Daily Anesthesiology Research Analysis
Three anesthesia-focused randomized clinical trials stand out today. Lateral-position placement of a bronchial blocker dramatically reduced malposition during thoracic surgery. An opioid-free perioperative pathway matched opioid-based care on pain and recovery while sharply reducing opioid use in bariatric surgery. THRIVE high-flow nasal oxygen prevented postoperative hypoxemia in elderly patients in the PACU.
Summary
Three anesthesia-focused randomized clinical trials stand out today. Lateral-position placement of a bronchial blocker dramatically reduced malposition during thoracic surgery. An opioid-free perioperative pathway matched opioid-based care on pain and recovery while sharply reducing opioid use in bariatric surgery. THRIVE high-flow nasal oxygen prevented postoperative hypoxemia in elderly patients in the PACU.
Research Themes
- Airway and lung isolation optimization in thoracic anesthesia
- Opioid-sparing perioperative pathways
- Postoperative respiratory support in elderly patients
Selected Articles
1. Lung isolation with a bronchial blocker placed in the lateral position for patients undergoing thoracic surgery: A multicenter, randomized clinical trial.
In this multicenter randomized trial (n=306), placing a bronchial blocker directly in the lateral decubitus position reduced malposition from 25.3% to 0.7%, lowered repositioning needs, and decreased postural injuries without prolonging intubation time. Patient and surgeon satisfaction were higher with lateral placement.
Impact: The magnitude of malposition reduction is large and directly addresses a common intraoperative problem in thoracic anesthesia. The findings are immediately implementable and likely to change standard placement workflows.
Clinical Implications: Adopting lateral-position bronchial blocker placement can reduce intraoperative malposition, re-fiberoptic adjustments, and posture-related complications, potentially improving oxygenation stability and surgical efficiency.
Key Findings
- Malposition incidence: 0.7% (lateral) vs 25.3% (supine), P<0.001
- Fewer repositioning maneuvers in the lateral group (median 0 vs 1, P<0.001)
- Lower incidence of postural injury with lateral placement (P<0.001)
- Intubation duration similar between groups (P=0.089)
- Higher patient and surgeon satisfaction with lateral placement (both P<0.001)
Methodological Strengths
- Multicenter randomized clinical trial with adequate sample size (n=306)
- Objective primary endpoint with clear operational definition (malposition)
Limitations
- Lack of blinding may introduce performance bias
- Conducted in a single country; generalizability to different practice settings requires validation
Future Directions: Evaluate cost-effectiveness, training protocols, and applicability across various bronchial blocker types and double-lumen tubes; assess impact on intraoperative gas exchange and postoperative outcomes.
UNLABELLED: Study objective Accurate bronchial blocker placement is essential for effective lung isolation during thoracic surgery. Approximately one-third of patients experience bronchial blocker malposition during the transition from the supine to lateral decubitus position. It has been unclear whether bronchial blocker placement directly in the lateral position can reduce the incidence of malposition. This study investigated the incidence of bronchial blocker malposition in the lateral versus supine position and evaluated the effectiveness of lateral placement. PATIENTS: Adults aged ≥18 years scheduled for thoracic surgery were enrolled. SETTING: Seven tertiary hospitals in China. INTERVENTIONS: Bronchial blockers were placed either in the lateral or supine position. MEASUREMENTS: The primary outcome was the incidence of bronchial blocker malposition. Secondary outcomes included the times of bronchial blocker reposition, perioperative complications, intubation duration, and satisfaction scores. MAIN RESULTS: Among 324 patients who underwent randomization, 306 completed the study (152 in the lateral group and 154 in the supine group). The incidence of bronchial blocker malposition was significantly lower in the lateral group (1/152 (0.7 %)) than in the supine group 39/154 (25.3 %), P < 0.001). The times of bronchial blocker reposition was also lower in the lateral group (median [interquartile range]: 0 [0,0]) than in the supine group (1.0 [1.0, 2.0], P < 0.001). Lateral bronchial blocker placement was associated with lower incidences of postural injury (P < 0.001). The median intubation duration (single-lumen tube intubation plus bronchial blocker placement) was similar between the two groups (P = 0.089). Patients and surgeons reported higher satisfaction scores in the lateral group (P < 0.001). CONCLUSIONS: Lateral bronchial blocker placement reduced the incidence of malposition in patients undergoing thoracic surgery; it was associated with fewer complications and higher satisfaction scores. These findings indicate that lateral placement is an effective approach with substantial advantages over conventional supine placement. Clinial trial registration:NCT05482230.
