Daily Anesthesiology Research Analysis

BACKGROUND: General anesthetic drugs may affect the risk of postoperative respiratory adverse events (PRAEs) in children, but the effect of anesthesia maintenance strategies on these events has not yet been widely validated. This study tested the hypothesis that anesthesia maintenance with propofol infusion in addition to inhalation anesthesia or alone would lead to a progressive reduction in the incidence of PRAEs. METHODS: This multicenter randomized clinical trial (AmPRAEC study) enrolled 760 children aged 0 to 12 yr who underwent adenotonsillectomy at 12 hospitals in China. Patients were randomly assigned to the intravenous anesthesia maintenance (IV group), the combined intravenous-inhalation anesthesia maintenance (IVIH group), or the inhalation anesthesia maintenance (IH group). Tracheal tubes were used for airway management, with all children undergoing awake extubation. The primary outcome was PRAE incidence in the postanesthesia care unit. RESULTS: A total of 760 children (median [interquartile range] age, 6 [4 to 7] years; 460 boys [60.5%]) were randomized, and 729 total samples were available for modified intention-to-treat analysis. The IV group had the lowest incidence of PRAEs (45 of 239 [18.8%]), followed by the IVIH group (70 of 246 [28.5%]) and the IH group (106 of 244 [43.4%]). Compared to the IH group, the IVIH group had a significantly lower risk of PRAEs (adjusted odds ratio [aOR], 0.44; 95% confidence interval [CI], 0.29 to 0.65; number needed to treat, 7). The IV group had significantly lower risk compared to both the IVIH group (aOR, 0.57; 95% CI, 0.36 to 0.90; number needed to treat, 6) and the IH group (aOR, 0.25; 95% CI, 0.16 to 0.39; number needed to treat, 3). CONCLUSIONS: Anesthesia maintenance with propofol infusion in addition to inhalation anesthesia or alone resulted in a progressive reduction in the incidence of PRAEs. Propofol intravenous anesthesia maintenance should be considered for children undergoing adenotonsillectomy.

OBJECTIVES: To evaluate the effectiveness of left stellate ganglion block (SGB) for inflammatory cytokines and short-term outcomes in cardiac surgery with cardiopulmonary bypass (CPB). DESIGN: Prospective, randomized, double-blinded clinical trial. SETTING: Single academic center hospital. PARTICIPANTS: We included patients aged 18 to 70 scheduled for cardiac surgery with CPB. INTERVENTIONS: Before anesthesia induction, the patients who were allocated to either the SGB group or the control group received SGB using either 0.5% ropivacaine or 0.9% saline. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the inflammatory cytokine concentration before (T0) and 6 hours (T1), 24 hours (T2), and 5 days (T3) after the block. Secondary outcomes included the incidence of SIRS 24 hours after surgery, immune function at each time point, intraoperative and postoperative complications, 30-day mortality, intensive care unit and hospital stay, and hospitalization costs. The analysis included 25 SGB and 25 control patients. Compared with the control group, the SGB group significantly inhibited elevated TNF-α concentration at 6 hours and 24 hours after the block (p < 0.05). SGB significantly reduced the SIRS 24 hours after surgery, decreased the neutrophil percentage at 6 hours after the block, and increased the lymphocyte percentage at 5 days after the block. Additionally, SGB decreased the incidence of ventricular fibrillation after reperfusion, postoperative delirium, and the occurrence of Clavien-Dindo grade III-IV. CONCLUSIONS: SGB effectively improves short-term outcomes in patients with cardiac surgery and CPB, possibly through modulating the neuro-endocrine-immune network to normalize sympathetic nervous system activity and stabilize perioperative tumor necrosis factor-α concentration.

OBJECTIVES: To investigate whether severe hyperoxia predisposes to end-organ complications and whether these complications contribute to in-hospital mortality among cardiogenic shock (CS) patients supported in venoarterial extracorporeal membrane oxygenation (VA-ECMO). DESIGN: Adult patients with CS from the Extracorporeal Life Support Organization Registry between 2010 and 2023 were categorized into normoxia (Pa o2 60-150 mm Hg), mild hyperoxia (Pa o2 151-300 mm Hg), and severe hyperoxia (Pa o2 > 300 mm Hg) based on their Pa o2 at 24 hours. The primary outcome was in-hospital mortality. End-organ complications were analyzed using multivariate logistic regression models, and causal mediation analysis was performed to estimate the direct and indirect effects of hyperoxia on mortality. SETTING: Multicenter, multinational prospective cohort study. PATIENTS: Adults with CS supported on VA-ECMO. INTERVENTIONS: Partial pressure of oxygen at 24 hours after VA-ECMO cannulation. MEASUREMENTS/MAIN RESULTS: A total of 10,541 patients were included (normoxia: 48.4%, mild hyperoxia: 30.0%, severe hyperoxia: 21.5%). There was higher in-hospital mortality in patients with severe hyperoxia (71.7%, adjusted OR [aOR]: 2.17; 95% CI, 1.19-2.50) and mild hyperoxia (63.8%, aOR: 1.34; 95% CI, 1.19-1.50) compared normoxia (52.7%; referent group). Severe hyperoxia was associated with more end-organ complications, which incrementally predicted higher mortality (aOR: 1.42; 95% CI, 1.25-1.61). Mediation analysis demonstrated that hyperoxia primary exerted a direct effect on mortality (86%), with contributions from neurologic (3.1%), hepatic (3.9%), renal (3.5%), and bleeding (2.3%) complications. CONCLUSIONS: Severe hyperoxia in patients with CS receiving VA-ECMO is associated with increased mortality and more end-organ complications. However, most of the effect of severe hyperoxia on mortality occurs via direct effects, independent of end-organ complications. These findings highlight the potential direct toxicity of hyperoxia and underscore the need for strategies to optimize oxygen delivery in this critically ill population.