Daily Anesthesiology Research Analysis
Today’s top anesthesiology papers advance perioperative risk prediction and blood management. A high-quality meta-analysis synthesizes the performance of postoperative pulmonary complication prediction models, two perioperative hemostasis syntheses inform antifibrinolytic use in pediatric surgery and desmopressin use in cardiac surgery with cardiopulmonary bypass.
Summary
Today’s top anesthesiology papers advance perioperative risk prediction and blood management. A high-quality meta-analysis synthesizes the performance of postoperative pulmonary complication prediction models, two perioperative hemostasis syntheses inform antifibrinolytic use in pediatric surgery and desmopressin use in cardiac surgery with cardiopulmonary bypass.
Research Themes
- Perioperative risk stratification and prediction modeling
- Pediatric perioperative blood management and antifibrinolytics
- Cardiac surgery hemostasis optimization with desmopressin under CPB
Selected Articles
1. Prediction models for postoperative pulmonary complications: a systematic review and meta-analysis.
This systematic review/meta-analysis of 123 studies (14 meta-analyzed; 1,004,029 patients) found that widely used PPC prediction models achieve moderate-to-good discrimination (e.g., ARISCAT 0.76; Xue 0.82) but suffer from limited external validation and high risk of bias. Clinical adoption should prioritize externally validated models with local calibration.
Impact: Provides the most comprehensive synthesis to date of PPC prediction model performance and limitations, guiding model selection and implementation in perioperative care.
Clinical Implications: Use externally validated PPC models (e.g., ARISCAT, Xue’s) with local recalibration; avoid overreliance on single c-statistics. Integrate models into preoperative optimization and shared decision-making while acknowledging heterogeneity and bias.
Key Findings
- Across 123 studies, 116 PPC models were identified; 14 models with 1,004,029 patients were meta-analyzed.
- Composite PPC discrimination: ARISCAT c-statistic 0.76 (95% CI 0.67–0.86), Xue’s 0.82 (0.75–0.89), CARDOT 0.73 (0.61–0.85).
- Postoperative pneumonia: DAGDA 0.81 (0.74–0.88), Wang 0.78 (0.70–0.86), Jin 0.75 (0.68–0.82).
- Postoperative respiratory failure: Yoon 0.90 (0.84–0.96), Nizamuddin 0.85 (0.78–0.92).
- High risk of bias in 90.2% of models and limited external validation constrain clinical utility.
Methodological Strengths
- Comprehensive multi-database search with CHARMS data extraction and PROBAST bias assessment.
- Bayesian meta-analysis pooling with prediction intervals; evaluation across composite and individual PPC endpoints.
Limitations
- Limited external validation cohorts and high risk of bias in most models.
- Heterogeneity in PPC definitions and predictor sets limits generalizability.
Future Directions: Prospective external validation with recalibration, head-to-head model comparisons, standardized PPC definitions, and impact analyses on clinical outcomes.
BACKGROUND: Postoperative pulmonary complications (PPCs) increase mortality, hospital stays, and healthcare costs. Multivariable prediction models can guide patient care by identifying high-risk patients. The discriminative ability and potential for clinical impact of PPC prediction models remains unclear. METHODS: We systematically searched Cochrane, Embase, and PubMed (up to June 2024) for studies developing or validating prediction models for PPCs that reported c-statistic. The primary outcome was the c-statistic of prediction models for composite PPCs, and the secondary outcome was the c-statistic for individual PPCs, including pneumonia, respiratory failure, reintubation, and others. Data were extracted using the CHARMS checklist, and bias was assessed with PROBAST. For models with data from three or more cohorts, discrimination was synthesised by pooling c-statistic using Bayesian meta-analysis, with heterogeneity assessed through prediction intervals. RESULTS: A total of 123 studies were included, covering 116 prediction models for PPCs, with 14 models (1 004 029 patients) eligible for meta-analysis. The c-statistic of all models ranged from 0.614 to 0.996 (median 0.80), with 50% of models self-reporting good (c-statistic >0.8) discrimination. In meta-analysis, the ARISCAT PPC score (summary c-statistic 0.76, 95% CI 0.67-0.86), Xue's model (0.82, 0.75-0.89), and CARDOT score (0.73, 0.61-0.85) demonstrated moderate (c-statistic 0.7-0.8) to good discrimination for composite PPCs; the DAGDA score (0.81, 0.74-0.88), Wang's model (0.78, 0.70-0.86), and Jin's model (0.75, 0.68-0.82) for postoperative pneumonia; and Yoon's model (0.90, 0.84-0.96) and Nizamuddin's model (0.85, 0.78-0.92) for postoperative respiratory failure. The reliability of these models, however, is currently limited by the lack of external validation cohorts. Overall, 90.2% of models were assessed as having a high risk of bias. CONCLUSIONS: Many prediction models postoperative pulmonary complications have been developed, but the clinical utility of the vast majority remains uncertain. CLINICAL TRIAL REGISTRATION: PROSPERO database (CRD42024580216).
