Daily Anesthesiology Research Analysis
Three impactful anesthesiology-critical care papers stand out today: a Cochrane review confirms corticosteroids probably reduce short-term mortality in sepsis, a large database study links higher central venous pressure to sepsis-associated AKI and delineates an optimal CVP range, and a diagnostic study develops and validates a gastric ultrasound equation specifically for patients after sleeve gastrectomy. Together they optimize sepsis care, hemodynamic targets, and aspiration risk assessment.
Summary
Three impactful anesthesiology-critical care papers stand out today: a Cochrane review confirms corticosteroids probably reduce short-term mortality in sepsis, a large database study links higher central venous pressure to sepsis-associated AKI and delineates an optimal CVP range, and a diagnostic study develops and validates a gastric ultrasound equation specifically for patients after sleeve gastrectomy. Together they optimize sepsis care, hemodynamic targets, and aspiration risk assessment.
Research Themes
- Sepsis management and corticosteroid therapy
- Hemodynamic targets to prevent sepsis-associated acute kidney injury
- Perioperative aspiration risk assessment using gastric ultrasound in altered anatomy
Selected Articles
1. Corticosteroids for treating sepsis in children and adults.
Across 87 randomized trials (24,336 participants), corticosteroids probably reduce 28-day mortality (RR 0.89) and in-hospital mortality (RR 0.90) in sepsis, may shorten ICU and hospital stay, and likely do not increase superinfection risk; effects on long-term mortality are uncertain. Evidence for continuous infusion versus bolus dosing remains very low certainty.
Impact: This high-quality Cochrane review provides updated, practice-informing estimates that steroids probably reduce short-term mortality in sepsis with acceptable safety, guiding ICU/anesthesia clinicians. It consolidates heterogeneous RCTs with GRADE and clarifies dosing mode uncertainty.
Clinical Implications: Consider low-to-moderate dose corticosteroids as an adjunct in septic shock per current protocols to improve 28-day and in-hospital mortality and shorten ICU/hospital stay, while monitoring for myopathy and secondary infection. Dosing as bolus versus infusion should follow local protocols given very low-certainty comparative evidence.
Key Findings
- Corticosteroids probably reduce 28-day mortality in sepsis (RR 0.89; 95% CI 0.84–0.95; moderate certainty).
- In-hospital mortality is probably reduced (RR 0.90; 95% CI 0.84–0.97); ICU and hospital length of stay may be shortened.
- No clear increase in superinfection risk (RR 0.96; 95% CI 0.86–1.07); muscle weakness risk remains very uncertain.
- Continuous infusion vs intermittent bolus effects are very uncertain across outcomes due to very low-certainty evidence.
Methodological Strengths
- Comprehensive, pre-specified Cochrane methodology with broad database/search coverage and GRADE assessment.
- Large aggregate sample (24,336 participants) across 87 RCTs, enabling precise mortality estimates.
Limitations
- Between-trial heterogeneity led to downgrading certainty for key outcomes.
- Very low certainty for comparisons of continuous infusion versus bolus dosing; some outcomes rely on smaller subsets.
Future Directions: Head-to-head trials comparing steroid regimens (dose, duration, infusion vs bolus) with standardized co-interventions and long-term outcomes, and stratified analyses by sepsis phenotype are needed.
BACKGROUND: Sepsis occurs when an infection is complicated by organ failure. Sepsis may be complicated by impaired corticosteroid metabolism. Thus, providing corticosteroids may benefit patients. This is an update of a review originally published in 2004 and previously updated in 2010, 2015 and 2019. OBJECTIVES: To examine the benefits and harms of corticosteroids in children and adults with sepsis. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, LILACS, ClinicalTrials.gov, ISRCTN and the WHO Clinical Trials Search Portal on 31 December 2023. In addition, we conducted reference checking and citation resear
2. Developing a method for ultrasound estimation of gastric volume in patients with previous gastric sleeve.
In 37 sleeve-gastrectomy subjects, the standard adult gastric ultrasound equation performed suboptimally. A new LASSO-derived equation incorporating antral cross-sectional area improved volume estimation accuracy in this altered anatomy cohort. A 2-hour clear-fluid fast appeared sufficient in this population based on gastric emptying kinetics.
Impact: Provides a tailored gastric ultrasound volume equation for a growing surgical population excluded from prior validations, directly informing aspiration risk assessment and NPO guidance.
Clinical Implications: For patients with prior sleeve gastrectomy, clinicians should consider the new equation when estimating gastric volume by ultrasound and may maintain a 2-hour clear-fluid fast preoperatively. This supports individualized aspiration risk stratification in bariatric-altered anatomy.
Key Findings
- Standard adult gastric ultrasound equation was statistically suboptimal in sleeve-gastrectomy patients.
- A new LASSO-derived equation using antral cross-sectional area improved volume estimation accuracy in this cohort.
- A 2-hour fast from clear fluids appeared sufficient to empty the stomach in post-sleeve patients.
Methodological Strengths
- Prospective, protocolized ultrasound measurements with multiple post-ingestion time points.