2. Effects of an opioid-free care pathway vs. opioid-based standard care on postoperative pain and postoperative quality of recovery after laparoscopic bariatric surgery: A multicentre randomised controlled trial.
In a two-center randomized trial (n=110), a fully opioid-free pathway (OFA plus first-line TENS) achieved pain trajectories and 3-month quality of recovery comparable to opioid-based care while reducing opioid consumption by ~45 mg morphine equivalents in PACU and ~40 mg during hospitalization.
Impact: Provides high-level evidence that a comprehensive opioid-free pathway maintains outcomes while substantially reducing opioid exposure—directly informing enhanced recovery and opioid stewardship in bariatric anesthesia.
Clinical Implications: Centers can implement OFA plus TENS as first-line postoperative analgesia in bariatric surgery to minimize perioperative opioids without sacrificing pain control or recovery, aligning with ERAS protocols and reducing opioid-related adverse effects.
Key Findings
- Primary pain trajectory from PACU arrival to ward transfer was equivalent between groups (MD 0.04, 95% CI -1.00 to 1.08; P=0.97)
- PACU opioid use reduced by ~45 mg morphine equivalents in the opioid-free pathway (P<0.0001)
- In-hospital opioid use further reduced by ~40 mg morphine equivalents (P<0.0001)
- PQRS total scores showed no significant differences up to 3 months
Methodological Strengths
- Randomized multicenter design with trial registration (NCT03756961)
- Clinically meaningful, patient-centered outcomes including PQRS and opioid consumption
Limitations
- Nonblinded design may introduce bias in ancillary care
- Sample size modest and limited to laparoscopic bariatric procedures
Future Directions: Assess generalizability to other surgeries, long-term opioid-related outcomes (persistent use), and cost-effectiveness; refine multimodal protocols and patient selection.
BACKGROUND: Opioid-free anaesthesia (OFA) may enhance postoperative recovery after bariatric surgery, but its combined effect with opioid-free interventions has not been studied. OBJECTIVES: To compare postoperative pain and recovery after laparoscopic bariatric surgery with a total opioid-free care pathway and conventional opioid-based treatment. DESIGN: A multicentre nonblinded controlled trial. SETTING: Two university hospitals in Sweden. PATIENTS: Adult patients scheduled for laparoscopic bariatric surgery were enrolled between May 2019 and November 2023. Of 837 patients screened, 112 were randomised, and 110 were included in the analysis: 55 in the intervention and 55 in the control group. INTERVENTIONS: Patients were randomised to an opioid-based standard care (control group) or to an opioid-free care pathway (intervention group), including intraoperative OFA and postoperative first-line transcutaneous electrical nerve stimulation (TENS) treatment. MAIN OUTCOME MEASURES: The primary outcome was the change in patient-reported postoperative pain intensity on a numerical rating scale (NRS) from arrival in the postanaesthesia care unit (PACU) until discharge to the surgical ward. Key secondary outcomes were postoperative pain intensity, in-hospital opioid consumption, and postoperative quality of recovery scale (PQRS) scores. RESULTS: There was no difference between the groups regarding the changes in pain intensity from arrival in PACU until discharge to the ward, with mean ± SD changes in NRS of 3.20 ± 3.01 (intervention) vs. 3.15 ± 2.25 (control); mean difference (MD) 0.04 [(95% confidence interval (CI), -1.00 to 1.08); P = 0.97], and pain intensity at 24 h ( P = 0.078), 72 h ( P = 0.060), and 3 months ( P = 0.30) postoperatively. The intervention group had a significantly lower opioid consumption in the PACU; mean morphine equivalents 6.08 ± 12.31 vs. 51.1 ± 14.9 mg; MD -45.0 (95% CI, -50.1 to -39.8) mg; P < 0.0001; and during the hospital stay MD -40.3 (95% CI, -54.4 to -25.9) mg; P < 0.0001. Total PQRS scores did not differ significantly over the 3-month follow-up. CONCLUSION: The opioid-free care pathway offers patients pain relief and recovery outcomes comparable to conventional opioid-based care and reduces opioid use after laparoscopic bariatric surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT03756961.