2. The Effect of Prophylactic Use of Antifibrinolytics During Pediatric Non-Cardiac Surgeries on Bleeding and Transfusions: A Systematic Review and Meta-Analysis.
Across 130 pediatric non-cardiac surgery studies, tranexamic acid (TXA) consistently reduced estimated blood loss (e.g., scoliosis −410 mL; craniofacial −14 mL/kg; tonsil/adenoid −21 mL) and, with aprotinin, reduced transfusion in craniosynostosis. TXA outperformed aminocaproic acid in scoliosis; evidence was inconclusive for VRO/VDRO and hip reconstruction.
Impact: Synthesizes broad pediatric evidence showing robust hemostatic benefits of TXA across common surgeries, directly informing anesthetic blood management strategies.
Clinical Implications: Consider prophylactic TXA as part of multimodal blood conservation in pediatric scoliosis, craniofacial, and tonsil/adenoid surgery; aprotinin may reduce transfusion in craniosynostosis. Tailor dosing and monitor for adverse events; evidence is limited for VRO/VDRO and hip reconstruction.
Key Findings
- TXA vs control reduced estimated blood loss by −410 mL in scoliosis, −14 mL/kg in craniofacial, and −21 mL in tonsil/adenoid surgery (all p<0.001).
- Aminocaproic acid vs control reduced scoliosis blood loss by −464 mL; TXA vs aminocaproic acid favored TXA by −391 mL (p<0.001).
- In craniosynostosis, TXA and aprotinin reduced intraoperative transfusion needs (−7 mL/kg and −20 mL/kg, respectively).
- No statistically significant benefit for VRO/VDRO or hip reconstruction analyses.
Methodological Strengths
- Large, surgery-specific synthesis across pediatric non-cardiac procedures with agent comparisons (TXA, aminocaproic acid, aprotinin).
- Clear primary outcomes (estimated blood loss, transfusion) with consistent direction of effect.
Limitations
- Heterogeneity in dosing regimens, surgical techniques, and study designs may affect pooled estimates.
- Limited data for certain procedures (VRO/VDRO, hip reconstruction) and safety outcomes.
Future Directions: Standardized dosing trials in specific pediatric procedures, safety surveillance, and head-to-head comparisons with aminocaproic acid and aprotinin.
