Daily Anesthesiology Research Analysis
Large-scale pediatric data support reducing preoperative clear fluid fasting to ≤1 hour without increasing pulmonary aspiration. A randomized noninferiority trial shows video-based, self-directed training on a new anesthesia workstation matches instructor-led teaching, easing education constraints. An HPI-guided strategy in prone spine surgery did not lower time-weighted hypotension but shortened total hypotension duration, underscoring nuanced benefits of predictive monitoring.
Summary
Large-scale pediatric data support reducing preoperative clear fluid fasting to ≤1 hour without increasing pulmonary aspiration. A randomized noninferiority trial shows video-based, self-directed training on a new anesthesia workstation matches instructor-led teaching, easing education constraints. An HPI-guided strategy in prone spine surgery did not lower time-weighted hypotension but shortened total hypotension duration, underscoring nuanced benefits of predictive monitoring.
Research Themes
- Liberalized preoperative fasting for pediatric anesthesia
- Scalable education and competency in anesthesia technology
- Predictive hemodynamic monitoring and intraoperative hypotension
Selected Articles
1. Impact of liberal preoperative clear fluid fasting regimens on the risk of pulmonary aspiration in children (EUROFAST): an international prospective cohort study.
Across 306,900 pediatric anesthetics, allowing clear fluids until 1 hour preoperatively or sip-til-send was noninferior to ≥2 hours fasting for confirmed pulmonary aspiration and regurgitation-related outcomes, with zero aspiration-related deaths. These data support liberalizing clear fluid fasting in children <16 years.
Impact: This is the largest prospective multicentre analysis to date directly comparing liberal clear fluid fasting strategies in pediatric anesthesia with robust noninferiority results.
Clinical Implications: Institutions can safely revise pediatric fasting policies to allow clear fluids up to 1 hour before anesthesia (and consider sip-til-send with appropriate safeguards), potentially improving hydration, comfort, and perioperative flow without increasing aspiration risk.
Key Findings
- Confirmed pulmonary aspiration incidence: sip-til-send 1.18/10,000; ≥1 h 0.96/10,000; control (≥2 h) 1.83/10,000.
- No aspiration-related mortality across 306,900 anesthetics.
- Both sip-til-send and ≥1 h regimens were statistically noninferior to ≥2 h for confirmed aspiration, transient regurgitation, and regurgitation requiring escalation of care.
Methodological Strengths
- Prospective multicentre design with very large sample size (306,900 anesthetics).
- Predefined outcome capture of regurgitation and aspiration with noninferiority comparisons.
Limitations
- Observational cohort with potential center-level confounding and policy selection bias.
- Very low event rates limit precision for subgroup analyses.
Future Directions: Cluster-randomized or stepped-wedge trials and high-risk subgroup analyses (e.g., emergency cases, gastroesophageal reflux) to refine patient selection and implementation protocols.
BACKGROUND: Preoperative fasting regimens designed to minimise the risk of pulmonary aspiration have undergone significant changes, but unequivocal evidence of the safety of reducing clear fluid fasting has been lacking. We compared the risk of pulmonary aspiration in children using three different recommendations for clear fluid fasting. METHODS: In this prospective multicentre cohort study, centres with >1000 paediatric anaesthesia cases per year were eligible. Regurgitation events, whether they were transient or led to consequences affecting postoperative care, were reported in detail. All centres also reported the number of anaesthetised children per year and which preoperative fasting regimen they used. RESULTS: The 31 participating centres contributed a total of 306 900 anaesthetic procedures. The incidence of confirmed pulmonary aspiration was 1.18:10 000 in the sip-til-send group, 0.96:10 000 in the ≥1 h group, and 1.83:10 000 in the control group. There was no mortality as a result of aspiration. The 95% confidence intervals of the differences in confirmed pulmonary aspiration between the control group and the ≥1 h clear fluid fasting and the sip-til-send group were -0.344 to 3.76 and -1.48 to 3.63, respectively. Both sip-til-send and ≥1 h clear fluid fasting were statistically noninferior to ≥2 h clear fluid fasting regarding the incidence of confirmed aspiration, transient regurgitation, and regurgitation leading to escalation of care or intensive care. CONCLUSIONS: The study provides evidence for the safety of reducing preoperative fasting time for clear fluids in children aged <16 yr from 2 h to ≤1 h.
2. Self-directed learning versus traditional instructor-led learning for education on a new anaesthesia workstation: a noninferiority, randomised, controlled trial.
In a single-centre randomized noninferiority trial (n=222), video-supported self-directed training on a new anesthesia workstation achieved competence rates noninferior to instructor-led workshops at ~3 months. This approach can reduce instructor time while maintaining user competency.
Impact: Demonstrates a scalable, evidence-based alternative to traditional instruction for device onboarding, addressing workforce and scheduling constraints without compromising competence.
Clinical Implications: Hospitals can deploy structured video-based self-directed modules for new anesthesia workstations to maintain competency across rotating staff, freeing instructor time for high-risk training and potentially improving device safety culture.
Key Findings
- Randomized noninferiority design with 222 participants; success rate difference -0.9% (90% CI -3.8% to 1.7%), meeting the 10% noninferiority margin.
- Both groups received a 1-hour session; competence on 12 tasks assessed ~3 months later.
