Daily Anesthesiology Research Analysis
Today’s top anesthesiology research includes: a multicenter stepped-wedge randomized trial showing targeted normoxemia safely reduces hyperoxemia without increasing hypoxemia in burn units; a double-blind RCT identifying a balanced remimazolam–remifentanil regimen for awake fiberoptic intubation; and a randomized trial demonstrating a motion sickness patch halves PONV risk in female thyroid surgery despite dual antiemetic prophylaxis.
Summary
Today’s top anesthesiology research includes: a multicenter stepped-wedge randomized trial showing targeted normoxemia safely reduces hyperoxemia without increasing hypoxemia in burn units; a double-blind RCT identifying a balanced remimazolam–remifentanil regimen for awake fiberoptic intubation; and a randomized trial demonstrating a motion sickness patch halves PONV risk in female thyroid surgery despite dual antiemetic prophylaxis.
Research Themes
- Perioperative oxygen management and safety
- Sedation strategies for awake fiberoptic intubation
- Enhanced PONV prevention in high-risk thyroid surgery
Selected Articles
1. Effect of targeting normoxemia on supplemental oxygen-free days for adults with acute thermal burns: A stepped wedge cluster randomized clinical trial.
In a multicenter stepped-wedge RCT across six US burn centers (n=1,437), targeting SpO2 90–96% increased time in normoxemia (77%→81%), reduced hyperoxemia (22%→17%), and did not increase hypoxemia (0.7% vs 0.8%). The strategy did not significantly increase oxygen-free days by day 28 but maintained safety and slightly improved hospital-free days to day 90.
Impact: This is a large, pragmatic, multicenter randomized evaluation of oxygen titration strategy specific to burn care, addressing a ubiquitous yet under-tested practice with safety endpoints.
Clinical Implications: Adopting a normoxemia target (SpO2 90–96%) in burn ICUs appears safe, reduces hyperoxemia exposure, and can be implemented without increasing hypoxemia; protocols should emphasize de-escalating FiO2 when SpO2 exceeds 96%.
Key Findings
- Time in normoxemia increased from 77% (usual care) to 81% (targeted normoxemia).
- Hyperoxemia exposure decreased from 22% to 17%; hypoxemia remained similar (0.7% vs 0.8%).
- No significant increase in supplemental oxygen–free days by day 28 (aMD 0.90 days; 95% CI -0.77 to 2.57; p=0.29).
- Hospital-free days to day 90 improved (aMD 3.47 days; 95% CI 0.19–6.76) with maintained safety.
Methodological Strengths
- Multicenter stepped-wedge cluster randomized design with pragmatic implementation
- Large sample size (n=1,437) with prespecified safety outcomes
Limitations
- Primary outcome (oxygen-free days) not significantly improved
- Potential for temporal and cluster effects inherent to stepped-wedge design; blinding not feasible
Future Directions: Evaluate patient-centered outcomes (e.g., wound healing, pulmonary complications), protocol adherence metrics, and cost-effectiveness; test normoxemia targeting in broader surgical/ICU populations.
BACKGROUND: Supplemental oxygen is essential in caring for adults with acute thermal burns but can expose patients to excess inspired oxygen. We sought to determine the safety and effectiveness of targeting normoxemia (peripheral oxygen saturation [SpO 2 ] 90-96%) in adults with acute thermal burns admitted to a specialized burn unit. We hypothesized that targeting normoxemia would increase the number of supplemental oxygen-free days (SOFDs) and safely reduce exposure to hyperoxemia. METHODS: In this multicenter cluster-randomized, stepped-wedge trial, we randomized six US burn centers to cross over from usual care to targeted normoxemia at three-month intervals between January 15, 2021, and October 15, 2022. In usual care, supplemental oxygen was determined by treating clinicians. In targeted normoxemia, we specified decreasing administered supplemental oxygen whenever SpO 2 was >96%. The primary outcome was SOFD, defined as the number of days alive and not receiving supplemental oxygen through Day 28. Safety outcomes included hypoxemia (SpO 2 < 88%), in-hospital mortality, and adverse events. RESULTS: The 1,437 enrolled patients were mean age 48 years, 26% female, 38% with full-thickness burns, and 11% mean total body surface area burned. The proportion of time spent in normoxemia increased from 77% in the usual care group to 81% in the targeted normoxemia group. Time spent with hyperoxemia (SpO 2 > 96%) decreased from 22% to 17%, and hypoxemia was similar between groups (0.7% vs. 0.8%). The raw mean number of SOFD was 18.8 days for targeted normoxemia and 17.2 days for usual care (adjusted mean difference [aMD], 0.90 days; 95% confidence interval [CI], -0.77 to 2.57; p = 0.29). Hospital-free days through Day 90 were greater among the targeted normoxemia group (71 days) than the usual care group (70 days) (aMD, 3.47 days; 95% CI, 0.19-6.76). In-hospital mortality to Day 90 occurred in 36 (5.7%) targeted normoxemia patients and 65 (8.1%) usual care patients (adjusted hazard ratio [aHR], 0.66; 95% CI, 0.31-1.42). CONCLUSION: Targeting normoxemia did not increase supplemental oxygen-free days among adults with acute thermal burns, but safely maintained clinical outcomes. LEVEL OF EVIDENCE: Therapeutic Care/Management; Level I. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04534972.
2. Efficacy and safety of remimazolam combined with remifentanil for sedation during awake fiberoptic intubation: a randomized controlled trial.
In a five-arm, double-blind RCT (n=150), remimazolam (0.2–0.6 mg/kg/h) plus remifentanil 0.05 mcg/kg/min provided effective AFOI sedation in patients with normal airways. Deep sedation occurred with remimazolam alone and higher remimazolam combination doses (0.4–0.6 mg/kg/h), supporting 0.2 mg/kg/h as the optimal balance between efficacy and safety.