OBJECTIVES: The objective of this meta-analysis is to determine the effect of intraoperative tranexamic acid, aminocaproic acid, and aprotinin on bleeding in pediatric surgery. STUDY DESIGN: A literature search was performed for the meta-analysis and systematic review in the following databases from inception until April 2023: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies included patients under 18 years of age, non-cardiac surgery, and administration of antifibrinolytics. Forest plots were used for statistical analysis. Primary outcomes were intraoperative blood loss and intraoperative blood transfusions. RESULTS: One hundred thirty articles met inclusion. Tranexamic acid compared to control resulted in an estimated blood loss of -410.0 mL p-value = < 0.001 for scoliosis surgery, -14.0 mL/kg p-value = < 0.001 for craniofacial surgery, and -21.0 mL p-value < 0.001 for tonsillectomy/adenoidectomy surgery. Aminocaproic acid compared to control resulted in an estimated blood loss of -464.0 mL p-value < 0.001 for scoliosis surgery. Tranexamic acid compared to aminocaproic acid resulted in an estimated blood loss of -391.0 mL p-value < 0.001 for scoliosis surgery. For blood transfusion during craniosynostosis surgery, tranexamic acid compared to control resulted in a mean decrease of -7 mL/kg p-value = 0.010 and aprotinin compared to control resulted in a mean decrease of -20.0 mL/kg p-value < 0.001. The analysis for VRO/VDRO and hip reconstruction did not reach statistical significance. CONCLUSIONS: In craniofacial, scoliosis, and tonsillectomy/adenoidectomy surgery, prophylactic administration of tranexamic acid results in lower estimated blood loss. Tranexamic acid and aprotinin are effective for reducing transfusion in craniofacial surgery. For scoliosis surgery, tranexamic acid is more efficacious than aminocaproic acid. More literature is needed to assess the efficacy of tranexamic acid in VRDO/VRO and hip reconstruction surgery and the efficacy of different dosing regimens.
3. Efficacy and Safety of Desmopressin in Terms of Bleeding and Transfusion in Cardiac Surgery With Cardiopulmonary Bypass: A Systematic Review and Meta-Analysis.
In 34 prospective studies (n=2,523), desmopressin modestly reduced 24-hour postoperative bleeding after CPB (WMD −96 mL; 95% CI −148 to −44). Effects on transfusion requirements and safety (re-exploration, thromboembolism, mortality) were assessed, with heterogeneity noted across studies.
Impact: Provides updated quantitative synthesis on desmopressin’s hemostatic effect after CPB, informing selective use in patients with platelet dysfunction risk.
Clinical Implications: Consider desmopressin as an adjunct in CPB cardiac surgery patients at risk for platelet dysfunction where a modest bleeding reduction is clinically valuable; balance against uncertain effects on transfusion and thrombotic risk, and institutional protocols.
Key Findings
- Meta-analysis of 34 prospective studies (n=2,523) showed desmopressin reduced 24-hour postoperative bleeding by ~96 mL (WMD −96.20 mL; 95% CI −148.44 to −43.96; p=0.0003).
- Secondary outcomes included transfusion amount/incidence and safety (re-exploration, thromboembolic events, mortality), with heterogeneity across studies.
- Findings support selective adjunctive use in CPB-related platelet dysfunction contexts, acknowledging modest effect size.
Methodological Strengths
- Multi-database search including prospective comparative studies with predefined primary/secondary outcomes.
- Quantitative synthesis of efficacy and safety across CPB cardiac surgery.
Limitations
- Heterogeneity in dosing, timing, surgical populations, and co-interventions; modest effect size.
- Incomplete reporting of some safety endpoints in individual trials; potential publication bias.
Future Directions: Well-powered RCTs targeting platelet dysfunction phenotypes with standardized dosing/timing, and pragmatic trials assessing transfusion and thrombotic outcomes.
Bleeding and transfusion during cardiac surgery are major sources of complications. Surgery and cardiopulmonary bypass can induce coagulopathy, including platelet dysfunction. Desmopressin has been shown to reduce bleeding and transfusion requirements, although with conflicting results. This study aimed to systematically evaluate the available evidence regarding the efficacy and safety of desmopressin in cardiac surgery with cardiopulmonary bypass. The Embase, MEDLINE, Cochrane Central, Web of Science, and ClinicalTrials.gov databases were searched for prospective studies comparing desmopressin with placebo in cardiac surgery with cardiopulmonary bypass. A meta-analysis with bleeding at 24 hours as the primary outcome and the amount and incidence of blood product transfusions as secondary outcomes was performed. Safety outcomes included re-exploration rate, thromboembolic events, and mortality. Thirty-four (34) studies comprising 2,523 patients were included. Bleeding at 24 hours was reduced in the desmopressin group (weighted mean difference, 96.20 mL; 95% confidence interval [CI] -148.44 to -43.96; p=0.0003 with heterogeneity [I