3. THRIVE Prevent Postoperative Hypoxemia in Elderly Patients Undergoing Laparoscopic Surgery in PACU: A Randomized Controlled Clinical Trial.
In a multicenter RCT of 200 elderly laparoscopic patients, THRIVE eliminated PACU hypoxemia (0% vs 29.2% with standard nasal cannula). THRIVE improved lung ultrasound scores, reduced the need for jaw lift maneuvers, and increased patient comfort without reported safety concerns.
Impact: Addresses a frequent and consequential postoperative complication in a high-risk population with a simple, scalable intervention that demonstrated striking efficacy.
Clinical Implications: Consider routine THRIVE use in PACU for elderly patients after laparoscopic surgery to prevent hypoxemia, improve comfort, and potentially reduce escalations (e.g., jaw thrusts, reintubation). Protocols should address contraindications and staff training.
Key Findings
- PACU hypoxemia: 0% with THRIVE vs 29.2% with standard oxygen (χ²=35.245)
- Improved post-oxygen lung ultrasound scores in THRIVE group
- Reduced frequency of jaw lifting maneuvers and higher patient comfort
- No safety signal identified in the reported outcomes
Methodological Strengths
- Prospective multicenter randomized controlled design with elderly target population
- Clinically salient primary endpoint (hypoxemia) with pragmatic secondary outcomes
Limitations
- Short-term PACU-focused outcomes; longer-term respiratory events not assessed
- Blinding not described; potential performance bias
Future Directions: Validate findings in broader surgical populations, evaluate cost-effectiveness, and determine optimal flow settings/duration; assess impact on escalation of care and readmissions.
BACKGROUND: Postoperative hypoxemia frequently occurs in elderly individuals undergoing laparoscopic procedures, often leading to severe consequences and prolonged stays in the post-anesthesia care unit (PACU). Conventional oxygen therapy methods are not entirely effective in preventing hypoxemia. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) delivers high-flow oxygen at rates up to 60 L/min, potentially enhancing respiratory function and tolerance to hypoxia. OBJECTIVE: To assess the effectiveness, safety, and patient tolerance of THRIVE in the early prevention of postoperative hypoxemia in elderly patients following laparoscopic surgery with general anesthesia. METHODS: This prospective, multicenter, randomized controlled trial enrolled 200 elderly patients undergoing laparoscopic surgery who were safely extubated after general anesthesia. Participants were randomly allocated to receive either conventional nasal cannula oxygen therapy or THRIVE. Between January 2023 and December 2023, cases were recruited from three participating centers. The main outcome measured was the occurrence of hypoxemia in the PACU. Secondary outcomes encompassed lung ultrasound scores after oxygen therapy, frequency of jaw lifting, reintubation rate, adverse events, and subjective patient comfort. RESULTS: The incidence of hypoxemia was significantly lower in the THRIVE group compared to the standard oxygen therapy group (0% vs 29.2%; χ² = 35.245; CONCLUSION: THRIVE is an effective strategy for reducing postoperative hypoxemia in elderly individuals undergoing laparoscopic procedures with general anesthesia. It facilitates pulmonary function recovery, enhances patient comfort, and may serve as a valuable intervention in the PACU setting.