Daily Anesthesiology Research Analysis
Three studies with direct perioperative relevance stand out today: a registered systematic review/meta-analysis quantifies clinically meaningful hypotension after intravenous paracetamol in ICU patients; a large meta-analysis defines prognostic factors for recurrent VTE and anticoagulant-related bleeding in cancer; and a national registry study links cranial surgery to lower in-hospital mortality in firearm-related pTBI with subdural hematoma. Together, they inform hemodynamic safety, anticoagul
Summary
Three studies with direct perioperative relevance stand out today: a registered systematic review/meta-analysis quantifies clinically meaningful hypotension after intravenous paracetamol in ICU patients; a large meta-analysis defines prognostic factors for recurrent VTE and anticoagulant-related bleeding in cancer; and a national registry study links cranial surgery to lower in-hospital mortality in firearm-related pTBI with subdural hematoma. Together, they inform hemodynamic safety, anticoagulation risk stratification, and neurotrauma surgical decision-making.
Research Themes
- Perioperative hemodynamics and medication safety
- Risk stratification for thrombosis and bleeding in oncology patients
- Neurotrauma surgical decision-making and outcomes
Selected Articles
1. Predictors of recurrent venous thromboembolism and bleeding in patients with cancer: a meta-analysis.
Across 33 studies (n=96,753), prior VTE, poorer ECOG performance status, advanced cancer, and specific tumor sites (lung, hepatobiliary, pancreas, genitourinary) were associated with higher recurrent VTE risk, while recent surgery and breast cancer were associated with reduced recurrence. Bleeding risk under anticoagulation rose with prior bleeding, ECOG ≥2, advanced cancer, and brain/GI/GU/prostate cancers. Findings were graded with high certainty and support risk-based anticoagulation decisions.
Impact: Provides a robust, GRADE-assessed synthesis of prognostic factors for both VTE recurrence and anticoagulant-related bleeding in cancer, directly informing individualized anticoagulation strategies.
Clinical Implications: Anesthesiologists and perioperative teams can use these factors to tailor perioperative anticoagulation (choice, timing, and intensity), procedural planning, and monitoring, especially in high-risk cancer subtypes or poor performance status.
Key Findings
- Higher recurrent VTE risk with prior VTE (aHR 1.50), ECOG >0 or >1 (aHR 1.81–2.44), and advanced cancer (aHR 1.38).
- Specific cancer sites increased recurrence: lung (aHR 1.78), hepatobiliary (aHR 2.37), pancreas (aHR 3.20), genitourinary (aHR 1.38).
- Recent surgery (aHR 0.56) and breast cancer (aHR 0.43) were associated with decreased recurrence risk.
- Bleeding risk increased with prior bleeding (aHR 2.41), ECOG ≥2 (aHR 2.10), advanced cancer (aHR 1.60), and brain/GI/GU/prostate cancers (aHR 1.72–2.25).
Methodological Strengths
- Random-effects meta-analysis with adjusted hazard ratios and GRADE certainty assessment
- Large aggregate sample (96,753) across 33 studies enabling robust subgroup insights
Limitations
- Heterogeneity across included studies and variable definitions of outcomes/exposures
- Combination of observational data with trials may introduce residual confounding
Future Directions: Develop and validate perioperative risk calculators integrating these prognostic factors to individualize anticoagulation decisions in cancer surgery pathways.
2. Effects of intravenous paracetamol on mean arterial pressure in critically ill patients: A systematic review and meta-analysis with trial sequential analysis.
Across eight observational ICU studies, IV paracetamol was associated with significant short-term decreases in MAP (MD −6.75 mmHg), as well as SAP and DAP, without changes in heart rate; effects appeared greater in febrile patients. Trial sequential analysis was used to assess robustness, and the review was PROSPERO-registered.
Impact: Quantifies a common but underappreciated hemodynamic effect of a widely used antipyretic/analgesic in critically ill patients, informing safer perioperative and ICU medication choices.
Clinical Implications: Anticipate and monitor for hypotension after IV paracetamol, especially in febrile patients; consider timing, dose adjustments, fluid status, and vasopressor readiness when using paracetamol for fever or analgesia in hemodynamically fragile patients.
Key Findings
- IV paracetamol reduced MAP by a mean difference of −6.75 mmHg within 30 minutes (p=0.0008).
- SAP and DAP also declined significantly, while heart rate did not change.
- Hypotensive effects were more pronounced in febrile patients.
- Trial sequential analysis was performed; the review was PROSPERO-registered.
Methodological Strengths
- Systematic review/meta-analysis with trial sequential analysis and prespecified outcomes
- ICU-focused evidence synthesis directly relevant to clinical practice
Limitations
- Based on observational studies with potential residual confounding
- Heterogeneity in patient populations and dosing; limited advanced hemodynamic parameters
Future Directions: Prospective hemodynamic trials to delineate mechanisms, dose-response, and risk modifiers (e.g., fever, vasodilation) and to guide mitigation strategies in high-risk ICU patients.
3. Association between cranial surgery and mortality among patients with firearm-related traumatic brain injury resulting in subdural hematoma.
In 1,894 firearm-related pTBI patients with subdural hematoma, cranial surgery was independently associated with lower in-hospital mortality (OR 0.49), with an even greater protective effect in those with midline shift >5 mm (OR 0.40). Results persisted after adjustment for injury characteristics and ICP-related device placement.
Impact: Provides actionable evidence that surgical intervention correlates with survival in a defined neurotrauma phenotype, informing perioperative triage and anesthetic planning.
Clinical Implications: For severe pTBI with SDH, especially with significant midline shift, early coordination for surgery may improve survival; neuroanesthesiologists should anticipate aggressive ICP control, hemodynamic optimization, and rapid access to blood products.
Key Findings
- Cranial surgery independently associated with lower in-hospital mortality (OR 0.49, 95% CI 0.34–0.71).
- Greater benefit in patients with midline shift >5 mm (OR 0.40, 95% CI 0.24–0.67).
- Associations held after adjusting for injury characteristics and ICP-monitoring interventions.
Methodological Strengths
- Large national registry with adjusted hierarchical regression modeling
- Predefined subgroup (MLS >5 mm) increasing phenotypic homogeneity
Limitations
- Retrospective observational design with potential selection bias and unmeasured confounding
- Lack of long-term functional outcomes beyond in-hospital mortality
Future Directions: Prospective studies evaluating functional outcomes and refining surgical indications/triage criteria for pTBI with SDH, integrated with anesthetic and critical care pathways.