- Participants included anesthesia nurses (n=97) and physicians (n=125), enhancing generalizability within perioperative teams.
Methodological Strengths
- Randomized, controlled, noninferiority design with prespecified margin.
- ClinicalTrials.gov registration and delayed competence assessment to test retention.
Limitations
- Single-centre study; external validity may vary across institutions and devices.
- Educational outcomes assessed; no direct measurement of clinical events or patient safety outcomes.
Future Directions: Multicentre trials linking training modality to device-related error rates, patient outcomes, and cost-effectiveness across diverse anesthesia platforms.
BACKGROUND: It is fundamental for patient safety that medical devices are correctly and competently applied. Shift work, especially in anaesthesia, poses challenges to provide timely comprehensive learning opportunities. Because personnel shortages encourage cuts to staff education, self-directed learning might alleviate these difficulties. METHODS: We conducted a single-centre, noninferiority, randomised, controlled trial in a large university-based anaesthesia department. Anaesthesia nurses and physicians were randomly assigned 1:1 to self-directed learning including a learning video (intervention) or to an instructor-led workshop (control). Both groups attended a 1-h teaching session on a new anaesthesia workstation. Around 3 months later, participants from both groups were assessed on 12 competences at an examination station. The defined primary outcome was the difference in success rates between groups. We hypothesised that the success rate of self-directed learning would be noninferior to instructor-led learning by a noninferiority margin of Δ=10%. RESULTS: Data from 222 participants (97 anaesthesia nurses, 125 physicians) were analysed. Participants were aged between 32 and 44 yr; 35.6% had <5 yr of professional experience. The success rate difference between both groups was -0.9% (90% confidence interval: -3.8%-1.7%), confirming the noninferiority of self-directed learning. DISCUSSION: Creating an educational video for the self-directed acquisition of necessary knowledge and skills to handle an anaesthesia workstation requires initial investment, but reduces substantially instructor time, as learners can study independently according to their needs. Video-supported self-directed learning of the handling of an anaesthesia workstation was not inferior to traditional teacher-led instruction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov(NCT05530382).
3. Effectiveness of hypotension prediction index software in reducing intraoperative hypotension in prolonged prone-position spine surgery: a single-center clinical trial.
In prone spine fusion, HPI-guided management did not lower the time-weighted average of intraoperative hypotension versus standard care but significantly reduced the total duration of hypotension per patient, without affecting postoperative complications. Findings suggest selective benefits of predictive monitoring on hypotension burden.
Impact: Provides randomized evidence on machine learning-guided hemodynamic management in a high-risk surgical context, clarifying which hypotension metrics may be modifiable.
Clinical Implications: HPI-guided strategies may help minimize total hypotension exposure even if TWA is unchanged; institutions should consider protocolized responses and evaluate benefit in broader, multicentre settings before wide adoption.
Key Findings
- Primary outcome not met: no significant difference in TWA of IOH (0.10 vs 0.15 mmHg; p=0.088).
- Total duration of hypotension per patient significantly reduced with HPI guidance (4 vs 11.2 minutes; p=0.019).
- No significant differences in postoperative in-hospital complications; 77 patients analyzed; trial registered (NCT05341167).
Methodological Strengths
- Randomized, single-blind design with pre-registered protocol.
- Clear primary and secondary outcomes; clinically relevant prone spine population.
Limitations
- Single-centre study with modest sample size; 8 exclusions for technical issues.
- Primary endpoint negative; clinicians could not be fully blinded to intervention.
Future Directions: Larger, multicentre RCTs testing protocolized HPI responses, evaluating patient-centered outcomes (AKI, MI, stroke) and cost-effectiveness; exploration of composite hypotension burden metrics.
Intraoperative hypotension (IOH) is associated with morbidity and mortality. The Hypotension Prediction Index (HPI), a machine learning-based tool, offers the opportunity for a proactive approach by predicting hypotensive events. This single center, single blind randomized clinical trial aimed to evaluate the hypothesis that an HPI software-guided approach to IOH management during prone position spine surgery could reduce its incidence compared to our standard care practices. 85 adult patients undergoing spine fusion surgery in the prone position were enrolled. Patients were randomized with a 1:1 allocation ratio. Participants were blinded to their group allocation. In the intervention group, the HPI software was actively used to guide IOH management. In the control group, HPI software readings were blinded, and standard care was administered. The primary outcome was the comparison of time-weighted average (TWA) of IOH between the two groups. Secondary outcomes included a comparison of the incidence of postoperative in-hospital events related to IOH between groups. 77 patients were included in the final analysis (39 in the intervention group), as 8 patients were excluded due to technical issues. No statistically significant difference was found between the intervention and control groups in the TWA of IOH (0.10 mmHg [0.05, 0.23] vs. 0.15 mmHg [0.09, 0.37], p-value 0.088). However, the total duration of hypotensive events per patient was significantly lower in the intervention group (4 min [0.5, 12.2] vs. 11.2 min [2.6, 20.1]; p-value 0.019). Postoperative complication rates did not differ significantly between the two groups. HPI-guided management did not significantly reduce the TWA of IOH compared to standard care in patients undergoing prone-position spine surgery. Complication rates were similar between the two groups.Clinical Trial Registration: This trial was registered with ClinicalTrials.gov (registration number: NCT05341167).