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.
BACKGROUND AND AIMS: Patients with cancer and venous thromboembolism (VTE) have a high risk of recurrent VTE and anticoagulant-related bleeding. This study aimed to identify prognostic factors for these complications. METHODS: A systematic review was performed for randomized trials and cohort studies evaluating prognostic factors for recurrent VTE or anticoagulant-related bleeding in adult patients with cancer and VTE. Adjusted hazard ratios (aHRs) for factors were pooled using random-effects meta-analysis. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS: Thirty-three studies (n = 96 753) were included in the meta-analyses. Factors with high certainty of association with increased risk of recurrent VTE included a previous history of VTE [aHR 1.50 (95% CI 1.08-2.09)], Eastern Cooperative Oncology Group (ECOG) performance status >0 [1.81 (1.34-2.46)] or >1 [2.44 (1.55-3.84)], advanced cancer [1.38 (1.15-1.65)], and specific cancer sites including lung [1.78 (1.29-2.46)], hepatobiliary [2.37 (1.70-3.30)], pancreas [3.20 (2.06-4.96)], and genitourinary [1.38 (1.14-1.67)]. Conversely, recent surgery [aHR 0.56 (95% CI 0.40-0.76)] and breast cancer [0.43 (0.23-0.81)] had a high certainty of association with a decreased risk. Factors with a high certainty of association with an increased risk of anticoagulant-related bleeding included a history of bleeding [aHR 2.41 (95% CI 1.50-3.88)], ECOG performance status ≥2 [2.10 (1.48-2.99)], advanced cancer [1.60 (1.29-1.97)], and cancers of the brain [2.25 (1.64-3.09)], gastrointestinal system [1.74 (1.44-2.11)], genitourinary system [1.90 (1.48-2.45)], and prostate [1.72 (1.26-2.34)]. CONCLUSIONS: The prognostic factors identified in this meta-analysis should be considered as part of risk stratification frameworks for anticoagulation management in patients with cancer and VTE.
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.
BACKGROUND: Intravenous administration of paracetamol to critically ill patients may have negative hemodynamic effects. However, such effects have not been adequately quantified. METHODS: We conducted a systematic review and meta-analysis of observational studies (published in English language in PubMed and/or EMBASE) conducted on intensive care unit (ICU) patients, reporting hemodynamic changes within 30 min of intravenous paracetamol administration for fever and/or analgesia. The primary outcome was the mean difference (MD) with 95% confidence interval [95%CI] in mean arterial pressure (MAP). Secondary outcomes were systolic and diastolic arterial pressure (SAP and DAP), heart rate (HR), and incidence of hypotension. Trial sequential analysis (TSA) was conducted to ascertain the robustness of findings. RESULTS: Eight studies were included. We observed significant reduction after paracetamol of MAP (5 studies, MD: -6.75 mmHg [-10.68; -2.82]; p = 0.0008; I CONCLUSIONS: Hypotension after intravenous paracetamol is frequent in the ICU, with significant reduction in MAP, SAP, and DAP but no effects on HR. Effects seem more pronounced in patients with fever. More advanced hemodynamic studies are needed to understand the mechanisms of paracetamol-induced hypotension. REGISTRATION: PROSPERO (CRD number 42024574919).
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.
OBJECTIVE: Firearm-related penetrating traumatic brain injury (pTBI) is highly morbid and causes heterogeneous intracranial injury patterns. As guidelines and practices evolve, tailored analysis of more homogeneous pTBI cohorts is needed to inform surgical management. Therefore, the aim of this study was to test the association between cranial surgery and survival among patients with pTBI resulting in subdural hematoma (SDH). METHODS: Patients with firearm-related pTBI and resultant SDH were retrospectively identified using the American College of Surgeons Trauma Quality Program dataset (2017-2019). The study exposure of interest was cranial surgery, and the primary outcome was in-hospital mortality. Adjusted hierarchical regression models were specified to test the association between cranial surgery and in-hospital mortality. To further increase the homogeneity of the presenting injury pattern, a subgroup analysis was performed in patients with SDH and midline shift (MLS) > 5 mm. RESULTS: A total of 1894 patients (84% male; median age 31 years) with firearm-related pTBI and SDH were included. The hierarchical logistic regression analysis demonstrated that cranial surgery was independently associated with lower odds of in-hospital mortality (OR 0.49, 95% CI 0.34-0.71; p < 0.001), even after risk adjustment for injury characteristics and placement of an external ventricular drain or intracranial pressure monitor. In a subgroup of 535 patients who presented with SDH and MLS > 5 mm, cranial surgery had a greater protective effect against in-hospital mortality (OR 0.40, 95% CI 0.24-0.67; p < 0.001). CONCLUSIONS: Cranial surgery was independently associated with lower in-hospital mortality among patients with firearm-related pTBI and SDH, and its protective effect was greater among patients with significant MLS. Further investigations of long-term functional outcomes are needed.