Daily Anesthesiology Research Analysis
A double-blind RCT in total hip arthroplasty found no ROTEM evidence of fibrinolysis or clinical benefit from routine tranexamic acid, supporting more selective use. A multicenter Anesthesiology study showed higher standardized ICU admission ratios after rapid response activations were associated with better neurologic outcomes. A large external validation confirmed a dose-dependent association between red blood cell transfusion and postoperative AKI in cardiac surgery.
Summary
A double-blind RCT in total hip arthroplasty found no ROTEM evidence of fibrinolysis or clinical benefit from routine tranexamic acid, supporting more selective use. A multicenter Anesthesiology study showed higher standardized ICU admission ratios after rapid response activations were associated with better neurologic outcomes. A large external validation confirmed a dose-dependent association between red blood cell transfusion and postoperative AKI in cardiac surgery.
Research Themes
- Selective antifibrinolytic use guided by viscoelastic testing
- ICU triage metrics and outcomes after in-hospital rapid response
- Transfusion practices and renal risk in cardiac anesthesia
Selected Articles
1. The effect of tranexamic acid on blood coagulation in primary total hip arthroplasty using rotational thromboelastometry: a randomized controlled trial.
In 50 primary THA patients, prophylactic TXA did not alter ROTEM parameters, did not reveal perioperative fibrinolysis, and did not improve clinical outcomes compared with placebo. Findings support avoiding routine TXA when fibrinolysis is not present and suggest ROTEM-guided, selective use in high-risk cases.
Impact: This RCT challenges routine TXA use by showing no ROTEM or clinical benefit without demonstrable fibrinolysis, promoting precision antifibrinolytic therapy.
Clinical Implications: Consider viscoelastic testing to identify hyperfibrinolysis and reserve TXA for patients with ROTEM evidence or high-risk profiles, rather than universal prophylaxis in THA.
Key Findings
- ROTEM showed normal-range coagulability in all patients with no perioperative fibrinolysis (no ML >15%).
- No differences between TXA and placebo in NATEM/T-APTEM variables or clinical outcomes, including blood loss.
- Postoperative ROTEM indicated a trend toward accelerated coagulation (shorter CT, CFT; higher A10), independent of TXA.
Methodological Strengths
- Double-blind randomized controlled design with placebo control
- Mechanistic assessment using ROTEM (NATEM and T-APTEM) with preregistration (NCT03897621)
Limitations
- Single-center, small sample size (n=50), potentially underpowered for rare events or small clinical differences
- Findings may not generalize to patients with preexisting hyperfibrinolysis or different surgical settings
Future Directions: Large, pragmatic RCTs stratified by ROTEM-defined fibrinolysis are needed to define selective TXA indications and dosing, and to assess bleeding, thromboembolic events, and patient-centered outcomes.
2. Impact of the Standardized Intensive Care Unit Admission Ratio on Outcomes in Rapid Response System Activations: A Retrospective Multicenter Study in Japan.
Across 8,794 RRS activations, higher standardized ICU admission ratios were associated with lower odds of poor neurological outcome or death at 30 days, though the association with mortality alone was not significant. Findings suggest that greater ICU utilization after rapid responses may improve neurologic outcomes.
Impact: Introduces a standardized, risk-adjusted ICU admission metric (SIAR) and links institutional ICU utilization patterns to clinically meaningful outcomes after RRS activations.
Clinical Implications: Hospitals can benchmark SIAR to optimize post-RRS triage practices, potentially prioritizing ICU admission for patients at risk of neurologic deterioration while studying mechanisms and resource implications.
Key Findings
- Median ICU admission rate after RRS was 0.33; median SIAR was 0.98 across 35 institutions.
- Higher SIAR was significantly associated with lower odds of CPC ≥3 or death within 30 days (adjusted OR per 0.1 SIAR increase 0.94; P < 0.001).
- Association with 30-day mortality alone was not statistically significant in adjusted models.
Methodological Strengths
- Large multicenter cohort with 8,794 RRS activations and hospital-level clustering
- Risk-adjusted metric (SIAR) and GEE logistic regression addressing intra-hospital correlation
Limitations
- Retrospective observational design limits causal inference and is subject to residual confounding
- Potential heterogeneity in RRS criteria, ICU admission thresholds, and case mix across institutions
Future Directions: Prospective studies should test SIAR-informed triage pathways, evaluate mechanisms (e.g., timing/level of care), and quantify resource utilization versus outcome benefits.
3. Blood transfusion and acute kidney injury after cardiac surgery: a retrospective observational study.
In 5,204 adults undergoing on-pump cardiac surgery, red blood cell transfusion showed a dose-dependent association with postoperative AKI, strongest when >2 units were transfused. The findings externally validate earlier work and underscore the need for restrictive, kidney-conscious transfusion strategies.
Impact: Provides robust external validation that the quantity of RBC transfusion independently elevates AKI risk after cardiac surgery, informing transfusion thresholds and patient blood management.
Clinical Implications: Adopt restrictive transfusion thresholds, minimize RBC units, and integrate AKI risk into intraoperative decision-making and consent; consider alternatives (cell salvage, antifibrinolytics when indicated).
Key Findings
- AKI occurred in 15.3% (798/5204) with KDIGO distribution: 77% stage 1, 11% stage 2, 12% stage 3.
- RBC transfusion (but not plasma or platelets) was significantly associated with AKI after adjustment using IPW logistic regression.
- Dose-response: 1–2 units increased probabilities of stage 1 AKI by 4% and stage 2–3 by 2%; >2 units increased stage 1 by 12% and stage 2–3 by 9%.
Methodological Strengths
- Large single-center cohort with detailed perioperative data and standardized KDIGO AKI criteria
- Causal modeling approach using inverse probability weighting to mitigate confounding
Limitations
- Retrospective design from a single center may limit generalizability and causal inference
- Nonemergent cases only; residual confounding from unmeasured factors possible
Future Directions: Prospective trials to test kidney-sparing transfusion strategies, integrate AKI risk prediction into PBM, and evaluate alternatives to RBC transfusion in cardiac surgery.