Daily Anesthesiology Research Analysis
A multicenter randomized trial shows that intravenous propofol maintenance markedly reduces postoperative respiratory adverse events in children undergoing adenotonsillectomy. A double-blind randomized trial indicates that pre-induction stellate ganglion block modulates inflammation and improves short-term outcomes after cardiopulmonary bypass. A 10,541-patient VA-ECMO cohort associates severe hyperoxia with higher mortality, mostly via direct effects, highlighting the need for oxygen titration.
Summary
A multicenter randomized trial shows that intravenous propofol maintenance markedly reduces postoperative respiratory adverse events in children undergoing adenotonsillectomy. A double-blind randomized trial indicates that pre-induction stellate ganglion block modulates inflammation and improves short-term outcomes after cardiopulmonary bypass. A 10,541-patient VA-ECMO cohort associates severe hyperoxia with higher mortality, mostly via direct effects, highlighting the need for oxygen titration.
Research Themes
- Perioperative strategies to reduce pediatric respiratory complications
- Autonomic modulation to attenuate cardiac surgery inflammation
- Oxygen management in VA-ECMO and mortality risk
Selected Articles
1. Effect of Intravenous, Inhalational, or Combined Anesthesia Maintenance on Postoperative Respiratory Adverse Events in Children Undergoing Adenotonsillectomy (AmPRAEC): A Multicenter Randomized Clinical Trial.
In 729 children analyzed by modified intention-to-treat, intravenous propofol maintenance yielded the lowest PACU respiratory adverse events (18.8%) versus combined (28.5%) and inhalational maintenance (43.4%). Adjusted odds ratios favored IV over IH (0.25) and over IVIH (0.57), with small numbers-needed-to-treat (3–7). Findings support choosing propofol infusion for maintenance in pediatric adenotonsillectomy.
Impact: This large multicenter RCT provides practice-changing evidence on anesthesia maintenance to reduce pediatric respiratory complications after adenotonsillectomy.
Clinical Implications: Prefer intravenous propofol maintenance over inhalational maintenance for pediatric adenotonsillectomy to reduce PRAEs; institutions should review protocols and training to support IV maintenance and PACU monitoring pathways.
Key Findings
- PRAE incidence: IV 18.8% (45/239), IVIH 28.5% (70/246), IH 43.4% (106/244).
- Adjusted odds ratios: IV vs IH aOR 0.25 (95% CI 0.16–0.39); IV vs IVIH aOR 0.57 (0.36–0.90); IVIH vs IH aOR 0.44 (0.29–0.65).
- Numbers-needed-to-treat: IV vs IH = 3; IV vs IVIH = 6; IVIH vs IH = 7.
- Airway managed with tracheal tubes and awake extubation across groups; primary endpoint assessed in PACU.
Methodological Strengths
- Multicenter randomized design with large pediatric sample and modified intention-to-treat analysis.
- Adjusted comparisons with confidence intervals and clinically interpretable NNTs.
Limitations
- Likely lack of provider blinding due to maintenance strategy differences.
- Outcomes focused on PACU events; no long-term respiratory or readmission data; single procedure type and country may limit generalizability.
Future Directions: Test IV maintenance across other pediatric procedures and risk strata, evaluate cost-effectiveness, and assess long-term respiratory outcomes and implementation strategies.
2. Ultrasound-Guided Stellate Ganglion Block Regulates Inflammatory Cytokines and Improves Short-Term Outcome after Cardiac Surgery with Cardiopulmonary Bypass: A Randomized Clinical Trial.
In a double-blind randomized trial (n=50), pre-induction left stellate ganglion block with ropivacaine reduced perioperative TNF-α elevations at 6 and 24 hours, lowered SIRS incidence at 24 hours, and decreased ventricular fibrillation after reperfusion and postoperative delirium. Changes in leukocyte subsets suggest immune modulation, and overall complications (Clavien-Dindo III–IV) were reduced.
Impact: This trial demonstrates that autonomic modulation via stellate ganglion block can attenuate inflammation and improve clinically meaningful outcomes after CPB, opening a low-cost adjunctive strategy.
Clinical Implications: Consider ultrasound-guided left SGB as an adjunct before induction in CPB cases to reduce inflammatory surge, arrhythmias, and delirium, pending validation in larger multicenter trials.
Key Findings
- Reduced TNF-α at 6 h and 24 h post-block versus control (p < 0.05).
- Lower incidence of SIRS at 24 h post-surgery with SGB.
- Leukocyte profile modulation: decreased neutrophil percentage at 6 h and increased lymphocyte percentage at 5 days.
- Lower rates of ventricular fibrillation after reperfusion, postoperative delirium, and Clavien-Dindo grade III–IV complications.
Methodological Strengths
- Prospective randomized double-blind design with standardized ultrasound-guided block.
- Assessment of both mechanistic biomarkers (TNF-α, leukocyte profiles) and clinically relevant outcomes.
Limitations
- Single-center small sample size (n=50) limits generalizability and power for rare outcomes.
- Short-term outcomes only; optimal dosing, laterality, and timing require further study.
Future Directions: Conduct multicenter RCTs powered for clinical endpoints (arrhythmias, delirium, ICU/hospital stay), explore dosing, laterality, and mechanistic pathways in neuro-immune modulation.
3. Hyperoxia and End-Organ Complications Among Cardiogenic Shock Patients Supported by Venoarterial Extracorporeal Membrane Oxygenation.
Among 10,541 VA-ECMO patients with cardiogenic shock, severe hyperoxia (PaO2 >300 mmHg at 24 h) was associated with higher mortality (71.7%; aOR 2.17) and more end-organ complications compared with normoxia. Mediation analysis suggested most of the mortality risk was a direct effect of hyperoxia (86%), underscoring potential oxygen toxicity.
Impact: This very large, contemporary cohort with mediation analysis provides actionable evidence to avoid severe hyperoxia on VA-ECMO, informing oxygen titration protocols.
Clinical Implications: Implement conservative oxygen targets and frequent PaO2 monitoring in the first 24 hours of VA-ECMO to avoid severe hyperoxia; embed protocolized titration and alarms into ECMO workflows.
Key Findings
- Mortality by oxygenation status at 24 h: severe hyperoxia 71.7% (aOR 2.17), mild hyperoxia 63.8% (aOR 1.34), normoxia 52.7%.
- Severe hyperoxia associated with increased end-organ complications; complications independently predicted higher mortality (aOR 1.42).
- Mediation: hyperoxia’s effect on mortality was primarily direct (86%); indirect pathways included neurologic (3.1%), hepatic (3.9%), renal (3.5%), and bleeding (2.3%) complications.
Methodological Strengths
- Very large multinational cohort with predefined PaO2 categories and multivariable adjustment.
- Use of causal mediation analysis to disentangle direct and indirect effects.
Limitations
- Observational design with potential residual confounding; PaO2 measured at 24 h may not capture earlier exposure.
- Lack of randomized oxygen targets and potential center-level practice variability.
Future Directions: Randomized trials of oxygen targets in VA-ECMO and implementation studies integrating closed-loop oxygen control to minimize hyperoxia.