- Model development using LASSO regression tailored to altered post-sleeve anatomy.
Limitations
- Single-center, small sample with ex-vivo water loading; external validation is needed.
- Performance of the equation for non-clear fluids and solid contents remains untested.
Future Directions: External, multicenter validation across bariatric procedures and evaluation under typical preoperative conditions (mixed fluids, varying NPO intervals).
BACKGROUND AND AIMS: Ultrasound estimation of gastric volume is useful preoperatively for identifying those at increased risk of aspiration; however, studies to date have excluded subjects with prior gastric surgeries. We aimed to assess the performance of the current equation used in non-pregnant adults for patients who had undergone gastric sleeve and develop a new equation for this population if necessary. Secondarily, we determined if a 2-hour fast from clear fluids is sufficient to empty the stomach in this population. METHODS: 37 subjects who had undergone a gastric sleeve in the last 10 years were randomly assigned to drink 100, 200 or 300 mL of water after fasting 8 hours from solids and 2 hours from clear fluids. Pre-drink and 0, 30, 60, 90 and 120 min post-drink scans measured antral grade and cross-sectional area. Subjects participated in up to three study visits drinking different volumes. RESULTS: The existing equation was statistically suboptimal. A new equation was created with variables identified by LASSO regression (Volume (mL)=15.5×CSA (cm
3. Re-exploring the association between the central venous pressure and the risk of sepsis-associated acute kidney injury according to the latest definition: Analysis of the MIMIC-IV database.
In 6,129 ICU sepsis patients, higher central venous pressure independently increased SA-AKI risk (≥10.19 mmHg: +33%; ≥13.67 mmHg: +48% vs <6.87 mmHg). Mortality showed a U-shaped relation to CVP, with the lowest 90-day mortality between ~4.9 and 13.1 mmHg, suggesting a mid-range CVP target may minimize SA-AKI and mortality.
Impact: Defines an actionable CVP range under the latest SA-AKI definition using robust modeling of a large ICU cohort, informing fluid/vasopressor strategies for anesthesiologists and intensivists.
Clinical Implications: Avoid excessive venous congestion in sepsis by targeting a CVP in the mid-range (~5–10 mmHg) when feasible, individualizing to cardiac function and ventilation. Monitor for SA-AKI risk when CVP rises above ~10–14 mmHg.
Key Findings
- CVP independently associated with SA-AKI; CVP ≥10.19 and ≥13.67 mmHg increased SA-AKI incidence by 33% and 48%, respectively.
- Restricted cubic spline showed a U-shaped association between CVP and mortality, with the lowest 90-day mortality around 4.89–13.12 mmHg.
- Findings support maintaining CVP roughly 4.9–10.2 mmHg to reduce SA-AKI and mortality risks.
Methodological Strengths
- Large cohort (n=6129) with modern SA-AKI definition; multivariable Cox models and spline analyses.
- Sensitivity via stratification and survival analyses adds robustness to risk estimates.
Limitations
- Retrospective single-database study with potential residual confounding and selection bias in CVP measurements.
- Generalizability may be limited outside the MIMIC-IV setting; causality cannot be inferred.
Future Directions: Prospective studies to test CVP-guided decongestion targets and evaluate kidney/organ outcomes, integrating venous ultrasound and dynamic congestion metrics.
OBJECTIVE: The lack of a standard definition for sepsis-associated acute kidney injury (SA-AKI) makes the association between central venous pressure (CVP) and SA-AKI risk unclear. This study analyzed the relationship between CVP levels and the incidence and mortality of SA-AKI based on the most recent definition of the disease. METHODS: This retrospective observational study utilized clinical records of sepsis patients from 2008 to 2019 admitted to the critical care unit (ICU) and in the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were included. Based on the Acute Disease Quality Initiative (ADQI) definition of SA-AKI, patients were stratified into SA-AKI and non-SA-AKI groups. Patients were further categorized into four groups based on the CVP levels by the optimal prediction of SA-AKI incidence retrospectively. Cox proportional hazards models and a restricted cubic splines (RCS) model were employed to evaluate the relationship between CVP levels and SA-AKI risk. Additionally, Kaplan-Meier survival analysis was conducted to compare disparities in primary and secondary endpoints across groups stratified by CVP levels. RESULTS: A total of 6129 patients were included. An independent relationship was observed between CVP levels and the risk of SA-AKI (p <0.001). Cox proportional hazards analysis demonstrated that SA-AKI incidence increased by 33% in patients with CVP≥10.19mmHg and 48% in patients with CVP≥13.67mmHg compared to patients with CVP<6.87mmHg. RCS analysis demonstrated a U-shaped association between CVP levels and mortality. In addition, the 90-day mortality risk decreased when CVP was between 4.89 and 13.12 mmHg (p< 0.001). CONCLUSION: Elevated CVP levels are associated with the occurrence of SA-AKI in sepsis patients. Maintaining CVP levels between 4.89mmHg and 10.19mmHg may help reduce the incidence and mortality of SA-AKI.