Impact: Provides dose-ranging, controlled evidence for a rapidly adopted sedative (remimazolam) in the high-stakes setting of awake fiberoptic intubation, informing safety thresholds.
Clinical Implications: For AFOI, consider remimazolam 0.2 mg/kg/h plus remifentanil 0.05 mcg/kg/min to minimize deep sedation while maintaining procedural conditions; avoid higher remimazolam infusion rates that increase oversedation risk.
Key Findings
- Five-arm double-blind RCT with 150 patients compared remimazolam and remifentanil dosing for AFOI.
- Deep sedation occurred in remimazolam alone and higher-dose combinations: 3.3% (Rm), 17.2% (RR0.4), 50.0% (RR0.6).
- Remimazolam 0.2 mg/kg/h plus remifentanil 0.05 mcg/kg/min balanced efficacy and safety best.
Methodological Strengths
- Prospective, double-blind randomized controlled design
- Dose-ranging, multi-arm comparison with standardized topical anesthesia
Limitations
- Population limited to patients with normal airways; generalizability to difficult airways is uncertain
- Primary outcome focused on depth of sedation; limited reporting on procedural success metrics
Future Directions: Assess performance in difficult airways, incorporate patient-centered outcomes (comfort, recall), and compare against alternative regimens (e.g., dexmedetomidine-based protocols).
INTRODUCTION: There has been not study determining if remimazolam combined with remifentanil is the reasonable dosing regimen for sedation during awake fiberoptic intubation (AFOI). This prospective double-blind randomized controlled trial compare efficacy and safety of sedation using different-dose remimazolam combined with remifentanil for AFOI procedure. METHOD: One hundred and fifty patients were randomly assigned to five groups receiving different interventions. The Rf group received only remifentanil infusion of 0.05 mcg/kg/min, the Rm group received only remimazolam 0.6 mg/kg/h, and the RR0.2, RR0.4 and RR0.6 groups received remifentanil 0.05 mcg/kg/min combined with remimazolam of 0.2, 0.4 and 0.6 mg/kg/h, respectively. After intravenous infusion of studied drugs for 3 min, AFOI was carried out under airway topical anesthesia. The primary outcome was the incidence of deep sedation during AFOI procedure. RESULTS: Deep sedation occurred only in the Rm, RR0.4 and RR0.6 groups, with incidences of 3.3%, 17.2%, and 50.0%, respectively ( CONCLUSIONS: Remimazolam 0.2-0.6 mg/kg/h combined with remifentanil 0.05 mcg/kg/min are effective and feasible dosing regimens of sedation for AFOI procedure in patients with normal airway, but the regimen including remimazolam 0.2 mg/kg/h should be the better choice for balancing efficacy and safety. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2100042917. Retrieved from http://www.chictr.org.cn/showproj.html?proj=65332 on January 31, 2021.
3. Effects of motion sickness patch on postoperative nausea and vomiting in female patients undergoing thyroid surgery: a randomized clinical trial.
In 162 female thyroid surgery patients receiving standard antiemetic prophylaxis, adding a motion sickness patch reduced 24-hour PONV from 34.6% to 18.5% (RR 0.536; 95% CI 0.310–0.925). This supports multimodal PONV prophylaxis that includes a transdermal anticholinergic-type intervention in high-risk settings.
Impact: Demonstrates incremental benefit of a motion sickness patch on top of dual prophylaxis in a homogeneous, high-risk surgical population, providing directly actionable prevention data.
Clinical Implications: For high-risk female thyroidectomy patients, consider adding a motion sickness patch to dexamethasone and palonosetron to further reduce PONV within 24 hours.
Key Findings
- Randomized trial in 162 female thyroid surgery patients on standard dual antiemetic prophylaxis.
- PONV within 24 hours reduced from 34.6% (control) to 18.5% (patch); RR 0.536 (95% CI 0.310–0.925; p=0.021).
- Secondary outcomes were collected (QoR-15, pain, sedation, GI recovery, adverse events), supporting comprehensive assessment.
Methodological Strengths
- Randomized allocation with standardized baseline prophylaxis
- Clinically meaningful, prespecified primary endpoint (24-hour PONV incidence)
Limitations
- Single surgical population (female thyroidectomy) may limit generalizability
- Limited reporting of secondary outcomes and adverse event profiles in the abstract
Future Directions: Validate in mixed-sex, diverse surgical populations; assess optimal timing and duration of patch use and interaction with other antiemetics; evaluate cost-effectiveness.
BACKGROUND: This study aims to investigate whether the application of motion sickness patch can effectively reduce the incidence of postoperative nausea and vomiting (PONV) in female patients undergoing thyroid surgery. METHODS: One hundred and sixty-two female patients undergoing thyroid surgery were randomly assigned into motion sickness patch group and control group. Both groups received standard prophylactic antiemetic therapy with intravenous dexamethasone (8 mg) and palonosetron (0.075 mg). The primary outcome was the incidence of PONV during the first 24 hours postoperatively. Secondary outcomes included PONV severity, 15-item quality of recovery, visual analogue scale pain score, ramsay sedation score, Post-anesthetic care unit residence time, time to first flatus and defecation, the incidence of adverse events, and the length of hospital stay. RESULTS: The incidence of PONV within the first 24 hours after surgery was significantly lower in the motion sickness patch group compared to the control group [18.5% (15 of 81) vs. 34.6% (28 of 81); relative risk, 0.536; 95% confidence interval, 0.310-0.925; P = 0.021]. CONCLUSIONS: The findings of this study indicate that the application of motion sickness patch can effectively reduce the occurrence of nausea and vomiting within 24 hours after thyroid surgery in female patients.