidence-informed synthesis addressing monitoring, targets, and interventions.
Limitations
- Consensus guidance rather than randomized evidence; heterogeneity of supporting studies.
- No formal systematic review/meta-analysis protocol detailed.
Future Directions: Prospective implementation studies to test protocolized MAP targets and selective CO/SV monitoring, and trials adjudicating fluid strategies incorporating perfusion markers.
3. Comparative potentiating effects of remimazolam, propofol and sevoflurane on rocuronium-induced neuromuscular block: a randomized controlled trial.
In 90 analyzed patients, time to first PTC did not differ among remimazolam, propofol, and sevoflurane. Sevoflurane prolonged time to TOF count reappearance versus propofol, whereas remimazolam behaved similarly to propofol. Free rocuronium concentration at first PTC was lower with remimazolam than propofol, yet overall potentiation remained weaker than sevoflurane.
Impact: Clarifies neuromuscular interaction profiles of a newer benzodiazepine (remimazolam) versus established agents, informing agent selection and dosing for safe neuromuscular management.
Clinical Implications: Remimazolam can be expected to have neuromuscular block potentiation similar to propofol and less than sevoflurane, supporting its use where rapid recovery and predictable reversal are desired. Quantitative neuromuscular monitoring remains essential.
Key Findings
- No difference among groups in time from rocuronium to first PTC reappearance.
- Sevoflurane significantly prolonged time to TOF counts 1 and 2 compared with propofol; no significant differences between sevoflurane and remimazolam.
- Free rocuronium concentration at first PTC was lower with remimazolam than propofol, yet overall potentiation was weaker than sevoflurane.
Methodological Strengths
- Randomized controlled design with electromyography-based quantitative neuromuscular monitoring.
- Concurrent measurement of free plasma rocuronium concentrations.
Limitations
- Single-center RCT with modest sample size; not powered for rare adverse events.
- Between-group anesthetic depth and other intraoperative variables may confound neuromuscular recovery kinetics.
Future Directions: Larger multicenter RCTs examining diverse surgical populations and integrating reversal agents and recovery endpoints (e.g., TOF ratio ≥0.9 time, PACU events).